UPDATE Closure of Seattle Pain Centers | Treating patients and reminder on pain management rules

The Washington State Department of Health, Washington State Medical Commission, and Washington State Health Care Authority released the following guidance and urged practitioners to accept and treat patients associated with Seattle Pain Center. Find additional resources at http://www.doh.wa.gov/Emergencies/PainClinicClosures.

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August 1, 2016

FROM: Washington State Department of Health, Washington State Medical Commission, and Washington State Health Care Authority

SUBJECT: UPDATE Closure of Seattle Pain Centers | Treating patients and reminder on pain management rules

On July 15, 2016 the Washington State Medical Commission suspended the license of Dr. Frank Li, former medical director of the Seattle Pain Centers (SPC). Seven of the eight SPC across the state are now closed.

This impacts about 8,000 patients—many of whom are on long-term, high-dose opioid treatment and will need medical care for their pain management needs.

Displaced patients may call or visit your clinic or emergency department, and we’re urging you to help address their medical needs. We understand you may be concerned about how you can treat these patients consistent with Washington’s Pain Rules.

Health practitioners who treat displaced patients should not fear disciplinary action from the state’s Medical Commission for ordering, prescribing, dispensing or administering controlled substances, including opioids, for legitimate medical purposes and in the course of professional practice.

Here are some steps to take to make sure your treatment of displaced patients follows state rules:

1. Get the patient’s medical records (SPC Patient records: 1-844-SPC-PAIN) and schedule an appointment.

2. Do a physical examination; evaluate their current condition, their care, and medication use and needs.

• Check the Prescription Monitoring Program to screen for prescriptions from other providers.
• Patients whose daily dosage is above 120 milligrams MED (orally) require a consultation with a pain management specialist, unless one of several exceptions applies (WAC 246- 919-861):
  • The patient is following a tapering schedule;
  • The patient requires treatment for acute pain which may or may not include hospitalization, requiring a temporary escalation in opioid dosage, with expected return to or below their baseline dosage level; or
  • The practitioner documents reasonable attempts to obtain a consultation with a pain management specialist and the circumstances justifying prescribing above 120 milligrams MED (orally) per day; or
  • The practitioner documents the patient's pain and function is stable and the patient is on a non-escalating dosage of opioids.
  Special attention should be given and a consult considered for patients less than 18 years of age, patients with complex comorbidities or multiple medications, and patients with other complications.
• For patients whose daily dosage is above 120 milligrams MED (orally) who do not have one of the exemptions listed above, a consultation is required.
  Consultations must include at least one of these steps:
  • An office visit with the patient and the pain management specialist;
  • A telephone consultation between the pain management specialist and the practitioner;
  • An electronic consultation between the pain management specialist and the practitioner; or
  • An audio-visual evaluation conducted by the pain management specialist remotely, where the patient is present with either the practitioner or a licensed healthcare practitioner designated by the practitioner or the pain management specialist.
• To find a pain management specialist, contact the patient’s healthcare plan.
• The pain rules also allow for telemedicine consultation.
• The University of Washington TelePain program provides a free service to support primary care providers in the management of patients who have complex cases or on high-dose opioids.

3. Develop a written treatment plan and ensure the patient understands your guidance.

4. Do a periodic review of the patient’s health status and medication needs.

Many of SPC patients may have been on high doses of opioids for years and are likely physiologically dependent. If your evaluation suggests reduction or elimination of opioids is an appropriate strategy, a slow taper is likely to be the most successful strategy rather than an abrupt stop, which will lead to withdrawal. According to the AMDG, unlike benzodiazepines, opioid withdrawal symptoms are rarely life threatening.

Note that some SPC patients may also be on long-term benzodiazepines. The Washington State Agency Medical Director’s Group (AMDG) recommends tapering of high-dose opioids before addressing benzodiazepine use.

For former SPC patients, you may want to:

• Develop a plan to taper the patient off of opioids (if your evaluation suggests this is an appropriate strategy).
• Prescribe naloxone for patients on greater than 90 MED or on combination therapy with other CNS depressants.
• Refer patients with potential substance use disorder to an addiction medicine specialist or the Washington Recovery Help Line at 1-866-789-1511, or via the Web at www.warecoveryhelpline.org
• Refer for case management or care coordination through the patient’s managed care plan.

In an effort to ensure broad awareness of this urgent issue, you may receive duplicates of this letter. We hope you’ll forgive any inconvenience. Please let us know if you have any ideas or concerns as we work together to manage this situation in the best way possible for these displaced patients.

Thank you for the services you provide to people in our state.

Dr. Kathy Lofy, State Health Officer, Washington State Department of Health

Dr. Dan Lessler, Chief Medical Officer, Washington State Health Care Authority

Melanie de Leon, JD, Executive Director, Medical Quality Assurance Commission

Additional information

• Find frequently asked questions on pain rules and their interpretation.
• Find more resources for healthcare providers at doh.wa.gov/pain. We will be updating the website as we get more information and resources.