What are the Washington State opioid prescribing guidelines?

Washington State Opioid Prescribing Guidelines

Washington State requires pain specialists to be consulted before increasing long-term opioid therapy dosage to >120 MME/day, and this consultation must confirm that the increase is both indicated and appropriate. 1

Washington State-Specific Requirements

Mandatory Consultation Threshold

• Before prescribing >120 MME/day, clinicians must obtain consultation from a pain specialist who agrees the dosage increase is indicated and appropriate 1
• This requirement is more restrictive than the CDC's general recommendation of caution at ≥90 MME/day 1
• Washington implemented these guidelines through the Washington Agency Medical Directors Group in 2015, making it one of the first states with specific dosing thresholds 1

Impact of Washington State Guidelines

• Following implementation of the 2007 Washington Interagency Guideline on Opioid Dosing, high-dose opioid prescribing (at the 75th, 90th, 95th, and 99th percentiles) declined significantly while median doses remained stable at 37.5 mg morphine-equivalent dose 2
• Fatal opioid overdoses in Washington State decreased starting in 2010 after implementation of risk mitigation strategies 1
• The Washington guidelines demonstrated that high-dose opioid therapy can be reduced without restricting access for patients at lower doses 2

Core Prescribing Framework (Aligned with CDC Guidelines)

Dosage Thresholds and Risk Stratification

• Up to 40 MME/day is considered low dose, 41-90 MME/day is moderate dose, and ≥91 MME/day is high dose 1, 3
• At ≥50 MME/day, implement additional precautions including increased follow-up frequency and offer naloxone with overdose prevention education to patients and household members 1
• Avoid or carefully justify dosages ≥90 MME/day based on individualized assessment, as overdose risk increases 2.0 to 8.9-fold compared to 1-20 MME/day 1, 4

Prescription Drug Monitoring Program (PDMP)

• Query Washington State's PDMP before initiating opioid therapy and review it at every prescription or minimally every 3 months to identify high-risk combinations, multiple prescribers, or excessive dosages 3, 5
• PDMPs are essential for reducing doctor shopping and identifying patients obtaining opioids from multiple sources 3, 6

Urine Drug Testing Requirements

• Implement urine drug testing at initiation of opioid therapy and at least annually, with more frequent testing for higher-risk patients 3, 5
• UDT helps identify non-compliance, prescription drug abuse, and illicit drug use 3, 6

Initial Assessment Requirements

Before Starting Opioids

• Document comprehensive history including pain characteristics, general medical condition, psychiatric status, substance use history, and screen for opioid abuse risk 3
• Establish physical diagnosis with appropriate imaging to correlate with subjective complaints, avoiding over-investigation that increases patient fear and opioid-seeking behavior 6
• Confirm medical necessity based on average moderate to severe pain (≥4 on 0-10 scale) and/or functional disability 3
• Stratify patients into low, medium, or high-risk categories for opioid misuse 3, 6

Treatment Goals and Agreements

• Establish realistic treatment goals for pain relief and functional improvement before initiating therapy, with discussion of discontinuation criteria if benefits don't outweigh risks 4, 3
• Obtain a robust opioid agreement signed by all parties to reduce overuse, misuse, abuse, and diversion 3, 6

Initiating and Titrating Opioid Therapy

Starting Therapy

• Initiate with low-dose, short-acting opioids rather than long-acting formulations 3, 6
• Avoid long-acting opioids for initiation of therapy, as they carry increased adverse consequences without superior effectiveness compared to short-acting opioids 3
• Wait at least five half-lives before increasing dosage, and at least one week before increasing methadone to ensure full effects of previous dosage are evident 1

Methadone-Specific Precautions

• Methadone should only be used after failure of other opioid therapy and only by clinicians with specific training in its risks and uses 3, 6
• Obtain electrocardiogram before initiating methadone, at 30 days, and yearly thereafter to monitor for QT prolongation 3, 6

Ongoing Monitoring and Maintenance

Effectiveness Assessment

• Periodically assess for ≥30% improvement in both pain relief and functional status without adverse consequences 3, 4
• Continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks 4
• Re-evaluate patients after each dosage increase for changes in pain, function, and risk for harm 1

Adherence Monitoring

• Monitor for adherence, abuse, and non-compliance through regular UDT and PDMP queries 3
• Monitor for side effects including constipation and manage appropriately, including opioid discontinuation when indicated 3

High-Dose Opioid Management

Patients Already on High Doses

• For established patients on ≥90 MME/day, explain non-judgmentally that evidence shows increased overdose risk at higher dosages and offer to collaborate on tapering to safer dosages 1
• Patients tapering from high doses after years of use may require very slow tapers with pauses to allow gradual accommodation 1
• Remain alert for anxiety, depression, and opioid use disorder that may be unmasked during tapering and arrange management of these comorbidities 1

When to Discontinue

• Discontinue opioid therapy for lack of response, adverse consequences, or abuse, with appropriate rehabilitation 3
• If patients don't experience improvement at ≥90 MME/day or have escalating dosage requirements, discuss alternative pain management approaches and consider tapering 1

Common Pitfalls to Avoid

• Never increase opioid dosages to >120 MME/day in Washington State without mandatory pain specialist consultation 1
• Avoid concurrent prescribing of opioids and benzodiazepines, as this combination significantly increases overdose risk 1
• Don't prescribe long-acting opioids for acute pain, as this is a high-risk practice contributing to the overdose epidemic 1
• Never abruptly discontinue opioids or rapidly reduce dosages from higher levels unless there are life-threatening issues like impending overdose 1