Prescription Restriction: How Washington is Addressing Opioid Addiction

Several bottles of prescription medication on a table.

There is no shortage of alarming statistics when it comes to opioids. More people died from opioid overdoses in 2017, two per day, in Washington than in traffic fatalities. The average Washingtonian in the same year was about as likely to have a prescription for an opioid as to be left-handed, roughly 8 percent and 10 percent, respectively. In 2011, when the number of opioid prescriptions peaked in the state, there were enough pills to give every Washingtonian about 15 doses, with 112 million doses prescribed throughout the state.

That last statistic comes from a recent state Office of the Attorney General lawsuit against pharmaceutical companies McKesson Corporation, Cardinal Health Inc., and Drug Corporation earlier this year.

That lawsuit claims the defending companies knowingly “flooded the State with prescription opioids, leading to high rates of opioid dependence.” Attorney General Bob Ferguson’s office claims the companies violated the Washington Consumer Protect Act (CPA). The defending companies filed a motion to dismiss the case, which is scheduled for a hearing on June 26.

Washington is relatively tame compared to other states, ranking 35th in the country for opioid deaths per 100,000 residents, according to the Centers for Disease Control and Prevention. The problem started creeping into the view of state regulators in the early part of this decade when opioid deaths first outpaced vehicle fatalities, explained Washington Medical Commission Policy Development Manager Michael Farrell. In response, the state Legislature passed ESHB 2876, which required the Medical Commission and four other state health boards to adopt rules around opioids prescribed for chronic pain (effective in mid-2011). Those boards then adopted rules designed to prevent prescription opioid-related deaths and they seemed to work, Farrell said—but then overdoses on illicit opiates like heroin started to spike. One problem, the regulators found, was the rules hadn’t accounted for opioids prescribed for short-term acute pain—think post-surgical meds. And it wasn’t uncommon for a patient to receive a month’s worth of opioids to treat pain that might only last a few days, which led to a surplus supply of addictive prescriptions and corresponding patterns of addiction.

Between 2010 and 2015, opioid-related deaths doubled, according to the Washington Medical Commission. In response, the state passed new legislation, ESHB 1427, which required the health boards to again create rules to curtail unnecessary prescriptions and dosages. Those rules went into effect Jan. 1 of this year, and require the following:

  • Registration with the state prescription monitoring program (PMP) to track opioid prescriptions for over-prescribing physicians and patients getting drugs from more than one place.
  • Prescription limits of a three-day supply of opioids for acute and sub-acute pain, with larger quantities requiring a pain specialist consultation—at the very least documentation showing the health-care provider sought out a specialist.
  • A one-hour education course required as part of health-care providers’ continuing medical education (CME).
  • Rules against giving patients both benzodiazepines—for example, valium or Xanax—and opioids without good reason and extensive follow-up.

The rules give health-care providers flexibility to accommodate for unique circumstances and patient needs. Still, the Washington Medical Commission has disciplined 21 physicians for overprescribing opioids in the last year, Farrell said. And it’s hard to pinpoint why. The most likely reasons? Pain is difficult to treat but opioids are a simple way to handle the symptoms, pain specialists in the state are hard to come by and often booked solid, and plenty of doctors still don’t fully grasp the new rules—or they don’t care.

Gerald Tarutis, for example, has been defending health-care providers for three decades and still encounters physicians who find themselves in legal trouble because of opioid prescriptions.

“I can tell you, I am representing a number of physicians who are prescribing way over the [allowable opioid dosages] and they are simply not aware or don’t understand or don’t believe or don’t accept that prescribing in greater numbers is inappropriate,” Tarutis said.

More generally, he added, doctors take an oath to ease their patients’ suffering and the alternatives to opioids present trickier issues.

“I think for physicians, it is difficult to tell people, look, you’re going to be in pain,” Tarutis added. “The reality is that you’re going to experience some pain and we can give you alternative therapies … but you’re still going to be experiencing a degree of pain, and that’s what life is like. I think that’s a very difficult thing for doctors to tell their patients and it’s very difficult for patients to accept. … It becomes a real conflict between doing what’s legally correct and take care of the patient’s needs, and I don’t know if there’s an answer for that.”