For several years, regulators and independent observers have been compiling a mountain of statistical evidence that shows a public health crisis involving the abuse of opioid analgesics. The new CDC Guideline roots the recommendations in such macabre statistics. A few highlights should suffice: in 2012, health care providers wrote 259 million prescriptions for opioid pain medication; opioid prescriptions per capita increased 7.3% from 2007 to 2012; and, from 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In Minnesota, a Star Tribune article asserted that 212 deaths were from prescription opioids in 2014, up from 23 in the year 2000. The problem is clearly national as well as local.
In the summer of 2015, DOLI put forth treatment parameters to help deal with the problem of opioid abuse. The parameters provide patient selection criteria, contraindications for prescription, a required risk assessment, and a written contract signed by patient and provider. They take effect when the prescription of opioid analgesics is anticipated to extend beyond 12 weeks.
The selection criteria include requirements that:
- All other reasonable medical treatment options have been exhausted;
- The patient does not have a history of failing to comply with treatment or failing to take medication as prescribed; and
- The patient does not have a current Substance Use Disorder.
The program of treatment includes requirements that:
- All opioid analgesic medications must be used in fixed schedules of dosing;
- All prescriptions for long-term treatment with opioid analgesic medication must be written only by the prescribing health care provider or the designated proxy;
- The prescribing health care provider must schedule regular follow-up visits with the patient;
- The prescribing health care provider must discuss with the patient the risks associated with the long-term treatment with opioid analgesic medication; and
- The patient and the prescribing health care provider must sign a formal written treatment contract.
That contract essentially requires the patient to comply with the schedule of dosage, the recommendations of the prescriber and the rules. The contract, in turn, requires the health care provider to comply with the rules and actively monitor their patients.
Importantly, the parameters also empower insurers to keep doctors accountable to these guidelines. By way of a notice, the provider is given an opportunity to correct a deviation from the parameters. In the event that proof is not provided to the insurer or the provider has failed to comply altogether, the insurer has the right to discontinue payment.
A look at the new CDC Guideline reveals 12 recommendations summarized as follows:
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks;
- Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety;
- Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy;
- When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids;
- When opioids are started, clinicians should prescribe the lowest effective dosage;
- When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed;
- Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation and every 3 months or more frequently thereafter;
- Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms;
- Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose;
- When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs;
- Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible; and
- Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
A review of these recommendations shows that the primary emphasis is on patient well-being and safety, which complements the Minnesota treatment parameters. Notably, the CDC acknowledges in the Guideline that there is very little clinical support for the efficacy of long-term opioid use for non-cancer pain. In fact, one of the experts that consulted for this project, Dr. Gary Franklin, is the author of a position paper issued in the fall of 2014 by the American Academy of Neurology. This paper argued that people with chronic noncancer pain should not be prescribed opioids long-term. The paper presented well-documented support for the conclusion that opioid use is usually unsuccessful and ultimately detrimental for patients suffering from chronic noncancer pain.
Minnesota has taken a step in the right direction. The CDC Guideline supports the new treatment parameters entirely. With all parties attentive to the public health crisis, the need to address chronic pain in efficacious ways, and the proper direction of medical benefits, injured workers stand only to benefit.
If you have any questions about medical benefits, treatment parameters, or any other workers’ compensation matter, please feel free to call or e-mail any one of our many experienced attorneys – www.HansenDordell.com / 651-482-8900.
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