CHRONIC PAIN & OPIOID PRESCRIBING GUIDELINES

Transcription

1 CHRONIC PAIN & OPIOID PRESCRIBING GUIDELINES The following guidelines have been reviewed and endorsed by the New Brunswick Medical Society July 2004

2 Chronic pain can be due to cancer or noncancer conditions. Chronic noncancer pain (CNCP) is generally defined as noncancer pain with a duration longer than the expected time for tissue healing or resolution of the underlying disease process. CNCP is different from acute pain in both its presentation and pathophysiology (Canadian Pain Society). Expected healing times may be found: 1. in the Physician Information Kit 2. on the internet at HYPERLINK Go to the work-related section. 3. on the internet at the WHSCC website HYPERLINK " Select either English or Français. Click on the Health Care Providers section tab at the top. Click on the Guidelines index on the left side and then NB General Guidelines for Expected Healing Times. A simple rule of thumb for chronic pain is that the expected healing time for most injuries is 6 months. Exceptions are listed in the table below: Soft tissue injuries 3 months Fractures of spine, pelvis, hip and femur Neurological injuries Amputations lower extremity Spinal surgery other than discectomy DSM IV distinguishes between pain disorders associated with psychological factors, and those associated with both psychological and medical factors. Nociceptive pain is pain associated with tissue damage. Neuropathic pain is pain associated with neurological injury. Central pain is pain initiated or caused by a primary lesion or dysfunction in the central nervous system. Often seen in the context of chronic musculoskeletal pain is the patient with chronic pain syndrome (or chronic pain disorder æ DSM IV) who takes a large variety of medications with questionable benefit and uses drugs inappropriately. These behavioural disturbances that characterize this disorder. There is generally an absence of objective clinical findings. Other behavioural traits of chronic pain syndrome include physical inactivity, inability to work and social isolation. Analgesic medication should only be prescribed in these patients as part of a carefully controlled integrated pain management program. The treatment goal in CNCP is: improved comfort and enhanced function (broadly defined to include physical, psychological and social function). Functional restoration goals can be conceptualized as a ladder with basic activities of daily living (toileting, washing, eating) as the bottom rung; instrumental activities of daily living (meal preparation, transportation, banking, grocery shopping) as the next rung; social activities as the next rung ~ likely overlapping with sedentary job demands; different job at reduced job demands as the next rung ~ assuming that the top rung is not sedentary job demands; modified work as the second from the top ~ assuming that the top rung is not sedentary job demands; and pre-accident job demands as the highest rung. Because of the challenge in managing claimants with CNCP, the WHSCC and the NBMS have developed some guidelines and an associated chronic pain reporting form. Especially challenging for physicians are cases where the patient demands treatment that the physician is not sure will be helpful in restoring function or is uneasy about prescribing. The protocols have been drafted to assist physicians in managing these cases by being able to defer to accepted standards.

3 Chronic pain protocol for CNCP Once a patient has exceeded the expected healing time for the injury and chronic pain is the primary disabling factor, the physician should use the WHSCC Form 10P for progress reports instead of the regular Form 10. If the patient subsequently has a new injury or surgery, then the physician should revert back to the regular Form 10 until the expected healing time for the new injury or surgery has being exceeded. The physician s assessment should include psychological and social function in addition to physical function. Functional destination on the functional roadmap of Form 10P refers to the ultimate functional goal. Will the patient be able to perform pre-accident duties? Or, will maximum rehabilitation potential be below preaccident duties? If so, what is the highest expected level of function æ modified job, alternate job, etc. Opioid prescribing protocol for chronic cancer pain WHSCC authorizes payment of long-term opiate prescriptions for claimants with chronic cancer pain. Opioid prescribing protocol for CNCP WHSCC authorizes payment of long-term opiate prescriptions for claimants with CNCP if: 1. there is evidence the patient has improvement in both pain and function (which includes return to appropriate work) on therapeutic trials of opiates. a. The physician should use a 2-week trial period to evaluate the efficacy of opioid therapy based on functional restoration goals. b. If significant functional improvement is not achieved, up to 3 additional trial periods may be authorized, during which the treatment plan will be altered to include adjunct therapy, change in opioid schedule, change in opioids. c. Extension of authorization for payment of a treatment regimen is based on the degree of success in meeting functional restoration goals; d. Reassessment of the efficacy of the treatment regimen on restoration or maintenance of function every eight weeks, once an appropriate treatment regimen has been identified. An occupational therapy functional assessment may be part of this re-evaluation. 2. this is not the first line of treatment; 3. this is part of an integrated approach to pain management; 4. there is a primary prescriber. Payment for opioids may be limited to those prescribed by the primary treating physician; 5. there is a written treatment agreement between the patient and the physician (opioid contract on Form 10P); 6. the route of administration is oral or transdermal. Sustained-release opiates are the preferred preparation in the management of chronic pain; 7. careful consideration has been given to behavioural presentations that suggest the potential for opiates to increase the complexity of the problem;

4 8. there is appropriate oversight by WHSCC; and 9. the patient is notified that when starting opioids, adjusting the dosage or starting other medications (especially OTC and herbal medications), there exists the potential to affect mental function; and that the patient is instructed to: a. give sufficient time away from driving or operating equipment to evaluate the impact of the medication(s) on mental function; and b. notify their employer. Authorization of payment for opioids The Commission: 1. will authorize payment for up to a 5-week supply at a time; 2. will authorize payment of an amount based on the CPS as a guideline to establishing reasonable supplied amounts. Physicians wishing to prescribed a higher dosage should discuss this ahead of time with a Commission Medical Advisor; 3. will not authorize payment for the following opioids, as part of a long-term treatment regimen: a. short-acting opioids, such as demerol and leritine. b. agonist-antagonist opioids, such as talwin and stadol. 4. will authorize payment for opioid patches. 5. will authorize payment of methadone for chronic cancer pain treatment. 6. will not authorize payment of methadone for acute noncancer pain treatment. 7. may authorize payment of methadone for the treatment of neuropathic chronic noncancer pain. 8. will authorize payment of methadone for other forms of chronic noncancer pain when: i) the purpose of methadone treatment is to manage substance dependence for opioids, where the ability of the claimant to safely achieve the highest possible level of function has been impaired by other opioids. Substance dependence as defined by the DSM IV is a pattern of use leading to three or more of: tolerance withdrawal over use of an extended period of time unsuccessful efforts to cut down or control excess of amounts of time obtaining, using or recovering from use important social, occupational or recreational activities are given up continued use despite persistent or recurrent physical or psychological problems

5 ii) WHSCC responsibility is limited to assisting the claimant in getting off opioids, that WHSCC has paid for. This problem is best managed upfront using a functional restoration approach to prevent the claimant getting to this state. iii) there is prior approval by the medical advisor. The prescribing physician has appropriate training and certification/authorization. There are written protocols for managing opioid dependency through methadone treatment. Dispensing is managed by one licensed pharmacy. iv) There is appropriate oversight by the medical advisor. v) Methadone treatment is part of a structured program to: get the claimant off opioids, and if that is not possible then to reduce opioid usage to the lowest possible dosage that supports safe performance of the highest possible function; and provide the claimant with counseling to address pain management strategies, coping strategies, and psychosocial barriers to functional improvement. The schedule of follow-up by the prescribing physician is established on an individual basis in discussion with the medical advisor. References 1. The College of Physicians and Surgeons of New Brunswick document Guidelines for Management of Non-Malignant Chronic Pain. 2. The document Drugs and Therapeutics for Maritime Practitioners, Volume 20 Number 5/6, October/December 1997, put out by the Dept. of Pharmacology at Dalhousie University and distributed through the NBMS. 3. The consensus statement and guidelines from the Canadian Pain Society (Pain Res Manage Volume 3 Number 4 Winter 1998) CMA Guide for Physicians in Determining Medical Fitness to Drive. 5. Motor Vehicle Collisions, Cdn Family Physician, 1998 April. 6. Opioid Use in Chronic Non-Malignant Pain: A Recommendation Paper by WCB Medical Directors. 7. The College of Physicians and Surgeons of Ontario document Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain.