Wyoming Workers Compensation Division Treatment Guidelines-Chronic Non-Malignant Pain

Transcription

1 Matthew H. Mead Gvernr State f Wyming Department f Wrkfrce Services DIVISION OF WORKERS COMPENSATION 1510 East Pershing Bulevard, Suth Wing Cheyenne, Wyming Jhn Cx Directr Lisa M.Osvld Deputy Directr Wyming Wrkers Cmpensatin Divisin Treatment Guidelines-Chrnic Nn-Malignant Pain Cmpensability shuld NOT be in questin at the time f the preauthrizatin. Over the past decade, there has been a dramatic increase in the use f piids t treat nn-cancer pain. Amng the wrkers cmpensatin ppulatin natinally, the prevalence f piid use is apprximately 32%. In Wyming, piids accunt fr 38% f all prescriptins with Oxycntin the number ne in ttal cst (as f September, 2015). These guidelines are intended fr use by Health Care Prviders (HCP) wh have been prviding acute pain management treatment t injured wrkers beynd 3 mnths (90 days) and where effrts t remve the cause f pain r t treat it with ther mdalities have failed. Applicatins f these guidelines are intended nly fr utpatient prescriptins f nn-parenteral cntrlled substances. These guidelines shuld nt be the sle determining basis fr identifying claimants at risk fr a drug use prblem and cannt substitute fr a thrugh assessment f the claimant r medical file review by a qualified HCP. The Divisin has apprved Oxycdne/APAP, Hydrcdne/APAP, Butrans patch, Oxycdne APAP, Oxycntin, Mrphine, Oxymrphne, Kadian, and the analgesic Tramadl fr the treatment f chrnic pain. All transmucsal and transdermal immediate release duragesic (fentanyl) agents, Subxne/Subutex, and Demerl will be denied fr chrnic nnmalignant pain relief. Transcutaneus piid analgesics will be cnsidered nly if there is dcumentatin that the disrder prevents adequate ral dsing. After the initial review, the Nurse Case Manager (NCM) can recmmend cverage apprval fr up t ne year with a yearly urine drug screen. If the urine drug screen is incnsistent, the NCM will request n-ging mnitring and will mnitr cmpliance fr the next year. I. Definitins Chrnic pain is defined as pain persisting beynd the expected nrmal healing time fr an injury, fr which traditinal medical appraches have been unsuccessful. Clinically significant imprvement in pain and functin is defined as a 30% imprvement in bth frm the riginal baseline at the time f injury. Hyperalgesia is defined as increased sensitivity t pain r enhanced intensity f pain sensitivity. Opiid induced hyperalgesia is a clinical phenmenn, characterized by Page 1 f 7 Ecnmic Develpment fr Wyming s Future. Phne

2 increasing sensitivity t pain, wrsening f pain despite increasing dses f piids, pain that becmes mre diffuse extending beynd the distributin f pre-existing pain caused by the txic effects f piid metablites. II. Health Care Prvider (HCP Medical Recrd Dcumentatin Dcumentatin may be cmpleted by a mid-level prvider Family Nurse Practitiner (FNP), r Physician Assistant-Certified (PA-C). A medical histry and physical examinatin dcumenting the presence f a recgnized medical indicatin fr the use f a cntrlled substance must be perfrmed, t include: Assessment f the pain and functin, using measurable scales. Assessment t include substance abuse histry, and assessment f underlying r cexisting diseases r cnditins. Assessment f prir relevant psychiatric histry, particularly including affective disrders and persnality disrders. Obtain Dcumentatin f relevant baseline clinical r labratry studies including a cpy f a baseline urine drug screen cmpleted at the end f the acute phase. A nte Dcumentatin f alternative strategies used fr managing the pain and why these mdalities are inapprpriate r ineffective. A nte indicating Dcumentatin f ne r mre specialists cnsultatins perfrmed. The written treatment plan shall include the fllwing: (written and shuld include the fllwing) Clearly stated, measurable bjectives with a specific timeframe fr cntinued piid use. A list f all current medicatins including dses with a descriptin f reprted pain relief frm each medicatin. Justificatin f the cntinued use f piids as it relates t the imprvement f the claimants recvery (wrk hardening, r vcatinal services). Dcumentatin f attempts at tapering and explanatin f why tapering attempts failed. Hw the claimant s respnse t medicatin will be assessed. Hw the HCP will adequately mnitr the claimant n a peridic basis t determine the cntinued need fr cntrlled substances. Further diagnstic evaluatin(s). Alternative treatments under cnsideratin. Risks, benefits, and duratin f the prescribed medicatins shall be explained t the claimant, including the expectatin f mandatry randm urine drug mnitring. Page 2 f 7 Ecnmic Develpment fr Wyming s Future. Phne

3 The treatment plan shall be revised as new infrmatin develps r at least every 90 days. Cntinued apprval f piid therapy will be dependent n the dcumentatin f the HCP, t include: A current signed treatment agreement. N relative cntraindicatins t the use f piids. N evidence f serius adverse utcmes frm piid use, including but nt limited t, accidental/intentinal verdse, cnstipatin, nausea, vmiting, sedatin, altered mental status, decreased cncentratin, pruritus, and myclnus, any accidents related t wrk r driving. Cnsultatin with a pain management specialist if the claimant s dse is ver 120 mg mrphine equivalents per day. Cnsultatin is als encuraged if the claimant has a c-mrbid substance use r prly cntrlled mental health disrder. N aberrant behavir is identified by PDMP. Claimant has been cperative with urine drug testing and there are n incnsistent findings. Dcumentatin f imprvement in bth pain intensity and functin. Dcumentatin f imprvement in bth pain intensity and functin with ANY INCREASE in piid dsing. When repeated dse escalatins ccur, the HCP shall dcument evaluatin f piid specific adverse effects, (cnsideratin f hyperalgesia), any change in verall health status, any deteriratin f reprted quality f life, cnsideratin f piid rtatin, and cnsideratin/results f any tapering effrts. If hyperalgesia is suspected/evident, reduce r discntinue piids, cnsider changing the piid t ne with less risk f neurtxic effects; and a nn-piid adjuvant such as acetaminphen r an NSAID. Other treatment mdalities r a rehabilitatin prgram may be necessary if the pain has differing etilgies r is assciated with a psychscial impairment. III. Treatment Agreement. (Infrmed Cnsent) The HCP shall discuss the risks and benefits f the use f cntrlled substances with the claimant. The agreement shuld include at a minimum: The cnditins under which piids will be prescribed including time frames fr reevaluatin. The claimant shall understand that the prescriptin f piids at this time shuld be cnsidered a therapeutic trial t determine whether chrnic piid therapy is apprpriate and effective. The claimant is infrmed f the HCP s bligatin t dcument clinically significant imprvement in pain and functin. The claimant is infrmed f their respnsibilities including urine drug mnitring, and full disclsure f all substances being taken. Page 3 f 7 Ecnmic Develpment fr Wyming s Future. Phne

4 Pssible side effects f lng term use. Risks f piid dependency. Imprtance f therapy and ther activities t relieve the symptms f the injury. Circumstances when a referral t a pain specialist, mental health prvider, r substance abuse specialist is required. A written cntract is mandatry unless the claimant is mentally r physically incapable. Please see example mdel frmats at wymingwrkfrce.rg IV. Peridic Review and Mdificatins The HCP shall peridically review the curse f treatment and prgress tward treatment bjectives with the claimant. Assess and dcument if BOTH pain AND functin have imprved at every ffice visit. Access and dcument the state s Prescriptin Drug Mnitring Prgram (PDMP) t ensure that the cntrlled substance histry is cnsistent with the prescribing recrd and the claimant s reprt. Dcument the claimant s clinical curse and utcme gals with attentin t disease prgressin, side effects, and emergence f new cnditins. If bth pain and functin have NOT imprved, cnsideratin f cnsultatin fr nnpiid management. (The need fr piids shall be questined and piids shuld pssibly be discntinued.) If bth pain and functin have imprved, but the claimant has nt returned t wrk, perfrm a re-assessment t determine if any clinical infrmatin has been missed, i.e., additinal diagnses cntributing t the pain, were any ther medicatins fr pain management given, did side effects ccur, is a psychlgical evaluatin warranted t help evaluate the claimant fr effective pain management, has screening fr elements f addictin been cmpleted. Cnsider participating in a team cnference with the claimant, emplyer, and divisin staff t explre return t wrk ptins, r vcatinal cunseling. V. Cnsultatins The HCP shall be willing t refer the claimant as necessary fr additinal evaluatins and treatments in rder t achieve treatment bjectives. It is recmmended that the prvider cnsider a request fr cnsultatin t a pain management specialist if: A dse in excess f 120 mg f ral mrphine daily r its equivalent is being used; please see wyingwrkfrce.rg fr a reference chart. Pain and functinal status have nt substantially imprved after 6 mnths f piid treatment A claimant wh has a histry f chemical dependency Page 4 f 7 Ecnmic Develpment fr Wyming s Future. Phne

5 A claimant wh appears t have significant prblems with depressin, anxiety, r irritability; (a psychlgical cnsultatin may be indicated in these cases) Relevant nging clinical r labratry studies (especially liver and kidney functin screens) including drug screens. The Divisin may request a pharmacy review and/r a peer t peer review t evaluate the claimant s current pharmaclgical treatment. VI. Addictin vs. Physical Dependence. Addictin is a behaviral syndrme characterized by psychlgical dependence and aberrant drug-related behavirs. Physical dependence and tlerance are nrmal physilgical cnsequences f extended piid therapy and are nt the same as addictin. Health Care Prviders are encuraged t seek cnsultatins if the claimant meets three (3) r mre f these criteria: Displays an verwhelming fcus n piid issues; i.e., discussin f piids ccupies a significant prtin f the ffice visit and impedes prgress with ther issues regarding the claimant s pain. There is a pattern f early refills (3 r mre) r escalating drug use in the absence f physician directin t d s. Multiple telephnes calls r ffice visits t request mre piids r prblems assciated with the piid prescriptin. Demnstrates pattern f prescriptin prblems fr a variety f reasns that may include lst medicatins, spilled medicatins r stlen medicatins. Has a supplemental surce f piids btained frm multiple prviders, emergency rms, r illegal surces. Have illicit drugs n urine screens. VII. Urine Drug Mnitring Given the difficulty in identifying drug use behavirs with subjective data, all claimants wh are prescribed a shrt-r lng-acting piid fr lng term pain management (defined as beynd the acute phase and/r greater than 3 mnths) will be drug tested at specified intervals and as requested by the Divisin. The mnitring plicy shall be made clear t the claimant during the initial ffice visit. A written agreement is preferred althugh nt required. All aspects f urine drug mnitring will be managed by the NCM/analyst. Mnitring shall include illicit drugs (ccaine, amphetamines, and methamphetamines), alchl, all current medicatins prescribed, and ther cmmnly prescribed piates. Testing shall be cmpleted by an apprved labratry. Page 5 f 7 Ecnmic Develpment fr Wyming s Future. Phne

6 A quantitative analysis may be required if the findings are incnsistent with prescribed therapy. Testing will be dne at least every 12 mnths fr lw risk claimants, every 3-6 mnths fr high risk claimants, and at the discretin f the Divisin. If the results indicate the prescribed drug(s) nt detected, an illicit drug is detected, r a nn-prescribed scheduled drug r a drug f cncern is detected, the prvider will dcument the discussin with the claimant and any subsequent actins, t include but nt limited t: Maintain current therapy and dcument justificatin. Change therapy/discntinue piids. Cnsider utcmes f retentin vs. discharge frm the practice. Cmmunicate with ther prviders as apprpriate. Limit supply; select drug with lw street value; schedule mre frequent visits; schedule mre frequent urine drug testing. Cnsult a pain specialist; cnsider substance abuse specialist. If the claimant refuses t submit t drug testing, cmpensatin fr the piids may be suspended until the testing is cmpleted. If the physician des nt cmply with the request fr drug testing, further cmpensatin may be denied until the testing is cmpleted. The claimant will be ntified by the Divisin. Any results psitive fr illicit drugs r nt cnsistent with the prescribed therapy will be sent t the NCM fr review. IX. Divisin Review The Analysts shall request a NCM review f the medical ntes and supprting dcumentatin t determine if the dcumentatin reflects the criteria as per the guideline requirements. If the dcumentatin requirements are met, the nurse can authrized the prescriptin fr piids fr up t ne year. If the medical ntes d nt meet the HCP dcumentatin requirements, r there is n indicatin the prescribing HCP dcuments substantial imprvement in the claimant s pain intensity r functin, r dcuments psychlgical barriers, the nurse shall cntact the HCP and ntify them that the recmmendatin will be made t deny further piids until the dcumentatin is cmplete. The claimant will als be ntified. The denial may include, but nt be limited t the fllwing circumstances: Evidence f misuse f abuse f the prescribed piid medicatin r ther drugs. Claimant is nncmpliant with the HCP treatment plan. The treating HCP has nt prvided medical dcumentatin, which supprts the use f this medicatin in the treatment f the allwed cnditins in this claim. Treatment resulted in severe adverse utcme. Page 6 f 7 Ecnmic Develpment fr Wyming s Future. Phne

7 At any time during the review, the NCM and Analyst may request a pharmacy evaluatin frm the Divisin s pharmacy benefit manager. If the Divisin denies payment fr piids fr any reasns ging frward, a final apprval fr 30 additinal days will be authrized t avid abrupt cessatin and allw fr tapering f the medicatin. *****Injured wrkers wh have been n cntrlled substances fr prlnged perids and cme under the care f a new physician present special prblems, these cases may be sent fr physician/pharmacy review by the Analyst r NCM.***** References Carr D.R, Gudas L. C. (1999). Acute pain. Lancet, 353: Chu, R., Fanciull, G.J., Fine, P.G., Adler, J.A., Ballantyne, J.C., Davies, P., et al. (2009). Clinical guidelines fr the use f chrnic piid therapy in chrnic nncancer pain. The Jurnal f Pain, 10:2, Federatin f State Medical Bards f the United States. (2004). Mdel Plicy fr the Use f Cntrlled Substances fr the Treatment f Pain. Internatinal Assciatin f Industrial Accidents Bards and Cmmissins (IAIABC). (2013). Reducing Inapprpriate Opiid Use in Treatment f Injured Wrkers, A Plicy Guide. Peppin J.F., Passik S.D., Cut J.E., Fine P.G., Christ P.J., Argff C. et al., (2012). Recmmendatins fr urine drug mnitring as a cmpnent f piid therapy in the treatment f chrnic pain. Pain Medicine, 13: Teuteberg, W.G. (2009). #142 Opiid-induced hyperalgesia. End f Life/Palliative Educatin Resurce Center, Medical Cllege f Wiscnsin. Retrieved 11/8/13 frm: Wyming Wrkers Cmpensatin Divisin wishes t acknwledge the wrks f Wrker s Cmpensatin State Bards f Arizna, Ohi, Washingtn, Clrad, and Massachusetts, upn which these guidelines are based. Page 7 f 7 Ecnmic Develpment fr Wyming s Future. Phne