W. Va. Code R. § 85-20-53

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 85-20-53 - Long-Term Opioid Therapy Guideline

53.1. These guidelines are used by the provider in the management of chronic nonmalignant pain. Chronic nonmalignant pain is defined as pain persisting beyond the expected normal healing time for an injury, for which traditional medical approaches have been unsuccessful. These guidelines do not apply to claimants whose pain is the result of a malignant process (cancer), or when the pain therapy is aimed at relieving intractable pain and suffering in the terminally ill when other measures fail, assuming a compensable diagnosis.

53.2. Successful management of intractable chronic non-malignant pain (hereinafter referred to as "chronic pain") usually does not require the use of opioid medications. There are other effective and non-pharmacologic treatment interventions available. Some carefully selected claimants with chronic pain may benefit from opioid maintenance analgesia (OMA). These claimants function better, are sometimes able to resume working, maintain improved pain control with acceptable side effects, and continue to use their medications in a responsible manner.

53.3. In some claimants, long-term OMA fails. Pain control is marginal, function does not improve, side effects prohibit ongoing therapy, or the claimant's ability to use the medication properly is poor or erratic. The key to success in the management of OMA is careful selection of candidates and monitoring.

53.4. Candidates for long -- term OMA should:

a. Have an established diagnosis that is consistent with chronic pain.

b. Have not responded to non-opioid treatment.

c. Not be pregnant. Claimants likely to become pregnant during the course of treatment must be advised of the risks to the fetus should pregnancy occur.

d. Not be using illegal drugs or abusing alcohol.

e. Be reliable claimants who are known to the physician and are expected to be compliant with the treatment protocol.

53.5. Long term OMA is contraindicated for claimants who have persistent pain out of proportion to physical findings and/or with no demonstrable lesion, and who meet the criteria for the diagnosis of "chronic pain syndrome".

53.6. Documentation recommendations for controlled substances prescribed within the guidelines.

a. A thorough medical history, physical examination, diagnosis and treatment plan should be documented, with particular attention focused on determining the cause(s) of the injured worker's pain, sleeplessness or anxiety.

b. The treatment plan should include the following information:

1. A list of all current medications (with doses), including medications prescribed by other physicians (whenever possible);

2. Therapies and procedures other than medications to manage/relieve pain;

3. Consultations with health care professionals;

4. Further planned diagnostic evaluation; and

5. Follow-up plan to assess progress.

c. The above standards for documentation are being recommended for inclusion in the provider's records. These records should be submitted to the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable.

53.7. Claimants with a personal history of addiction (or in their immediate family) or poor impulse control are at an increased risk of failing to comply with an OMA regimen.

The risk of abuse or adverse outcome is high if any of the following factors are present:

a. History of active use of alcohol or other substance abuse.

b. Co-morbid psychiatric disorders.

c. Poor response to opioids in the past for the same condition.

53.8. All potential candidates for long-term OMA, with a positive history of any of the above risk factors, must undergo a psychiatric or psychological evaluation to determine the appropriateness of long-term OMA to rule out co-morbid psychiatric disorders and the potential for addiction.

53.9. In addition, any claimant who has been on opioids without evidence of improvement must also undergo a psychological evaluation.

53.10. The report of such an evaluation must be provided to the claimant's Workers' Compensation Division Claims Manager as soon as possible after starting the OMA.

53.11. There is no clinical indication for using injectable opioid preparations for claimants with chronic pain. Injectable opioid preparations should only be used in cases of acute pain. They should never be prescribed as a self-medication on an as needed basis.

53.12. Continuation of Long-Term OMA:

a. If low to moderate dose opioid therapy has not provided at least partial analgesia, then long-term OMA is not indicated.

b. Complete analgesia is not the goal of long-term OMA. The efficacy of the therapy is measured not only by reduction in pain but also by improvement in physical and social function. Therefore, documentation of pain and function is essential to monitor the success of the therapy. Functional tool: Table 18.3 of the AMA Guides, Fifth Edition, or a comparable tool.

c. Monitoring of the progress of the therapy must be documented on the attached forms every 30 days the first three months and every 60 days the next six months.

d.

d. A specialist experienced in pain management selected by the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, shall evaluate every claimant on long-term OMA annually to determine the need for continuing OMA.

e. A treatment agreement between the patient and the provider is recommended.

53.13. Definitions for this Section:

a. Acute pain is the normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and acute illness. It is generally time-limited and is responsive to opioid therapy among other therapies.

b. Chronic Non-malignant Pain is an evolving pathological process that can be defined as pain persisting beyond the expected reasonable healing time for an injury despite medical treatment.

c. Chronic Pain Syndrome (CPS): Any claimant presenting with persistent pain of at least three months duration, which may be consistent with or significantly out of proportion to physical findings, and who has at least two of the four criteria listed below should be considered a CPS patient.

1. A progressive deterioration in ability to function at home, socially, or at work.

2. A progressive increase in health care utilization (such as repeated physical evaluations, diagnostic tests, requests for pain medications, and/or invasive procedures).

3. Demonstrable mood disturbance.

4. Clinically significant anger.

d. Qualifications of the Pain Management Specialist for evaluating and treating:

1. A pain management specialist must be Board-certified by the American Board of Medical Specialists. At this time, the only such Board is the American Board of Anesthesiology and this board will be available to all pain practitioners in the next year.

2. He/she must be licensed by the State of WV.

3. He/she should have at least three years experience in chronic pain management, behavioral management, and/or addiction

4. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will annually provide a list of approved chronic opioid pain management specialists, based on the above criteria and satisfactory objective measures of prior performance.

e. Qualifications of the Psychologist for evaluating and treating:

1. The psychologist must be licensed by the State of WV.

2. He/she should have at least three years experience in chronic pain management, behavioral management, and/or addiction.

3. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will annually provide a list of approved chronic opioid pain evaluating psychologists, based on the above criteria and satisfactory objective measures of prior performance.

f. Qualifications of the Psychiatric Addiction Specialist for evaluating and treating:

1. The psychiatrist must be licensed by the State of WV.

2. He/she must be Board-certified in Psychiatry.

3. He should have at least three years experience in treating patients with addictive disorders and have active hospital privileges in the treatment of same.

4. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will annually provide a list of approved psychiatric addictive specialists, based on the above criteria and satisfactory objective measures of prior performance.

53.14. Guidelines for the prescription for controlled substances schedules II - IV (refer to Table § 85-20-B for controlled substances schedule)

a. Schedule II drugs should be prescribed on an outpatient basis for no longer than two weeks after initial injury or following a subsequent operative procedure.

b. Schedule III drugs should be prescribed on an outpatient basis for no longer than six weeks after initial injury or following a subsequent operative procedure.

c. Schedule IV opioid drugs should be prescribed on an outpatient basis for no longer than six weeks after initial injury or following a subsequent operative basis.

d. Schedule IV sedative and anxiolytic drugs should be prescribed on an outpatient basis for no longer than six months after initial injury or following a subsequent operative procedure.

e. To prescribe medications beyond the above guidelines, authorization must be obtained from the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable. Authorization requests must include documentation as described in the Rule. It is recommended that providers utilize less potent medications when continued use is indicated.

53.15. The Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, will not reimburse for treatment in methadone maintenance programs. These programs are specifically intended to manage opiate addiction and the Commission, Insurance Commissioner, private carrier or self-insured employer, whichever is applicable, shall not reimburse costs of treatment, medication, or any other expense associated with these programs.

V. SPECIAL RULES ON DRUGS AND MEDICATIONS

W. Va. Code R. § 85-20-53