Washington: New opioid prescribing guideline called bold, clinically focused

"Effective use of opioids must result in clinically meaningful improvement in function," says the Washington Department of Labor and Industries. "Continuing to prescribe opioids in the absence of clinically meaningful improvement in function or after the development of a severe adverse outcome is not proper and necessary care in the Washington state workers' compensation system."

The wording is included in the executive summary of Washington's guideline for prescribing opioids to treat pain in injured workers, which becomes effective in July. The department's recently released document caught the attention of at least one workers' comp practitioner.

"These new guidelines represent a bold, clinically-focused, evidence-based, administratively-tight step that will lead to material changes in opioid use for the state," said Michael Gavin, chief strategy officer of the utilization management company PRIUM, in a blog post. "If every state, every carrier, every employer enforced, or perhaps were allowed to enforce such guidelines, we could eliminate a significant portion of the opioid problem in comp."

Interdisciplinary pain management and prevention offer positive results (04/18/13)
Early identification works best (04/18/13)
WCRI study shows wide variations in narcotics prescribing patterns (08/08/11)
WCRI narcotics study points up need for additional research (08/08/11)
Physicians' group seeks FDA label change to combat opioid misuse (10/01/12)

A state advisory committee developed the guideline "based on the best available clinical and scientific evidence from a systematic review of the literature and a consensus opinion," according to the document. The goal is "to provide standards that ensure the highest quality of care for injured workers" in the state.

The new guideline identifies adverse outcomes related to the use of opioids, especially the potential for tolerance to its analgesic effects. "The traditional prescribing practice was to use escalating doses to overcome this effect," the guideline explains. "However, evidence is accumulating that chronic, high-dose use may lead to the development of abnormal pain sensitivity (opioid-induced hyperalgesia)."

The use of opioids to treat workers' comp claimants after an initial, acute phase should continue only if there is clinically meaningful improvement in function, defined as "an improvement in function of at least 30 percent as compared to the start of treatment or its response to a dose change. A decrease in pain intensity in the absence of improved function is not considered CMIF."

Prescribing opioids for work-related injuries is broken down into the acute phase -- zero to six weeks after injury or surgery, the subacute phase -- six to 12 weeks, and the chronic phase. There are specific suggestions and requirements for when and if the use of opioids will be covered in each phase.

"In general, opioid use for acute pain should be reserved for post surgery, for the most severe pain (e.g., pain scores greater than 7), or when alternative treatments such as NSAIDs and non-pharmacological therapies are ineffective," the guideline states. "Evidence does not support the use of opioids as initial treatment for back sprain or other strains, but if they are prescribed, use should be limited to short term," less than 14 days.

For the chronic phase, providers must receive prior authorization from the department. Several criteria must be met in order to receive prior authorization.

The guideline also includes a section on discontinuing chronic opioid therapy treatment. Three treatment options are explained. The second or third will only be covered if the first and second are ineffective. They are:

Medication assisted treatment.
Drug free outpatient treatment.
Residential treatment.

Read more at the WorkersComp Forum homepage.

February 18, 2013

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