Governor Tom Wolf released the guidelines for safe prescribing of opioids in workers’ compensation matters on July 16. The guidelines, which “are intended to supplement and not replace clinical judgment,” split the practice recommendations into two categories: (1) treatment of acute, sub-acute and post-operative pain and (2) treatment of chronic pain.
For acute, sub-acute and post-operative pain, the guidelines recommend first prescribing up to 3,000 mg/day of an over-the-counter pain reliever, potentially in combination with use of an non-steroidal anti-inflammatory drug (NSAID). When that does not work, the guidelines recommend prescribing a limited supply of a non-opioid muscle relaxant such as cyclobenzaprine or baclofen. Other pre-opioid treatments recommended are non-opioid medications such as gabapentin, pregabalin and duloxetine and physical and support pain treatment modalities such as rest, ice, physical therapy, chiropractic care, music and meditation. If opioids are necessary for moderate to severe acute pain, the guidelines provide that they “should be used in the lowest effective dose for the shortest duration possible with the initial prescription not exceeding a seven-day supply.”
For chronic pain, the guidelines recommend first “considering” non-pharmacological treatment options and non-opioid pain treatment options. Before opioids are administered for chronic pain, doctors should conduct and document a comprehensive patient history, examine the patient for mental health issues, order urine drug screens and check the Prescription Drug Monitoring Program. Opioids should only be continued “if clinically-meaningful improvements are observed and patients are not experiencing unacceptable adverse effects.” The guidelines also provide that clinicians should clearly document the prescribed daily opioid dose and calculate and document the oral morphine equivalent daily dose (MEDD). Of note, the guidelines point out that there is no data to support improved efficacy with daily doses greater than 90 mg/day MEDD.
Comment: The guidelines, while not legally binding on the prescribing physicians, can be useful in the setting of a utilization review determination for ongoing opioid prescriptions as utilization reviewers often cite and rely on treatment guidelines in coming to their determinations. When a prescribing physician fails to follow the guidelines, employers/insurers should consider requesting a utilization review.
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