Opioid management

For end-of-life care for workers, the goal is to provide the support needed to manage pain.

When a worker is being treated for cancer, their opioid dose is more likely to escalate. The decision maker can approve these increases as prescribed by the physician.

Support the worker’s care by following the medical advice of the physician.

• Take time to review the information in the file and get an understanding of the worker’s injury and their needs. Determine if any information is missing before contacting the worker.
• Contact the worker to confirm their prescribed opioid medication payment is approved.
• Send the opioid prescription approval letter to the worker and the service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.
• Review annually (or sooner, if needed) by contacting the worker to discuss any concerns, and obtaining updated medical reporting from the worker’s prescribing physician.

For workers who are in the acute stage of their recovery, the goal is to approve payment for opioids prescribed by their physician for a short period of time (to a maximum of 12 weeks).

Communicate with workers and, where appropriate, physicians to ensure they are aware of the risks of long-term opioid use (beyond 12 weeks) and that the use of opioids beyond the acute treatment period is not typically recommended.

Note: Opioids are not typically needed longer than four weeks from date of accident, surgery or recurrence.

When the first progress report from a specific physician indicates opioids are being prescribed, a system-generated letter is automatically sent to the prescribing physician informing that opioid use should end within the first two to four weeks from prescription date. The same letter is also automatically sent to the worker.

Contact the worker to:

• Discuss how long they think they might need the medication.
• Explain the risks of extended opioid use and offer other types of support or pain management suggestions.
• Confirm their medication dosage.
• If appropriate, explain the reasons why opioids are only approved for a short period of time (up to 12 weeks).

Send the opioid limited approval letter to the worker, and the service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.

At eight weeks, contact the worker to confirm if their opioid prescription will end by week 12.

If the worker does not anticipate their opioid prescription will end by week 12, explain that a completed opioid package is required to approve payment of prescribed opioids beyond 12 weeks. Ask the worker to complete the package with their physician and return the completed package within two weeks.

If the worker cannot be reached by phone, send a custom letter to advise the worker that they must respond within seven days of receiving the letter in order to further authorize opioid payments after the initial approval date (i.e., a maximum of 12 weeks).

At 10 weeks, if a response is not received, follow up with the worker verbally and confirm that an extension may not be approved if the required information is not received within the next two weeks. If the worker cannot be reached by phone, send the worker another custom letter requesting the information. Attach the opioid package to the letter.

At 12 weeks, if the information is not received or is incomplete:

• Send the opioid prescription denial – no signed agreement letter to the worker, and/or
• Send the opioid treatment agreement incomplete letter outlining what information is missing to the physician. Attach a copy of the opioid treatment agreement form.

When the required information is received, follow the process outlined in the “Longer-term care” section below.

When a worker confirms they are no longer taking opioid medication, or if the above information is not received, the decision maker will send the opioids denied/discontinued letter to the worker.

For workers where opioid use is anticipated or prescribed for longer than 12 weeks, the goal is to assist with a pain management strategy focused on minimizing harm.

• Review the opioid treatment agreement form and the medication management report.
• Call the worker to fill out the opioid use checklist.
• Calculate the morphine equivalents (MEQ)Morphine equivalent (MEQ), sometimes referred to as morphine milligram equivalent (MME) or morphine equivalent dose (MED), is commonly used to compare opioid use..
• Use the medical consultant review form to refer to a medical consultant to ask the following:
  • Are the opioids improving pain and functioning?
  • Are there any significant side effects or risks with ongoing opioid use?
  • Is there a need for the medical consultant to contact the worker’s physician to discuss the worker’s treatment plan (i.e., if pain/functioning is not improving and/or the opioids are potentially harming)?
  • Are there any other pain management treatment recommendations?

When the medical consultant does not have any concerns about the opioid use:

• Contact the worker to confirm the approval for opioids.
• Send the worker the opioid prescription approved letter with the treatment recommendations, and, if appropriate, a service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.
• Send the claim to a case assistant for ongoing monitoring only if no other decision making is required.

When the medical consultant does have concerns about the opioid use:

• Ask them to contact the prescribing physician to ensure all information has been considered and to develop a plan to address the concerns.
• If they agree to approve the opioids, follow the directions above.
• If opioids are still not approved send the opioids denied/discontinued letter to the worker.

For workers who take opiod medications beyond 12 weeks, their opioid use is monitored and an annual review is completed to confirm that opioid medication continutes to benefit the worker. The goal is to ensure the worker’s wellbeing is maintained and the prescribed opioid dosage has not increased.

The prescribing physician should send updated medication management reports whenever medications are prescribed, or at a minimum of every three months. If there are no concerns identified in the reports (i.e., increased dosage, decreased function, change in prescribing physician or pharmacy), the claim will continue to be monitored until the annual review.

Monitoring

The claim owner will:

• Keep in contact with the worker and review the claim every three months to confirm the physician has sent in an updated medical management report. If it is missing, send the opioid medication management reporting letter to the physician.
• Ensure there are no changes in the following:
  • Medication
  • Dosages
  • Side effects
  • Prescriber
  • Pharmacy
  • Updated medical reports from the physician regarding opioid use

Document any changes in a file note and proceed to the tapering section.

Annual or ad hoc review

An opioid review should be completed annually or whenever there are concerns:

• Contact the worker to discuss any concerns and complete the opioid policy checklist.
• Calculate the MEQ.
• If the MEQ is over 90 per day and/or the worker is not meeting their treatment goals, ask a medical consultant to review other treatment options (see below for more information). A referral to a medical consultant can also be made if there are increases to the opioid use or the worker is experiencing significant side effects.
• If the MEQ is 90 per day or lower and the worker is meeting their treatment goals, send the opioid prescription approval letter for up to one year to the worker, and an approval letter to the pharmacy. Include the dosage, frequency and time frame in the letter.
• If ongoing coverage is not being provided, an alternative support and/or pain management plan, as well as manager approval must be in place before discontinuing an opioid prescription approval.
• Monitor as outlined above.

Medical consultant reviews

A medical consultant review is required when the worker is taking:

• Medication administered to the worker by injection.
• Medication that is greater than 90 MEQ per day.
• More than one long-actingLong-acting opioids slowly release medication over a longer period of time. The effects are intended to last longer, and therefore require less frequent doses. and one short-actingShort-acting opioids release medication rapidly, so that the effects are more immediate but may not last. More frequent doses are required for sustained effects. opioid.
  • Some formulations are a combination of both short and long-acting (e.g. Oxycontin). The total dose amounts (and MEQ of the specific opioids) must be combined to calculate the total morphine equivalents received.
• Special drugs such as methadone, buprenorphine (including Suboxone, Butrans, and others), ketamine, cannabinoids, fentanyl and Demerol.

A medical consultant review is also required when:

• The opioid treatment agreement notes serious side effects.
• There is a change in prescribing physician or dispensing pharmacy.
• The worker or treating physician requests help to taper off.
• The worker requests payment for past opioid medications that the decision maker was not aware were being taken.

Before asking for a medical consultant review, call the worker to complete the opioid use checklist. Use the medical consultant opioid review form.

If the medical consultant has no concerns with opioid use:

• Contact the worker to confirm the approval for opioids.
• Send the worker the opioid prescription approved letter with the treatment recommendations, and, if appropriate, a service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.
• Send the claim to a case assistant for ongoing monitoring only if no other decision making is required.

If the medical consultant has concerns with the opioid use, ask the medical consultant to contact the physician to ensure all information has been considered. If ongoing coverage is not being provided, an alternative support and/or pain management plan, as well as manager approval must be in place before discontinuing an opioid prescription approval.

If the medical consultant and physician reach an agreement to taper opioid dosage, call the worker to discuss the next steps and go to the tapering step below.

If an agreement is not reached, create a customized taper plan (e.g. decreasing doses covered) to reduce to a safe level to address the medical harms identified (ask the medical consultant for assistance). The goal of the taper is to reduce approval for opioid medications to up to a maximum of 90 MEQ but may be down to 0 MEQ. Once the taper plan is created:

• Send the worker the opioid prescription approved letter but customize it to outline the taper plan the treatment recommendations, and a service provider custom letter to the pharmacy. Include the taper dosage, frequency and time frame in the letter.
• Monitor the worker’s progress in the taper.
• Send the tapering plan conclusion letter and a service provider custom letter to the pharmacy. If opioids are still approved, provide the dosage, frequency and time frame.

A tapering program should be considered when there are ongoing increases to the worker’s medication/dosage: there are significant negative side effects such as functioning challenges or the worker or physician asks for a tapering program.

The goal is to help the worker decrease or eliminate their opioid usage. A worker can participate in a tapering program more than once.

In all cases, discussion with the worker, prescribing physician and medical consultant is an important part of determining the treatment plan. Educate the worker on the benefits of a tapering program and how it can help and explore other alternatives. A medical consultant can be part of the discussion as well.

Note: The College of Physicians and Surgeons of Alberta (CPSA) recommends that physicians use extreme caution when exceeding the 90 MEQ dose, as the Canadian guideline for opioids for chronic non-cancer pain recommendeds restricting the prescribed dose to less than 90 MEQ. In the interest of safety, this is the maximum dosage WCB will fund.

This guideline means that if the worker is not able to decrease or eliminate their opioid use and the physician continues to prescribe, the decision maker can still approve coverage up to 90 MEQ per day.

Similarly, if the worker is unable to completely taper, the maximum amount of approved coverage should be 90 MEQ. This may be approved as long as the worker and physician are providing the required information (i.e., updated opioid treatment agreement and opioid use checklist).

If the worker agrees to take part in a medication management assessment and/or tapering program:

• Call the worker to complete the opioid use checklist.
• Send the medication management program referral form to worker’s file to the clinical consultant to confirm if a referral to an assessment or a program is ready to proceed. If the clinical consultant confirms the referral is not able to proceed, discuss the case with the clinical consultant to confirm why. Develop an alternative plan with the assistance of the medical consultant, clinical consultant and physician. Call the worker to discuss and send the opioid tapering denied letter.
• If the referral is ready to proceed, send a medical package to either CBI Calgary North or CBI Edmonton Southwest.
• Call the worker to confirm the referral and send the opioid tapering assessment referral letter.
• Approve the treatment plan as outlined in the assessment.
• Send the opioid prescription approval letter to the worker and the service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.
• Continue to approve opioids, as agreed, as part of the treatment plan until the tapering program is complete.

If the worker no longer requires opioids at the end of the taper:

• Update the authorized medication line at the conclusion of the taper with the approval end date.
• Send the tapering plan conclusion letter and a service provider custom letter to the pharmacy.
• Send the claim to a case assistant for ongoing monitoring only if no other decision making is required.

If the worker still requires opioids, but has tapered to a 90 MEQ per day or less, continue to provide coverage. Then:

• Send a tapering plan conclusion letter to the worker, outlining the next steps.
• Send the opioid prescription approval letter to the worker and the service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.
• Continue to monitor annually, updating the opioid use checklist before each review.

If the worker goes through a tapering program and is not able to reduce their medications to 90 MEQ per day, or if they decline to participate, or do not complete the program, provide coverage up to a maximum of 90 MEQ per day. Then:

• Follow the recommendations from the medical management program case conference.
• If the worker participated in the tapering program, send a tapering plan conclusion letter to the worker outlining the next steps. If the worker did not participate in the taper, send the opioid prescription approval letter to the worker.

Send the service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.

• Send to the case assistant to monitor annually, updating the opioid use checklist.

A physician may wish to help a worker taper without attending a program. In this case:

• Ask a medical consultant to call the physician to confirm an appropriate treatment plan.
• Send the opioid prescription approval letter to the worker and the service provider custom letter to the pharmacy. Include the dosage, frequency and time frame in the letter.
• Carefully monitor to ensure that progress complies with the agreed-upon treatment plan.

If tapering is not progressing, ask a medical consultant to contact the physician to confirm next steps.

A worker may be prescribed opioids in a scenario that is not outlined above. These scenarios could include:

• The worker and physician disagree with the suggestion of an opioid taper or the tapering plan itself.
• The worker or physician don’t provide the required information.
• The worker has another medical condition that may be impacted by opioids such as sleep apnea or the use of other (street) drugs.
• Other challenges not outlined above.

If any of the above occurs, the decision maker should consider the following:

• Talk to the worker about their medication background to get a good understanding of their history, usage and needs. Complete the opioid use and initial opioid policy checklists.
• If information is missing, are there other ways to gather what is needed (e.g. a medication management form)?
• Talk to a medical consultant or send the file for a medical consultant review.
• Talk to an opioid coach, a Coaching and Resource Team member, or a floor coach.

Follow the approval process if the review indicates that approving opioids payment is appropriate. If it is not appropriate, work with the worker, prescribing physician and, if needed, a medical consultant to identify an alternate pain management plan.

An alternative support and/or pain management plan, as well as manager approval must be in place before discontinuing an opioid prescription approval.