Opioid management

For workers who are prescribed opioid medication in the acute stage of their recovery, WCB may approve payment for opioids prescribed by their authorized prescriber for a maximum of two weeks.

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 authorized prescriber indicates opioids are being prescribed, a system-generated letter is automatically sent to the authorized prescriber informing that opioid use should end within the first two 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 two weeks).

When the worker anticipates opioids:

• Will not be required beyond two weeks, ask the worker to contact you immediately if their authorized prescriber plans to prescribe opioid medication beyond two weeks.
• Will be required for up to four weeks, explain an additional two-week authorization can be provided (four weeks in total) with reporting from the authorized prescriber providing the reason for the extension, a treatment goal, and a plan to reduce opioid medication.
• Will be required beyond four weeks; advise the worker a completed opioid package is required to approve payment of opioid medication beyond four weeks. Send the opioid worker cover letter with package and ask the worker to complete the package with their authorized prescriber within two weeks.

Send the opioid acute prescription approval letter to the worker authorizing an initial two weeks and send the Service Provider Custom letter to the pharmacy dispensing the medication. Include the dosage, frequency and time frame in the letter.

Acute treatment extension (two to four weeks)

If the authorized prescriber submits medical reporting recommending an extension of acute opioid treatment, review the reporting to confirm if a reason for the extension, a treatment goal and plan to reduce opioid medication is included in the report. Consider a walk-in medical consultant review for an opinion with regards to the rationale for the extension beyond two weeks. 

Contact the worker to discuss the recommendation for the extension and discuss:

• How long they think they might need the opioid medication.
• The risks of extended opioid use and other types of support for pain management suggestions.
• The medication dosage.

When appropriate, explain an additional two-week authorization will be provided (four weeks in total).

If the extension is approved, send the opioid acute prescription approval letter to the worker authorizing an extension to four weeks, and the Service Provider Custom letter to the pharmacy dispensing the medication. Include the dosage, frequency, and time frame in the letter.

Although an opioid package is not required unless opioid medication goes beyond four weeks, the decision maker should send the opioid package sooner, if it is anticipated opioid medication will be required beyond four weeks and if the opioid package was not previously sent. The decision maker will send the opioid worker cover letter with the opioid package and ask the worker to complete the package with their authorized prescriber within two weeks.

If the opioid package 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.

If the opioid package 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 authorized prescriber. Attach a copy of the opioid treatment agreement form.

When the required information is received, follow the process outlined in the Long-term opioid therapy section below. Claims for long-term opioid treatment will be reviewed by a case manager. 

When a worker confirms they are no longer taking opioid medication, send the opioids denied/discontinued letter to the worker.

For workers who are prescribed opioid medication beyond four weeks, the goal is to assist with a pain management strategy focused on minimizing harm.

The authorized prescriber must provide a progress report within four weeks of initiating long-term opioid therapy, and every three months thereafter.

The decision maker will:

• Review the opioid treatment agreement form and the medication management report.
• Call the worker to fill out the opioid use check list and opioid initial application policy checklist.
• Calculate the morphine equivalents (MEQ)The MEQ is a way to demonstrate the equivalency of all opioids to that of morphine. The purpose of finding the equivalency is to put all opioids on the same level to compare and calculate how much a person is taking..

Medical consultant opioid review

After completing the opioid checklist, the decision maker determines whether an opioid review by a medical consultant is required.

Note: In some circumstances, after completing the Opioid Policy Application Checklist, an opioid medical consultant referraThis would be a specialized review by a medical consultant through the black MARF desk.l may be indicated.  This is a different type of referral than a medical consultant review.

An opioid medical consultant review desk is required when:

• The medication is administered to the worker by injection.
• Medication is greater than 90 MEQ per day.
• There is 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 are prescribed such as benzodiazepines, hypnotics, sedatives, methadone, buprenorphine (including Suboxone, Butrans, and others), cannabinoids, fentanyl, and Demerol. For Ketamine prescriptions, refer to the 4-11 Non-standard medical aid treatment decision procedure.
• The prescriber is recommending only up to one more month of opioids beyond 4 weeks.
• The prescribing physician has requested contact with a WCB physician regarding opioid medications and/or a tapering program. 

A medical consultant review is also required when:

• The medical reporting notes serious side effects.
• There is a change in the authorized prescriber.
• The worker or authorized prescriber requests help to taper off.
• The worker requests payment for past opioid medications that the decision maker was not aware were being taken.

When an opioid review is required, notify the worker of the review and continue to pay for the opioid medication while the review is taking place. Prior to a medical consultant opioid review consider whether additional assessments, such as a medical status examination and functional capacity examination, is indicated if the diagnosis, treatment plan and effects of the opioids on function are unclear.

Use the medical consultant review form to refer to a medical consultant to ask the following:

• Is there a demonstrable improvement in the worker’s pain and functioning (e.g., a 30% reduction in pain symptoms)?
• 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 authorized prescriber to discuss the worker’s treatment plan (i.e., if pain/function is not improving and/or the opioids are potentially harmful)?
• Are there any other pain management treatment recommendations?

The decision maker reviews the medical consultant's opioid review along with the initial Opioid Policy Application checklist that was completed and determines if the conditions as outlined in policy are met. Update the checklist if required or complete a new checklist. Follow the steps indicated on the updated or new checklist.

When the medical consultant does not have any concerns about the opioid use, the decision maker will:

• Contact the worker to confirm the approval for opioids.
• Send the worker the opioid long-term prescription approval letter and, if appropriate, a Service Provider Custom letter to the pharmacy dispensing the medication. Include the dosage, frequency, and time frame in the letter.
• Continue to manage the claim through recovery.

When the medical consultant does have concerns about the opioid use, the decision maker will:

• Review the information in the medical consultant's opioid review and determine if the worker is meeting the WCB opioid policy criteria for ongoing support of the medication.
• If opioids will not be approved contact the worker to explain the decision, offer tapering and send the opioids denied/discontinued letter to the worker.
• Once the decision to deny the opioids is communicated, send a task to the medical consultant to contact the authorized provider to discuss either:
  • A CBI pain clinic medication management program,
  • A two-day assessment at the CBI pain clinic to develop an opioid taper which the authorized provider can follow,
  • An acceptable individualized opioid taper plan as suggested by an alternate provider with expertise in tapering.
• Continue to approve opioids, until the taper is concluded, if the worker is willing to taper opioids.
• If the worker is not willing to taper opioids, discontinue support for opioids with supervisor and manager approval.
• Inform the worker that the above options are always available in the future should they change their mind.

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

The authorized prescriber 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 authorized prescriber), the claim will continue to be monitored until the annual review.

Monitoring

The case assistant or decision maker will:

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

Document any changes in a file note and have the claim assigned to a case manager for an ad hoc review.

Annual or ad hoc review

An opioid review should be completed annually or an ad hoc basis, whenever there are concerns:

• Contact the worker to discuss any concerns and complete the opioid policy checklist.
• Calculate the MEQThe MEQ is a way to demonstrate the equivalency of all opioids to that of morphine. The purpose of finding the equivalency is to put all opioids on the same level to compare and calculate how much a person is taking..
• If the MEQ is 90 mg per day or lower, there are no increases to the opioid use, the worker is not experiencing significant side effects, and the worker is meeting their treatment goals, send the opioid long-term prescription approval letter for up to one year to the worker, and an approval letter to the pharmacy dispensing the medication. 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.
• If the worker has not returned to work a medical status and functional capacity examination could be considered if there is not a clear diagnosis, treatment plan or if opioids are not improving function and facilitating a return to work. 

Medical consultant opioid review

Complete a medical consultant review when required. See more information under long term opioid therapy for when a medical consultant review may be required. 

A medical consultantRefers to a medical consultant who is not an opioid medical consultant. review is required when:

• Medical reporting notes serious side effects.
• There is a change in the authorized prescriber.
• The worker or authorized prescriber requests help to taper off.
• The worker requests payment for past opioid medications that the decision maker was not aware were being taken.

An opioid medical consultant reviewThis would be a specialized review by a medical consultant through the black MARF desk. is required when:

• The medical reporting notes serious side effects.
• There is a change in the authorized prescriber.
• The worker or authorized prescriber requests help to taper off.
• The worker requests payment for past opioid medications that the decision maker was not aware were being taken.
• The medication is 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 are prescribed such as benzodiazepines, hypnotics, sedatives, methadone, buprenorphine (including Suboxone, Butrans, and others), cannabinoids, fentanyl and Demerol. For Ketamine prescriptions, refer to the 4-11 Non-standard medical aid treatment decision procedure.
• The prescriber is recommending only up to one more month of opioids beyond 4 weeks. 

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

If after a review of the medical consultant's review, the worker is meeting the WCB opioid policy criteria for ongoing support of the medication, the decision maker will:

• Contact the worker to confirm the approval for opioids.
• Send the worker the opioid long-term prescription approval letter with the treatment recommendations, and, if appropriate, a Service Provider Custom letter to the pharmacy dispensing the medication. 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 after review of the medical consultant's memo it is determined that the worker is not meeting the WCB opioid policy criteria for ongoing support of the medication:

• Contact the worker to explain the decision, offer tapering and send the appropriate denial letter.
• Once the decision is communicated to the worker, send a task to the medical consultant to contact the authorized prescriber to discuss either:
  • A CBI pain clinic medication management program,
  • A two-day assessment at the CBI pain clinic to develop an opioid taper which the authorized provider can follow,
  • A community opioid taper as developed by the authorized provider, that is acceptable to WCB,
  • An opioid taper as suggested by an authorized prescriber, that is acceptable to WCB.
• Continue to approve opioids, until the taper is concluded, if the worker is willing to taper opioids.
• If the worker is not willing to taper opioids, discontinue support for opioids with supervisor and manager approval.
• Inform the worker that the above options are always available in the future should they change their mind.

Once the tapering plan is created:

• Contact the worker to discuss the taper plan and send the opioid long-term prescription approval letter but customize it to outline the taper plan and the treatment recommendations.
• Send a Service Provider Custom letter to the pharmacy dispensing the medication. Include the taper dosage, frequency and time frame in the letter. 

Upon completion of the tapering plan:

• Send the Tapering Plan Conclusion letter and a custom letter to the pharmacy dispensing the medication. 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 non-physiological processes required for bodily functions or the worker or authorized prescriber 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, authorized prescriber 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.

Referral for medication management program (MMP) assessment and/or tapering program

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 within six weeks of the referral.
• Send the medication management program referral form to the clinical consultant to confirm readiness for assessment or program enrollment.
• If the clinical consultant confirms the referral:
  • will not proceed, discuss the case with the clinical consultant to understand the reason. Develop an alternative plan with input from the medical consultant, clinical consultant and authorized prescriber. Call the worker to explain why the referral cannot proceed and the alternative plan that has been developed. Obtain the worker's agreement to participate in the alternative plan. Communicate the decision to not approve a tapering program in writing. Include details of the agreed-upon alternative plan and continue to approve opioid medication, as agreed, until the plan is complete.
  • will proceed, call the worker to confirm the referral is being made and communicate the referral decision in writing. Send a medical information package (MIP) to CBI central intake.

Monitor the opioid tapering program

Review the MMP assessment report for recommendations. There are four tapering options available:

• Worker specific telephone consultation following a file review: This is designed to provide expert assistance to a treating physician who are preparing to engage in the tapering process with a patient in the community.
• Medication management program (MMP) assessment: The worker attends a two-to-three-day assessment to identify the most appropriate tapering process to facilitate safe, sustainable withdrawal from opioids. The decision maker consults with the worker and other stakeholders in the formulation of a plan.
• Assessment and medication management program: If criteria are met after the assessment, the worker will start a program for up to seven weeks. The program introduces non-pharmaceutical techniques for pain management.
• Individualized assessment (does not meet program admission criteria): This assessment may be considered for circumstances such as when the worker is prescribed methadone or injection opioids. This option requires a discussion with an opioid medical consultant (i.e., black MARF desk) and supervisor before making the referral.

Approve the treatment plan recommendations as outlined in the MMP assessment. Communicate the tapering (medication reduction) plan in writing to the worker and the dispensing pharmacy.

Continue monitor the tapering program, participate in case conferences as required and approve opioids based on the recommended tapering plan outlined until the program is complete. 

Opioid tapering program conclusion

Review the outcome following completion of the tapering program. 

If the worker completes the program, review the plan outlined by the treatment team. Confirm the outcome of the tapering program and next steps in writing to the worker and dispensing pharmacy. Additionally, indicate whether the worker no longer requires opioids, or if they still require opioids, the maximum amount of opioid medication that may be approved (dosage, frequency and time frame). 

If the worker did not participate in or complete the tapering program or they were unable to reduce their medications to 90 MEQ per day, follow the recommendations from the MMP case conference. If partial opioid medication coverage is indicated, ensure the maximum coverage is 90 MEQ per day.  Send the appropriate letter to the worker and the dispensing pharmacy to communicate the discharge plan and coverage for opioid medications, if appropriate.

Continue to manage the claim as appropriate or send the claim to a case assistant complete to monitor opioid medication annually if no active case management is required. 

If new prescriptions are submitted by the worker for more/other opioid medication following the tapering program, review the reason for prescribing the opioid medications. Additionally, consider the outcome from the previous tapering program and continue to follow these recommendations, when appropriate (i.e. the opioids continue to be prescribed for the same medical condition as previous). In some circumstances, it may be reasonable to consider approval of opioid medication following a compensable surgery. When this occurs, return to the beginning of this procedure to restart the process.

Tapering plan with an authorized prescriber

An authorized prescriber may wish to help a worker taper without attending a program. In this case:

• Ask a medical consultant to call the authorized prescriber to confirm an appropriate treatment plan.
• Communicate the opioid prescription coverage decision to the worker and the pharmacy dispensing the medication. 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 authorized prescriber to confirm next steps.

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

When a worker is in palliative care, their opioid dose may escalate. The decision maker can approve these increases as prescribed by the authorized prescriber.

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

• 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 long-term prescription approval letter to the worker and the Service Provider Custom letter to the pharmacy dispensing the medication. 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 authorized prescriber.

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

• The worker and authorized prescriber disagree with the suggestion of an opioid taper or the tapering plan itself.
• The worker or authorized prescriber doesn’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, authorized prescriber 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.