Application 4: Prescribed Opioid Analgesics (Narcotics)

1. What are the objectives of the WCB regarding the authorization of prescribed opioid analgesics (narcotics)?

As part of an overall approach to effective, appropriate claims management, including the provision of and payment for medical aid, the WCB ensures that prescribed opioid analgesics (narcotics) support treatment goals including safe and early recovery, return to function and return to work.

2. What is the focus of this policy?

In the authorization of payment for prescribed opioid analgesics (narcotics), the primary focus of this policy is the management of chronic, non-malignant pain rather than acute (generally up to 12 weeks following injury), peri-operative or palliative care situations.

3. For the purposes of this policy, what are prescribed opioid analgesics (narcotics)?

For the purposes of this policy, prescribed opioid analgesics (narcotics) refer to prescription medications, legally available in Canada, including but not limited to those identified by the College of Physicians and Surgeons of Alberta on their Triplicate Prescription Program Medication List.

4. Will the WCB authorize services to assist with medication management?

The WCB may refer an injured worker for medication assessment and management including addiction assessment and treatment, narcotic cessation and/or rehabilitation programs.

5. Are there medical guidelines, regarding the use of prescribed opioid analgesics (narcotics) in managing chronic non-malignant pain, which the WCB expects physicians will follow?

The College of Physicians and Surgeons of Alberta has adopted The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain for physicians’ use in prescribing opioid analgesics (narcotics), particularly with respect to chronic, non-malignant pain. The WCB expects that physicians will follow those guidelines, including but not limited to the following:

• to the extent possible, the underlying medical process causing the pain should be established and the course of treatment commensurate with the condition
• where appropriate, an adequate trial of non-opioid analgesics should have been carried out
• opioid analgesics would not ordinarily be prescribed for patients whose pain is idiopathic or primarily determined by psychological factors
• a history of remote, recent or current substance abuse is a strong contra-indication
• the goal of opioid analgesic therapy is demonstrable improvement in function and substantial reduction in pain, but not necessarily pain elimination

6. Under what circumstances would the WCB generally authorize payment for prescribed opioid analgesics (narcotics)?

The WCB may authorize payment for prescribed opioid analgesics (narcotics) when:

• an injured worker is in the early, acute stage of treatment for a compensable injury (generally the first 12 weeks following injury)
• an injured worker is being treated in the later stages of a terminal disease which generally means a life expectancy of 12 months or less
• an injured worker is being treated for severe injuries with recognized, organically based pain

The WCB may also authorize payment for prescribed opioid analgesics (narcotics) for the management of chronic, non-malignant pain when:

• the prescribed opioid analgesics are part of an integrated, multi-disciplinary approach to pain management
• the prescribed opioid analgesics do not form the first line of treatment for longer-term or chronic injuries, and
• there is evidence that treatment with prescribed opioid analgesics is resulting in demonstrable improvement in the injured worker’s function, progress towards return to work and substantial reduction in pain.

Each case will be decided on its own merits.

7. Does the WCB impose any conditions when authorizing prescribed opioid analgesics (narcotics)?

If the WCB authorizes payment for prescribed opioid analgesics (narcotics) for the management of chronic, non-malignant pain, it will monitor treatment and will require that:

• there is only one prescriber (generally the injured worker’s primary treating physician)
• there is only one dispensing pharmacy
• except in immediate post-injury, operative, peri-operative or palliative situations, the prescribed opioid analgesic is not given by injection
• the prescribed medication is generally limited to one long-acting and/or one short acting opioid analgesic at any given time
• there be a written ‘use of treatment’ agreement between the injured worker and the prescribing physician, which, at a minimum, identifies the prescriber, the pharmacy, conditions regarding early refills and the risks associated with prescribed opioid analgesic use
• the ‘use of treatment’ agreement, in a manner and form acceptable to the WCB, be on file with the WCB following the start of opioid analgesic prescriptions and no later than 12 weeks following the date of injury
• the prescribing physician must report, on a regular basis in a manner and form prescribed by the WCB, with respect to matters including but not limited to, the dosage and frequency of prescribed medication, baseline and periodic updates on function level, pain intensity and any modification to the treatment plan

8. Under what circumstances would the WCB suspend or discontinue authorization of prescribed opioid analgesics (narcotics)?

The WCB may suspend or discontinue authorization of payment for prescribed opioid analgesics when:

• increases in dosage do not result in improvement in function, including progress towards return to work and a clinically significant reduction in pain
• the prescribed opioid analgesics result in medical complications and/or significant, serious side effects (e.g., non-physiological processes required for bodily functions, medications required to counteract side effects reasonably attributable to opioid analgesics)
• medical advice indicates the prescribed opioid analgesics are delaying or imperiling the injured worker’s recovery, return to function and/or work
• there is evidence of repeated dosage adjustment that has not been prescribed or authorized
• there is evidence that the prescribed opioid analgesics are being misused, used in a manner not intended by the prescribing physician or inconsistent with the intended purposes of the medication.

Each case will be decided on its own merits.

9. When is this policy application effective?

This policy application [Application 4: Prescribed Opioid Analgesics (Narcotics)] is effective May 1, 2006 except when noted otherwise in a specific policy section(s).