Opioid management - Archived Mar 11, 2024

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.

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 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 medial 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.

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.

If it is anticipated opioid medication will be required beyond four weeks and if the opioid package was not previously sent, send the opioid worker cover letter with 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..
• 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?

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:

• Ask the medical consultant to contact the authorized prescriber to ensure all information has been considered and to develop a plan to address the concerns.
• Review the medical consultant’s report and determine if the continued approval is appropriate. If so, follow the directions above.
• 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. Proceed to the tapering plan in the Ad hoc review below.

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 wellbeing 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 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 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 the MEQ is 90 per day or lower 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. 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 benzodiazepines, hypnotics, sedatives, 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 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.

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 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 the medical consultant has concerns with the opioid use, ask the medical consultant to contact the authorized prescriber to ensure all information has been considered.

If the medical consultant and authorized prescriber reach an agreement to taper opioid dosage, call the worker to discuss the next steps and go to tapering program (see below for more information).

If an agreement is not reached, an alternative support and/or pain management plan, as well as manager approval must be in place before discontinuing authorization for opioid medication.

In this case, in consultation with a medical consultant, create a customized taper plan (e.g., decreasing doses covered) to reduce to a safe level to address the medical harms identified. The goal of the taper plan is to reduce approval for opioid medications to up to a maximum of 0 to 90 MEQ. A customized taper plan is completed when the worker or their authorized prescriber are not participating (this is not the same as a tapering program in a clinic). Once the taper 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 the treatment recommendations, and a service provider custom letter to the pharmacy dispensing the medication. Include the taper dosage, frequency, and time frame in the letter.
• Monitor the worker’s progress in the taper plan.
• Upon completion of the taper plan, send the tapering plan conclusion letter and a service provider 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.

Note: The College of Physicians and Surgeons of Alberta (CPSA) recommends that authorized prescribers use extreme caution when exceeding the 90 MEQ dose, as the Canadian guideline for opioids for chronic non-cancer pain recommends 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 authorized prescriber 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 authorized prescriber 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 the worker’s file to generate a task to the clinical consultant to confirm if a referral for 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 authorized prescriber. Call the worker to discuss and send the opioid tapering denied letter. Include the details of the agreed-upon alternate plan and continue to approve opioid medication, as agreed, until the alternate plan is complete.
• If the referral is ready to proceed, the clinical consultant will ask the decision maker to send a medical package to CBI central intake.
• 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 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.
• 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 tapering program:

• Send the tapering plan conclusion letter and a service provider custom letter to the pharmacy dispensing the medication.
• 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 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.
• 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 long-term prescription approval letter to the worker.

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

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

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.
• 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.
• 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.

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.