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Acute treatment (zero to two weeks)
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. 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.
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Administrative tasks
When approving opioids for the acute phase (0-2 weeks), send the: - Opioid acute prescription approval (CL035J)
- Service provider custom letter (SP000A) to the pharmacy
When opioid medication is not approved, send the Opioids denied/discontinued (CL035B) to the worker. If the worker requires opioids beyond four weeks, send the following: - Opioid acute prescription approval (CL035J)
- Service provider custom letter (SP000A) to the pharmacy
- Opioid worker cover letter with package (CL035K)
The opioid package includes: - Cover letter (CL035K)
- Opioid treatment agreement (C913)
- Medication management report (C914)
- Opioid risk assessment checklist (C942)
- Summary of recommendations & roadmap
- Messages for patients taking opioids
- Policy 04-06, Part II, Application 4: Prescribed Opioid Analgesics
When a signed agreement has not been received, send the Opioid prescription denial -CL035C and the SP035C) Update the authorized medication (AUM) line with the authorized time frame for approved opioids (not more than two weeks from the date of accident or surgery), an extension for an additional two weeks (four weeks in total), or the end date if opioid use has ended. Note: when a payment is requested for an opioid and the date of service is beyond two weeks a task will be sent as a reminder to follow up with the worker. Once a payment request is completed by Medical Aid, an exception is generated to the decision maker Unauthorized Restricted DIN Payment Requested
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Long-term opioid therapy (approving opioids beyond four weeks)
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 reviewAfter 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), ketamine, cannabinoids, fentanyl, and Demerol.
- 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.
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Administrative tasks
When considering approving long term opioids (beyond four weeks) send the following if it is not already on file: - Opioid initial policy application checklist (FM034A)
- Opioid use checklist (FM035A)
- Opioid treatment agreement (C913)
To calculate the morphine equivalent, select the MEQ calculator tab from the Opioid and cannabis claim management database in the Electronic Workplace. Copy and paste the the information into a file note Medical payment processing/description "Opioid Medications & MEQ Values”. Attach the file note to the authorized medication (AUM) line.
eCO tasks
Update the authorized medication (AUM) line with the authorized time frame for approved opioids (not more than one year), or the end date if opioids are denied or discontinued. To refer for an Opioid Review, complete the FM007A form from the eCO Create Referral screen. - For a medical consultant review send a task “Opioid Medical Review” to the Team MARF Desk.
- For an opioid medical consultant review, send a task to the Black MARF Desk and include in the task description the “Team # Black MARF Medical Review”.
- Include the date of the FM007A that contains the questions.
Complete the benefit detail tab in the authorization medication line (AUM) with an end date (no more than 2 to 4 weeks for approval) and update the Additional information section with “Opioid Review Pending”. Ensure the file note: - Lists all opioid medications the claimant is taking including the applicable DIN and dosage.
- Indicates the MEQ/day for all the opioid medications.
Refer to the Opioid and cannabis claim management database in the Electronic Workplace. If opioids are approved beyond 4 weeks send the Opioid long-term prescription approval (CL035A). If opioids beyond 4 weeks are not approved send Opioid denied/discontinued (CL035B).
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Monitoring, annual reviews and ad hoc reviews
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 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 reviewComplete 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 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), ketamine, cannabinoids, fentanyl, and Demerol.
- 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.
- Create 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.
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Administrative tasks
Review the C914 as it is submitted quarterly If regular updates are not received send: Opioid medication management reporting (SP035E) When reviewing for ongoing approval after the initial approval has been done: - Send the ongoing opioid policy checklist (FM034B). If conditions 1-5 have not been met, apply policy and offer tapering
- Complete MEQ calculation
- Create a file note “opioid medications and MEQ value” and include all of the medications and the MEQ/day for all the opioids
- If approved, send Opioid long-term prescription approval (CL035A).
- If denied, send Opioid denial CL035B.
eCO task - Update the authorized medication (AUM) line with the authorized time frame for approved opioids (not more than one year). Complete the FM007A form from the eCO create a referral screen. - For a medical consultant review send a task “Opioid Medical Review” to the Team MARF Desk.
- For an opioid medical consultant review, send a task to the Black MARF Desk and include in the task description the “Team # Black MARF Medical Review”.
- Include the date of the FM007A that contains the questions.
Complete the benefit detail tab in the authorization medication line (AUM) with an end date (no more than 2 to 4 weeks for approval) and update the Additional information section with “Opioid Review Pending”. Refer to the Opioid and Cannabis Claim management site on the internal Electronic Workplace.
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Tapering program
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. 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.
- Decision maker will participate in case conferences as required.
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 is 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): in cases such as the worker being prescribed methadone or injection opioids, this may be supported. Prior to referral, this requires a discussion with the black MARF desk and Supervisor.
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, the maximum amount to be approved will be guided by the multi-disciplinary teams tapering plan based on the latest plan: - 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: - Follow the recommendations from the medical management program case conference. If partial coverage is indicated based on these recommendations, the maximum coverage is 90 MEQ per day.
- 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.
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Administrative tasks
Opioid use checklist (FM035A) needs to be completed within six weeks of referral Complete medication management program referral to clinical consultant (FM974A) Send opioid tapering assessment referral (CL035E) ensure opioid decision has been communicated in writing prior to referral Send medical information package (MIP) with: - Investigation/specialist/IME reports
- Medical consultant report
- Medical consultant file reviews
- Physical therapy/chiropractic repots/program reports
- C040
- C050
Arrange payment for travel, meal and accommodation allowances when required Send Opioid tapering plan authorization (CL035F) Send Tapering plan conclusion (CL035G) at the end of program outlining the discharge plan and authorized medications Note: if new prescriptions are submitted by the worker for more/other opioid medication following the tapering program, customer service will need to review and action as outlined above in the Cl035G letter. In cases of further compensable surgery etc., restart the process by sending a new Opioid use checklist FM035A If the tapering program is denied send Opioid prescription and tapering denied (CL035D) eCO task - Update the authorized medication (AUM) line with the authorized time frame for approved opioids (not more than one year), or the date of conclusion at the end of the taper.
Refer to the Opioid and Cannabis Claim management site on the internal Electronic Workplace.
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Palliative care
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.
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Administrative tasks
Opioid long-term prescription approval letter (CL035A) Service provider custom letter (SP000A) eCO task - Update the authorized medication (AUM) line with the authorized time frame for approved opioids (not more than one year).
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Other scenarios
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.
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Administrative tasks
Opioid use checklist (FM035A) Initial opioid policy checklist (FM034A) Medication management form (C914) Refer to the Opioid and Cannabis Claim management site on the internal Electronic Workplace.
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