New Rules Governing Long-Term Treatment with Opioid Medication
In its rule making capacity, the Department of Labor & Industry anticipates making its proposed rules establishing criteria for long-term treatment with opioids effective mid-July, 2015.
Minn. Rule 5221.6110 will govern the long-term use of opioid medications for intractable pain. The rules will apply to both health care providers who plan to use opioid medications for at least 90 days or who have been prescribing opioid medication for at least 90 days.
Under the new rules, a prescribing health care provider must assess the employee’s level of pain and function using validated, peer reviewed scientific methods. Before treating an employee with long-term opioid medications, the prescribing provider must determine that the employee cannot maintain function at work or in activities of daily living without the long-term of use opioid medications; that the employee does not have somatic symptom disorder; that all other reasonable medical treatment options have been exhausted as determined by a pain medicine specialist or other specialist; that the employee does not have a history of failing to comply with treatment; and that the employee does not have a current substance abuse disorder. In addition, a urine drug test must confirm that the patient is not using any illegal substances.
Before beginning long-term treatment with opioid medications, the prescribing health care provider must also determine whether any contra-indications to such long-term use exist, such as the presence of other respiratory conditions, depression, pregnancy, any mental disorder referenced in the DSM-5, or an impression that the employee is a suicide risk or has poor impulse control. If an assessment finds that there is a high risk of dependence or abuse, the provider may refer the employee to a pain medicine specialist or addiction medicine specialist for a second opinion before initiating long-term treatment.
If long-term treatment is initiated with a high risk employee, the prescribing provider must perform and document closer monitoring, including performing urine drug testing at least twice a year and reviewing the employee’s prescription history in the Minnesota prescription monitoring program at each visit.
In all cases, the prescribing provider must also have a detailed written plan of treatment specifying the medication to be used, the frequency and scheduling of dosing, the duration of use, and the potential side effects. The prescribing provider is also required to provide written reports of workability. If long-term treatment with opioids is discontinued, the prescribing health care provider must document a schedule of tapering dosages and offer alternative pain management treatment.
There must also be a written treatment contract between the health care provider, which must be made part of the employee’s medical record and include, in part, the following: the goals of long-term treatment with opioids; an agreement by the employee to comply with treatment prescribed in addition to opioid medication; a statement that only one refill replacement will be provided based on a report that the prescription or medication was lost or stolen; a statement that prescriptions will not be renewed earlier than scheduled; a statement that the employee will notify the prescribing health care provider of medications received from other health care providers; and a statement that the health care provider has discretion to discontinue treatment with opioids if the employee does not comply with any of the other agreements.
The prescribing health care provider must document the monitoring of long-term opioid use in the medical record, which will require the provider to schedule regular follow up visits at least quarterly in the first year of treatment and no less than annually thereafter. There is an exception for high risk employees, who must be seen more often. At each visit the provider must assess pain and function and assess the success of the treatment program in meeting its goals. At each follow up visit, the provider must assess possible side effects, misuse of medications, potential addictive behaviors, and other contradictions to continuing opioid treatment. The provider must assess the employee’s adherence to the entire program of treatment. In addition, at least semi-annually, the provider must review the employee’s prescription history in the Minnesota prescription monitoring program. The provider has discretion to order urine drug testing as part of monitoring and the provider is required to refer the employee to a pain medicine specialist if there is a sudden or progressive increase in the dosage of opioid medication required or if the goals of the treatment program are not being met;.
If a prescribing provider fails to comply with the requirements of these rules, the insurer may send the provider notice of the failure. Within 30 days, the provider must initiate a plan to come into compliance with the rules. If the provider fails to initiate a plan, the insurer may then deny payment for treatment with opioid medications.
When the rules become effective in mid-July 2015, health care providers will have three months to come into compliance with the rules.
You can read the complete proposed rules establishing criteria for long-term treatment with opioid analgesic medication for workers’ compensation injuries here.