New York State Medical Treatment Guidelines for Opioid-Related Medications in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for medications related to opioids. These directives aim to assist healthcare professionals in managing medications associated with opioid therapy within the scope of comprehensive care.

Healthcare professionals with expertise in prescribing medications linked to opioids can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most appropriate pharmaceutical treatments for their patients.

It is important to emphasize that these principles are not intended to replace clinical judgment or professional expertise. The management of medications related to opioids should involve collaboration between the healthcare provider and the patient, considering individual factors such as medication interactions, treatment efficacy, and potential adverse effects.


  • Tramadol, classified as an opioid partial agonist, distinguishes itself by lacking the propensity to cause gastrointestinal ulcers or worsen conditions like hypertension or congestive heart failure. However, its opioid-like side effects may restrict its utility. It’s not typically a first-choice medication and its pain-relieving efficacy is comparable to commonly used NSAIDs. Considered a fourth-line option for neuropathic pain, it might suit patients intolerant to tricyclic antidepressants.
    • Potential side effects include impaired alertness or nausea.
    • Tramadol has addictive properties, thus abrupt cessation can precipitate withdrawal.
    • Caution is advised in patients with a seizure history or those taking medications lowering seizure thresholds like MAO inhibitors, SSRIs, and TCAs.
    • Avoid in individuals with prior opioid addiction, as fatalities have been linked to emotional disturbances or concurrent alcohol or opioid use.
    • Significant renal or hepatic dysfunction necessitates dosage adjustments.
    • Concurrent use with other serotonergic agents like SSRIs, SNRIs, or TCAs may lead to serotonin syndrome.



  • Methadone, an opioid analgesic, presents complex pharmacokinetic and pharmacodynamic profiles along with notable side effects. Despite equianalgesic tables suggesting its potency, repetitive dosing reveals it to be approximately ten times more potent due to its extended elimination half-life. This prolonged half-life poses risks of respiratory depression, cardiac rhythm disturbances, and drug interactions. Extreme caution is warranted, especially in patients with pre-existing cardiac, psychiatric, or respiratory conditions.
  • Doses and dosing schedules for analgesic use differ from those for addiction management, demanding rigorous patient monitoring and side-effect surveillance. Methadone initiation should be conservative, adhering to the principle of “start low, go slow,” and it’s not recommended for opioid-naïve patients.



  • Buprenorphine, a partial opioid agonist, primarily known for treating opioid addiction, also finds application in managing severe chronic pain. Its ceiling effect reduces the risk of respiratory depression and death, making it appealing for individuals with opioid addiction histories. Available in buccal film, tablet, and transdermal patch formulations, it’s crucial to note that only the buccal film and transdermal patch are approved for pain management.
  • Buprenorphine tablets may be suitable for patients with both addiction and pain histories, albeit at lower doses than those for addiction treatment. The advantage lies in its reduced potential for misuse and addiction.



  • Tapentadol, an opioid agonist, is indicated for moderate to severe acute pain management in adults. Its extended-release form is prescribed for moderate to severe non-acute pain in adults and neuropathic pain associated with diabetic peripheral neuropathy when continuous opioid analgesia is necessary.
  • Similar to opioids, tapentadol’s side effects may limit its use. Caution is advised in patients with severe renal impairment, and reduced dosages are recommended for moderate hepatic impairment. There’s no standard equianalgesic dose conversion guidance to oral morphine for tapentadol. Starting at lower doses and adjusting based on patient response is advisable.
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