New York State Medical Treatment Guidelines for Opioids for Non-acute Pain in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for using opioids to manage non-acute pain. These directives aim to assist healthcare professionals in prescribing opioids appropriately within the scope of comprehensive care.

Healthcare professionals with expertise in prescribing opioids for non-acute pain can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable opioid treatments for their patients.

It is important to emphasize that these principles are not intended to replace clinical judgment or professional expertise. The use of opioids for non-acute pain should involve collaboration between the healthcare provider and the patient, considering individual factors such as pain severity, treatment goals, and potential risks associated with opioid use.

Long-Term Use of Opioids in the Opioid-Naïve Patient: Opioid Therapeutic Trial

Overview

  • An opioid trial involves testing the effectiveness of opioid use over a period to determine if it achieves the goals of increased function and reduced pain.
  • Before considering long-term opioid use, physicians should ensure that other pain management methods, such as physical therapy, behavioral therapy, and non-opioid measures, have been attempted and failed.
  • A successful opioid trial typically lasts between 30 to 60 days, during which the patient shows sustained improvement in function and pain levels.
  • Patients should be monitored weekly during the trial period.

 

Goals and Objectives of Opioid Trial

  • A successful trial should achieve the following goals:
    • Improved function, including the ability to return to work or perform daily activities, along with at least a 30% reduction in pain, supported by validated objective measures of improvement.
    • Absence of significant adverse side effects.
    • Absence of aberrant drug-related behaviors.
  • If these goals are not met within 30 to 60 days, the trial should be stopped, opioids tapered off or discontinued, and an alternative pain treatment approach considered.
  • In some cases, it may become apparent early in the trial that the patient is not responding to opioids, and in such cases, the trial should be stopped as soon as clinically feasible to minimize risks.

 

Risk Assessment/Stratification

  • Before initiating a therapeutic opioid trial, patients should undergo physical and psychological assessments, including evaluation for alcohol or drug addiction, dependence, or abuse.
  • Screening for potential comorbidities and risk factors is essential to monitor anticipated risks effectively.
  • The Opioid Risk Tool (ORT), a validated clinical instrument, can be used to assess the risk of substance abuse, misuse, or addiction.
  • Patients should be categorized as low, medium, or high risk for abuse.
  • High-risk patients, such as those with active substance abuse or a history of prescription opioid abuse, generally should not be prescribed chronic opioids.
  • High-risk patients deemed appropriate for chronic opioid treatment should be managed by physicians specializing in addiction medicine.
  • Patients with a history of substance abuse or other psychosocial risk factors should be co-managed with physicians specializing in addiction medicine.

 

Therapeutic Trial Criteria (Opioid-Naïve Patient)

  • Before initiating opioid therapy in an opioid-naïve patient, certain trial criteria need to be fulfilled:
    • Exhaustion of other pain management options, including active therapies, cognitive behavioral therapy, pain self-management techniques, and other relevant medical interventions.
    • Comprehensive evaluation and documentation of the patient’s pain condition, overall medical status, psychosocial history, psychiatric condition, and substance use history.
    • Absence of untreated psychosocial issues complicating or driving the clinical presentation.
    • Opioid use should only be considered when the potential benefits are deemed to outweigh potential harm, and the physician is committed to monitoring treatment effects, with a plan to discontinue opioid therapy if necessary.
    • The trial should begin with a baseline assessment of function and pain.
    • The treatment plan should include the continuation of appropriate adjunct therapies in line with the recommendations provided in the New York Non-Acute Pain Medical Treatment Guidelines, aimed at alleviating pain and aiding the patient in managing their condition.
    • Coordination of care should be ensured as part of the treatment plan.
    • The patient should have a clear understanding of all expectations regarding opioid use, including the necessity for a therapeutic trial.
    • Defined functional and pain goals must be agreed upon by both the physician and the patient.
    • A thorough review of the full spectrum of side effects should be conducted, and a Patient Informed Consent for Opioid Treatment Form, outlining the risks and benefits of opioids, must be signed by both the patient and the physician.
    • A written Patient Understanding for Opioid Treatment Form, outlining the responsibilities of both the provider and the patient in opioid therapy, including the acknowledgment that prescriptions will be obtained from a single practitioner, must be signed by both parties.
    • Physicians prescribing opioid therapy must adhere to I-STOP and other relevant legislation.
    • Physicians are encouraged to complete the education recommended by the FDA, specifically the Risk Evaluation and Mitigation Strategies (REMS).

 

Therapeutic Trial

  • There is no evidence indicating the superiority of any specific opioid for initial therapy.
  • The trial should document sustained improvement in pain control (at least a 30% reduction on validated pain measures) and enhanced functional status, such as returning to work or improved ability to perform daily activities.
  • When initiating opioid therapy, start with a low dose, gradually increase, and monitor effectiveness until the optimal dose is achieved.
  • Follow-up every seven to ten days is recommended to adjust dosage and assess clinical efficacy.
  • During dosage adjustment, advise the patient to refrain from engaging in safety-sensitive activities until a stable dosage is established and it is confirmed that the opioid does not cause sedation.
  • Urine Drug Testing (UDT) and random pill counts should be conducted as part of monitoring opioid therapy.
  • If treatment goals are not being met, the opioid trial should be reevaluated.

 

 

Long-Term Use of Opioids: Transitioning/Managing Patients on Existing Opioid Therapy

Overview

  • Physicians managing patients on long-term opioids should undertake a thorough reassessment and reevaluation of the patient’s medical status, transitioning to management and treatment in line with the principles outlined for safe long-term opioid care
  • Patients who are already on long-term opioids should not have their medications abruptly discontinued solely because they have not met the trial criteria or the criteria for safe long-term opioid management outlined in this guideline. It’s important to note that the New York Non-Acute Pain Medical Treatment Guidelines do not mandate opioid cessation for this subset of patients who have been on long-term opioid therapy. The objective is to transition to the standards of care specified below and avoid sudden cessation of opioids in patients who have been on long-term therapy before the initiation of these guidelines.

 

Approach

  • A careful reassessment and documentation of the patient’s pain condition, overall medical status, psychosocial history, psychiatric condition, and substance use history should be conducted to evaluate the effectiveness and safety of existing opioid therapy.
  • Comprehensive physical, psychological, and/or psychiatric assessments, including a thorough evaluation for alcohol or drug addiction, dependence, or abuse, should be performed.
    • Risk Assessment: Screening for potential comorbidities and risk factors is vital for monitoring anticipated risks. Notably, personal or family history of substance abuse is the most significant predictive factor for misuse.
    • Risk Stratification: Patients should be categorized as low, medium, or high risk for abuse based on behaviors, validated clinical instruments, and prior history of abuse.
    • The risk of substance abuse, misuse, or addiction should be evaluated using recommended and validated clinical instruments

 

  • If untreated psychosocial issues are identified as driving or complicating the clinical presentation, appropriate referral options should be provided.
  • Identification and/or continuation of suitable adjunct non-opioid therapies consistent with the recommendations provided in the New York Non-Acute Pain Medical Treatment Guidelines should be ensured to alleviate pain, enhance function, and aid the patient in coping with their condition.
  • Initial frequent monitoring and reevaluation schedules should be established to assess the effectiveness and safety of existing opioid therapy, determine the need for modification/discontinuation of opioids, develop a monitoring plan including urine drug testing (UDT), pill counts, need for specialty consultation/co-management, initiation of non-opioid adjunct therapies, and review and completion of Patient Understanding for Opioid Treatment Form and Patient Informed Consent for Opioid Treatment Form.
  • Physicians should maintain awareness of and compliance with relevant federal and state-controlled substance legislation and regulations.
  • The goal is to transition to the standards of care specified below and avoid abrupt discontinuation of opioids in patients who have been on long-term therapy before the initiation of the New York Non-Acute Pain Medical Treatment Guidelines.
  • Consideration of other comorbid conditions that require attention (e.g., depression, anxiety, morbid obesity) should be made, with appropriate referrals as necessary.

 

Ongoing, Long-Term Opioid Management

Overview

  • Once the decision is made to initiate and/or continue chronic opioid therapy, it becomes the responsibility of the physician to regularly monitor the safety and effectiveness of ongoing treatment, focusing on improved patient function and pain relief.

 

Principles for Safe Management

  • Chronic opioid therapy should only commence after explicit agreement between the patient and physician, documented through forms such as the Patient Informed Consent for Opioid Treatment and Patient Understanding for Opioid Treatment.
  • Any changes in opioid dose, type, or patient condition should prompt updates to the Patient Informed Consent for Opioid Treatment and Patient Understanding for Opioid Treatment forms, duly signed by both patient and physician.
  • Prescriptions should originate from a single practitioner and be filled at a single pharmacy, complying with state and federal laws.
  • Utilization of the lowest effective dose possible, balancing the phenomenon of tolerance with pain relief. Strategies may include opioid rotations, occasional dose reductions, or reinstating previously successful treatment plans.
  • Continual review of the overall therapy plan, emphasizing non-opioid methods of pain control and the maintenance of functional status, in line with recommendations outlined in the New York Non-Acute Pain Medical Treatment Guidelines.
  • Encouragement and reinforcement of active exercise to support patient self-management.
  • Consideration of referral to specialists in Pain Medicine and/or Addiction Medicine, without necessarily implying a recommendation to taper, deprescribe, or discontinue any specific medication, but rather to seek additional expertise.
  • Monitoring and Screening:
    • Regular review and documentation of pain relief, functional status, medication use, and side effects, documented at each patient encounter.
    • Risk assessment/stratification to guide the frequency of monitoring based on patient risk levels.
    • Random urine drug testing at least annually, with frequency adjusted according to risk category.
    • Unannounced pill counts as indicated, especially in cases of aberrant behavior.
  • If there are no reasons identified for dose reduction or discontinuation, and the patient benefits from opioid therapy (as supported by validated measures of improved function and pain), continued opioid use may be appropriate. However, ongoing assessment and monitoring are necessary.
  • Limited use to a maximum of two opioids: a long-acting opioid for sustained pain relief and a short-acting opioid for occasional rescue use.
  • If considering more than two opioids for long-term use or if patients require more than 50 MED/24hrs, seeking a second opinion from a specialist certified in Addiction Medicine or Pain Medicine is strongly recommended.
  • All opioid medications should be used cautiously in patients at risk of abuse, with buccal-delivered medications avoided.
  • Warning regarding acetaminophen use in combination products: Prolonged use exceeding recommended daily doses can lead to hepatotoxicity, including over-the-counter medications.

 

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