New York State Medical Treatment Guidelines for Optimizing Opioid Treatment in workers compensation patients

The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for enhancing opioid treatment for non-acute pain . These directives aim to assist healthcare professionals in optimizing the use of opioids within the scope of comprehensive care.

Healthcare professionals with expertise in managing opioid treatment can rely on the guidance outlined by the Workers Compensation Board to make well-informed decisions about improving the effectiveness and safety of opioid therapy for their patients.

It is crucial to emphasize that these principles are not intended to replace clinical judgment or professional expertise. The optimization of opioid treatment should involve collaboration between the healthcare provider and the patient, considering individual factors such as pain management goals, opioid dosing, and potential risks associated with opioid use.


Optimizing Opioid Treatment

  • Patients receiving chronic opioid therapy require regular monitoring and re-evaluation to assess patient adherence and progress toward treatment objectives, with documentation in the medical record during each patient visit.
  • The Pain Assessment and Documentation Tool (PADT) offers an effective method for systematically recording each encounter, aiding in the organization and review of care.


Assessing Effects of Long-Term Opioid Therapy

Physician Assessment of Current Opioid Therapy:

  • The physician should evaluate or re-evaluate the risks and benefits associated with the patient’s ongoing opioid therapy, considering factors such as:
    • Functional status and pain levels.
    • Potential adverse effects resulting from current opioid doses
    • Age of the patient, especially if elderly.
    • Presence of psychiatric disorders that may impact treatment.
    • Underlying conditions that could exacerbate opioid-related adverse effects, such as COPD, CHF, sleep apnea, or a history of renal/hepatic dysfunction, including any newly diagnosed conditions and medications associated with them.
    • Concurrent drug combinations that might enhance opioid adverse effects, such as sedative-hypnotics, benzodiazepines, or barbiturates, unless their use is medically or psychiatrically indicated (and accompanied by increased monitoring).


Management of Significant Adverse Effects:

  • If substantial adverse effects are noted from opioid therapy, the physician should consider reducing the opioid dosage and re-evaluating the patient’s condition.
  • Tapering or discontinuation of opioids may be necessary due to various factors like tolerance development, hyperalgesia, decreased opioid efficacy, non-compliance with the opioid agreement, or intolerable side effects.
  • In complex cases, particularly those involving addiction or opioid tapering, inpatient treatment may be warranted.


Patient Informed Consent for Opioid Treatment Form:

  • The Patient Informed Consent for Opioid Treatment Form (found in Appendix F) includes the following information:
    • Potential side effects associated with the medication, which may include but are not limited to: confusion or impaired judgment, nausea, constipation, vomiting, drowsiness, coordination difficulties, balance issues, slowed breathing (with the potential for respiratory failure and fatality), exacerbation of depression, and dry mouth.
    • Hyperalgesia, a condition where increased opioid dosage might lower the pain threshold and heighten pain sensitivity. Symptoms often alleviate with a reduction in opioid dosage.
    • Increased risk of side effects when opioids are combined with other substances, including alcohol.
    • Risks of tolerance, dependence, and addiction.
    • Specific considerations for males, such as potential effects on testosterone levels affecting sexual desire and performance.
    • Specific considerations for females, including the risk of pregnancy while taking opioids and the potential for newborn dependence.


Patient Understanding for Opioid Treatment Form:

  • The Patient Understanding for Opioid Treatment Form (found in Appendix G) outlines the following points:
    • Agreement to take medications as prescribed, obtaining them from a single pharmacy.
    • Clarification that medications will be prescribed by the signing physician, or in their absence, by a covering physician.
    • Commitment to continue active therapy alongside opioid treatment.
    • Recognition of the importance of employing other pain management techniques to function effectively with non-acute pain.
    • Treatment goals, emphasizing improvements in both pain levels and functional abilities, including potential return to work.
    • Agreement to refrain from alcohol and other non-prescribed drugs.
    • Expectation of urine drug tests (UDT) and blood tests, along with understanding the consequences of unexpected results, including positive screens for non-prescribed drugs or alcohol.
    • Understanding the reasons for discontinuation of opioid management, such as non-compliance or diversion.
    • Understanding the reasons for tapering or discontinuation of opioids, typically over a 30-day period or through referral for addiction treatment if the opioid trial or treatment is unsuccessful.
    • Importance of safe storage of medications.
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