January 18, 2013

Washington L&I’s new guidelines for opioids Rx to treat injured workers

Washington State’s Department of Labor & Industries (L&I) has issued new guidelines for prescribing opioids to treat injured workers.  Some of the more noteworthy references in the guideline publication are the following:

*In general, opioid use for acute pain should be reserved for post surgery, for the most severe pain (e.g. pain scores ≥ 7), or when alternative treatments such as NSAIDs and non-pharmacological therapies are ineffective. Evidence does not support the use of opioids as initial treatment for back sprain or other strains, but if they are prescribed, use should be limited to short-term (e.g. ≤ 14 days).

* If opioids are to be prescribed for longer than 6 weeks, the provider must seek authorization from L&I. With the exception of catastrophic injuries, the provider must perform the following best practices before L&I will authorize payment for opioids beyond the acute phase:

– Access the state’s PMP to ensure that the controlled substance history is consistent with the prescribing record and worker’s report.

– Document clinically meaningful improvement in function and pain with acute use.

– Screen worker for depression.

– Screen for opioid risk If the worker has current substance use disorder (excluding nicotine) or a history of opioid use disorder, opioid use beyond the acute phase is rarely indicated.

– Administer a baseline urine drug test (UDT). If results reveal “red flags” such as the confirmed presence of cocaine, amphetamines or alcohol, opioid use beyond the acute phase is not indicated. Unless cannabis use disorder is diagnosed, the presence of cannabis on a UDT does not preclude the use of opioids.

– Re-examine and consider discontinuation or taper of concurrent sedative-hypnotics and/or benzodiazepines.

* If opioids are to be prescribed beyond 12 weeks post-injury or post-surgery, the provider must receive prior authorization by L&I.  Further, in order to receive such prior authorization, several important conditions must be documented, including:

– Clinically meaningful improvement in function (greater than or equal to 30%) has been established with opioid use in the acute or subacute phase.

– Failure of trials of reasonable alternatives to opioids.

– Signed treatment agreement (pain contract).

– A time limited treatment plan, addressing whether chronic opioid therapy is likely to improve the worker’s vocational recovery.

– Consultation with a pain management specialist if the worker’s dose is above 120 mg per day.

The guidelines become effective July 1, 2013.

A copy of the complete guideline can be found at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/FINALOpioidGuideline010713.pdf

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