Date: April 10, 2017

Dear Provider:

In March of 2016, the CDC released the Guidelines for Prescribing Opioids for Chronic Pain. The summary of evidence demonstrates that the risk of opiate use greatly outweighs the benefit for the majority of patients. Their in-depth review echoed conclusions drawn by many other organizations- the benefit gained from the long-term use of opiates for chronic, non-cancer pain does not outweigh the associated risks of using the medication. Population studies of death rates and prescribing practices demonstrate a close relationship between the amount of opiates prescribed and deaths related to their use. In short, there is inadequate evidence to support long-term opiate use for chronic, non-cancer pain.

Tuality Health Alliance's Policy for opioid reduction for chronic non-cancerous pain of the back and spine is based on the Oregon Health Authority (OHA) Prioritized List Guideline Notes implemented by the State of Oregon on July 1, 2016 and defined by OHA Prioritized list Guideline Notes 56 and 60. The guideline notes define the progression for opioid reduction associated with treatment of chronic pain of the back and spine from July 1, 2016 through December 31, 2017.

Opioid medication for conditions of the back and spine will be covered until June 1, 2017 on THA's current 90 Morphine Equivalent dose (MEQ). Continuing after June 1, THA will require an individual treatment plan including a tapering schedule with an end to opioid therapy by December 31, 2017. The treatment plan needs to include non-pharmacological treatments such as Physical Therapy, Chiropractic care, Acupuncture or other treatments referenced in OHA Guideline Note 56 of the prioritized list.

Within the next few weeks some providers will be receiving a focused list of patients within their practice. These patients have been identified as receiving chronic opioid treatment for back or spine pain and will need an opioid reduction schedule for continued coverage of their opioid medication. Please contact us if they are no longer being treated by you or others within your practice.

If a Provider believes the patient has developed a dependence and/or addiction to opioids and cannot be tapered off before or by January 1, 2018, the patient should be evaluated for a substance abuse disorder which is covered on Line 4 of the prioritized list. Please contact the Washington County Mental Health Member Service at 503-291-1155 for information on substance abuse referrals.

THA realizes treating chronic opioid patients for non-cancer pain of the back and spine can be difficult and the intent of the guidelines can and will be difficult to apply in certain cases. By using these guidelines as a standard for reducing and eventually stopping opioid use for chronic non-cancer pain of the back and spine, the patient will not be dependent on a drug that is harmful to themselves and indirectly to others.

An excellent resource manual titled "Pain Treatment Guidelines", produced by the Southern Oregon medical community can be found at http://professional. oregonpainguidance.org/ >: OPG Guidelines >: The Opioid Prescribers Guidelines. Additional provider guidance and resources will soon be available on THA's web page at tualityhealthalliance.org.

Sincerely,

 

Walter Hardin, D.O.

 


 

 

Health Share/Tuality Health Alliance

Policy V-21

Subject: Opioid Prescribing for Chronic Back and Spine Conditions

Objective:

To be compliant with OHA Prioritized list Guideline Note 60, Opioid Prescribing for conditions of the back and spine.

Definition:

Chronic pain is any pain that lasts for more than three to six months since onset. The pain can become progressively worse and reoccur intermittently, outlasting the usual healing process.

Policy:

  1. All THA members on chronic opioid therapy with a diagnosis associated with chronic back or spinal pain as of 01/01/17 need to be on an individual treatment plan which includes:
    1. A taper plan with an end to opioid therapy no later than January 1, 2018.
    2. A taper plan must include nonpharmacological treatment strategies as listed in Oregon Health Authority Guideline Note 56.
    3. The diagnoses affected by Guideline Note 60 are on lines 351, 361, 401 and 532.
  2. Guideline Note 56 identifies nonpharmacological treatments as:
    1. First line medications (NSAIDs, acetaminophen, and/or muscle relaxers).
    2. Up to 4 therapy visits consisting of Osteopathic Manipulation Therapy, Chiropractic Manipulation Therapy, Acupuncture, Physical Therapy, Occupational Therapy, Aqua therapy, and Massage Therapy.
    3. When available, yoga and/or supervised exercise therapy.
    4. A total of 30 therapy visits per year can be approved using any combination of the above evidence-based therapies when available and medically appropriate.
  3. Prior authorizations for opioid therapy may be approved for 30 to 90 days with a valid tapering schedule.
  4. If the member has been unsuccessful in following the providers tapering plan and the provider believes the patient has developed dependence and/or addiction related to their opioids, the patient may receive substance use treatment with Washington County Mental Health.

References:

Oregon Health Authority Guideline Note 60
Oregon Health Authority Guideline Note 56
Oregon Health Authority Guideline Note 6
CDC Guidelines for Prescribing Opioids for Chronic Pain-United States, 2016

Formulated: April 2017
Reviewed:  
Revised:  

 


GUIDELINE NOTE 6, REHABILITATIVE AND HABILITATIVE THERAPIES

Lines
34,50,61,72,75,76,78,85,95,96,135,136,140,154,157,164,182,187,188,200,201,205,206, 212,259,261,276,290,292,297,305,306,314,322,346,350,353,360,361,364,381,382,392, 406,413,421,423,427,428,436,447,459,467,470,471,482,490,501,512,558, 561,574,592,611

A total of 30 visits per year of rehabilitative therapy and a total of 30 visits per year of habilitative therapy (physical, occupational and speech therapy) are included on these lines when medically appropriate. Additional visits, not to exceed 30 visits per year of rehabilitative therapy and 30 visits per year of habilitative therapy, may be authorized in cases of a new acute injury, surgery, or other significant change in functional status. Children under age 21 may have additional visits authorized beyond these limits if medically appropriate.

Physical, occupational and speech therapy are only included on these lines when the following criteria are met:

  1. therapy is provided by a licensed physical therapist, occupational therapist, speech language pathologist, physician, or other practitioner licensed to provide the therapy,
  2. there is objective, measurable documentation of clinically significant progress toward the therapy plan of care goals and objectives,
  3. the therapy plan of care requires the skills of a medical provider, and
  4. the client and/or caregiver cannot be taught to carry out the therapy regimen independently.

GUIDELINE NOTE 60, OPIOID PRESCRIBING FOR CONDITIONS OF THE BACK AND SPINE

Lines 351,361,401,532
Opioid medications are only included on these lines under the following criteria:

For acute injury, acute flare of chronic pain, or after surgery:

  1. During the first 6 weeks opioid treatment is included on these lines ONLY
    1. When each prescription is limited to 7 days of treatment, AND
    2. For short acting opioids only, AND
    3. When one or more alternative first line pharmacologic therapies such as NSAIDs, acetaminophen, and muscle relaxers have been tried and found not effective or are contraindicated, AND
    4. When prescribed with a plan to keep active (home or prescribed exercise regime) and with consideration of additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, AND
    5. There is documented verification that the patient is not high risk of opioid misuse or abuse.
  2. Treatment with opioids after 6 weeks, up to 90 days after the initial injury/flare/surgery, is included on these lines ONLY:
    1. With documented evidence of improvement of function of at least thirty percent as compared to baseline based on a validated tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
    2. When prescribed in conjunction with therapies such as spinal manipulation, physical therapy, yoga, or acupuncture.
    3. With verification that the patient is not high risk for opioid misuse or abuse. Such verification may involve
      1. Documented verification from the state's prescription monitoring program database that the controlled substance history is consistent with the prescribing record
      2. Use of a validated screening instrument to verify the absence of a current substance use disorder (excluding nicotine) or a history of prior opioid misuse or abuse
      3. Administration of a baseline urine drug test to verify the absence of illicit drugs and non-prescribed opioids.
    4. Each prescription must be limited to 7 days of treatment and for short acting opioids only
  3. Chronic opioid treatment (>90 days) after the initial injury/flare/surgery is not included on these lines except for the taper process described below.

Transitional coverage for patients on long-term opioid therapy as of July 1, 2016:

For patients on covered chronic opioid therapy as of July 1, 2016, Opioid medication is included on these lines only from July 1, 2016 to December 31, 2016. During the period from January 1, 2017 to December 31, 2017, continued coverage of opioid medications requires an individual treatment plan developed by January 1, 2017 which includes a taper with an end to opioid therapy no later than January 1, 2018. Taper plans must include nonpharmacological treatment strategies for managing the patient's pain based on Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE. If a patient has developed dependence and/or addiction related to their opioids, treatment is available on Line 4 SUBSTANCE USE DISORDER


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How to Approach an Opioid Taper/Cessation

Indication Recommended Length of Taper Degree of Shared Decision Making About Opioid Taper Intervention/Setting
Substance Use Disorder No Taper
Immediate Referral
None
Provider's choice alone
Intervention: Transition to medication assisted treatment (Buprenorphine or Methadone) maintenance therapy, Naloxone rescue kit.

Setting: Inpatient or outpatient Buprenorphine (OBOT) or Methadone

Diversion No Taper* None
Provider's Choice Alone
Determine need based on actual use of opioids, if any
At risk for Immediate severe harms Weeks to months Moderate
Provider led & patient views sought
Intervention:Supportive Care
Naloxone rescue kit

Setting: Outpatient opioid taper

Therapeutic Failure Months Moderate
Provider led & patient views sought
Intervention: Supportive Care.
Naloxone rescue kit

Setting: opioid taper

Option: buprenorphine (OBOT)

At risk for smaller harms Months to year Moderate
Provider led & patient views sought
Intervention: Supportive care.
Naloxone rescue kit Setting: Outpatient opioid taper
Option: buprenorphine

Table by Melissa Weimer, DO, 2016


Opioid Tapering Flow Sheet

START HERE

Consider opioid taper for patients with opioid MED> 90 mg/d or methadone> 30 mg/d, aberrant behaviors,
significant behavioral/physical risks, lack of improvement in pain and function.

  1. Frame the conversation around tapering as a safety issue.
  2. Determine rate of taper based on degree of risk.
  3. If multiple drugs involved, taper one at a time (e.g., start with opioids, follow with BZPs).
  4. Set a date to begin and set a reasonable date for completion. Provide information to the patient
    and establish behavioral supports prior to instituting the taper. See OPG guidelines.

 

OPIOID TAPER

Opioids

Basic principle: For longer-acting drugs and a more stable patient, use slower taper. For shorter-acting drugs,
less stable patient, use faster taper.

  1. Use an MED calculator to help plan your tapering strategy. Methadone MED calculations increase
    exponentially as the dose increases,so methadone tapering is generally a slower process.
  2. Long-acting opioid: Decrease total daily dose by 5-10% of initial dose per week.
    Short-acting opioids:Decrease total daily dose by 5-15% per week.
  3. See patient frequently during process and stress behavioral supports. Consider UDS, pill counts, and POMP to
    help determine adherence.
  4. After% to Y2 of the dose has been reached, with a cooperative patient, you can slow the process down.
  5. Consider adjuvant medications: antidepressants, gabapentin, NSAIDs, clonidine, anti-nausea, anti-diarrhea
    agents.

 

MED for Selected Opioids

 

Opioid Approximate Equianalgesic
Dose (oral and Transdermal)
Morphine (reference) 30mg
Codeine 200mg
Fentanyl transdermal 12.5mcg/hr
Hydrocodone 30mg                                            Morphine Equivalent Dosing (MED) Calculator:  
Hydromorphone           7.5mg                      agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm »
Methadone Chronic      4mg         
Oxycodone 20mg
Oxymorphone 10mg
Tapentodol 75mg
Tramadol 300 mg

 

OPIOID PRESCRIBING GUIDELINES  -	A Provider and Community Resource                May 2016

 


Tapering Opioids:

  • Opioid taper should be considered for patients on >90 MED or methadone >30mg/day, aberrant
    behaviors, significant behavioral/physical risks, or lack of improvement in pain and function
  • Calculate total daily Morphine Equivalent Dose of all opioids.Opioid dose calculator available
    at http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm »
  • Taper dose of opioid by 5-15% per week
  • Follow-up with the patient frequently and provide behavioral supports.
  • After 1/4 to 1/2 of the dose has been reached, with a low risk patient, you may slow the process down.
  • Consider adjuvant therapies as needed including antidepressants, gabapentin, NSAIDS,clonidine,
    anti-nausea and anti-diarrheal medications.
  • See the Oregon Pain Guidance website for additional information on opioid tapers
    at http://www.www.oregonpainguidance.com/clinical-tools/ »

 

Oregon Prescription Drug Monitoring Program(OPDMP);

  • Sign up for the Oregon Prescription Drug Monitoring Program at http://www.orpdmp.com »
  • A delegate may be authorized to access the OPDMP on behalf of the prescriber.
  • Check the OPDMP BEFORE prescribing any opioids or other controlled substances.

References:

  1. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. Centers for Disease
    Control and Prevention MMWR. 15 March 2016. Early Release/Vol
    65. http://thalliance.wpengine.com/wp-content/uploads/2017/05/rr6501e1er-ebook.pdf »
  2. Oregon Pain Guidance Pain Treatment Guidelines: A Provider and Community
    Resource. www.oregonpainguidance.org. » Updated May 2016.

Western Oregon Advanced Health


ANCILLARY/DIAGNOSTIC GUIDELINE NOTES FOR THE (from Oregon Health Plan website)

(from Oregon Health Plan website)

11112016 PRIORITIZED LIST OF HEALTH SERVICES AS IMPLEMENTED

 

Table 04

Low Back Pain – Potentially Serious Conditions ("Red Flags") and Recommendations for Initial Diagnostic Work-up

Possible cause

Key features on history or physical examination

Imaging*

Additional studies*

Cancer

  • History of cancer with new onset of LBP

MRI

ESR
  • Unexplained weight loss
  • Failure to improve after 1 month
  • Age >50 years
  • Symptoms such as painless neurologic deficit, night pain or pain increased in supine position
Lumbosacral plain radiography
  • Multiple risk factors for cancer present

Plain radiography or

MRI

Spinal column infection
  • Fever
  • Intravenous drug use
  • Recent infection
MRI ESR and/or
CRP
Cauda equina syndrome
  • Urinary retention
  • Motor deficits at multiple levels
  • Fecal incontinence
  • Saddle anesthesia

MRI

None

Vertebral compression fracture
  • History of osteoporosis
  • Use of corticosteroids
  • Older age
Lumbosacral plain radiography

None

Ankylosing spondylitis

  • Morning stiffness
  • Improvement with exercise
  • Alternating buttock pain
  • Awakening due to back pain during the second part of the night
  • Youngerage

Anterior-posterior pelvis plain radiography

ESR and/or
CRP, HLA-B27
Nerve compression/ disorders
(e.g. herniated disc with radiculopathy)
  • Back pain with leg pain in an L4, L5, or S1 nerve root distribution present < 1 month
  • Positive straight-leg-raise test or crossed straight-leg-raise test

None

None

  • Radiculopathic** signs present >1 month
  • Severe/progressive neurologic deficits (such as foot drop), progressive motor weakness
MRI*** Consider
EMG/NCV
Spinal stenosis
  • Radiating leg pain
  • Older age
  • Pain usually relieved with sitting

(Pseudoclaudication a weak predictor)

None None
  • Spinal stenosis symptoms present >1 month
MRI** Consider
EMG/NCV

* Level of ev1dence for d1agnost1c evaluat1on IS vanable
** Radiculopathic signs are defined for the purposes of this guideline as in Guideline Note 37 with any of the following:

  1. Markedly abnormal reflexes
  2. Segmental muscle weakness
  3. Segmental sensory loss
  4. EMG or NCV evidence of nerve root impingement
  5. Cauda equina syndrome,
  6. Neurogenic bowel or bladder
  7. Long tract abnormalities

*** Only if patient is a potential candidate for surgery or epidural steroid injection

Red Flag: Red flags are findings from the history and physical examination that may be associated with a higher risk of serious
disorders. CRP = C-reactive protein; EMG =electromyography; ESR =erythrocyte sedimentation rate; MRI =magnetic resonance
imaging; NCV = nerve conduction velocity.

Extracted and modified from Chou R, Qaseem A, Snow V, eta/: Diagnosis and Treatment of Low Back Pain: A Joint Clinical
Practice Guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007; 147:478-491.

The development of this guideline note was informed by a HERC coverage guidance. See
http://www.oregon.gov/oha/herc/Pages/blog-adv-imaging-low-back.aspx »

3-15-2016

 

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GENERAL RESOURCES

 

CDC Guideline for Prescribing Opioids for Chronic Pain

https://www.cdc.gov/drugoverdose/prescribing/guideline.html »

Oregon Opioid Prescribing Guidelines

https://public.health.oregon.gov/PreventionWellness/SubstanceUse/Opioids/Documents/taskforce/oregon-opioid-prescribing-guidelines.pdf »

Washington State Agency Medical Directors' Guideline

http://thalliance.wpengine.com/wp-content/uploads/2017/05/OpioidGdline.pdf »

Oregon Prescription Drug Monitoring Program

Http://www.orpdmp.com/»

PRACTICE RESOURCES

Oregon Pain Guidance Resource

http://portlandprofessional.oregonpainguidance.org/tools-for-professionals/ »

My Top Care – practical resources on how to implement changes to prescribing for providers, patients and pharmacists

http://mytopcare.org/prescribers/ »

Documentation Templates – The Pain Assessment and Documentation Tool

http://thalliance.wpengine.com/wp-content/uploads/2017/05/Passik.pdf »

Interagency Guideline on Opioid Dosing for Chronic Non–cancer Pain

http://thalliance.wpengine.com/wp-content/uploads/2017/05/OpioidGdline.pdf »

Oregon Pain Guidance Website – useful information for patients and providers about managing pain, risks, preventing overdose, and real stories

http://portlandmetro.oregonpainguidance.org/ »

CDC Guideline Resources: Clinical Tools

https://www.cdc.gov/drugoverdose/prescribing/clinical-tools.html »

Urine Drug Testing Resources

http://mytopcare.org/prescribers/about-urine-drug-tests/ »

PROVIDER EDUCATION

Providers’ Clinical Support System for Opioid Therapy (PCSS-O)

http://pcss-o.org/ »

Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT)

http://pcssmat.org/ »

CDC’s Clinician Outreach and Communication Activity (COCA)

https://www.cdc.gov/drugoverdose/prescribing/trainings.html »

Boston University Safe and Competent Opioid Prescribing (SCOPE)

https://www.scopeofpain.com/ »

My Top Care

http://mytopcare.org/prescribers/ »

NALOXONE

Oregon Pain Guidance Naloxone Site

http://portlandprofessional.oregonpainguidance.org/overdose-naloxone/information-for-pharmacists/ »

Naloxone for overdose prevention/treatment

https://public.health.oregon.gov/ProviderPartnerResources/EMSTraumaSystems/Pages/epi-protocol-training.aspx »

Naloxone

http://prescribetoprevent.org/prescribers/palliative/ »

PATIENT EDUCATION

CDC Patient and Partner Tools

https://www.cdc.gov/drugoverdose/prescribing/patient-tools.html »

Opioid Information, Side, Pain Relief, etc

http://mytopcare.org/patients/ »

 

Above resources are from OHSU resource appendix from Adult Safe Opioid Prescribing Guideline for Chronic, Non–End Of Life Pain and Practice Resources for Clinical implementation.

Additional Resources

OPG Oregon Pain Guidance; Southern Oregon

http://professional.oregonpainguidance.org/introduction/