Opioid and sedative-hypnotic coverage: An update

WorkSafeBC’s provision of health care benefits focuses on supporting physicians in following evidence-based medical best practices. The goal: to achieve optimum outcomes and safe return to work for injured workers. Our pain management principles and medical best practices follow the BCMA’s Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain: Reference Guide for Clinicians.

WorkSafeBC’s long-established policy is to cover the costs of opioid and sedative-hypnotic medications for injured workers for up to 8 weeks postinjury or postsurgery. Under special or extenuating circumstances, WorkSafeBC may cover the costs beyond this acute period.

Clinical evidence suggests that long-term use of high-dose opioids may be associated with certain risks, including developing tolerance, de­pendence, and potential addiction, as well as accidental death and heightened pain sensitivity. In addition, long-term use of opioids may not improve physical function or pain management.

While opioid prescriptions con­tiue to be covered for 8 weeks post­injury or postsurgery, starting this spring, WorkSafeBC will introduce a new practice for the reimbursement of prescription sedative-hypnotics and other drugs in the benzodiazepine class.

Sedative-hypnotics
Sedative-hypnotics are generally prescribed for patients with sleep disturbances. For WorkSafeBC to cover the costs of these prescriptions, their use must be directly related to a compensable injury.

Where the injured worker is having difficulty sleeping as a direct result of a compensable injury, WorkSafeBC may pay for sedative-hypnotic medication for up to 2 weeks postinjury or postsurgery. WorkSafeBC does not pay for this class of medication to treat sleep disturbances on a long-term basis. 

In particular, WorkSafeBC does not reimburse for sedative-hypnotics used for chronic pain or muscle spasm. Instead, we fund treatments that ad­dress the injured worker’s underlying issues and compensable injuries.

There are exceptions where WorkSafeBC will consider reimbursement:

• Compensable psychiatric conditions, such as PTSD, where the worker is under the care of a psychiatrist.
• Preoperative or pre-procedure use of a sedative-hypnotic medication—a prescription for 1 to 2 days will be covered.
• Spinal cord injuries—this class of medication will be covered to treat spasticity associated with significant compensable spinal cord injuries.

Prescriptions beyond WorkSafeBC’s time limits
If WorkSafeBC receives a request for a prescription for opioids beyond 8 weeks postinjury/surgery or sedative-hypnotics beyond 2 weeks postinjury/surgery, we may send prescribing phy­sicians a form (68D80) that asks if they intend to continue the prescription.

If the answer is yes, the form will request further information on risk-scoring the patient and goals for pain/function improvement; subsequently, a medical advisor will contact the physician to discuss the request for extension. If the answer is no, the form is complete.

Whether the answer is yes (requiring full completion of the form), or no (requiring no further information), you have 2 weeks to complete and return the form. The form is billable as a “standardized assessment form” using fee code 19909 ($75).

Please note that WorkSafeBC in­cludes tramadol (Tramacet) in the list of controlled opioids. The above procedure applies to prescriptions of these medications beyond 8 weeks postinjury/surgery.

Evidence-based practice
The new WorkSafeBC practice regarding sedative-hypnotics is consistent with evidence-based best practices.

There is no evidence available on the efficacy or effectiveness of benzo­diazepines in treating musculo­skeletal chronic pain.[1-3] In addition, no evidence-based clinical practice guidelines from national or international major pain organizations recommend the use of benzodiazepines to treat pain[4] or muscle spasms.

For more information
WorkSafeBC’s practice directive on Claims with Opioids, Sedative-Hypnotics or Other Drugs of Addiction Prescribed is posted at WorkSafeBC.com. Click on Health Care Pro­viders, then Physicians, and finally Policy & Practice.
—Peter Rothfels, MD
Chief Medical Officer, and Director,
Clinical Services, WorkSafeBC

References

1. Institute for Clinical Systems Im­provement. 4th ed. Assessment and Management of Chronic Pain. 4th ed.
2. van Tulder MW, Touray T, Furlan AD, et al. Muscle relaxants for non-specific low-back pain. Cochrane Database Syst Rev 2003;(2)CD004252. 
3. King SA, Strain JJ. Benzodiazepine use by chronic pain patients. Clin J Pain 1990;6:143-147.
4. O’Connor AB, Dworkin RH. Treatment of neuropathic pain: An over­view of recent guidelines. Am J Med 2009;122:S22-S32.