New coverage for opioid and sedative-hypnotic medications

WorkSafeBC’s provision of health care benefits focuses on supporting attending physicians in following evidence-based medical best practices. The goal is to achieve optimum outcomes and safe return to work for injured workers.

Consequently, our pain management principles and medical best practices follow Doctors of BC’s Evidence-Based Recommendations for Medical Management of Chronic Non-Malignant Pain: Reference Guide for Clinicians. The guidelines for management of chronic noncancer pain can be found online at bcmj.org/worksafebc/evidence-based-treatment-chronic-pain (BCMJ 2010;52:515).

In accordance with these principles and practices, clinical evidence suggests that the long-term use of high-dose opioids to manage pain may be associated with certain risks. These risks include developing tolerance, dependence, and potential addiction to these medications, as well as heightened pain sensitivity and accidental death. In addition, long-term use of opioids may not improve physical function or pain.

As a result, WorkSafeBC is updating its policy on coverage of costs for opioid and sedative-hypnotic medications. Effective 1 January 2015, WorkSafeBC will cover the cost of opioid medication for up to a maximum of 4 weeks postinjury or postsurgery. (Our current policy allows for payment up to 8 weeks postinjury or postsurgery.)

In exceptional cases, WorkSafeBC may pay for extensions of opioid prescriptions beyond the 4-week acute period (see the details, below). There is no change, however, in the duration of coverage for sedative-hypnotics—WorkSafeBC will pay for sedative-hypnotic medication for up to 2 weeks.

Sedative-hypnotics coverage
Sedative-hypnotics are generally prescribed for patients with sleep disturbances. WorkSafeBC will cover the costs of these prescriptions only when their use is directly related to compensable injuries.

Should an injured worker be having difficulty sleeping as a direct result of a compensable injury, WorkSafeBC may pay for sedative-hypnotic medication for up to 2 weeks. WorkSafeBC does not pay for this class of medication to treat sleep disturbances on a long-term basis and does not pay for sedative-hypnotics when they’re prescribed for chronic pain. Instead, WorkSafeBC funds long-term treatments that address the injured worker’s underlying issues and compensable injuries.

Three other circumstances WorkSafeBC will consider for reimbursement of sedative-hypnotics are as follows:
•    Compensable psychiatric conditions, such as posttraumatic stress disorder, if the worker is under a psychiatrist’s care.
•    Preoperative or preprocedure (including imaging) use of sedative-hypnotic medication—prescription coverage for 1 to 2 days.
•    Treatment of spasticity associated with significant compensable spinal cord injuries.

Opioid prescriptions that exceed time limits
If WorkSafeBC receives a request to pay for an opioid prescription beyond 4 weeks, the prescribing physician will be sent a form asking if the intent is to continue the prescription. If the answer is yes, the physician will be asked on the form to provide further information on risk-scoring the patient’s goals for pain and functional improvement. A WorkSafeBC medical advisor will then contact the physician to discuss the extension request.

If the answer is no, the physician needs to simply tick the box in question, indicating that opioid medications are no longer recommended.

Regardless of whether the intent is to continue prescribing opioids, the physician must complete and return the form within 2 weeks. The form is billable as a “standardized assessment form,” using fee code 19909 ($75) or fee code 19910 ($70).

The payment for opioid medication prescriptions will be extended for up to 4 weeks—in addition to the 4-week period allowed by policy—to allow time for the physician to respond and for WorkSafeBC to complete its review.

Please note that WorkSafeBC includes tramadol/Tramacet in its list of controlled opioids.

For more information
WorkSafeBC’s Practice Directive on Claims with Opioids, Sedative-Hypnotics or Other Drugs of Addiction Prescribed is posted on worksafebc.com. Click on Health Care Providers, then Physicians, then Policy & Practice. (We will be updating the Practice Directive in January 2015 to reflect the new 4-week time limit for payment of opioid medication.)
—Nancy McLachlan, LLB
—Peter Rothfels MD, ASAM

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.