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Commission adopts rules on opioid use

Effective May 1, 2018 healthcare providers prescribing opioids, related prescriptions, and pain management treatment to workers’ compensation claimants must comply with the recently developed nine rules adopted by the North Carolina Industrial Commission and approved by the state’s Rules Review Commission.

The purpose of the rules is to curtail misuse of opioids and other pain medications. The Industrial Commission, which sees the rules as proactive measures, aims to encourage non-opioid and non-pharmacological means for treating pain, along with promoting evaluation and treatment of employees with substance use disorder.

The rules cover pain prescriptions administered immediately after an injury and through the chronic phase, defined as continued treatment after 12 weeks. Although the Commission specifies that neither the recently adopted Opioid Utilization Rules or related guidance from the agency are meant to replace professional medical judgment, the Commission is unambiguous about several measures.

First, healthcare providers are to prescribe the lowest effective dosage of a targeted controlled substance, not to exceed a 50 mg morphine equivalent dose per day, using only short-acting opioids. Also, neither fentanyl, methadone, or carisoprodol is to be prescribed in the acute phase. Further, the rules do not allow prescribing benzodiazepines for pain or as muscle relaxers in the acute or chronic phase.

The rules allow for exceptions and waivers in case of a disagreement among healthcare providers and employers/carriers, or where a claimant may disagree with the prescribed treatment. The Commission notes it is expected the parties will be able to resolve disputes about treatment. If they cannot, the agency will step in and issue an order, if requested.

“An employer or carrier may authorize treatment outside of the Rules based on medical documentation and communication with the healthcare provider. Nothing in the Rules prevents the parties from reaching an agreement for safe recommended treatment outside the Rules,” the agency adds.

In promulgating the recent rules, the Industrial Commission reviewed opioid and pain management measures in more than a dozen states and also benefited from recommendations from its interdisciplinary task force appointed in February 2017. The task force included representatives from public health, TPAs, healthcare providers, and attorneys for injured workers and employers. Stephanie Gay, vice president of the North Carolina Association of Self-Insurers, also served on the task force.

The rules are available on the agency’s website, along with a companion guide which explains and interprets the rules and walks the reader through a number of plausible scenarios. The Commission anticipates the guide will be updated and says it is open to requests and recommendations.

Recent data from the National Council on Compensation Insurance and from the California Workers’ Compensation Institute, among others, shows opioid use falling in workers’ compensation, thanks to steps taken by regulators and payors and because of public awareness.

NCCI reports that in 2012, 55% of claimants with a prescription were prescribed an opioid; by 2016, that share decreased to about 45%. California reports that between 2007-2017, opioid prescriptions in workers’ compensation declined from 32.1% of all prescriptions to 23.2%.