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Rules target opioid prescriptions

The North Carolina Industrial Commission is proposing rules that specify protocols healthcare providers should follow when prescribing opioids and related pain medications.

Specifically, providers must document the need for an opioid, and prescribe medication not to exceed a five-day supply, or seven-day post-surgery. Also, providers are asked to use the lowest effective dose, not to exceed 50 MME/day, using one-short acting opioid only.

The proposed rules specify healthcare providers are not to use transdermal, transmucosal, or buccal opioids without documenting that oral dosing would be inadequate. In chronic pain management, the rules propose administering a presumptive urine drug test.

“The provider has discretion regarding prescribing opioid while waiting for confirmatory UDT results. After the first UDT, administer 2-4 UDTs per year within the provider’s discretion using the same protocol,” the rules state.

The Industrial Commission has included provisions about prescribing benzodiazepines, carisoprodol, opioid antagonists, as well as non-pharmacological pain treatment and dependence or addiction referrals.

A public hearing is scheduled for March 2, 2018 at 2:30 p.m., and the Commission will accept written comments until March 19, 2018. The earliest effective date of the proposed rules, if approved by the Rules Review Commission and adopted by the Industrial Commission, would be May 1, 2018.

The agency adopted a labor-intensive, comprehensive process in developing the guidelines. Chairman Charlton Allen appointed a multi-disciplinary task force in February 2017 and the task force met regularly over several months. The Commission also reviewed rules and policies followed by 15 or so states. Meredith Henderson, executive secretary at the agency, will discuss the proposed rules in an hour-long presentation at the upcoming annual conference of the North Carolina Association of Self-Insurers.

The task force included representatives from public health, TPAs, the North Carolina Hospital Association, Pain Society of the Carolinas, the North Carolina Society of Anesthesiologists, and attorneys for injured workers and employers, among others. Stephanie Gay, vice president of the North Carolina Association of Self-Insurers, also served on the task force.

As has been amply documented, the U.S. is grappling with an opioid crisis. According to a 2014 study from the Centers for Disease Control and Prevention, North Carolina is among the dozen or so states where there may be more prescriptions than people (between 96-143 prescriptions per 100 people.) A 2012 report from the CDC noted that physicians nationwide had written 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills.

Observers have also pointed out that not only are too many physicians prescribing opioids for injured workers when alternatives are available, they are often not monitoring their patients as called for in various guidelines. In its study of longer-term opioid use, The Workers Compensation Research Institute found only 4% - 9% of injured workers received psychological evaluations and only 3% - 8% received psychological treatments.

“Even in states with the highest use of these services, only one in three injured workers with longer-term opioid use had a psychological evaluation and one in seven received psychological treatment,” WCRI reported.