DESCRIPTION
Pain is an inevitable part of life, serving either as a warning or notice of actual or perceived injury. It is the most common reason an individual seeks medical care. According to the United States government’s annual report of Americans’ health, 25% of adults suffered a daylong bout of pain in the past 30 days and 10% of Americans suffer from pain every day. The most common location of pain is back pain, followed by headaches and arthralgias.
The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” This definition makes it clear that pain is more than a physical reaction to a stimulus and that there are multiple kinds of pain which require classification to assist in determining treatment pathways.
The most common categories of pain classification are acute and chronic. Acute pain usually results from injury or inflammation. It is the normal predicted physiologic response with survival value. It may play a role in the healing process by promoting behavior that minimizes reinjury and is usually of short duration. While 2 to 3 months is a generally accepted time frame for an acute pain condition, there is no clear understanding when or how it can transition into chronic pain, a condition which serves no useful purpose in a healing process. Chronic pain typically develops from acute pain between 3 to 6 months and is considered pathologic.
In the treatment of pain, understanding the equianalgesic effect of various opioids and their differing doses by converting them into morphine equivalent dosing (MED or MEqD) assists in decision making for adequate but not excessive pain control. Information on this conversion can be found from many sources. One user-friendly source can be found at the Center for Disease Control: http://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.
This policy addresses the use of opioids for the treatment of acute pain.
This policy is not intended to address the use of opioids in the treatment of active cancer pain, hospice care, or pain relief associated with a diagnosis of sickle cell anemia.
POLICY
The use of opioids in the treatment of acute pain is considered medically appropriate if ALL of the following criteria/documentation are provided:
Diagnosis
is not for pain of
active
cancer or hospice/end-of-life pain relief, or pain relief associated
with a diagnosis of sickle cell anemia
Diagnosis and medical reason for the requested medication is clearly indicated accompanied by supporting records
Diagnoses that do not fall into the category of surgical repair, tissue damage with visible inflammation, physical injury or other condition with a typical measurable timeline for healing require a second opinion (e.g., pain specialist, oncologist) in agreement with the necessity for the use of opioids in their treatment for individuals with an elevated morphine equivalent daily dose greater than 90 mg/day and/or a history of substance abuse disorder (including alcohol).
Review of history and physical
Initial urine drug screen assessment
Risk assessment for aberrant behavior associated with opioid misuse, such as scores from ANY ONE of the following tools:
SOAPP® (Screener and Opioid Assessment for Patients with Pain) for a new opioid user
COMM™ for a current opioid user
ORT (Opioid Risk Tool)
Pain management agreement signed by individual and provider (copy provided)
Recent copy of state controlled substance database (screenshot including requested agent sufficient)
For the initial request, the choice is for a short-acting opioid with dosage to be calculated using MEqD (morphine equivalent dosing) [see http://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf]
If the initial opioid prescriptive was not effective, documentation of all analgesics failed, including start/end dates and response(s) must be provided.
APPLICABLE TENNESSEE STATE MANDATE REQUIREMENTS
BlueCross BlueShield of Tennessee’s Medical Policy complies with Tennessee Code Annotated Section 56-7-2352 regarding coverage of off-label indications of Food and Drug Administration (FDA) approved drugs when the off-label use is recognized in one of the statutorily recognized standard reference compendia or in the published peer-reviewed medical literature.
SOURCES
American Pain Society. (2009, February). Opioid treatment guidelines. The Journal of Pain. Retrieved February 4, 2016 from http://www.jpain.org/article/S1526-5900(08)00830-4/pdf.
Centers for Disease Control and Prevention. (2016) Proposed 2016 guideline for prescribing opioids for chronic pain. Retrieved February 4, 2016 from http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0001.
Centers for Disease Control and Prevention. (2016). National Center for Injury Prevention and Control. Common elements in guidelines for prescribing opioids for chronic pain. Retrieved February 4, 2016 from http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids 20160125-a.pdf.
State of Tennessee: Rules of the Tennessee Department of Health. (2012). Division of Pain Management Clinics. Chapter 1200-34-01-.09 Training Requirements. Retrieved February 17, 2016 from http://share.tn.gov/sos/rules/1200/1200-34/1200-34-01.20120326.pdf.
Washington State Department of Labor and Industries. (2013, July). Guideline for prescribing opioids to treat pain in injured workers. Retrieved January 28, 2016 from National Guideline Clearing Clearinghouse.
ORIGINAL EFFECTIVE DATE: 7/1/2016
MOST RECENT REVIEW DATE: 2/15/2024
ID_Pharmacy
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