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 after between 3 to 6 months and is considered pathologic. Chronic pain may have no known triggering event or initial acute pain condition.
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 chronic pain. While acknowledging that chronic pain may be undertreated, it is also intractable. The use of opioids in its treatment does not provide for complete elimination of pain in most cases, which in itself is not proof of undertreatment, but is often the nature of side-effects or rebound effects of overtreatments of many opioid agents.
It must also be understood that many prescriptive opioid agents are associated with misuse, abuse and diversion and that healthcare providers have contributed, often inadvertently, to such activity. It is the purpose of this policy to assist in the prevention of the misuse of opioid analgesics for chronic pain conditions.
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 chronic pain not associated with active cancer, hospice/end-of-life pain relief, or pain relief associated with a diagnosis of sickle cell anemia is considered medically appropriate if ANY ONE of the following:
Request is for initial treatment with ALL of the following:
Diagnosis, evaluation and medical assessment for the requested medication is clearly indicated accompanied by supporting records indicating ALL the following:
Nature of pain
Intensity of pain
Past and current treatments of pain (e.g., receiving opioids in treatment of acute pain)
Underlying or co-occurring disorders and conditions
Effect of the pain on physical and psychological functioning
Review of history, physical examination and laboratory findings
Current urine drug screen assessment
Social and vocational assessment to identify supports and obstacles to treatment and rehabilitation
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)
Screen for depression and other mental health disorders (provide applicable tools/scores)
Documentation of review of state controlled substance database (screenshot including requested agent sufficient)
Individual with a diagnosis of intractable pain (defined as pain that is difficult to manage, alleviate, remedy, or cure, is sustained and persistent rather than brief and intermittent, and interferes with activities of daily living) from a chronic condition lasting for greater than or equal to 90 days with an elevated morphine equivalent daily dose greater than 90 mg/day and/or a history of substance abuse disorder (including alcohol) has treatment by or consultation with specialist in pain medicine or oncologist meeting ANY ONE of the following (as defined in the Rules of the Tennessee Department of Health Division of Pain Management Clinics Chapter 1200-34-01-.09 Training Requirements):
Appropriate residency program in physical medicine and rehabilitation, anesthesiology, addiction medicine, neurology, neurosurgery, family practice Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS)
Board Certification approved by the ACGME or AOABOS
Subspecialty certification in pain medication and others recognized by the ABMS or AOABOS with a certificate of added qualification from the Bureau of Osteopathic Specialists
Board certification by the American Board of Pain Medicine
Board certification by the American Board of Interventional Pain Physicians
Completion of forty (40) hours of in-person, live-participatory AMA Category I or AOABOS Category I CME coursework in pain management
10 hours continuing education courses during each health care provider’s licensure renewal cycle which shall be a part of the continuing education requirements established by each of the health care provider’s respective boards addressing a minimum of ANY ONE of the following:
Prescribing controlled substances
Drug screening or testing, including usefulness and limitations
Pharmacological and non-pharmacological pain management
Completing a pain management focused history and physical examination and maintaining appropriate progress notes
Comorbidities with pain syndromes
Substance abuse and misuse including diversion, prevention of same, and risk assessment for abuse
Treatment plan in place between member and provider, including goals, monitoring and periodic drug testing agreement
Dosages of opioids are to be calculated using MEqD (morphine equivalent dosing) [e.g., http://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf]
Therapeutic trial should begin with ANY ONE of the following:
Short-acting opioids for opioid-naïve individuals at lowest dose possible
Lowest-dose long-acting opioid possible
Request is for maintenance therapy or dosage reevaluation with ALL of the following:
Diagnosis, evaluation and medical assessment for the requested medication is clearly indicated accompanied by supporting records indicating ALL the following:
Nature of pain as affected by medication
Intensity of pain with opioid analgesia
Past and current treatments of pain and any changes requested
Underlying or co-occurring disorders and conditions
Effect of the pain on physical and psychological functioning/improvements/worsening
Review of history, physical examination and laboratory findings
Current urine drug screen assessment
Social and vocational assessment to identify supports and obstacles to treatment and rehabilitation-changes and updates
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)
COMM™ for a current opioid user
ORT (Opioid Risk Tool)
Pain management agreement signed by individual and provider, updated in the past six months
Documentation provided of the results of assessment of chronic opioid therapy with ANY ONE of the following:
Outcome of ALL of the following (the 5 A’s):
Analgesia - is there a reduction in pain
Activity - demonstrated improved level of function
Adverse effects evident
Aberrant substance related behaviors
Affect or mood of individual
Results of assessment tool such as “Pain, Enjoyment and General Activity” (PEG) scale
Individual with a diagnosis of intractable pain (defined as pain that is difficult to manage, alleviate, remedy, or cure, is sustained and persistent rather than brief and intermittent, and interferes with activities of daily living) from a chronic condition lasting for greater than or equal to 90 days with an elevated morphine equivalent daily dose greater than 90 mg/day and/or a history of substance abuse disorder (including alcohol) has treatment or consultation with specialist in pain medicine or oncologist meeting ANY ONE of the following as defined in the Rules of the Tennessee Department of Health Division of Pain Management Clinics Chapter 1200-34-01-.09 Training Requirements:
Appropriate residency program in physical medicine and rehabilitation, anesthesiology, addiction medicine, neurology, neurosurgery, family practice Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS)
Board Certification approved by the ACGME or AOABOS
Subspecialty certification in pain medication and others recognized by the ABMS or AOABOS with a certificate of added qualification from the Bureau of Osteopathic Specialists
Board certification by the American Board of Pain Medicine
Board certification by the American Board of Interventional Pain Physicians
Completion of forty (40) hours of in-person, live-participatory AMA Category I or AOABOS Category I CME coursework in pain management
10 hours continuing education courses during each health care provider’s licensure renewal cycle which shall be a part of the continuing education requirements established by each of the health care provider’s respective boards addressing a minimum of ANY ONE of the following:
Prescribing controlled substances
Drug screening or testing, including usefulness and limitations
Pharmacological and non-pharmacological pain management
Completing a pain management focused history and physical examination and maintaining appropriate progress notes
Comorbidities with pain syndromes
Substance abuse and misuse including diversion, prevention of same, and risk assessment for abuse
Treatment plan in place between member and provider, including goals, monitoring and periodic drug testing if any changes from previously submitted plan
Dosages of opioids are to be calculated using MEqD (morphine equivalent dosing) [e.g., http://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf]
Long-acting, extended-release opioid formulations, or short-acting opioids for breakthrough pain should be prescribed at lowest possible dose, including available abuse-deterrent formulations, in an approval duration no longer than 6 months not to exceed current BCBST quantity limits
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.
Federation of State Medical Boards. (2012, March). Model policy for the use of opioid analgesics in the treatment of chronic pain. Retrieved February 4, 2016 from http://www.azdo.gov/Files/FSMBPainMgmt.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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