Medical Aid – Opioids Policy 25-012 | Effective Date: January 1, 2020

Statements

The Canadian Medical Association remains concerned about the potential harms of opioids, including dependence, overdose and death. Opioids are a class of medication that are highly addictive and have the potential to cause more harm than good in some situations.

Under ss. 41(1), WorkSafeNB may provide medical aid that it considers necessary as a result of a worker’s  work-related injury.

As such, WorkSafeNB manages, monitors and controls the use of opioids as a medical treatment by:

• Designating opioids as effective for the treatment of certain injuries or diseases;
• Determining if opioids are appropriate for individual rehabilitation plans;
• Following accepted medical prescribing guidelines; and
• Promoting harm reduction.

When opioids are prescribed for treatment of terminal cancer, due to a workplace injury or disease, this policy will not apply.

Interpretation

1.0 Designating Opioids as an Effective Treatment

WorkSafeNB includes opioids on a default formulary when the injured worker is:

• In the acute stages of treatment for a compensable injury (the first two weeks following an injury or discharge from hospital, whichever is later);
• Being treated for severe injuries with recognized, objective biological pain;
• Diagnosed and being treated for cancer as a compensable disease; or
• Being treated in the later stages of a compensable, terminal disease, which generally means a life expectancy of 12 months or less.

When opioids are not included on an injured worker’s default formulary or when prescription limits are exceeded, WorkSafeNB reviews the request to pay for prescribed opioids on a case-by-case basis using the guidelines in section 2.0 of this policy.

1.1 Standards for the Responsible Management of Opioids

Prior to approving payment for opioids, WorkSafeNB requires that opioids be:

• Prescribed by an appropriate health care provider licensed by law to prescribe opioids;
• Dispensed by an individual approved by the New Brunswick Pharmacists’ Association to dispense opioids; and
• Prescribed for two weeks following a new accident or post-surgery, and for a maximum of 50 mg morphine equivalents per day in keeping with recommendations of both the College of Physicians and Surgeons of New Brunswick, and the Canadian Medical Association.

WorkSafeNB uses recognized standards for approving use of opioids, which includes:

• Avoiding the routine and continued use of opioids for acute pain;
• Avoiding the simultaneous prescription of opioids and benzodiazepines or other sedating medications;
• Ensuring injured workers are prescribed opioids in the appropriate quantity and dosage and for the appropriate duration;
• Following the World Health Organization Pain Relief Ladder;
• Completing a medical history and physical examination of the injured worker;
• Identifying the underlying medical and psychosocial sources causing the pain and developing a treatment plan and goals based on the analysis;
• Not prescribing opioids for injured workers whose pain is idiopathic or primarily caused by psychological factors;
• Understanding that the goal of opioid analgesic therapy is demonstrable improvement in function and sustained reduction in pain rather than only pain relief;
• Considering the injured worker’s history of remote, recent or current substance abuse as a strong contraindication; and
• Discussing with injured workers the proper use of opioids, the possible side effects of the medication and the conditions for which opioids are being prescribed (i.e., quantity, dosage and limit being prescribed for the injured worker).

When opioids are prescribed outside the standards and guidelines in this policy, WorkSafeNB will contact the prescriber and offer support to ensure an appropriate opioid prescription for the injured worker.

To assist health care providers with meeting these standards, WorkSafeNB has developed the WorkSafeNB Opioid Review Process handbook.

1.2 Controls for the Responsible Management of Opioids

WorkSafeNB has developed controls to verify that prescribed opioids are within the established quantity, dosage and duration limits established for the injured worker by the treating health care provider. It allows WorkSafeNB to limit:

• Approval for opioids to one licensed prescriber; and/or
• Payment of opioids to one licensed dispenser.

In addition, WorkSafeNB requires health care providers to regularly report to WorkSafeNB on treatment goals and progress and to identify any potential misuse or abuse.

WorkSafeNB requires pharmacies to ensure that any injured worker must return their previously prescribed opioid patches, both used and unused, to the pharmacy prior to receiving their next opioid patches.

2.0 Approving and Managing Opioid Treatment for an Individual Injured Worker’s Rehabilitation

When opioids are prescribed outside the circumstances outlined in section 1.0, WorkSafeNB makes decisions to pay for prescribed opioids on a case-by-case basis. For opioids to be approved for payment, there must be:

• Evidence of demonstrable improvement in function measured on a validated functional assessment tool such as the Québec Pain Disability Scale (QPDS) or The Short Form (SF 36) Health Survey;
• Sustained reduction in pain; and
• A signed therapeutic agreement between the health care provider and the injured worker and completion of the WorkSafeNB Opioid Review Process handbook.

When opioids are prescribed beyond the initial two weeks or are not part of the injured worker’s default formulary, dosing limits apply in keeping in line with the College of Physicians and Surgeons of New Brunswick guidelines. These dosage limits are as follows:

• Up to a maximum of 90 mg morphine equivalent per day; and
• A maximum of four weeks approval at a time, for a maximum of 12 weeks.

Any opioid prescription beyond 12 weeks requires completion of a validated functional assessment tool every 12 weeks which must be reviewed by a medical advisor.

Ongoing approval is subject to demonstration of functional improvement after the initial 12-week review and thereafter, at the discretion of a medical advisor, with a minimal frequency of once per year. The WorkSafeNB Opioid Review Process handbook must be completed for ongoing approval.

WorkSafeNB will continue to apply best practices in the management of opioids for injured workers. For injured workers with prescriptions outside the guidelines prior to the effective date of this policy, continued funding of the prescription requires a harm reduction plan in keeping with the Canadian Medical Association guidelines.

2.1 Monitoring Treatments and Suspending Payment

WorkSafeNB periodically reviews injured workers’ treatment plans and goals and may offer a harm reduction program, suspend or discontinue payment for opioids prescribed for the treatment of a compensable injury or disease when, in its opinion, the prescribed opioids are:

• Not resulting in improvement of function and reduction of pain;
• Harming or impeding the injured worker’s recovery, improvement in function and/or return to work;
• Resulting in serious side effects;
• Being used in a manner not intended by the prescriber;
• Being used in combination with sedatives, such as benzodiazepines;
• Being used with an authorization of medicinal cannabis, other than as part of harm reduction; or
• Contributing to an unsafe medication regime.

2.2 Excessive or Illegal Use of Opioids

In addition to the controls and standards outlined in section 1.0 of this policy, WorkSafeNB has adopted the following controls:

• Monitoring prescription records to detect potentially problematic patterns of prescribing;
• Requiring that the prescribed opioid be compounded with another substance to reduce its resale value; and/or
• Generally only authorizing payment for the generic brand even if an equivalent brand- name opioid is available at the same cost.

Under the Controlled Drugs and Substances Act it is illegal to unlawfully give, sell, administer or lend opioids to anyone or to falsely attempt to obtain opioids. If there are reasonable grounds to suspect that the use of opioids is contrary to the Controlled Drugs and Substances Act, WorkSafeNB is obligated to notify the appropriate authorities.

2.3 Harm Reduction (Dependency and Addiction)

Even when administered properly, the use of opioids can lead to opioid use disorders, previously referred to as dependence or addiction.

When there is reasonable evidence that opioid use disorder resulted from the treatment of a compensable injury or disease, WorkSafeNB pays for the costs of harm reduction programs. WorkSafeNB works with the treating physician and injured worker to determine the appropriate course of action and modifies the treatment plan accordingly. The following conditions apply:

• When there is a delay in accessing the appropriate program, WorkSafeNB reviews ongoing payment for opioids with the treating health care provider;
• When harm reduction treatment is considered with the use of medication, buprenorphine – naloxone (brand name Suboxone) is the preferred first-line treatment when possible; and
• A stepped and integrated care approach will be used, in which treatment intensity is continually adjusted to accommodate the injured workers needs and circumstances over time.

When there is no indication that the injured worker has opioid use disorder, it is appropriate to reduce the amount and frequency of the opioid, also referred to as tapering, as part of a harm reduction plan.

If the injured worker refuses to participate in a WorkSafeNB-approved harm reduction program without a reasonable explanation, WorkSafeNB will continue to work with the injured worker and the prescriber to ensure the injured worker’s safety. WorkSafeNB may also determine whether to reduce or suspend benefits under ss. 41(16) and Policy 21-214 Determining Continued Eligibility for Loss of Earnings Benefits.