Medical Aid – Opioids Policy 25-012 | Effective Date: March 18, 2025

Policy

Under subsection 41(1) of the Workers’ Compensation Act (WC Act), WorkSafeNB may provide medical aid that it considers necessary as a result of a worker’s work-related injury. Using this authority, WorkSafeNB has determined when payment for the use of opioids will be authorized.

The Canadian Medical Association (CMA) 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. Moreover, the use of opioids as a treatment for many chronic conditions has been shown to be ineffective.

WorkSafeNB includes opioids on a formulary in the following specific medical circumstances:

• The worker is in the acute stages of treatment for a compensable injury (limited to the first two weeks following an injury or discharge from hospital, whichever is later, at a maximum dose of 50 mg morphine equivalents per day) where short-term opioid therapy is considered necessary by the health care provider; or
• The worker has been diagnosed and is being treated for cancer as an occupational disease; or
• The worker is being treated in the later stages of a terminal occupational disease, which generally means a life expectancy of 12 months or less.

In all medical circumstances outside of the above, WorkSafeNB recommends the optimization of non-opioid therapy rather than a trial of opioids. However, other circumstances may be considered for a trial of opioids, on a case-by-case basis, based on evolving medical evidence.

Opioid therapy is generally not recommended for patients with active substance use disorders or untreated psychiatric illnesses.

WorkSafeNB applies best practices in the management of opioids for workers. For 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 CMA guidelines.

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

Interpretation

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

• Designating opioids as effective for the treatment of specific injuries or occupational diseases;
• Determining on a case-by-case basis if opioids are appropriate outside of specific circumstances;
• Following accepted medical prescribing guidelines; and
• Promoting harm reduction.

Standards for the responsible management of opioids

2. 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 a maximum of 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 the CMA.

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

• Avoiding the routine and continued use of opioids for acute pain beyond two weeks;
• Avoiding the simultaneous prescription of opioids and benzodiazepines or other sedating medications;
• Ensuring 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 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 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;
• Encouraging the use of multidisciplinary approaches for compensable conditions, including physiotherapy and psychosocial support, to enhance pain management and reduce reliance on opioids;
• Using a risk assessment tool for substance use disorder, previous opioid use disorder, or risk of addiction when considering the worker’s history of remote, recent or current substance abuse as a strong contraindication (e.g., CAGE-AID or other validated substance abuse screening tool) for use of opioids beyond the initial two weeks post-injury or surgery, or for any prescription that exceeds 50 mg morphine equivalents per day; and
• Considering any existing mental illnesses the worker may have that puts them at a risk for adverse outcomes (generally anxiety and depression, including International Classification of Diseases, 9^th revision definitions as well as “psychiatric diagnosis”, “mood disorder”, and post-traumatic stress disorder); and
• Discussing with 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 worker).

4. When opioids are prescribed outside the standards and guidelines in this policy, WorkSafeNB will contact the prescriber and offer support (e.g., review of the WorkSafeNB Opioid Review Process handbook) to ensure an appropriate opioid prescription for the worker.

Controls for the responsible management of opioids

5. Approval for opioids is limited to one licensed prescriber and/or payment of opioids is limited to one licensed dispenser.

6. Health care providers regularly report to WorkSafeNB on treatment goals, progress and identification of any potential misuse or abuse.

7. Pharmacies ensure that any worker returns their previously prescribed opioid patches, both used and unused, to the pharmacy prior to receiving their next opioid patches.

Opioids prescribed outside specific circumstances and/or prescription limits

8. When considering payment for workers who are using opioids outside the specific circumstances as outlined in this policy, 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 worker and completion of the WorkSafeNB Opioid Review Process handbook.

9. When opioids are prescribed beyond the initial two weeks or are not a part of the worker’s formulary, WorkSafeNB recommends: 

• Restricting the prescribed dose to less than 50 mg morphine equivalents daily, with a maximum of 90 mg morphine equivalents daily, should the higher dose of 90 mg morphine equivalent be shown to achieve and maintain measurable functional improvement; and
• Each approval is reviewed every four weeks.

10. For patients currently on high-dose opioid therapy (more than 90 mg morphine equivalent daily), gradual dose tapering to the maximum dose of 90 mg morphine equivalent daily is suggested to reduce risks associated with long-term high-dose use.

11. Any opioid prescription beyond 12 weeks requires completion of a validated functional assessment tool. 

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

Monitoring treatments and suspending payment

13. WorkSafeNB periodically reviews 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:

• Failing to improve function and reduction of pain;
• Harming or impeding the 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.

Excessive or illegal use of opioids

14. WorkSafeNB has adopted the following additional 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.

15. 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.

Harm reduction

16. 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. 

17. WorkSafeNB works with the treating physician and 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, oral agonist therapy (OAT) is the preferred first-line treatment with options such as:
  • oral buprenorphine / oral buprenorphine – naloxone (brand name Suboxone),
  • extended-release buprenorphine (BUP-XR) subcutaneous monthly depot injection (brand name Sublocade), or
  • oral methadone;
• OAT with slow-release oral morphine is supported as a second-line treatment when first-line treatments cannot be used or are found to be ineffective;
• A stepped and integrated care approach is used, in which treatment intensity is continually adjusted to accommodate the workers needs and circumstances over time;
• Non-mandatory psychosocial treatments, interventions, and supports are supported as adjunct treatments to opioid agonist therapy to increase treatment retention; and
• When workers with opioid use disorder request to pursue withdrawal management, an OAT (methadone or buprenorphine) is offered as part of a slow taper strategy in conjunction with close long-term support. A longer taper approach may also be supported in case of discontinuation of OAT.

18. As part of a harm reduction program, WorkSafeNB supports the use of overdose prevention education and access to take-home naloxone kits.

19. When there is no indication that the 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. 

20. If the worker refuses to participate in a WorkSafeNB-approved harm reduction program without a reasonable explanation, WorkSafeNB will continue to work with the worker and the prescriber to ensure the worker’s safety. WorkSafeNB may also determine whether to reduce or suspend benefits under section 41.2 of the WC Act and Policy 21-214 Continued Entitlement to Compensation Payments for Loss of Earnings.

Previous versions

• 25-012 Medical Aid - Opioids release 4, effective January 1, 2020
• 25-012 Medical Aid – Opioids release 3, effective September 26, 2018
• 25-012 Medical Aid – Opioids release 2, effective September 6, 2013