BWC's opioid rule for prescribers
Based on Ohio's opioid prescribing guidelines, we developed an opioid prescribing rule effective Oct. 1, 2016. It applies to all BWC-certified prescribers and is designed to help prevent opioid dependence for Ohio's injured workers through its three primary goals.
- Encourage prescribers to incorporate best clinical practices when prescribing opioids for treating Ohio's injured workers.
- Establish provisions and criteria for treating opioid dependence that arises secondary to treatment with opioid medications covered by BWC.
- Provide and strengthen BWC's peer review processes for opioid prescribing that address noncompliance with opioid prescribing and other quality of care issues in our system.
If you suspect your patient is at risk for dependency, addiction, or overdose, please consider these resources.
Provider education and free CMEs
Best clinical practices
We will not reimburse for opioid prescriptions written by prescribers who fail to comply with Ohio's best prescribing practices as outlined by the Ohio State Medical Board and reinforced by the Ohio Administrative Code (OAC). The rule reinforces important foundational elements of appropriate opioid utilization and customizes it for our population. Because injured workers have a vulnerability that differs from the general population, an additional level of opioid prescribing oversight is required by prescribers. The rule outlines the details needed for this necessary oversight.
Checkpoints: Tighter controls on duration and daily dose of opioid prescribing, as measured by milligrams of Morphine Equivalent Dose (MED)
Pay attention to the duration of time an injured worker may be on opiates. For example, prescriber dose/duration checkpoints to review pain treatment plans are:
- 50 mg MED/Day for more than six weeks after injury or during the subacute injury phase;
- 80 mg MED/Day or for more than 42 to 84 days;
- 80 to 120 mg MED/Day or for more than 12 weeks for the chronic pain phase.
Opioid treatment programs reimbursed
Be aware of red flags that may arise when treating the injured worker. Fortunately, BWC ensured the rule includes policies for supporting an injured worker and his or her physician if the injured worker receiving opioids covered by BWC wants to stop using them. BWC will reimburse for opioid treatment programs that include medication assisted treatment, behavioral and psychological counseling and inpatient detoxification. If necessary, BWC will reimburse for up to 18 months as long as the injured worker follows the plan developed collaboratively with his or her physician. For added safeguards, this rule allows the injured worker to relapse twice during the 18-month period. In addition, the injured worker may complete these programs without adding drug dependency as an allowed claim condition as long as the injured worker has a treatment plan.
Peer review will now be included as a new component of utilization review for BWC prescribers as outlined in the rule. Although this process falls outside our progressive disciplinary process, it similarly could result in BWC decertifying a physician.
For more information about this rule, email BWC pharmacy benefits.
Opioid prescribing guidelines
Ohio's opioid prescribing guidelines are designed for physicians treating patients with chronic, non-terminal pain. They're based on data that shows patients who receive higher doses of prescribed pain medications are at an increased risk for addiction or overdose.
BWC recommends that all prescribers follow this step-by-step process when prescribing opioid analgesics and managing your patient's pain treatment. When managing opioid analgesics for more than 12 continuous weeks, prescribers must:
- Review and follow the Ohio Administrative Code Chapter on Drug Treatment of Intractable Pain (OAC 4731-21). Notice the documentation requirements of a thorough medical evaluation, informed consent, an individualized treatment plan and an evaluation by a specialist in the body area perceived as the pain source. Incorporating the four A's of chronic pain treatment is required in your assessment;
- Activities of daily living
- Adverse side effects
- Aberrant drug-taking behaviors
- Review the patient's progress towards treatment objectives and provide ongoing assessment of the patient's functional status, including the ability to engage in work or other gainful activities, quality of life, etc. Multiple validated tools to monitor functional status are available;
- Register in the Ohio Automated Rx Reporting System (OARRS) and use the OARRS data as an additional check on patient compliance. Remember this is required by BWC rule;
- Monitor for an 80 MED (Morphine Equivalent Dose) per day trigger at which point you should review the treatment plan and gauge its effectiveness and safety. Use the 80 MED trigger to assess addiction risk or mental health concerns, including the need to refer to an addiction medicine specialist if appropriate;
- Establish a pain agreement that includes prescribing parameters and expectations. For example, the patient should engage only one physician and utilize one pharmacy for long-term opioid analgesic medication management;
- Perform an opioid risk assessment. There are several risk assessments available that can be found online;
- Consider a urine drug screen when appropriate. Note: OAC 4731-21 requires chart documentation of drug-screen results when obtained;
- Educate the patient on the potential adverse effects of long-term opioid therapy and include written handouts/materials in the process;
- Communicate with involved healthcare providers as part of the essential steps in the process.
Important: On Oct. 1, 2016, BWC moved to a 60 MED trigger and a six to eight week time table to address our unique injured worker population where return to work is paramount.
For more resources about opioid prescribing in Ohio, click on any one of the topics listed below.