The use of opioids is widespread in the treatment of numerous injuries in New York. Although prescribed by a number of doctors, great care must be taken when opioids are found to no longer be necessary. Recently, Judges have ordered both the carrier and the claimant to submit drug weaning programs when an IME doctor finds that the use of opioid drugs is no longer necessary for the claimant’s continued treatment.
What is a Drug Weaning Program and Why is It Necessary?
In New York Workers Compensation claims the use of opioids by the claimant is subject to the 2014 Non-Acute Pain Medical Treatment Guidelines (“MTG”) recommendations in section F.2.b, Long Term Use of Opioids: Transitioning/Managing Patients on Existing Opioid Therapy. The claimant’s physician must abide by the MTG recommendations to ensure that the management and treatment of a patient with non-acute pain is performed according to the principles for safe long-term opioid management and guidelines for optimizing opioid care pain (F.2.c [F.2.c.i-F.2.c.ii] and F.3 [F.3.a, F.3.b.i-iv, F.3.b.c.i-ii, F.3.d.i-iv, F.3.e.i-vi]).
Some of the MTG recommendations include: the need to routinely monitor the safety and effectiveness of treatment (improved function and pain control), an informed consent form (F.3.c), opioid understanding form (F.3.c.ii), appropriate monitoring and screening (random urine drug testing (F.3.d.i-iv), unannounced pill count(s), and evaluation and monitoring for adverse effects of and interactions with medications (F.3.b.i-ii and Table 3: Adverse Effects of Opioids).
The goal is to improve or maintain function and allow the patient to control or manage pain that includes the use of the lowest possible dose of opioids, if indicated, and limited to two opioids (long acting and short acting), a Functional Maintenance Care Plan with patient participation in an independent self-management program.
In summary, the goal in patients who have been on long term opioids prior to the adoption of the Non-Acute Pain Medical Treatment Guidelines is to transition them to accepted standards of care and to avoid abrupt discontinuation of opioids.
Tapering/discontinuation of opioids
Tapering/discontinuation of opioids may be necessary due to the development of tolerance, hyperalgesia, decreased effectiveness, lack of compliance with the opioid contract or intolerable side effects.
Further, when the carrier’s IME doctor finds the use of opioid medications is no longer necessary, the WCLJ may order both the carrier and the claimant to submit a proposed drug weaning program for the WCLJ’s consideration.
The Board’s Suggestions for Drug Weaning Programs
- A decrease by 10% of the original dose per week is usually well tolerated with minimal physiological adverse effects.
- Some patients can be tapered more rapidly (over 6 to 8 weeks) without problems.
- If opioid abstinence syndrome is encountered, it is rarely medically serious although symptoms may be unpleasant.
- Symptoms of abstinence syndrome, such as nausea, diarrhea, muscle pain and myoclonus can bemanaged with clonidine 0.1- 0.2 mg orally every 6 hours or clonidine transdermal patch (0.1 mg/24 hours), with weekly evaluations during the taper while monitoring often for significant hypotension and anticholinergic side effects.
- In some patients it may be necessary to slow the taper timeline to monthly, rather than weekly dosage adjustments.
- Symptoms of mild opioid withdrawal may persist for six months after opioids have been discontinued.
- Rapid re-occurrence of tolerance can occur for months or years after prior chronic use.
- Consider using adjuvants, such as antidepressants, to manage irritability or sleep disturbance, or anticonvulsants for neuropathic pain.
- Do not treat withdrawal symptoms with opioids or benzodiazepines after discontinuing opioids.
- Referral for counseling or other support during this period is recommended if there are significant behavioral issues.
- Referral to a physician specializing in addiction medicine or to a pain specialist and/or an inpatient/outpatient medically assisted detoxification program should be made for complicated withdrawal symptoms.
The Board specifically notes that special care should be taken in recognizing and managing behavioral issues during Opioid Tapering. It is considered an extremely sensitive time in the claimant’s treatment. The Board notes that special care should be taken to preserve the patient-physician therapeutic relationship during this time to avoid precipitating doctor-shopping, illicit drug use or other risky patient behaviors. Further, the appropriate referral or consultation should be made , if necessary. For example, any suicidal thoughts should prompt immediate psychological consultation.
What should the carrier do if a Drug Weaning Program is ordered?
The claimant should be scheduled for an IME with a specialist who is Board Certified in Addiction Medicine or Pain Medicine.