Oct 25, 2016 | MAD News


The Board Panel, in a recent October 2016 Decision, considered the issue of whether a Claimant’s opioid medications were appropriate.

Significantly, in this case the claimant was classified with a permanent total disability. He was also on opioid medications since the inception of the claim in 2002.  He had rotated through a number of pain management treatment providers with the most recent provider, Dr. Salcedo, starting treatment in 2011. While with this practice group, the claimant was rotated through numerous opioid medications with none providing any objective functional improvement in his condition.  The claimant’s current medications were: Soma 250mg, Lunesta 3mg, Exalgo 16mg, Fentora 800mg, and Klonopin.

A record review was completed by Dr. Grammar, which found that the claimant’s treatment deviated from the NAP Guidelines for a number of reasons, but most significantly that the Morphine equivalent dose was in excess of 100mg per day.  The recommendation was to wean the opioid medications with a two-month extinction, along with the discontinuance of the muscle relaxer, Soma.

Interestingly, Dr. Salcedo sought authorization for Evzio, which temporarily reverses the side effects of opioid medications in situations of overdose.

Dr. Salcedo’s testimony was taken, and he indicated that the claimant had chronic opioid use and pain tolerance, along with dependency.  The doctor indicated he was in the process of weaning, but then described a generic plan to reduce the claimant’s intake. He also testified that the claimant failed to demonstrate any functional gains. The described plan was to circulate and rotate new opioids to determine claimant’s best functionality.

At a hearing in January 2016, the judge found that weaning was medically necessary and directed Dr. Salcedo to implement a weaning program or refer the claimant to an appropriate rehabilitation program. An appeal was filed to this decision.  The basis of the appeal was that the judge should have directed a weaning program in conformity with the consultant’s weaning recommendation.

Thereafter, Dr. Salcedo recommended rotating the claimant’s opioid medications by shifting the claimant from Exalgo to Belbuca and then weaning the claimant off of Fentora.  The provider’s reasoning for the transition of medications was that the current regimen does not provide any functional gains.

An addendum was sought from Dr. Grammar, who reiterated his opinion that the medications deviated from the NAP Guidelines, and that weaning could take six to eight weeks, with prolonged weaning taking a period of six to eight months.

A second record review was sought by a new consultant, who indicated the opioids could be weaned at a rate of 10% to 15% per month over six to nine months.

At a hearing in June 2016, the Judge found that Dr. Salcedo’s plan to rotate medications addresses the current concerns of tolerance and escalation of symptoms due to opioid tolerance.  The judge then directed Dr. Salcedo to continue with the weaning program. Again, an appeal of this decision was filed. The basis for this appeal was that opioid rotation was inappropriate in the absence of objective functional improvement from the use of opioid medications.

After a thorough review of the facts of both appeals, the Board noted, importantly, that long term opioid users, although given the protection of Subject Number 046 – 457, were still required to come into compliance with the NAP Guidelines.  The Board specifically held that the Subject Number and the Guidelines are not in conflict with each other, but rather the Guidelines make clear that the goal for long-term opioid users is to be transitioned into the standards of care set forth within the NAP Guidelines.

The Board specifically indicated there was not enough evidence to demonstrate that Dr. Salcedo was transitioning this claimant’s care into the standards set forth within the NAP Guidelines.  The Board also held that the Guideline’s standards of care require a multi-disciplinary approach to pain management that is function-oriented and goal-specific.  The goal of opioid therapy is functional restoration – not merely pain elimination.  The Board discussed that the NAP Guidelines provide that weaning from opioids can be done at a decrease of 10% per week without significant health risks to the claimant.  It was also discussed that in complicated cases, a referral to an addiction specialist should be made to assist with detoxification and withdrawal symptoms.

When rendering a final conclusion in this claim, they noted that the Office of Alcoholism and Substance Abuse Services in the State of New York provides a list of certified inpatient and outpatient treatment facilities for addiction management.  They directed the carrier to cover the costs of the claimant addiction treatment program, 30 days’ worth of medication fill following the Decision, and payment for any narcotic prescription thereafter, only if written by an addiction treatment program provider.

The Board specifically found the claimant’s current medications were not in compliance with NAP Guidelines, that any further opioid use must be consistent with the NAP Guidelines, and that compliance must be insured through urine screening.

So what is our take away?

  1. Well, to answer our initial question regarding whether to wean or not, the Board is clearly moving toward weaning when there is no functional improvement from the opioid medications.
  1. If you have a claimant who is a long-term opioid user, you should review the medical records to determine whether there is objective functional improvement being demonstrated from the continued use of opioid medications. If not, obtain a record review to determine if the claimant’s medications are in compliance with the NAP Guidelines.
  1. Push for weaning that is in compliance with the NAP Guidelines. The Board is standing by the criteria within the NAP Guidelines even when the claimant has been prescribed opioid medications for an extensively long period of time.
  1. The Board is directing claimants to take action on behalf of themselves for their own care. The Decision also indicates that once non-compliance with the NAP Guidelines has been found that Carriers are liable for the payment of one last time-specific fill, and only for scripts filled by an authorized addiction specialist thereafter, along with the cost of the addiction treatment program.  Based on the language of this Decision, payment of the program and the scripts through the program, even if it is not a WC authorized provider, is required.

Below are links to both the Decision, as well as the New York State Office of Alcoholism and Substance Abuse Services’ list of certified treatment facilities.



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