Opioid Rules

Opioid medication is sometimes used to treat chronic, non-cancer pain. Chronic, non-cancer pain may develop after an acute injury episode. It is defined as pain that typically persists beyond two to four months following the injury. Here are the requirements for opioid coverage:

Under what conditions will L&I or the self-insurer pay for oral opioid treatment for chronic, non-cancer pain?

L&I or self-insurer may pay for oral opioids for the treatment of chronic, non-cancer pain caused by an accepted condition when that treatment is proper and necessary.

Reference WAC 296-20-03019.
Also see WAC 296-20-01002 for the definition of "proper and necessary" health care services.

What are the authorization requirements for treatment of chronic, non-cancer pain with opioids?

No later than 30 days after the attending physician begins treating the worker, the attending physician must submit:

• A written report with the following:
• A treatment plan with time-limited goals.
• A consideration of relevant prior medical history.
• A summary of conservative care rendered to the worker that focused on reactivation and return to work.
• A statement on why prior or alternative conservative measures may have failed or are not appropriate as sole treatment.
• A summary of any consultations that have been obtained, particularly those that have addressed factors that may be barriers to recovery.
• A statement that the attending physician has conducted appropriate screening for factors that may significantly increase the risk of abuse or adverse outcomes (e.g., a history of alcohol or other substance abuse).

• An opioid treatment agreement signed by the worker and the attending physician. This agreement is renewed every six months. The treatment agreement must outline the following:
• Risks and benefits of opioid use,
• Conditions under which opioids will be prescribed,
• Physician's need to document overall improvement in pain and function, and
• Worker's responsibilities.

Reference WAC 296-20-03020.

What documentation is required to be submitted for continued coverage of opioids to treat chronic, non-cancer pain?

In addition to the general documentation required by L&I or the self-insurer, the attending physician must submit the following information at least every 60 days:

• Documentation of drug screenings, consultations, and all other treatment trials.
• Documentation of outcomes and responses, including pain intensity and functional levels.
• Any modifications to the treatment plan.

The physician must use a Opioid Progress Report form or a substantially equivalent form, to document the patient's improvement in pain intensity and functional levels. This form may be included as part of a 60 day report.

Reference WAC 296-20-03021.

How long will L&I or the self-insurer continue to pay for opioids to treat chronic, non-cancer pain?

L&I or the self-insurer will continue to pay for treatment with opioids so long as the physician documents:

• Substantial reduction of the patient's pain intensity; and
• Continuing substantial improvement in the patient's function.

Once the worker's condition has reached maximum medical improvement, further treatment with opioids is not payable. Opioid treatment for chronic, non-cancer pain past the first three months of such treatment without documentation of substantial improvement is presumed to be not proper and necessary.

Reference WAC 296-20-03022.

When may L&I or the self-insurer deny payment of opioid medications used to treat chronic, non-cancer pain?

Payment for opioid medications may be denied in any one of the following circumstances:

• Absent or inadequate documentation.
• Noncompliance with the treatment plan.
• Pain and functional status have not substantially improved after three months of opioid treatment.
• Evidence of misuse or abuse of the opioid medication or other drugs, or noncompliance with the attending physician's request for a drug screen.

Reference WAC 296-20-03023.

Will L&I or the self-insurer pay for nonopioid medications for the treatment of chronic, non-cancer pain?

L&I or the self-insurer may pay for nonopioid medication for the treatment of chronic, non-cancer pain when it is proper and necessary.

For example, some drugs such as anti-convulsants, anti-depressants, and others have been demonstrated to be useful in the treatment of chronic pain and may be approved when proper and necessary.

Reference WAC 296-20-03024.