Opioid and Benzodiazepine Therapies

Introduction

Opioids and Benzodiazepine are two medications frequently prescribed to injured employees, and each medication, given long-term, present risks such as dependency, increased sedation, and respiratory depression, especially when used concurrently. 

Opioid medications carry a dependency risk as high as 26% of patients receiving opioids for non-cancer-related pain, and 1 of every 550 patients who start an opioid therapy die of opioid related causes. This increased to 1 in 32 patient deaths for those receiving doses of 200 morphine milligram equivalent (MME) or higher. 

Benzodiazepine therapies cause mood alteration and can lead to dependence. Studies have also shown the medication loses effectiveness in a relatively short period of time, but recovery to reverse abuse of the medication is a challenging, long-term process. 

For these reasons, North Dakota Century Code §65-05-40 references the potential non-payment of opiate and benzodiazepine therapies exceeding specified limitations, and the purpose of this policy is to outline the circumstances in which Workforce Safety & Insurance (WSI) will no longer offer coverage of opioid and benzodiazepine therapies and define the parameters of medical necessity required to apply for an exemption to the rule.

Policy

Effective August 1, 2021, WSI will no longer cover:

• A combination of opiate and benzodiazepine drugs (No exceptions) 
• Opioid therapy exceeding 90 MME per day 
• More than a 7-day supply of opioid medication within a single outpatient transaction during the initial 30-day period of therapy 
• Benzodiazepine therapy extending beyond a cumulative duration of 4 weeks 

The limitations of this policy do not apply to:

• Opioid therapy prescribed for active and aftercare cancer treatment 
• Opioid therapy prescribed for treatment of a substance use disorder 
• Opioid therapy prescribed in the following settings: 
  • End-of-life and hospice care 
  • An emergency room 
  • An inpatient hospital 
  • A long-term care facility 
  • An Assisted living facility 
• Benzodiazepine therapy prescribed for treatment of an anxiety disorder

An injured employee currently meeting or exceeding these thresholds and not falling under the noted exemptions will be required to come into compliance with the requirements by July 1, 2022. 

To exceed the limitations outlined above, an injured employee will need to prove medical necessity. For detailed guidance on exemption parameters, see Appendix: Medical Necessity for Opioid and Benzodiazepine Therapies.

References (Optional)

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1, last accessed 7/26/2021. 

New England Journal of Medicine. 2016 Apr 21:374(16):1501-1504. 

Opioids for Pain, Indicators and Screening Tests for Risk of Substance Use Disorder/Addiction, Abuse and Misuse. ODG by MCG. (2021, February 12). https://www.odgbymcg.com/odg-link?tags=%20Opioids%20for%20Pain|%20Indicators%20and%20Screening%20Tests%20for%20Risk%20of%20Substance%20Use%20Disorder/Addiction|%20Abuse%20and%20Misuse&formfield_country=US&st=st&ltdplan=182&stdEndDateMax=364&thispage=treatment&formfield_physicaldemandlevel=All%20Classes&rtwoption=bp_target, last accessed 7/26/2021. 

Opioids for Pain, Criteria for Use. ODG by MCG. (2021, February 12). https://www.odgbymcg.com/odg-link?tags=%20Opioids%20for%20Pain|%20Indicators%20and%20Screening%20Tests%20for%20Risk%20of%20Substance%20Use%20Disorder/Addiction|%20Abuse%20and%20Misuse,%20Opioids%20for%20Pain|%20Criteria%20for%20Use&formfield_country=US&st=st&ltdplan=182&stdEndDateMax=364&thispage=treatment&formfield_physicaldemandlevel=All%20Classes&rtwoption=bp_target, last accessed 7/26/2021. 

Krebs, E.E., Lorenz, K. A., Bair, M. J., Damush, T. M., Wu, J., Sutherland, J. M., Asch S., Kroenke, K. (2009). Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference. Journal of General Internal Medicine, 24(6), 733-738. http://doi.org/10.1007/s11606-009-0981-1, last accessed 7/26/2021. 

Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD-PHQ). The PHQ was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues. For research information, contact Dr. Spitzer at [email protected]. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc 

Skinner HA (1982). The Drug Abuse Screening Test. Addict Behav 7(4):363-371. Yudko E, Lozhkina O, Fouts A (2007). A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treatment 32:189-198

Appendix

Medical Necessity for Opioid and Benzodiazepine Therapies

The following guidelines outline the information WSI reviews when determining medical necessity for exceeding the opioid and benzodiazepine therapy thresholds. These criteria will be subject to review as WSI deems necessary, but at least once every two years. 

Documentation 

The submitted treatment plan must be consistent with the WSI Utilization Review process. Recent documentation should demonstrate attempts to taper opioid use and employ non-opioid therapies for pain control.

Psychosocial Consult 

An injured employee should complete a psychosocial consult with a healthcare provider, preferably a licensed psychologist or psychiatrist outside the treating healthcare provider’s network, to address the risk and harms of opioid use per the Centers for Disease Control Guideline for Prescribing Opioids. 

The psychosocial consult should include a risk stratification plan as well as standardized screening using validated tools for mental health and substance abuse. Examples of acceptable screening tools include: 

• Generalized Anxiety Disorder 7-Item (GAD-7) 
• The Seven-Item Patient Health Questionnaire (PHQ-7) 
• The Four-Item Patient Health Questionnaire for Anxiety and Depression (PHQ-4) 
• Drug Abuse Screening Test (DAST) 
• Alcohol Use Disorders Screening Test (AUDIT