PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY / PROCEDURE
Policy/Procedure Number: MPRP4049
Lead Department: Health Services
Policy/Procedure Title: Chronic Opioid Therapy in Chronic NonExternal Policy
Cancer Pain
Internal Policy
Next Review Date: 10/1/2016
Original Date: 01/05/2012
Last Review Date: 10/1/2015
Applies to:
Medi-Cal
Healthy Kids
Employees
Reviewing
Entities:
IQI
P&T
QUAC
OPERATIONS
EXECUTIVE
COMPLIANCE
DEPARTMENT
Approving
Entities:
BOARD
COMPLIANCE
FINANCE
PAC
CEO
COO
Approval Signature: Robert L. Moore, MD, MPH
CREDENTIALING
DEPT. DIRECTOR/OFFICER
Approval Date: 10/1/2015
I.
RELATED POLICIES: N/A
II.
IMPACTED DEPTS.:
III.
DEFINITIONS: N/A
IV.
ATTACHMENTS:
A. Taken from, The Journal of Pain, Vol, 10 No 2 (February), 2009: pp 113- 130. Available at
www.sciencedirect.com
1. Appendix B. Glossary
2. Appendix 4. Risk Assessment Tool (ORT)
3. Appendix 5. Risk Assessment Tool (D.I.R.E. Score)
4. Appendix 6. Sample Informed Consent form
5. Appendix 7. Sample Medication use Agreement
6. Appendix 8. Monitoring Tool — Pain Assessment and Documentation Tool (PADT), Progress Note
V.
PURPOSE:
The purpose of this policy is to adopt and apply an evidenced based medicine approach in the guideline used
in benefit design for the management of chronic opioid therapy (COT) for PHC member’s being treated for
chronic non- cancer pain (CNCP). Treatment with chronic opioid medications comes with inherent concerns
and risks to include; potential misuse, mortality, dependence and diversion. This policy further elaborates
the role of the health plan, prescribers and member in helping to ensure that PHC members receive the
highest quality and most cost effective management of their chronic non-malignant pain.
BACKGROUND
Partnership HealthPlan of California’s (PHC’s) aim is to consistently apply evidence-based medicine to the
criteria used in clinical guideline development the area of chronic opioid usage in treatment of chronic pain
management. In 2009, the American Pain Society and The American Academy of Pain Medicine published
clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain. The plan has adopted
this guideline as the standard of care for PHC members.
http://www.jpain.org/article/PIIS1526590008008316/fulltext
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Policy/Procedure Number: MPRP4049
Lead Department: Health Services
☒External Policy
Policy/Procedure Title: Chronic Opioid Therapy in Chronic
Non-Cancer Pain
☐Internal Policy
Next Review Date: 10/1/2016
Original Date: 01/05/2012
Last Review Date: 10/1/2015
☒ Healthy Kids
Applies to: ☒ Medi-Cal
☐ Employees
VI.
POLICY / PROCEDURE:
A. Role of the Health Plan
1. PHC identifies its members being treated with COT for CNCP through following methods;
administrative data review, prior authorization requests beyond current benefit design, prior
authorization renewal, provider input or other reasonable means of referral. For a request to meet
medical necessity criteria the request must be accompanied by the supporting documents either from
the attached appendices taken from the American Pain Society or by a like document submitted by
the requesting physician as outlined in the procedure.
a. Ongoing pain management is part of the scope of primary care and is to be managed and
coordinated by the primary care practitioners. The plan provides access to pain management
referral specialists (in person or by phone) to assist the primary care physicians in management
of complex patients. Pain management specialist involvement may be requested and required
when there is high dose (greater than 120mg of morphine sulfate or equivalent use/day)
escalation and/or transition to a formulary preferred opioid. The role of the specialist is to
evaluate the member and provide consultative assistance and appropriate specialty interventions
to the member. The plan provides regular education on best practices in chronic pain
management to the network.
b. The Plan provides education on best practices in chronic pain management at academic detailing
visits.
c. The plan assists the prescribers by identifying outliers such as members utilizing high dose
opioids, members with known compliance problems, members receiving controlled substances
from multiple prescribers and shares this information with the prescriber.
d. The plan provides tools to prescribers such as model pain contracts, sample risk assessment
tools, restricted drug status and urine drug screening standards to assist the prescribers in safely
prescribing opioids to PHC members.
e. The plan establishes prior authorization criteria, and quantity limits for certain controlled
substances through its Pharmacy and Therapeutics Committee and Physicians Advisory
Committee to maximize the cost effective and highest quality of care to its members.
B. Role of the Prescribers
1. As prescribers of controlled substances for PHC members, the treating practitioners have a unique
role and set of responsibilities to ensure that members receive the highest quality of care and service.
Specific responsibilities of prescribers include:
a. Review and be knowledgeable about PHC’s standards of care, prior authorization criteria and
the APS clinical guideline for management of non-malignant pain.
b. Follow PHC’s prior authorization processes for use of non-formulary medications and submit
documentation from the medical record to support the requests. When evidence of failure of a
formulary medication is submitted supporting documentation must included evidence of a good
faith trial and appropriate management of side effects before a non-formulary medication is
considered.
c. Utilize a medication use agreement (sometimes called a pain contract) for all PHC members
receiving controlled substances for three months or longer. See attached for a model contract
d. Order and evaluate a urine drug screen for all members on chronic opioid therapy at least yearly
e. As long as available, obtain and review a Patient Activity Report (PAR) through the States
Department of Justice database known as Controlled Substances Utilization Review and
Evaluation System (CURES) at least yearly. The web site for signing up for on-line CURES
reporting is http://ag.ca.gov/bne/cures.php
f. Minimum three (3) member visits/year.
Page 2 of 4
Policy/Procedure Number: MPRP4049
Lead Department: Health Services
☒External Policy
Policy/Procedure Title: Chronic Opioid Therapy in Chronic
Non-Cancer Pain
☐Internal Policy
Next Review Date: 10/1/2016
Original Date: 01/05/2012
Last Review Date: 10/1/2015
☒ Healthy Kids
Applies to: ☒ Medi-Cal
☐ Employees
g. Provide education to PHC members about the appropriate goals of pain management therapy
and provide ancillary services as appropriate.
h. Evaluate all PHC members undergoing treatment for chronic pain for behavioral health
conditions such as depression regularly at each visit and provide behavioral health treatment
and/or referral as necessary.
C. Role of the member
1. Each PHC member has an important role and set of responsibilities with respect to their
management of chronic pain.
a. The member is responsible for complying with all of the requirements of the pain contract. Any
violation of the contract may be ground to discontinue utilizing a safe tapering process of the
controlled substance.
b. Understand and be informed about the management of chronic pain.
c. Actively engage in self-management of the chronic pain and focus on improving the member’s
ability to function within the patient’s environment.
d. Address behavioral health conditions as recommended by the patient’s treating practitioners.
D. Opioid use and Dependence
1. All opioid use can lead to tolerance, dependence and addiction. Use of agents such as methadone
and buprenorphine / naloxone (Suboxone) for withdrawal and addiction treatment is limited to only
physicians with special state and federal licenses. Methadone can be prescribed by any physician
with a Drug Enforcement Administration (DEA) license for treatment of acute or chronic pain and
only limited use for temporary maintenance or detoxification when an addicted patient is admitted to
acute care facilities. Buprenorphine, buprenorphine/naloxone use is limited to physicians who meet
certain qualifying requirements from US Food and Drug Administration (FDA) and Secretary of
Health and Human Services (HHS) and have been assigned a unique identification number.
Buprenorphine drug products are non-capitated drugs for PHC Medi-Cal line of business and
qualified prescribers will need to obtain Treatment Authorizations from State Medi-Cal.
VII.
REFERENCES:
A. Opioid Treatment Guidelines. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic
Noncancer Pain. Chou, et. al., The Journal of Pain, Vol 10, No 2 (February) 2009: pp 113-130.
VIII.
DISTRIBUTION:
A. PHC Department Directors,
B. PHC Provider and Practitioner Manuals,
C. SharePoint
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE:
A. Pharmacy Services Director
X.
REVISION DATES:
Medi-Cal
01/16/14; 10/1/2015
Healthy Kids
01/16/14; 10/1/2015
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Policy/Procedure Number: MPRP4049
Lead Department: Health Services
☒External Policy
Policy/Procedure Title: Chronic Opioid Therapy in Chronic
Non-Cancer Pain
☐Internal Policy
Next Review Date: 10/1/2016
Original Date: 01/05/2012
Last Review Date: 10/1/2015
☒ Healthy Kids
Applies to: ☒ Medi-Cal
☐ Employees
PREVIOUSLY APPLIED TO:
PartnershipAdvantage:
MPRP4049 - 01/05/2012 to 01/01/2015
XI.
POLICY DISCLAIMER:
A. In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with
involvement from actively practicing health care providers and meets these provisions:
1. Consistent with sound clinical principles and processes;
2. Evaluated and updated at least annually;
3. If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will
be disclosed to the provider and/or enrollee upon request.
B. The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with
similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the
benefits covered under PHC.
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