Summary of Notable Changes to the Chronic Pain Medical Treatment Guideline

This document provides a summary of some notable changes to the proposed Chronic Pain Medical Treatment Guideline but does not comprehensively list all changes.

·  The Dosing and Time to Therapeutic Effect subsection for Opioids has been updated. Previously, consideration for lowering dosage was recommended when dosage exceeds 120 MME and/or if the patient is sedentary with minimal function. The dosage has been lowered to 50 MME. Also, if the patient reaches a dose above 90 MME per day, it is appropriate to taper or refer to a pain or addiction specialist. These changes are consistent with federal CDC guidelines. Clarifying language has also been added as follows:

2012 language / Proposed 2017 language
When patient’s dosage exceeds 120 mg of morphine per day and/or the patient is sedentary with minimal function, consideration should be given to lowering the dosage. Consultation may be necessary. / A daily dosage above 50 MME may be appropriate for certain patients. However, when the patient’s dosage exceeds 50 MME per day and/or the patient is sedentary with minimal function, consideration should be given to lowering the dosage. Some patients may require dosages above 90 MME per day. However, if the patient reaches a dosage above 90 MME per day, it is appropriate to taper or refer to a pain or addiction specialist. The provider should also adhere to all requirements in this guideline and closely monitor the patient as this is considered a high risk dosage.

·  The Neurostimulation section has been updated. The Guideline now differentiates between traditional low-frequency spinal cord stimulators (SCS) and newer high-frequency ones based on recently published research.

o  Previously, SCS was not recommended for patients with the major limiting factor of persistent axial spine pain. Traditional SCS continue to be not recommended, but now high-frequency SCS may be used for patients with predominantly axial back pain.

o  Previously, SCS was allowed for a subset of patients who have a clear neuropathic radicular pain (radiculitis). Now, it is specified that traditional or other SCS may be indicated.

o  Also, it is now stated that an independent PT/OT must evaluate functional gains prior to trial discontinuation. This is consistent with the rest of our evaluation recommendations.

·  Language has been added on functional gains throughout the Guideline. This includes recommended functional questionnaires in QPOP and/or the Patient Specific Functional Scale.

·  In the General Guideline Principles under “Re-evaluation of Treatment”, time to produce effect has been added to the time period when you should see positive results or re-evaluate the treatment plan. This change reflects the Division’s original intent of how guideline timeframes should be used.

·  The Topical Drug Delivery section has been updated by adding the following language: “If ordered compounded topicals are reviewed by the payer, the payer must evaluate and approve or deny each ingredient separately.” This is to be consistent with recently adopted changes to Rule 18.