North Carolina Opioid Rule Goes into Effect May 1, 2018

The North Carolina Industrial Commission adopted opioid prescribing guidelines effective May 1, 2018. The rules are specific to care being provided to injured workers in North Carolina. Here is a summary of the more critical points of the new guidelines.

Section .0102—Definitions

• Acute phase defined as 12 weeks of treatment following accident of injury or following aggravation of injury
• Chronic phase defined as the continued treatment of pain following the 12 week acute phase using a targeted medication
• Presumptive urine drug test means an initial urine drug test that identifies negative specimens and presumptive positive specimens, and is interpreted through visual examination.
  • Examples include dipstick tests and drug test cups.
  • A health care provider who is providing pain management treatment in the chronic phase to an employee may administer a presumptive urine drug test that is qualitative and interpreted or analyzed with instrumental or chemical assistance if the health care provider believes, in his or her medical opinion, that a more sensitive presumptive urine drug test is appropriate and is likely to reduce the need for a confirmatory urine drug test.
• Confirmatory urine drug test means a definitive urine drug test that verifies the results of a urine drug test. A confirmatory urine drug test identifies individual drugs and drug metabolites.
  • Health care providers shall use a confirmatory drug test for the lowest number of drug classes necessary based on the results of the presumptive urine drug test, not to exceed 21 drug classes.
• Targeted controlled substance means any controlled substance included in G.S. 90-90(1) or (2) or G.S. 90-91(d). (click on statute citation and refer to paragraph indicated to see lists)

Section .0200—First Prescription in Acute Phase
(This section does not apply if injured worker had been treated with an opioid for 12 weeks immediately preceding the effective date of the rule.)

• Physician must document that non-pharma pain treatment is not appropriate or was tried and failed
• Physician should prescribe fewest possible days of a targeted medication, but no more than 5 days supply
• Can only prescribe 1 targeted medication for 1st prescription
• Physician should prescribe lowest possible MED not to exceed 50 MED
• Limits use of transcutaneous, transdermal, transmucosal, or buccal opioid preparations unless physician can demonstrate oral options did not work
• No fentanyl prescriptions allowed in acute phase
• No benzodiazepines allowed in acute phase
• No carisoprodol allowed in the acute phase if another targeted medication is prescribed
• If injured worker is receiving carisoprodol or a benzo from another prescriber, must inform patient of potential risks and inform other prescriber of the new prescription
• Prior to prescribing a targeted medication, physician must check Controlled Substance Reporting System (CSRS) for use of targeted medications over the prior 12 months

Section .0202—Subsequent Prescriptions of Targeted Medication in Acute Phase

• Physician should not prescribe more than 1 targeted medication at a time during acute phase
• Physician should prescribe fewest possible days of targeted medications
• Physician should prescribe lowest MED not to exceed 50 MED of a short-acting opioid, but may prescribe 50-90 MED after medical justification
• If a physician wants to prescribed a targeted medication beyond 30 days, the following requirements must be met:
  • Must use a drug risk screening tool
  • Must initiate a presumptive drug screening test
    • If positive for non-prescribed drugs or negative for prescribed drugs, physician may order confirmatory drug test
    • Document test results
  • Must document medical necessity for going beyond 30 days
• Limits use of transcutaneous, transdermal, transmucosal, or buccal opioid preparations unless physician can demonstrate oral options did not work
• No fentanyl prescriptions allowed in acute phase
• No benzodiazepines allowed in acute phase
• No carisoprodol allowed in the acute phase if another targeted medication is prescribed
• If injured worker is receiving carisoprodol or a benzodiazepine from another prescriber, the new prescriber must inform patient of potential risks and inform the other prescriber of the new prescription
• Prior to prescribing a targeted medication, physician must check the Controlled Substance Reporting System (CSRS) for use of targeted medications over the prior 12 months

Section .0203—Prescribing Targeted Drugs in Chronic Phase

• Physician must document that non-pharma pain treatment is not appropriate or was tried and failed
• Physician must use a drug risk screening tool
• Physician should not prescribe more than 1 targeted medication at a time during chronic phase unless medical necessity is documented
• Physician may not prescribe more than 2 targeted medications at a time — one long-acting and one short-acting
• Physician should prescribe fewest possible days of targeted medications
• Physician should prescribe lowest MED not to exceed 50 MED of a short-acting opioid, but may prescribe 50-90 MED after medical justification
• Physician may prescribe over 90 MED with prior-authorization and periodic review of medication/dosing
• Limits use of transcutaneous, transdermal, transmucosal, or buccal opioid preparations unless physician can demonstrate oral options did not work
• Physician may prescribe transdermal fentanyl in chronic phase with prior authorization
• Physician may prescribe methadone to treat pain in chronic phase with prior authorization
• No benzodiazepines allowed in chronic phase
• Physician may prescribe carisoprodol with a targeted medication in chronic phase with prior authorization
• If injured worker is receiving carisoprodol or a benzodiazepine from another prescriber, the new prescriber must inform patient of potential risks and inform other prescriber of the new prescription
• Prior to prescribing a targeted medication, physician must check CSRS for use of targeted medications over the prior 12 months and at every visit or every three months — whichever is more frequent
• Prior to prescribing first targeted drug in chronic phase, the physician must conduct a presumptive urine drug test and conduct periodic testing while targeted drug is prescribed
  • No few than 2 tests per year
  • No more than 4 tests per year without prior authorization
• If presumptive test reveals use of non-disclosed drugs or lack of use of prescribed drugs, physician must order a confirmatory drug test
• If injured worker changes to a new health care provider during the chronic phase, the new health care provide must complete a new drug risk screening

Section .0301—Opioid Antagonists

• Physician should consider co-prescribing an antagonist if one of the following conditions are present:
  • Injured worker is taking a benzodiazepine and one other targeted medication
  • Prescribed drug exceeds 50 MED per day
  • Injured worker has a history of drug overdose risk
  • Injured worker has a history of substance abuse disorder
  • Injured worker has history or mental health issue that could put them at risk for an overdose
  • Injured worker has a co-morbid condition that places them at greater risk for opioid toxicity
• Employer or carrier has choice of product

Section .0400—Non-pharmacological treatment of pain

• This section encourages health care providers to explore using non-pharmacological treatments for pain and provides some examples of treatment

Section .0500—Substance Abuse Disorder Treatment

• If health care provider believes injured worker is a candidate for substance abuse disorder treatment, the insurance carrier or employer may request additional information from the referring provider.

North Carolina joins a growing number of states that are aggressively addressing the over-prescribing of opioids to injured workers. To aid in the implementation of the new guidelines, the Industrial Commission also published a companion guide. We applaud their efforts and look forward to helping our customers manage these new rules.

The latest version of the rule and companion guide can be found here.

If you have questions on this rule, please contact Brian Allen at brian.allen@mitchell.com.