The following is excerpts from Oregon Health Authority’s changes to the Prioritized List of Health Services for OHP patients pertaining to pain management. Oregon’s Pain Management Commission released these changes on treating back conditions on 4/28/16. This work was based on the CDC Guideline for Prescribing Opioids for Chronic Pain, 2016.
Until now, the OHP has limited treatment to patients who have muscle weakness or other signs of nerve damage. Beginning in 2016, treatments will be available for all back conditions. Before treatment begins, providers will assess patients to determine their level of risk for chronic back pain, and whether they meet criteria for a surgical consultation. Based on the results, one or more of the following covered treatments may be appropriate:
- Chiropractic manipulation
- Cognitive behavioral therapy (a form of talk therapy)
- Medications (including short-term opiate drugs, but not long-term prescriptions)
- Office visits
- Osteopathic manipulation
- Physical and occupational therapy
- Surgery (only for a limited number of conditions where evidence shows surgery is more effective than other treatment options)
- In addition, yoga, intensive rehabilitation, massage, and/or supervised exercise therapy are recommended to be included in the comprehensive treatment plans.
Why did HERC undertake this process?
Back pain and other back conditions are very common for OHP members. In 2013, about 8 percent of OHP recipients saw a provider for back conditions, and over half of those individuals received narcotic medications, often for many months.
What is the history of OHP coverage of treatments for back conditions?
- OHP historically has covered only the back conditions with radiating symptoms of weakness or numbness due to nerve damage, for a full range of services such as physical therapy, chiropractic, acupuncture and surgery.
- People with back pain without nerve symptoms were limited to primary care visits and medications such as narcotics.
- In January, 2016, the HERC decided to remove coverage for epidural steroid injections for back pain and revise the guideline note on diagnostic imaging for back pain.
- In May, 2016 the HERC approved several additional changes, including changing the requirements for patients already on opioid therapy who would need to work with their provider to establish a plan to transition to other pain management strategies, including nonpharmacologic treatments, by January 1, 2018.
CONDITION: CONDITIONS OF THE BACK AND SPINE WITH URGENT SURGICAL
NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE
Patients seeking care for back pain should be assessed for potentially serious conditions (“red flag”) symptoms requiring immediate diagnostic testing. Patients lacking red flag symptoms should be assessed using a validated assessment tool in order to determine their risk level for poor functional prognosis based on psychosocial indicators.
For patients who are determined to be low risk on the assessment tool, the following services are included:
- Office evaluation and education, up to 4 total visits, consisting of the following treatments: Osteopathic/chiropractic manipulation therapy
- Physical or Occupational Therapy
- First line medications: NSAIDs, acetaminophen, and/or muscle relaxers.
- Opioids may be considered as a second line treatment, subject to the limitations on coverage in Guideline Note 60 OPIOID PRESCRIBING FOR CONDITIONS OF THE BACK AND SPINE. See evidence table.
For patients who are determined to be high risk on the validated assessment tool, the following treatments are included:
Office evaluation, consultation and education
- Cognitive behavioral therapy re-evaluated every 90 days with documented evidence of decreasing depression or anxiety symptomatology, improved ability to work/function, increased self-efficacy, or other clinically significant, objective improvement.
- Medications, subject to the limitations on coverage of opioids in Guideline Note 60 OPIOID PRESCRIBING FOR CONDITIONS OF THE BACK AND SPINE. See evidence table.
The following evidence-based therapies, when available, are encouraged: yoga, massage, supervised exercise therapy, intensive interdisciplinary rehabilitation.
A total of 30 visits per year of any combination of the following evidence-based therapies when available and medically appropriate. These therapies are only covered if provided by a provider licensed to provide the therapy and when there is documentation of measurable clinically significant progress.
- Rehabilitative therapy (physical and/or occupational therapy
- Chiropractic or osteopathic manipulation
GUIDELINE NOTE 60, OPIOID PRESCRIBING FOR CONDITIONS OF THE BACK
CONDITIONS OF THE BACK AND SPINE WITH URGENT SURGICAL INDICATIONS ICD-10: G83.4 (cauda equina), M43.1 (spondylolisthesis), M47.0 (anterior spinal artery compression syndromes, vertebral artery compression syndromes), M47.1 (spondylosis with myelopathy), M48.0 (spinal stenosis), M50.0 (cervical disc disorders with myelopathy), M51.0 (intervertebral disc disorder with myelopathy), M53.2X (spinal instabilities), Q76.2 (spondylolisthesis)
SCOLIOSIS ICD-10: M41 (scoliosis), M96.5 (postradiation scoliosis), Q67.5 (congenital deformity of spine), Q76.3 (congenital scoliosis due to congenital bony formation), Z47.82 (encounter for other orthopedic aftercare following scoliosis surgery)
CONDITIONS OF THE BACK AND SPINE ICD-10: F45.42 (Pain disorder with related psychological factors), G83.4, G95.0, M24.08, M25.78, M40, M42.0, M43, M45, M46.1, M46.4-M46.9, M47, M48.00-M48.38, M48.8-M48.9, M49.8, M50, M51, M53.2-M3.9, M54, M62.830, M96.1-M96.4, M99.0, M99.12-M99.13, M99.20-M99.79, M99.81-M99.84, Q06.0-Q06.3, Q06.8-Q06.9, Q76.0-Q76.2, Q76.4, S13.0XXA-S13.0XXD, S13.4XXA-S13.4XXD, S13.8XXA-S13.8XXD, S13.9XXA-S13.9XXD, S16.1XXA-S16.1XXD, S23.0XXAS23.0XXD, S23.100A-S23.100D, S23.101A-S23.101D, S23.110A-S23.110D, S23.111A-S23.111D, S23.120A-S23.120D, S23.121A-S23.121D, S23.122AS23.122D, S23.123A-S23.123D, S23.130A-S23.130D, S23.131A-S23.131D, S23.132A-S23.132D, S23.133A-S23.133D, S23.140A-S23.140D, S23.141AS23.141D, S23.142A-S23.142D, S23.143A-S23.143D, S23.150A-S23.150D, S23.151A-S23.151D, S23.152A-S23.152D, S23.153A-S23.153D, S23.160AS23.160D, S23.161A-S23.161D, S23.162A-S23.162D, S23.163A-S23.163D, S23.170A-S23.170D, S23.171A-S23.171D, S23.3XXA-S23.3XXD, S23.8XXA-S23.8XXD, S23.9XXA-S23.9XXD, S33.0XXA-S33.0XXD, S33.100A-S33.100D, S33.101A-S33.101D, S33.110A-S33.110D, S33.111A-S33.111D, S33.120AS33.120D, S33.121A-S33.121D, S33.130A-S33.130D, S33.131A-S33.131D, S33.140A-S33.140D, S33.141A-S33.141D, S33.5XXA-S33.5XXD, S33.8XXAS33.8XXD, S33.9XXA-S33.9XXD, S34.3XXA-S34.3XXD, S39.092A-S39.092D, S39.82XA-S39.82XD, S39.92XA-S39.92XD
CONDITIONS OF THE BACK AND SPINE WITHOUT URGENT SURGICAL
INDICATIONS: ICD-10: G95.0, M40, M42, M43.0- M43.2, M43.8, M45, M46.4-M46.99,M47.2-M47.9,M48.0 (spinal stenosis), M48.1, M48.3, M48.8-M48.9, M49, M50.1-M50.9, M51.1- M51.9, M53.8-M53.9, M54.1, M96.1-M96.4, M99.2-M99.7, M99.81-M91.85, Q06.0-Q06.3,Q06.8-Q06.9, Q76.0-Q76.2, Q76.4, S13.0XXAS13.0XXD, S23.0XXA-S23.0XXD,S23.100A-S23.100D,S23.110AS23.110D, S23.120A-S23.120D,S23.122A-S23.122D,S23.130AS23.130D,S23.132A-S23.132D,S23.140A S23.140D, S23.142A-S23.142D, S23.150A-S23.150D,S23.152A-S23.152D,S23.160AS23.160D, S23.162A-S23.162D,S23.170A-S23.170D,S33.0XXAS33.0XXD, S33.100A-S33.100D,S33.110A-S33.110D,S33.120AS33.120D, S33.130A-S33.130D,S33.140A-S33.140D,S34.3XXA-S34.3XXD
The following restrictions on opioid treatment apply to all diagnoses included.
For acute injury, acute flare of chronic pain, or after surgery:
- During the first 6 weeks after the acute injury, flare or surgery, opioid treatment is included ONLY
- When each prescription is limited to 7 days of treatment, AND
For short acting opioids only, AND
- When one or more alternative first line pharmacologic therapies such as NSAIDs, acetaminophen, and muscle relaxers have been tried and found not effective or are contraindicated, AND
- When prescribed with a plan to keep active (home or prescribed exercise regime) and with consideration of additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, AND
- There is documented lack of current or prior opioid misuse or abuse.
- When each prescription is limited to 7 days of treatment, AND
- Treatment with opioids after 6 weeks, up to 90 days, requires the following
- Documented evidence of improvement of function of at least thirty percent as compared to baseline based on a validated tools.
- Must be prescribed in conjunction with therapies such as spinal manipulation, physical therapy, yoga, or acupuncture.
- Verification that the patient is not high risk for opioid misuse or abuse. Such verification may involve
- Documented verification from the state’s prescription monitoring program database that the controlled substance history is consistent with the prescribing record
- Use of a validated screening instrument to verify the absence of a current substance use disorder (excluding nicotine) or a history of prior opioid misuse or abus
- Administration of a baseline urine drug test to verify the absence of illicit drugs and non-prescribed opioids.
- Each prescription must be limited to 7 days of treatment and for short acting opioids only
- Further opioid treatment after 90 days may be considered ONLY when there is a significant change in status, such as a clinically significant verifiable new injury or surgery. In such cases, use of opioids is limited to a maximum of an additional 7 days. In exceptional cases, use up to 28 days may be covered, subject to the criteria in #2 above.
For patients with chronic pain from diagnoses on these lines currently treated with long term opioid therapy, opioids must be tapered off, with a taper of about 10% per week recommended. By the end of 2016, all patients currently treated with long term opioid therapy must be tapered off of long term opioids for diagnoses listed. If a patient has developed dependence and/or addiction related to their opioids, treatment is available under diagnosis SUBSTANCE USE DISORDER.
Pain Management Education Requirements
- Pain management should be a collaborative and integrated approach rather than provided by a single specialist whose preferred approaches might not work best for all patients they provide care for. Any health care professional that is responsible for assessing the needs of a patient with acute and/or chronic pain should have the information and confidence to treat safely and effectively
- Oregon’s Prescription Drug Monitoring Program reported in 2012 that twenty percent of Oregonians (about 760,000) live with chronic pain.
- Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health reports Oregon was first in the nation for non‐medical use of prescription pain relievers in 2010‐2011.
- Drug Enforcement Agency changed hydrocodone‐combination drugs to a Schedule II drug under the Controlled Substances Act effective October 2014.
- 2015 Legislative session approved SB 152 that added the ability to prescribe the Schedule II hydrocodone combination drugs to optometrist’s scope of practice.
Health Evidence Review Commission approved revisions to the OHP Prioritized List that will result in coverage of evidence‐based, effective therapies to treat painful back conditions based on a bio‐psycho‐social model of care.
- Proposed Solution
Statewide efforts are being made to mitigate the risks and associated harms of opioid prescription medications. Concurrently, alternative care models are being recommended for the treatment and management of pain.
This measure would identify additional health care professionals required to complete the one‐hour web‐based pain education module developed by the Oregon Pain Management Commission (OPMC). Information is essential to successful pain management and expanding the pain education requirement will improve the care of patients with pain in Oregon.
The OPMC recommends that all provider types that have the potential to interact with and/or treat patients in pain should have knowledge about pain and pain management. Existing statute (ORS 413.590) identifies ten health care professionals required to complete continuing education related to pain and pain management prior to renewal of licensure. Based on current models of care that support a bio‐psycho‐social and integrative approach for the treatment of pain, the commission recommends the following additional health care professionals be required to complete the one hour web‐based training offered by the Commission:
- Social workers
- Professional counselors and marriage & family therapists
- Massage therapists
- Pharmacy technicians
- Expanded practice dental hygienist
Oversight for the completion of the continuing education would be through each of the professional licensing boards similar to current mechanisms; most already have a professional continuing education requirement.
Pain management education required of certain licensed health care professionals:
Physician assistant, nurse, psychologist, chiropractic physician, naturopath, acupuncturist, pharmacist, pharmacy technician, dentist, dental hygienist, optometrist, social worker, professional counselor and therapist, massage therapist, occupational therapist, physical therapist professionals must complete the pain management education program every 4 years.
The Oregon Medical Board, in consultation with the Pain Management Commission, shall identify by rule physicians licensed under ORS chapter 677 who, on an ongoing basis, treat patients in chronic or terminal pain and who must complete the pain management education program.
Agency: Oregon Health Authority
Division/Program: Health Policy and Analytics/Oregon Pain Management Commission
Concept Subject or Title: Oregon Pain Education Provider Requirement
Concept Contact Person: Denise Taray E-Mail: firstname.lastname@example.org
Agency Legislative Coordinator: Sarah Lochner E-Mail: email@example.com