Medications (POL-120)

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Chapter: 
CLAIMS

Subject: 
MEDICATIONS

Effective Date:
March 31, 2004

Last Update:
May 18, 2023

PURPOSE STATEMENT

The purpose of this policy is to explain how the Workers Compensation Board (WCB) determines authorization for payment of prescription medications, including opioids.

REFERENCE

Workers Compensation Act R.S.P.E.I. 1988, Cap. W-7.1, Section 18(1), 18(2), 18(3)

Workers Compensation Board Policy, POL-64, Health Care Providers – Roles and Responsibilities

Workers Compensation Board Policy, POL-92, Health Care Benefits

Workers Compensation Board Policy, POL-153, Medical Cannabis

DEFINITION

In this policy:

“Opioids” means natural or synthetic narcotic analgesics (pain medication).

POLICY

General Principles

  1. The Workers Compensation Board (WCB) is committed to supporting injured workers during their recovery. The WCB supports the use of medication that is appropriate in the treatment of a work-related injury.

    This policy establishes the conditions for authorization for payment and safe use of medications, including opioids, in the treatment of work-related injuries.

Eligibility Criteria

  1. The WCB may authorize payment for reasonable and necessary medications used in the treatment of a work-related injury when a worker has an approved claim. In order for prescription medications to be authorized for payment, the medication must be:
  • Prescribed by a licensed physician, dentist, nurse practitioner or other health care provider recognized by the WCB.

  • Dispensed by a licensed pharmacist.

    In addition, the dosage, frequency of use, and total amount of the prescribed medication must be consistent with the Canadian Pharmacists’ Association Compendium of Pharmaceuticals and Specialties and must be clearly indicated in reports submitted to the WCB by prescribing health care providers.

  1. The WCB may refuse or limit the authorization for payment of prescription medications that are ineffective, inappropriate, or harmful, including those which may lead to dependency or addiction.
  2. WCB policy, POL-153, Medical Cannabis, sets out the specific circumstances and conditions under which approval for medical cannabis may be considered.

Opioids

  1. The following sections outline the WCB’s criteria for the authorization for payment of opioids prescribed in the treatment of work-related injuries and details WCB’s ongoing monitoring to ensure that opioid treatment is achieving the desired treatment outcomes.

    Authorization for Payment of Opioids for Acute Pain

  2. Non-opioid medication should be the first choice for treating pain, especially pain associated with soft tissue injuries. However, short term use of opioid medication to treat moderate to severe acute pain resulting from an injury or surgery may be considered reasonable and appropriate.
  3. The WCB will only authorize the payment of prescribed opioids for acute pain under the following circumstances:
  • All legal and regulation requirements have been met.
  • Use conforms to the Canadian Guideline for Opioids for Chronic Non-Cancer Pain (2017) and is to a maximum dose of 50 mg of morphine equivalent per day. 
  • Approval is limited to two weeks post injury or post-surgery.

Authorization for Payment of Opioids for Chronic Non-Cancer Pain

  1. The WCB may authorize payment of prescribed opioids for chronic non-cancer pain when all of the following criteria are met:
  • The prescription of opioids is part of an integrated approach to pain management.
  • The prescription is prescribed consistently by a single health care provider.
  • The route of prescription is oral or topical.
  • Careful consideration is given to behavioral symptoms that suggest opioids may increase the complexity of the worker’s condition.
  • There is evidence that treatment with opioids will result in improvement of the worker’s condition.
  • The prescription pattern follows regular dosing of long-acting oral opioids, with infrequent short-acting oral dosages of the same opioid for breakthrough pain.
  • There is appropriate monitoring by the WCB.
  • Use conforms to the Canadian Guideline for Opioids for Chronic Non-Cancer Pain (2017) and is to a maximum dose of 90 mg morphine equivalent per day.
  • There is a signed copy of a therapeutic agreement between the worker and physician, such as the Patient Agreement for Long-Term Opioid Therapy, and an Opioid Management Form signed by the prescribing physician, provided to the WCB.

Authorization for Payment of Opioids for Palliative or Cancer Care

  1. For palliative or cancer care, WCB may authorize payment of opioids in any form and through any method of administration that is recommended by the treating health care provider.

    Monitoring

  2. The WCB will periodically review medical information related to the worker’s treatment plan and goals to ensure that opioids continue to be necessary and effective in treating the work-related injury or illness.

    The WCB may suspend or discontinue authorization for payment of prescribed opioids when:

  • Increases in dosage do not result in improvement in function (based on validated outcome measures acceptable to the WCB), progress towards return to work or a reduction in pain. 
  • The prescribed opioids result in significant, serious side effects (e.g., non-physiological processes required for bodily functions, medications required to counteract side effects reasonably attributable to opioids).
  • The prescribed opioids are harming or impeding the worker’s recovery, improvement in function, or return to work. 
  • There is evidence of repeated dosage adjustments that have not been prescribed by a consistent health care provider or authorized by WCB.
  • There is evidence that the prescribed opioids are being misused, used in a manner not intended by the prescribing health care provider, or is inconsistent with the intended purposes of the medication.

HISTORY

May 18, 2023 – Amended to reflect current medical guidelines and maximum dosing thresholds for the prescribing of opioids.

July 30, 2021 – Non-substantive edits to terminology.

October 25, 2018 - Amended to update the provisions related to limits on medication authorizations to be consistent with the new policy, Medical Cannabis (POL-153). Additional amendments reflect to update references and terminology.

November 22, 2016 - Amended to allow approval of medications not generally authorized under exceptional circumstances, and to update the list of prescribing health care providers and opioid treatment methods.

February 16, 2011 - Amended to clarify that automatic approval of opioids post injury or post-surgery will be limited to two weeks.

May 28, 2009 - Amended to include that a signed copy of a therapeutic agreement between the worker and physician must be provided to the Workers Compensation Board prior to the authorization of long-term opioid prescription for chronic non-cancer pain. Also, a section has been added related to the suspension or discontinuation of authorization of payment for prescribed opioids.

May 24, 2007 - Amended to reflect changes to the Registered Nurses Act and Regulations as well as current medical practice regarding the prescription of Opioids.

March 31, 2004 - Replaces the “Medication” policy which was rescinded on June 23, 2003.

Board of Directors Approval Date: March 31, 2004