North Carolina Administrative Code › Title 11 - INSURANCE › Chapter 23 - INDUSTRIAL COMMISSION › Subchapter M - RULES FOR THE UTILIZATION OF OPIOIDS, RELATED PRESCRIPTIONS, AND PAIN MANAGEMENT TREATMENT IN WORKERS' COMPENSATION CLAIMS › Section .0200 - UTILIZATION RULES FOR OPIOID AND OTHER PHARMACOLOGICAL PAIN MANAGEMENT TREATMENT › Section 23M .0202 - PRESCRIPTION OF MEDICATION FOR PAIN IN AN ACUTE PHASE FOLLOWING THE FIRST PRESCRIPTION

Current through Register Vol. 39, No. 2, July 15, 2024
(a) This Rule
				  applies to prescriptions for medication to an employee for pain during an acute
				  phase that are written after a first prescription as described in Rule .0201 of
				  this Section.
(b) Before
				  prescribing a targeted controlled substance, a health care provider shall
				  document his or her medical opinion in the medical record that
				  non-pharmacological and non-opioid therapies are insufficient to treat the
				  employee's pain.
(c) A health care
				  provider shall not prescribe more than one targeted controlled substance at a
				  time in an acute phase.
(d) A
				  health care provider shall prescribe the lowest number of days' supply of a
				  targeted controlled substance necessary in his or her medical opinion to treat
				  an employee's pain.
(e) A health
				  care provider shall prescribe the lowest effective dosage of a targeted
				  controlled substance, not to exceed 50 mg morphine equivalent dose per day,
				  using only short-acting opioids. However, the health care provider may
				  prescribe a morphine equivalent dose higher than 50 mg per day, but not higher
				  than 90 mg per day, after documenting the medical justification for the
				  prescription, including a comparison of the expected benefits to the employee
				  versus any potential risks of increasing the employee's dosage. If the health
				  care provider prescribes a morphine equivalent dose higher than 50 mg per day
				  in an acute phase, the health care provider shall review at all subsequent
				  evaluations whether the employee experienced the expected benefits and consider
				  whether to continue the higher dosage and document the medical record
				  accordingly. The dosage limits in this Paragraph apply only to an opioid
				  prescription being prescribed pursuant to this Rule.
(f) A health care provider shall not
				  prescribe transcutaneous, transdermal, transmucosal, or buccal opioid
				  preparations without documentation in the medical record that oral opioid
				  dosing is medically contraindicated for the employee.
(g) A health care provider shall not
				  prescribe fentanyl for pain in an acute phase.
(h) A health care provider shall not
				  prescribe benzodiazepines for pain or as muscle relaxers in an acute
				  phase.
(i) A health care provider
				  shall not prescribe carisoprodol and a targeted controlled substance in an
				  acute phase.
(j) If an employee is
				  taking benzodiazepines or carisoprodol prescribed by another health care
				  provider, the health care provider shall not prescribe a targeted controlled
				  substance to the employee without advising the employee of the potential risks
				  of combining a targeted controlled substance and benzodiazepines or
				  carisoprodol. The health care provider shall also communicate with the health
				  care provider prescribing the benzodiazepines or carisoprodol to inform that
				  health care provider of the prescription of a targeted controlled
				  substance.
(k) A health care
				  provider shall review the information in the CSRS pertaining to the employee
				  for the preceding 12-month period every time the health care provider
				  prescribes a targeted controlled substance in an acute phase. The health care
				  provider shall document in the medical record the review and any potential
				  contraindications to prescribing a targeted controlled substance found in the
				  CSRS. The effective date of this Paragraph is November 1, 2018, or shall
				  coincide with the date of application in S.L. 2017-74, s. 15.(e), and any
				  amendments thereto, whichever is earlier.
(l) After an employee has received the first
				  prescription of a targeted controlled substance as described in Rule .0201 of
				  this Section and an additional 30 days of treatment with a targeted controlled
				  substance, the health care provider may only continue treatment with a targeted
				  controlled substance after fulfilling the following requirements:
(1) The health care provider shall administer
				  and document in the medical record the results of a presumptive urine drug test
				  as defined in Rule .0102 of this Subchapter. The health care provider may meet
				  this requirement by requiring that the employee take a random, unannounced
				  urine drug test. If the test results are positive for non-disclosed drugs or
				  negative for prescribed controlled substances, the health care provider shall
				  obtain confirmatory urine drug testing as defined in Rule .0102 of this
				  Section. Nothing herein prevents a health care provider from ordering
				  confirmatory urine drug testing for a medical reason other than the presumptive
				  urine drug test results if the medical reason is documented in the medical
				  record. The health care provider may obtain the confirmatory urine drug test
				  results before prescribing a targeted controlled substance. Alternatively, the
				  health care provider may order a limited supply of a targeted controlled
				  substance pending the results of the confirmatory urine drug test. The results
				  of any confirmatory urine drug test shall be documented in the medical
				  record.
(2) The health care
				  provider shall administer and document in the medical record the results of a
				  tool for screening and assessing opioid risk that has been validated by
				  clinical studies. Examples of these tools include the following:
(A) NIDA Quick Screen V1.0 and NIDA-Modified
				  ASSIST V2.0 (National Institute on Drug Abuse), available at
https://www.drugabuse.gov/sites/default/files/files/QuickScreen_Updated_2013(1).pdf;
(B) Screener and Opioid Assessment
				  for Patients with Pain (SOAPP)® Version 1.0 (Inflexxion, Inc.), available
				  at http://nhms.org/sites/default/files/Pdfs/SOAPP-14.pdf
(C) SOAPP-Revised (Inflexxion, Inc.),
				  available at
https://www.painedu.org
and
(D) Opioid Risk Tool (ORT) (Lynn Webster,
				  MD), available at
				  http://agencymeddirectors.wa.gov/Files/opioidrisktool.pdf
(3) The health care provider shall review and
				  document in the medical record whether the information obtained by complying
				  with Paragraph (k) of this Rule or Subparagraphs (1) or (2) of this Paragraph,
				  or any other aspects of the employee's medical records or examination, indicate
				  an increased risk for opioid-related harm. If the health care provider
				  continues the prescription of a targeted controlled substance despite any
				  increased risks identified, the health care provider shall document in the
				  medical record the reasons justifying the continued prescription.