GUIDELINE NOTE 60, OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE

Lines 346,​361,​402,​530

Opioid medications are only included on these lines under the following criteria. Time periods described below are relative to the patient’s initial injury or condition for which opioids were originally prescribed, regardless of whether the individual or any plan paid for the medication. Providers are encouraged to consider the recommendations of the Oregon Opioid Prescribing Guidelines Task Force when prescribing opioid medications: Oregon Acute Opioid Prescribing Guideline (October 2018) and the Oregon Chronic Opioid Prescribing Guidelines (2017-2018).

For acute conditions and flares

During the first 6 weeks after an acute injury, acute flare of chronic pain, or surgery opioid treatment is included on these lines ONLY:

1. When each prescription is limited to 7 days of treatment, AND
2. For short acting opioids only, AND
3. 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
4. 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
5. There is documented evaluation of the patient’s risk factors for opioid misuse or abuse (e.g., history of opioid misuse, verification of prescription history in the PDMP).

During subacute period

Treatment with opioids after 6 weeks of continuous therapy and up to 90 days after the initial injury/flare/surgery is included on these lines ONLY:

1. With documented evidence of improvement of function of at least thirty percent as compared to baseline based on a validated tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ).
2. When prescribed with a plan to keep active (home or prescribed exercise regime) and additional therapies such as spinal manipulation, physical therapy, yoga, or acupuncture, when available.
3. With 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 abuse
   • Administration of a baseline urine drug test to verify the absence of illicit drugs and non-prescribed opioids.
4. Each prescription must be limited to 7 days of treatment and for short acting opioids only

Long-term opioid therapy

Long-term opioid treatment (>90 days) after the initial injury/flare/surgery is included on these lines as described below.

For patients receiving long-term opioid therapy (>90 days) for conditions of the back and spine, continued coverage of opioid medications requires a comprehensive individual treatment plan for chronic pain, taking into account the biological, behavioral, psychological and social factors which may influence each individual’s experience of chronic pain as well as any current and past treatments. Treatment plans should be prescribed (unless contraindicated) with a plan to keep active (home or prescribed exercise regimen) and should include additional therapies such as spinal manipulation, physical therapy, yoga or acupuncture unless contraindicated and if available in a patient’s community and reasonably accessible to the patient. The treatment plan should conform with the Oregon Chronic Opioid Prescribing Guidelines (2017-2018). A taper plan may be indicated if and when clinically appropriate.

Opioid tapers

Opioid taper plans are not required in order for continued inclusion of long-term opioid therapy on these lines. Providers initiating taper plans are encouraged to follow Oregon Opioid Tapering Guidelines (January 2020). Taper plans should include nonpharmacological treatment strategies for managing the patient’s pain. During the taper, behavioral health conditions need to be regularly assessed and appropriately managed.