How should opioid tapering be done under California’s MTUS and the formulary regulations that are being developed?
That was the subject of comments recently submitted by the California Applicants’ Attorneys Association pursuant to the 2nd 15-day comment period on the proposed formulary (see links at end of this post).
Clearly the DWC is behind the eight-ball and needs to get the formulary regulations finalized if payors and treaters are going to implement the new formulary as of January 1, 2018.
CAAA’s recent suggestions revolve around three points, all dealing with the tapering section of the proposed formulary regulationswhich is under Section 9792.27.3, the MTUS Drug Formulary Transition section.
First, CAAA is troubled by the proposed removal of the reference to “safe” weaning and tapering and the substitution of language requiring that a physician report “include a treatment plan setting forth a medically appropriate weaning, tapering, or transitioning of the worker to a drug pursuant to the MTUS…”. I don’t speak for CAAA, but it appears the concern is that a focus on “medically appropriate” weaning and tapering may not necessarily encompass a “safe” course of weaning and tapering. CAAA argues that there is “no sound rationale or public policy argument for removing the word “safe”. Obviously the concern is that what may be “medically appropriate” in the abstract may not be safe for a particular patient.
Second, CAAA’s comments propose that the formulary incorporate the Centers for Disease Control Guidelines for Tapering Opioids for Chronic Pain. CAAA argues that the CDC tapering guidelines will better ensure that medical providers meet their standard of care to patients.
A close look at the Opioids Treatment Guidelines adopted by the DWC in June 2016 reveals that Section 4.2 deals with “Methods for Tapering Opioids”. This includes a recommendation to “Taper in outpatient setting using 10%─25% per week taper, with or without buprenorphine (Suboxone) support after opioid has ended.”
Supplementary materials developed by the DWC had examined various tapering guidelines, including those used in Canada, Washington State, the American Academy of Pain Medicine and the 2014 ACOEM guidance.
Contrast this with the CDC recommendations cited by CAAA which recommend individualized tapering plans , cautioning “Go slow”, and which say that “A decrease of 10% of the original dose per week is a reasonable starting point.” According to the CDC guidelines, “Some patients who have taken opioids for a long time might even find slower tapers (e.g. 10% per month) easier.”
The CDC seems to be recommending a slower taper. But whether the DWC would be amenable to reopening the Opioid Guidelines at this point is doubtful.
The third CAAA objection to the proposed formulary is that it does not reference a safe tapering and weaning plan under subsection (b)(4) of the proposed Section 9792.27.3, a section which deals with previously approved drug treatment.
The DWC will be finalizing the formulary regs any day now.
Come January 2018 we will start to see how all this plays out in the real world. The focus will shift from legalese about the regs to how tapering & weaning is handled with real workers.
Unfortunately, there are many in the California system who are hooked on pain meds.
This could be a rough ride for some folks.
Here are the September 22, 2017 CAAA comments:
And here is the 2nd 15-day version of the formulary:
http://www.dir.ca.gov/dwc/DWCPropRegs/MTUS-Formulary/MTUS-Formulary.htm
And here are the 2016 Opioid regulations:
Stay tuned.
Julius Young
