Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Scope.
Subparts
2 to
4 apply to use of medication
in an outpatient setting. Subparts
2 to
4 do not require a health
care provider to prescribe any class of drugs in the treatment of any
patient.
Subp. 2.
Nonsteroidal anti-inflammatory drugs (NSAIDs).
Nonsteroidal anti-inflammatory drugs (NSAIDs) are drugs with
analgesic, antipyretic, and anti-inflammatory effects. The term "nonsteroidal"
is used to distinguish these drugs from steroids. NSAIDs act as inhibitors of
the enzyme cyclooxygenase. For the purposes of this subpart, NSAIDs include
diflunisal but not other salicylates or acetaminophen. NSAIDs can be divided
into two groups, nonselective NSAIDs and COX-2 inhibitors. Examples of
nonselective NSAIDs include diclofenac, diflunisal, etodolac, fenoprofen,
flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meclofenamate,
mefenamic acid, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam,
sulindac, and tolmetin. An example of a COX-2 inhibitor is celecoxib.
A. NSAIDs are indicated for the symptomatic
relief of acute and chronic musculoskeletal pain. NSAIDs must be prescribed at
the lowest clinically effective dose, as determined by the prescribing health
care provider, but not to exceed the manufacturer's maximum daily
dosage.
B. When treating
musculoskeletal pain, a generic nonselective NSAID is indicated unless a COX-2
inhibitor is indicated as specified in item C.
(1) When a nonselective NSAID is used,
treatment must begin with generic ibuprofen or generic naproxen. If there is a
medical contraindication documented by the prescribing health care provider to
each of the medications in this item, then treatment may begin with any other
generic nonselective NSAID.
(2)
Other generic nonselective NSAIDs are not indicated unless one-week trials of
each of ibuprofen and naproxen have been ineffective in reducing the patient's
pain by at least 50 percent as determined by the prescribing health care
provider.
(3) Nonselective NSAIDs
that are not available as generics are not indicated.
C. A COX-2 inhibitor may be indicated instead
of a nonselective NSAID for:
(1) patients
over 60 years of age;
(2) patients
with a history of gastrointestinal bleeding or peptic ulcer disease;
or
(3) patients with a history of
gastrointestinal side effects with nonselective NSAID use.
However, for any patient meeting any of the criteria of
subitems (1) to (3) who is taking aspirin or who is at an increased risk of
cardiovascular disease, a COX-2 inhibitor is not indicated and a nonselective
NSAID is indicated as allowed in items A and B, together with gastroprotective
medication.
D.
NSAIDs are indicated only for the shortest duration needed as determined by the
prescribing health care provider.
(1) NSAIDs
prescribed within the first four weeks after the date of injury are limited to
no more than two weeks of medication per prescription or refill.
(2) NSAIDs prescribed more than four weeks
after the date of injury may not be for more than one month of medication per
prescription or refill.
(3) NSAIDs
prescribed more than 12 months after the date of injury may not be for more
than three months of medication per prescription or refill.
Subp. 3.
Opioid
analgesics.
An opioid is any agent that binds to opioid receptors. There
are three broad classes of opioids: opium alkaloids, such as morphine and
codeine; semisynthetic opioids such as heroin and oxycodone; and fully
synthetic opioids such as meperidine and methadone. Opioid analgesics include
codeine, hydrocodone, levorphanol, methadone, morphine, hydromorphone, and
oxycodone.
A. Opioid analgesics are
indicated for the symptomatic relief of acute and chronic pain that has been
inadequately relieved by nonopioid medications. Opioid analgesics must be
prescribed at the lowest clinically effective dose, as determined by the
prescribing health care provider.
B. When treating pain, a generic oral opioid
analgesic is indicated.
(1) When an oral
opioid analgesic is used for the symptomatic relief of acute or chronic pain,
treatment must begin with one of the following: generic codeine, generic
hydrocodone, generic oxycodone, or generic morphine, unless there is a medical
contraindication documented by the prescribing health care provider. If there
is a medical contraindication documented by the prescribing health care
provider to each of the medications in this item, then treatment may begin with
any other generic oral opioid analgesic.
(2) Other generic opioid analgesics are not
indicated for oral use for the symptomatic relief of acute or chronic pain
unless one-week trials of each of hydrocodone, oxycodone, and morphine have
been ineffective in reducing the patient's pain by at least 50 percent as
determined by the prescribing health care provider.
(3) Generically available combinations of an
oral opioid and a nonopioid analgesic may be prescribed instead of that opioid
analgesic as otherwise allowed under subitems (1) and (2).
(4) Oral opioid analgesics that are not
available as generics and combinations of an oral opioid analgesic and a
nonopioid analgesic that are not available as generics are not
indicated.
C. A course
of oral opioid analgesics or combination of an oral opioid and a nonopioid
analgesic is limited as provided in subitems (1) to (3).
(1) Oral opioid analgesics prescribed within
the first four weeks after the date of injury are limited to no more than two
weeks of medication per prescription.
(2) Oral opioid analgesics prescribed more
than four weeks after the date of injury may not be for more than one month of
medication per prescription.
(3)
Continued prescription of oral opioid analgesics for more than 12 weeks may be
for more than one month of medication and must comply with all of the
requirements of part 5221.6110.
D. Meperidine is not indicated in the
treatment of acute or chronic pain.
E. Transcutaneous opioid analgesics are only
indicated in patients with a documented disorder that prevents adequate oral
dosing.
F. Oral transmucosal and
buccal preparations are only indicated for the treatment of breakthrough pain
and only in patients with a documented disorder that prevents adequate dosing
with swallowed medications.
Subp.
4.
Muscle relaxants.
A muscle relaxant is a drug which decreases the tone of a
muscle. For the purposes of this subpart, muscle relaxants include
carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol,
orphenadrine, and tizanidine. This subpart does not limit the use of
medications that may be used to treat spasticity.
A. Muscle relaxants are indicated for the
symptomatic relief of acute and chronic musculoskeletal pain. Muscle relaxants
must be prescribed at the lowest clinically effective dose, as determined by
the prescribing health care provider, but not to exceed the manufacturer's
maximum daily dosage.
B. When
treating musculoskeletal pain, a generic muscle relaxant is indicated.
(1) When a muscle relaxant is used, treatment
must begin with one of the following: generic carisoprodol, generic
chlorzoxazone, generic cyclobenzaprine, generic methocarbamol, or generic
tizanide. If there is a medical contraindication documented by the prescribing
health care provider to each of the medications in this item, then treatment
may begin with any other generic muscle relaxant.
(2) Metaxolone and orphenadrine are not
indicated unless one-week trials of each of carisoprodol, chlorzoxazone,
cyclobenzaprine, methocarbamol, and tizanide have been ineffective in reducing
the patient's pain by at least 50 percent as determined by the prescribing
health care provider.
(3)
Generically available combinations of a muscle relaxant and an analgesic may be
prescribed instead of that muscle relaxant as otherwise allowed under subitems
(1) and (2).
(4) Muscle relaxants
that are not available as generics, and combinations of a muscle relaxant and
an analgesic that are not available as generics, are not indicated.
C. A course of muscle relaxants or
combination of a muscle relaxant and an analgesic is limited as provided in
subitems (1) to (3).
(1) Muscle relaxants
prescribed within the first four weeks after the date of injury are limited to
no more than two weeks of medication per prescription or refill.
(2) Muscle relaxants prescribed more than
four weeks after the date of injury are limited to no more than one month's
worth of medication per prescription or refill.
(3) Treatment with muscle relaxants for more
than three consecutive months is not indicated.
D. Benzodiazepines are not indicated as
muscle relaxants for the symptomatic relief of acute and chronic
musculoskeletal pain.
