Pain Management Resources and Opioid Use

Recent News!

Fewer members using opioids - those who are, are using less

Objective

The Department of Health Care Policy and Financing (the Department) has implemented and plans to continue to implement policies designed to impact the opioid overdose epidemic. The objective of this page is to provide a central source for Department opioid policy information, resources regarding pain management and opioid prescribing for the provider, member pain management resources, and additional related information. The Department is following the lead of the Colorado Consortium for Prescription Drug Abuse Prevention in reducing the misuse of prescription opioids. In order to support this Governor-assigned task force the currently implemented policies describing limitations on morphine milligram equivalents (MME), short acting opioid pill quantities, early interruption of opioid dosing escalations, and dental provider specific policies are briefly listed:

MME - Prior Authorization required for Rx exceeding 200MME
Short-acting opioid pill quantity limits - 120 per 30 days for chronic (non-naïve) short-acting opioids
Opioid Naïve Policy - Member identified as opioid naïve if they have not had an opioid Rx filled within 180 days, days-supply will be limited for opioid naïve to 7 days (56 pills, short-acting opioid only), after 3 fills of 7 days-supplies are written, provider may be required to complete provider-provider consult with pain management specialist
Dental provider quantity limit is 4 days (24 pills, short-acting opioid only)

Through these policies, the Department is attempting to reduce potentially inappropriate opioid utilization, high risk/high dose prescribing, and reduce unnecessary escalation to higher dose opioid utilization. Recognizing there are special needs and necessity for individual assessment for many members, the Department provides provider-provider consults with a pain management specialist free of charge to the provider and member and are available by request (sspps.co-dur@ucdenver.edu). Compassionate pain management and opioid safety are important to the Department and the consult service provides an additional expert evaluation of safety and efficacy of members' pain management regimens.

The Department strongly encourages the provider use the Prescription Drug Monitoring Program when prescribing controlled substances to all members.

Courtesy of National Safety Council on Acute Pain:

Morphine Equivalents Limitations: Lowering the Max Dose Ceiling

Current MME Maximum is set at 200MME

2/1/2016: MME limitation was initially implemented at 300MME
10/1/2017: MME decreased from 300MME to 250MME
11/1/2018: MME decreased from 250MME to 200ME

The Department continues to advance toward its goal of 120 MME without a specific time mentioned in the policy. The policy document initially identifying the MME limitations can be found here:

Morphine Milligram Equivalents Policy

MME for opioid prescriptions are counted in a cumulative manner. If a single prescription for an opioid exceeds the MME limit, then it will require prior authorization. If multiple different opioid prescriptions are provided, then the MME for each will be added until the prescription that exceeds the MME limit will require prior authorization. The morphine equivalence calculator the Department bases their calculations on can be found here:

Morphine Equivalent Conversion Table

Short-Acting Opioids

Courtesy of National Safety Council on Acute Pain:

How Effective is Your Pain Medication? NNT Score Ibuprophen 200 mg+ Acetaminophen 500 mg 1.5 Diclofenac 200 mg 1.7 Ibuprophen 200 mg 2.5 Morphine 10 mg IM 2.7 Oxycodone 10 mg+ Acetaminophen 500 mg 3.5 Oxycodone 15 mg 4.6

You need to ass 1000 mg acetaminophen plus 10 mg oxycodone to make oxycodone as effective as 200 mg ibuprophen.

Pain Management Resources for Providers

Prescription Drug Monitoring Program (PDMP): Health First Colorado strongly recommends using the PDMP when precribing controlled substances. Signing up is incredibly easy.

Practice Guidelines:

Additional Information on the Tapering and Discontinuing of Opioids:

Disclaimer

HCPF is not recommending this calculator to be used as a reference for converting a patient from one opioid to another, conversion is a complex process and we recommend consulting a specialist. The reference calculator is provided as it is the source of opioid milligram equivalents quantification used by HCPF. Please exercise great caution when converting patients from one opioid to another as issues of cross-tolerance and agent pharmacokinetics can create a potentially life-threatening situation. If a telephone consult is needed with a pain management physician (free of charge for Medicaid members), please email SSPPS.co-dur@ucdenver.edu.

VA Tapering and Dicontinuing Opioids Fact Sheet

Additional Information:

Courtesy of National Safety Council on Acute Pain:

200 mg Ibuprophen provides as much pain relief as a 10 mg morphine shot

Recent Legislation Pertinent to Opioid Prescribing

State of Colorado:

HB19-1287: Treatment For Opioids And Substance Use Disorders, concerning methods to increase access to treatment for behavioral health disorders, and, in connection therewith, making an appropriation.
SB19-013: Medical Marijuana Condition Opiates Prescribed For, concerning the conditions for medical marijuana use for disabling medical conditions, and, in connection therewith, adding a condition for which a physician could prescribe an opioid to the list of disabling medical conditions for medical marijuana use.
SB19-227: Harm Reduction Substance Use Disorders, concerning the identification of certain individuals with a substance use disorder; and making an appropriation.
SB19-228: Substance Use Disorders Prevention Measures, concerning the safe use, storage, and disposal of antagonist drugs; and making an appropriation.
HB18-1007: Substance Use Disorder Payment And Coverage, concerning payment issues related to substance use disorders.
SB18-022: Clinical Practice For Opioid Prescribing, concerning clinical practice measures for safer opioid prescribing.
SB18-168: Medicaid-assested Treatment Through Pharmacies, concerning payment reform in the medical assistance program to provide access to medication-assisted treatment for the prevention of relapse for persons suffering from substance use disorders.
HB18-1003: Opioid Misuse Prevention, concerning measures to prevent opioid misuse in Colorado, and, in conncection therewith, making an appropriation.

Federal

H.R.6: SUPPORT for Patients and Communities Act

Opioid Overdose Resources

Naloxone rescue product coverage is published in the Appendix P

Nasal Narcan and Prefilled naloxone syringe with nasal atomizer are available without prior authorization.

Substance Abuse and Mental Health Services Administration (SAMHSA) Resources

Additional Training and Resources:

Get Naloxone Now: Online interactive trainings for community members/first responders on naloxone administration
Prescribe to Prevent: Information for prescribers, pharmacists and community members
How to Administer Nasal Spray Naloxone

Find a Pharmacy that Provides Naloxone and Nasal Atomizers

Patient Education

CDC Opioid Fact Sheet
CDC Patient Information Page for Opioids
American Hospital Association (AHA) - What you need to know
American Academy of Family Physicians (AAFP) - Pain Management and Opioid Abuse Resources
Medication Safe Use and Disposal Pamphlet
List of Pain Relief Medications
Please refer to the respective Regional Accountable Entity (RAE) for additional help connecting with care and information

Substance Use Disorder Assistance/Prevention

Pharmacological Coverage for Medication Assisted Treatment (MAT) can be found on the Appendix P
Medicaid Behavioral Health Organizations Services
Peer Assistance Services
Substance Abuse and Mental Health Services Administration
NIH National Institute on Drug Abuse
The National Alliance for Advocates for Buprenorphine Treatment's Clinical Opiate Withdrawal Scale

Currently available non-drug services covered by Medicaid for use in conjunction with drug treatment

Screening, Brief Intervention and Referral to Treatment SBIRT Billing Manual
Behavioral Health Services
Physical Therapy (PT) /Occupational Therapy (OT), massage in conjunction with PT/OT
Colorado 1500 Specialty Manual (Mental Health Program)

Disclaimer
The State of Colorado believes it is important to provide information about opioids and intends this page to be a resource. It is intended to provide additional information about opioids, their use, potential misuse, as well as information about substance abuse/misuse programs, however it is not meant to be all inclusive. This page provides links to a handful of external websites that are not the property of, or the responsibility of the State of Colorado. Upon the selection of such a link you will leave the Colorado Department of Health Care Policy and Financing’s website. The State of Colorado is not responsible for the content of the linked web pages or the dependability, accuracy or information security of these sites. The State of Colorado does not endorse or sponsor the companies, products or services that may be offered at these websites nor should such an endorsement be implied. The links are not listed in any particular order of importance.