Non-Acute Pain

1 MedicalTreatmentGuidelinesNon-Acute PainEffective May 2, 2022 Adapted by NYS Workers Compensation Board ( WCB ) from MDGuidelines with permission of Reed Group, Ltd. ( ReedGroup ), which is not responsible for WCB s modifications. MDGuidelines are Copyright 2019 Reed Group, Ltd. All Rights Reserved. No part of this publication may be reproduced, displayed, disseminated, modified, or incorporated in any form without prior written permission from ReedGroup and WCB. Notwithstanding the foregoing, this publication may be viewed and printed solely for internal use as a reference, including to assist in compliance with WCL Sec. 13-0 and 12 NYCRR Part 44[0], provided that (i) users shall not sell or distribute, display, or otherwise provide such copies to others or otherwise commercially exploit the material. Commercial licenses, which provide access to the online text-searchable version of MDGuidelines , are available from ReedGroup at NYS WCB MTG Non-Acute pain 1 Contributors The NYS Workers Compensation Board would like to thank the members of the New York Workers Compensation Board Medical Advisory Committee (MAC).

2 The MAC served as the Board s advisory body to adapt the American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines to a New York version of the Medical Treatment Guidelines (MTG). In this capacity, the MAC provided valuable input and made recommendations to help guide the final version of these Guidelines. With full consensus reached on many topics, and a careful review of any dissenting opinions on others, the Board established the final product. New York State Workers Compensation Board Medical Advisory Committee Joseph Canovas, Esq. Special Counsel New York State AFL-CIO Linda L. Clark, MD, MS (FACOEM, FACPM) Senior Health Advisor, Common Ground Health, Rochester, NY Kenneth B. Chapman, MD Director pain Medicine, SIUH Northwell Health Systems Assistant Clinical Professor, NYU Langone Medical Center Adjunct Assistant Professor, Hofstra Medical School Cristina Demian, MD, MPH, FACOEM Medical Director, Finger Lakes Occupational Health Services Associate Professor, University of Rochester Medical Center Department of Environmental Medicine Tildabeth Dorscher, MD Fellowship Director, Addiction Medicine Fellowship, Jacob s School of Medicine Medical Director, Phoenix House of NYC and LI Clinical Assistant Professor, Department of Family Medicine, University at Buffalo Robert Goldberg, DO Senior Attending Physician, Department of Rehabilitation, Beth Israel Hospital and Medical Center of NYC Faculty Institute for Family Health at the Icahn School of Medicine at Mount Sinai Clinical Professor of Rehabilitation Medicine.

3 Philadelphia College of Osteopathic Medicine Member Council on Medical Education of the American Medical Association Former Dean and Professor of Physical Medicine and Rehabilitation and Health Policy Touro College of Osteopathic Medicine and Former Clinical Associate Professor of Rehabilitation Medicine, New York Medical College Hemant Kalia, MD MPH FIPP Program Director, Interventional Spine & pain Fellowship. Rochester Regional Health System, Rochester, NY Clinical Assistant Professor, Physical Medicine & Rehabilitation, University of Rochester, NY Clinical Assistant Professor: Department of Internal Medicine, Physical Medicine & Rehabilitation and pain Management. Lake Erie College of Osteopathic Medicine Board of Directors, Monroe County Medical Society Editor-in-Chief, Advances in Clinical Medical Research & Healthcare Delivery NYS WCB MTG Non-Acute pain 2 Frank Kerbein, SPHR Director, Center for Human Resources The Business Council of New York State, Inc.

4 Winston C. Kwa, MD MPH Medical Director, Mount Sinai Selikoff Centers for Occupational Health-Mid-Hudson Valley Associate Professor, Mount Sinai School of Medicine Jade Malcho, MD Instructor of Clinical Emergency Medicine Addiction Medicine Physician Department of Emergency Medicine University of Rochester Medical Center Scott Matthews, MD Fellow, Addiction Medicine Fellowship, Jacob s School of Medicine State University of New York at Buffalo Jacqueline M Moline, MD, MSc Professor and Chair, Occupational Medicine, Epidemiology and Prevention At Zucker School of Medicine at Hofstra/Northwell Director, Occupational and Environmental Medicine of Long Island Director, Northwell Queens WTC Clinical Center Nicholas E. Nacca, MD, FAACT Assistant Professor of Emergency Medicine Department of Emergency Medicine University of Rochester Medical Center Joseph Pachman, MD, PhD, MBA, MPH Licensed Psychologist and Physician Board Certified in Occupational Medicine Fellow in ACOEM Vice President and National Medical Director, Liberty Mutual James A.

5 Tacci, MD, JD, MPH Medical Director and Executive Medical Policy Director, New York State Workers Compensation Board Edward C. Tanner, MD Chair, Department of Orthopaedics at Rochester General Hospital Past President, New York State Society of Orthopaedic Surgeons (NYSSOS) Member, American Academy of Orthopaedic Surgeons (AAOS) Member, American Association of Hip and Knee Surgeons (AAHKS) Timothy Wiegand, MD Associate Professor, Emergency Medicine, Addiction Medicine and Medical Toxicology University of Rochester Medical Center NYS WCB MTG Non-Acute pain 3 Table of Contents A. General Guideline Principles .. 6 Medical Care .. 6 Rendering Of Medical 6 Positive Patient Response .. 6 Re-Evaluate Treatment .. 6 Education .. 6 Acuity .. 7 Initial Evaluation .. 7 Diagnostic Time Frames .. 7 Treatment Time Frames .. 7 Delayed Recovery .. 7 Active Interventions .. 7 Active Therapeutic Exercise Program.

6 8 Diagnostic Imaging And Testing Procedures .. 8 Surgical Interventions .. 8 Pre-Authorization .. 9 Psychological/Psychiatric Evaluations .. 9 Personality/Psychological/Psychosocial Intervention .. 9 Functional Capacity Evaluation (FCE) .. 10 Return To 11 Job Site Evaluation .. 11 Guideline Recommendations And Medical Evidence .. 11 Experimental/Investigational Treatment .. 11 Injured Workers As Patients .. 12 Scope Of Practice .. 12 B. Definition .. 13 C. Introduction .. 13 NYS WCB MTG Non-Acute pain 4 Key Concepts .. 13 D. Evaluation and Diagnostic Procedures .. 17 History Taking and Physical Examination .. 18 Personality / Psychological / Psychosocial Clinical Evaluation for pain Management .. 22 Diagnostic Studies (Imaging, Electrodiagnostic Studies (EDX), Special Studies, Laboratory Testing) .. 24 E. Non-Pharmacological Approaches .. 24 Delayed Recovery .. 24 Psychological Evaluation and Intervention.

7 25 Non-Pharmacological Treatment Options .. 26 Non-Acute pain Management Programs (Interdisciplinary or Functional Restoration pain Management Program) .. 27 Multidisciplinary Programs .. 28 Goals of pain Management Programs .. 28 Types of Programs .. 29 Duration of Programs / Interventions .. 29 F. Pharmacological Approaches .. 30 Non-Opioid Medications and Medical Management .. 31 Opioids: Initiating Transitioning and Managing Long-Term Oral Opioids .. 40 Guidelines for Optimizing Opioid Treatment .. 49 Opioid-Related Medications: Tramadol, Methadone, Buprenorphine and Tapentadol .. 65 G. Spinal Cord Stimulator and Intrathecal Drug Delivery .. 67 Implantable Spinal Cord Stimulator (SCS) .. 67 Peripheral Nerve Stimulation (PNS) .. 70 Intrathecal Drug Delivery ( pain Pumps) .. 71 H. Functional Maintenance Care .. 72 General Recommendations for Functional Maintenance Care .. 73 Appendix A: Fear-Avoidance Beliefs Questionnaire (FABQ).

8 76 Appendix B: Frequently Used Tests of Psychological Functioning .. 78 Appendix C: pain Assessment and Documentation Tool (PADT) .. 84 NYS WCB MTG Non-Acute pain 5 Appendix D: Dosing Thresholds for Selected Opioids .. 88 Appendix E: Urine Drug 90 Appendix F: Patient Informed Consent for Opioid Treatment Form .. 95 Appendix G: Patient Understanding for Opioid Treatment Form .. 96 Appendix H: Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics .. 97 Appendix I: Guidance on Tapering Benzodiazepines .. 104 Appendix J: Gabapentinoids Tapering .. 112 NYS WCB MTG Non-Acute pain 6 A. General Guideline Principles The principles summarized in this section are key to the intended application of the New York State Medical Treatment Guidelines (MTG) and are applicable to all Workers Compensation Medical Treatment Guidelines. Medical Care Medical care and treatment required as a result of a work-related injury should be focused on restoring functional ability required to meet the patient s daily and work activities with a focus on a return to work, while striving to restore the patient s health to its pre-injury status in so far as is feasible.

9 Rendering Of Medical Services Any medical provider rendering services to a workers compensation patient must utilize the Treatment Guidelines as provided for with respect to all work-related injuries and/or illnesses. Positive Patient Response Positive results are defined primarily as functional gains which can be objectively measured. Objective functional gains include, but are not limited to, positional tolerances, range of motion, strength, endurance, activities of daily living (ADL), cognition, psychological behavior, and efficiency/velocity measures which can be quantified. Subjective reports of pain and function may be considered and given relative weight when the pain has anatomic and physiologic correlation in proportion to the injury. Re-Evaluate Treatment If a given treatment or modality is not producing positive results within a well-defined timeframe, the provider should either modify or discontinue the treatment regime.

10 The provider should evaluate the efficacy of the treatment or modality 2 to 3 weeks after the initial visit and 3 to 4 weeks thereafter. These timeframes may be slightly longer in the context of conditions that are inherently mental health issues, and shorter for other non-musculoskeletal medical conditions ( pulmonary, dermatologic etc.). Recognition that treatment failure is at times attributable to an incorrect diagnosis a failure to respond should prompt the clinician to reconsider the diagnosis in the event of an unexpected poor response to an otherwise rational intervention. Education Education of the patient and family, as well as the employer, insurer, policy makers and the community should be a primary emphasis in the treatment of work-related injury or illness. Practitioners should develop and implement effective educational strategies and skills. An education-based paradigm should always start with communication providing reassuring information to the patient.