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5221.6105 Medications

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 patients 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) Oral opioid analgesics prescribed more than 12 weeks after the injury may be for more than one month of medication per prescription if there has been a clinical evaluation to confirm the need for an efficacy of the prescription and a clinical evaluation at least every six months thereafter during continued use of opiate analgesics.

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 months 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.

Statutory Authority:  MS s 176.103; 176.83

History:  35 SR 138

Posted:  Aug. 16, 2010

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