7 Colo. Code Regs. § 1101-3-17-08-9
Recommendation 127. Medication reconciliation is required at the initial visit and periodically during treatment to avoid medication errors and to discuss side effects, drug interactions, and expected functional goals. Reconciliation includes the following elements:
* current medication name, dosage, frequency, and route;
* patient understanding of indication;
* potential interaction of prescription and over-the-counter medications;
* drug allergies;
* comorbid medical issues;
* history of substance abuse; and
* checking the Colorado Prescription Drug Monitoring Program (PDMP) when prescribing controlled substances.
Recommendation 128. A therapeutic trial of medications is recommended to evaluate the effect on functional status. The length of a medication trial will depend on the individual medication, and the patient should be informed on the time to expected benefit. If no functional benefit is observed at that time, the medication should be discontinued.
Recommendation 129. Medications should be initiated at the lowest dose expected to result in functional improvement and then titrated based on clinical response.
Recommendation 130. If anticonvulsants are being considered for neuropathic pain or any medications are being considered for long-term chronic pain management, refer to the Chronic Pain Disorder Medical Treatment Guidelines (MTGs) medications section.
Recommendation 131. Tricyclic antidepressants are acceptable as the first-line agent for neuropathic pain, particularly in the setting of insomnia. They are not recommended as a first-line agent for depression.
Recommendation 132. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are acceptable as a second-line agent for neuropathic pain if a tricyclic antidepressant offers inadequate relief. However, duloxetine is acceptable as a first-line agent for a patient who is a candidate for pharmacologic treatment of both chronic pain and depression.
Recommendation 133. Selective serotonin reuptake inhibitors (SSRIs) are acceptable for treating depression. They are not recommended for neuropathic pain.
Recommendation 134. The time frames for antidepressant medications are as follows:
* Time to produce effect: up to 6 months, depending on the medication.
* Maximum duration: up to 12 months, with monitoring.
Recommendation 135. Evaluation and ongoing monitoring for suicidal ideation and mood swings are required for all patients being considered for antidepressant medications.
Recommendation 136. A screening electrocardiogram is acceptable prior to initiating treatment with a tricyclic antidepressant or selective serotonin reuptake inhibitor (SNRI) to assess cardiovascular risk.
Recommendation 137. Non-benzodiazepine muscle relaxants, except for carisoprodol, are acceptable as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful, musculoskeletal conditions. The maximum duration is 2 weeks, or longer if used only at night.
Recommendation 138. While use of tizanidine (alpha-2 adrenergic agonist) is "off-label" for musculoskeletal conditions other than centrally mediated spasticity, its use is acceptable for patients who might functionally benefit from the medication's shorter half-life based on the provider's discretion.
Recommendation 139. Benzodiazepines and carisoprodol are not generally recommended. They are not recommended for use in combination with opioids.
Recommendation 140. Acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) are acceptable for initial analgesic treatment. Long-term use of acetaminophen or NSAIDs should be evaluated on a case-by-case basis; see the Chronic Pain Disorder Medical Treatment Guidelines (MTGs) for more information.
Recommendation 141. Co-prescription of a proton pump inhibitor, histamine H2-receptor antagonists (H2-blockers), or prostaglandin analog with non-steroidal anti-inflammatory drugs (NSAIDs) is acceptable to reduce risk of duodenal or gastric ulceration in patients with concurrent antiplatelet or corticosteroid therapy.
Recommendation 142. Cyclooxygenase-2 (COX-2) inhibitors are acceptable for patients who do not tolerate traditional non-steroidal anti-inflammatory drugs (NSAIDs) or for patients who the treating provider feels may be at risk for complications. They are not recommended as a first-line agent for short-term use in patients at low risk for complications with NSAIDs.
Recommendation 143. Perioperative use of acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs), either alone or in combination with other medications, to optimize analgesia is recommended.
Recommendation 144. Opioid medications are not generally recommended. Rare exceptions include either of the following:
* acute, severe functionally limiting pain in a patient for whom other non-opioid medications are contraindicated; or
* acute, severe functionally limiting pain that is refractory to non-opioid medications and nonpharmacologic treatment and an absence of risk factors for potential misuse or abuse. This includes postoperative use.
Recommendation 145. Prior to prescribing an opioid medication, all of the following steps are required:
* documented results of a rapid risk assessment for developing opioid use disorder (e.g., Opioid Risk Tool [ORT]); and
* risk assessment of developing opioid-related adverse events; and
* review data on the Colorado Prescription Drug Monitoring Program (PDMP); and
* education on the short- and long-term risks and side effects of opioid therapy; and
* realistic goals of opioid therapy and the anticipated course of recovery; and
* establish the lowest effective dose and shortest duration of therapy; and
* education on the safe storage and disposal of opioid medications; and
* develop a discontinuation plan for opioids prior to prescribing.
Recommendation 146. When opioids are prescribed, the time frames are as follows:
* The optimum duration is 3 days or less.
* The maximum duration is 7 days.
* Whenever opioids are prescribed for more than 7 days, providers must follow all recommendations for screening and follow-up of chronic pain use. See the Chronic Pain Disorder Medical Treatment Guidelines (MTGs).
Recommendation 147. Long-acting opioids are not recommended for the treatment of acute, subacute, or postoperative pain.
Recommendation 148. Due to the elevated risk of death due to respiratory depression, opioids should not be prescribed with benzodiazepines, antihistamines, or other central nervous system depressants or when there is a significant risk resulting from concurrent alcohol or substance use.
Recommendation 149. Opioid medications, including tramadol, are not generally recommended for use in patients with a history of opioid dependence. However, if an opioid medication is deemed clinically appropriate, a referral to a pain management specialist is acceptable.
Recommendation 150. Tobacco cessation (including medication, behavioral, and laboratory support) is acceptable when tobacco use is expected to negatively impact claim-related medical outcomes. Medications may include nicotine patches, gum, inhaler, lozenges or nasal spray, bupropion, or varenicline.
Recommendation 151. Topical medications as single agents are acceptable for pain management for acute and subacute upper extremity injuries. This includes topical capsaicin, lidocaine, and non-steroidal anti-inflammatory drugs (NSAIDs) when oral NSAID use is contraindicated due to systemic side effects.
Recommendation 152. Topical medications must be started with the lowest dose expected to result in functional improvement and then titrated until functional improvement is noted.
Recommendation 153. For information about compounded topical agents and chronic pain considerations, see the Chronic Pain Disorder Medical Treatment Guidelines (MTGs). The recommendations in that MTG are also applicable to acute and subacute shoulder injury.
7 CCR 1101-3-17-08-9