The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing decisions made by the Workers Compensation Board ("WCB") regarding his entitlement to coverage for opioid medications and Cyclobenzaprine. A file review was held on June 6, 2019 to consider the worker's appeal.

Issue

Whether or not the worker is entitled to coverage for opioid medications after January 10, 2019;

Whether or not the worker is entitled to coverage for Cyclobenzaprine.

Decision

That the worker is entitled to coverage for opioid medications after January 10, 2019;

That the worker is not entitled to coverage for Cyclobenzaprine.

Background

This claim has been the subject of a previous appeal. Please see Appeal Commission Decision No. 148/97 dated June 26, 1997. The background will therefore not be repeated in its entirety.

The worker has an accepted claim for a workplace accident that occurred on November 5, 1986. Accepted compensable diagnoses were right shoulder regional myofascial pain syndrome and right rotator cuff tendonitis. The worker has received various benefits over the course of his claim, including coverage for opioid and other medications. The worker's medications have been subject to periodic review by the WCB.

On May 29, 2018, the worker's family physician provided the WCB with a Progress - Opioid Management Report, which indicated a Pain Score of 9/10 and an Aggregate Functional Score of 16/40, with no reported side effects. On June 25, 2018, a medical advisor to the Pain Management Unit ("PMU") at the WCB contacted the worker's family physician to discuss the Report. The WCB medical advisor to the PMU noted that based on the information on file, the use of opioid medications did not appear to be providing any benefit to the worker with respect to pain or function.

On June 25, 2018, the WCB medical advisor to the PMU advised the family physician of concerns with respect to the side effects of the long-term use of opioid medications. He also noted that the worker had been prescribed a Benzodiazepine and Cyclobenzaprine, a muscle relaxant, and advised of concerns with respect to the concurrent use of these medications with opioids "…due to the negative cognitive side effects of these medications and negative combined effects on respiration…" The WCB medical advisor to the PMU stated that as the risk/benefit ratio for the use of opioids was not considered favourable, the use of opioids was not eligible for financial support, but would remain eligible for support for a sixteen week weaning process.

On September 19, 2018, the WCB's Compensation Services advised the worker that a review of his medications had been completed, and they were unable to approve ongoing financial support for the use of opioids as the potential benefits associated with the opioid medications did not outweigh the possible risks and/or side effects based on the nature of his injury. Compensation Services further advised that the risk/benefit ratio for the use of Cyclobenzaprine was not considered favourable by the WCB and the use of this medication was not eligible for financial support.

On December 4, 2018, the worker requested that Review Office reconsider Compensation Services' decision. The worker referred to the effect that withdrawing financial support for these medications would have on his livelihood.

On February 12, 2019, Review Office determined that there was no entitlement to coverage for opioid medications beyond January 10, 2019, and no entitlement to coverage for Cyclobenzaprine. Review Office accepted and placed weight on the opinion of the WCB medical advisor to the PMU. Review Office acknowledged that the worker had pain complaints, but found that the side effects and risks of opioid medications and Cyclobenzaprine outweighed their benefits.

On April 4, 2019, the worker appealed the Review Office decision to the Appeal Commission and a file review was arranged.

Reasons

Applicable Legislation and Policy

The Appeal Commission and its panels are bound by The Workers Compensation Act (the "Act"), regulations and policies of the WCB's Board of Directors. As the worker's claim arose from a 1986 workplace accident, his benefits are assessed under the Act as it existed at that time.

Subsection 4(1) of the Act, as it read in 1986, provided that where a workman suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid.

Subsection 24(1) of the Act stated that the WCB "…may provide for the injured workman such medical, surgical, and hospital treatment, transportation, nursing, attendant care, medicines, crutches, and apparatus...as it may deem reasonably necessary at the time of the injury, and thereafter during the disability, to cure and relieve from the effects of the injury…"

Subsection 24(11) further stated, in part, that medical aid provided by the WCB shall at all times be subject to the supervision and control of the WCB.

WCB Policy 44.120.10, Medical Aid (the "Medical Aid Policy") sets out general principles regarding a worker's entitlement to medical aid, which is defined to include drugs. The Medical Aid Policy states that the WCB's objectives in funding medical aid are to promote a safe and early recovery and return to work, enable activities of daily living, and eliminate or minimize the impacts of a worker's injuries. The Policy further provides that the WCB will refuse or limit the funding of any medical aid it considers excessive, ineffective, inappropriate or harmful.

WCB Policy 44.120.20, Opioid Medication (the "Opioid Policy") recognizes that physicians are confronted with the challenge of prescribing opioids in a way that balances their ability to relieve pain and improve function while minimizing side effects and risks. The stated intent of the Opioid Policy is to provide parameters for the authorization and payment of opioids. The Opioid Policy provides that the WCB may suspend or discontinue authorization of payment for opioid medication in circumstances which include when the side effects or risks of opioid medication outweigh their benefit.

Worker's Position

The worker indicated that he is seeking to have his medications, in particular Tylenol 3s, covered by the WCB. The worker stated that Tylenol 3s provide him with relief from the effects of his workplace accident and injury. He submitted that his financial position is very low and he needs all the help he can get.

The worker said that he was recently put on new medication (for an unrelated condition), which limits what he can take to relieve the pain from his injury. He noted that his doctor has taken him off other medications because of their interaction with this new medication, and his only recourse for pain relief is Tylenol 3s. He said he has tried cortisone injections in the past but they do not work for him and do not help his arm. He has been refused for surgery because of his age and being a high risk for surgery. The worker noted that his doctor monitors him and he has blood work done once a month to ensure that his consumption of medication is safe.

Employer's Position

The employer did not participate in the appeal.

Analysis

Issue 1. Whether or not the worker is entitled to coverage for opioid medications after January 10, 2019.

For the appeal on this issue to be successful, the panel must find, on a balance of probabilities, that opioid medications are reasonably necessary to cure and provide relief from the effects of the worker's workplace injury. The panel is able to make that finding.

Information on file indicates that the worker has been prescribed Tylenol 3 for almost 20 years at least. In the notes from his call-in examination of the worker on February 22, 2018, the WCB medical advisor stated that the worker reported he takes up to six Tylenol 3 a day and that the dose of Tylenol 3 had remained stable over the last number of years. He infrequently increased the dose to eight tablets a day. The worker had not demonstrated any side effects beyond constipation in relation to the use of this medication. He had recently trialed a prescription for Tylenol 4, which was accepted as a financial responsibility of the WCB on a trial basis, but had not been prescribed any further Tylenol 4. The WCB medical advisor advised that Tylenol 3 remained appropriate in relation to the compensable injury.

The panel notes that in his memorandum to file dated June 25, 2018, the WCB medical advisor to the PMU documented his telephone conversation with the family physician, where he outlined his view that the use of opioid medications did not appear to be providing any benefit to the worker with respect to pain or function. He noted concerns with respect to the side effects of the long-term use of opioid medications, and concerns with the concurrent use of two other medications with opioids, due to the negative cognitive side effects of these medications and negative combined effects on respiration. The medical advisor noted that the risk/benefit ratio for the use of opioids was not considered favourable.

The panel acknowledges and respects the opinion of the WCB medical advisor to the PMU. The panel recognizes the concerns which were identified with respect to potential risks or side effects from the use of opioid medications as outlined by the WCB medical advisor to the PMU, but notes that such side effects do not appear to have manifested themselves as a result of the worker's use of the opioid medications for almost 20 years, up to this point in time. In the circumstances of this case, the panel is of the view that there is a sustained benefit overall to the worker from the use of the opioid medications in terms of both pain and function.

The panel acknowledges the challenge with prescribing opioids and fully accepts the Opioid Policy. Given the particular facts of this case, including the fact that the worker has been taking opioids for decades, his advanced age, the overall relatively static or sustained benefit from the use of opioids, and the absence of any significant side effects beyond constipation having manifested themselves in relation to the use of these medications, the panel is satisfied, on a balance of probabilities, that the opioid medications are reasonably necessary to cure and provide relief from the effects of the workplace injury. The panel is further satisfied that ongoing coverage of the opioid medications at this time is consistent with the Medical Aid and Opioid Policies.

The worker indicated that his family physician monitors him to regularly ensure that his consumption of medication is safe. The panel notes that the best practices listed under the Administrative Guidelines in the Opioid Policy do speak to monitoring the use of opioids and adherence to the opioid treatment plan. The panel agrees with the WCB medical advisor's advice at the time of the February 22, 2018 call-in examination, that the worker's "…use of Tylenol 3…should be reviewed on an annual basis with an accompanying narrative report from the treating physician as well as an Opioid Progress Management report."

Based on the foregoing, the panel finds, on a balance of probabilities, that the opioid medications are reasonably necessary at this time to cure and provide relief from the effects of the worker's workplace injury. The worker is therefore entitled to coverage for opioid medications after January 10, 2019.

The worker's appeal of this issue is allowed.

Issue 2. Whether or not the worker is entitled to coverage for Cyclobenzaprine.

For the appeal on this issue to be successful, the panel must find that the medication Cyclobenzaprine is reasonably necessary to cure and provide relief from the effects of the workplace injury. The panel is not able to make that finding.

The panel understands that Cyclobenzaprine is a muscle relaxant.

In a memo to file dated May 17, 2018, the WCB medical advisor to the PMU noted concerns with respect to the side effects of this medication and the need for a muscle relaxant to treat injury "now 31 years remote." On May 22, 2018, the WCB medical advisor to the PMU wrote to the worker's family physician, requesting that he:

Please advise…as to the reported symptoms and objective clinical findings in relation to the compensable injury that would support the presence of muscle spasm severe enough to require treatment with a muscle relaxant. As there would be concern with regard to the use of a muscle relaxant in combination with Opioids and Benzodiazepines in a [age] year old given the possible negative impact on cognition, memory and balance, please advise as to how this concern is being addressed and the risks mitigated.

There is no indication on file of any response having been received to that request. As a result, the panel is unable to find that the use of Cyclobenzaprine is related to the compensable injury.

The panel therefore finds that this medication is not reasonably necessary to cure and provide relief from the effects of the workplace injury, and the worker is not entitled to coverage for Cyclobenzaprine.

The worker's appeal of this issue is dismissed.

Panel Members

M. L. Harrison, Presiding Officer
A. Finkel, Commissioner
M. Kernaghan, Commissioner

Recording Secretary, J. Lee

M. L. Harrison - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 2nd day of August, 2019