Knowledge Center

Knowledge Center Items Inside the Impact of Opioid Usage on Workers’ Compensation

Inside the Impact of Opioid Usage on Workers’ Compensation

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The National Institute of Drug Abuse estimates that every day more than 115 people in the U.S. die after overdosing on opioids. Opioids represent the strongest pain medications available,  and typically come in pill form. They are given to treat severe or chronic pain, including, for example, pain from surgery, sports injuries, workplace injuries or cancer. The economic burden from prescription opioid misuse, according to the Centers for Disease Control and Prevention (CDC), is estimated at $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.

Furthermore, most experts agree that there has never been a more profound impact on the cost of Workers’ Compensation insurance claims from a single issue than the abuse of opioid prescriptions for chronic pain management. More than $6 billion is spent on prescription drugs in the Workers’ compensation field on an annual basis, representing approximately 19% of overall medical costs, according to a national medical claims processor. Other findings include:

  • Nearly 70% of pain drugs prescribed are opioids, a third of overall prescriptions.
  • Individuals using opioids over an extended time may experience tolerance, leading to a higher dose to obtain the same level of pain relief. This often leads to escalating doses of opioids over time.
  • Higher doses for extended periods are associated with higher rates of dependence, higher rates of addiction, poor health outcomes and significantly higher claims cost.

Other statistics also underscore how the Workers’ Compensation system is directly affected by the far-reaching societal impacts of the opioid epidemic in the U.S. In 2016, according to the CDC, the U.S. prescribing rate for opioids was 61 prescriptions per 100 persons. NCCI data shows that injured workers who were prescribed at least one prescription in 2016 received three times as many opioid prescriptions as the U.S. opioid prescribing rate. 

Beyond the Cost of Claims: Tackling the Issue

Increased Workers’ Compensation costs are not the only exposure that employers face from opioid misuse by employees suffering from chronic pain as a result of an on-the-job injury. Appellate courts in four states have held that employers and insurers are financially accountable for overdose deaths tied to injured workers.  

What can be done to address the risks associated with opioid dependence and abuse? Workers’ Compensation providers and claims managers should implement programs that require the conservative use of opioid medication for treatable pain. The primary goals should be for clinical, meaningful improvement of function and prevention of dependency and addiction to opioids. Following is a checklist of questions that can help you and your insureds evaluate their Workers’ Compensation program management of opioid risk:

  • What percentage of the Workers’ Compensation pharmacy claims is managed by a prescription benefit manager (PBM)?
  • Does the program or PBM use a closed formulary where opioid prescriptions require prior authorization and approval?
  • Has the PBM established flags to identify situations that pose a greater risk of addiction, overdose and death?
  • Have the PBM and Workers’ Compensation Claims Management (WCCM) vendors implemented adequate controls to identify misuse and abuse of prescription medications?
  • What procedures do the PBM and WCCM vendors follow if misuse is identified?
  • Does the program reimburse for alternative treatments such as physical therapy, therapeutic massage or acupuncture?
  • Are Workers’ Compensation treatment providers following conservative opioid prescribing guidelines?

RPS specializes in providing agents and brokers with Workers’ Compensation insurance solutions to address their clients’ needs. For more information about our programs, please contact us.

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