All posts tagged opioids

Drug Use Skyrockets among American Workers

Tableau of drugs- pills, coke, marijuana, and alcohol.

Drug use is rapidly increasing among American workers, as more states liberalize marijuana laws, cocaine makes a resurgence and more people abuse amphetamines and heroin.

A new study by Quest Diagnostics Inc., a workplace drug-testing lab, found that the number of workers testing positive for illicit drugs is higher than at any time in the last 12 years.

That puts employers in a tricky predicament, particularly if employees are using at work, which could reduce productivity and also make them more susceptible to workplace injuries since they may not be as focused as they should be on their work.

In 2016, 4.2% of the 8.9 million urine drug tests that Quest conducted for employers turned up positive, compared to 4% in 2015 and 3.5% in 2011. The rate was the highest since 2004, when 4.5% of tests showed evidence of potentially illicit drug use.

While there were marked increases in positive tests for most illicit drugs, the surprising excption was prescription opioids like hydrocodone and oxycodone, thanks o stricter enforcement in many jurisdictions around the country.

Marijuana is the most commonly used drug among U.S. workers and was identified in 2.5% of all urine tests for the general workforce in 2016, up from 2.4% a year earlier. In oral fluid testing, which detects recent drug use, marijuana positivity increased nearly 75%, from 5.1% in 2013 to 8.9% in 2016.

The highest increases for marijuana usage among workers seemed to be in states that have recently legalized the recreational use of marijuana.

The number of workers testing positive in Colorado rose 11%, while in Washington there was a 9% increase. The rates of increase were more than double the increase nationwide in 2016.


Changes in test-positives by drug:

  • Amphetamine: Up 8%
  • Marijuana: Up 4.2%
  • Heroin: Zero (after 146% increase in four years prior)
  • Oxycodone: Down 4%
  • Cocaine: Up 12%



Implications for businesses

About 12% of workers who die on the job test positive for drugs or alcohol in their system at the time of the incident. And incidentally, one OSHA study found that the most dangerous occupations, like construction and mining, also have the highest drug use rates among workers.

Employers suffer from hiring substance abusers in many ways. Not only do they run the risk of having deadly or dangerous accidents occur, but substance abusers also cost employers money in other ways, including poor productivity and decision-making.

Substance abusers may:

  • Have poor work performance.
  • Frequently call in sick or arrive late.
  • Frequently change workplaces.
  • Struggle with productivity.
  • Injure themselves or others at work.


The takeaway

If you’re concerned, you can initiate an effective workplace drug program that includes drug testing before hiring and during employment – and the consequences for violating the rules.

You should have in place rules for working while under the influence and the ramifications for doing so.

You may also want to consider an employee assistance program for employees who feel they may have a problem, as well as for those who feel they’re developing a problem. A quality assistance program will offer services such as counseling to deal with substance abuse problems.

You may also want to consider holding meetings about health and safety and drug use. Provide education about what addiction looks like and why people begin to abuse drugs/alcohol. Education can help employees understand how to support those that are struggling, as well as remove negative stereotypes often associated with addiction.

Provide health benefits that offer a more “comprehensive coverage” for addiction. This includes addiction assessment (screening), treatment, aftercare and counseling.


Measure Aims to Reduce Unnecessary Opioid Prescriptions

Pharmacist in pharmacy (Digital Composite)

Employers and insurers in California are enthusiastic about the prospects of legislation that aims to reduce the chances of injured workers getting hooked on opioids when they are recovering from workplace injuries.

Senate Bill 482, which is sailing the through the Legislature, would require doctors to first check the state’s prescription drug monitoring system before writing a prescription for opioids.

The bill is moving through the state Legislature after a new study found that doctors have been seriously curtailing the amount of opioid prescriptions they write to injured workers. The study found that stronger laws on prescription drug monitoring were likely a main reason for opioid prescriptions having waned during the study period.

SB 482 aims to further tackle the opioid scourge that has hit injured workers hard, leading to addictions that reduce the chances of them returning to their at-injury employer. California has already seen a decrease in the opioid prescriptions for injured workers, but if this legislation passes, it would strengthen safeguards even further.

SB 482, authored by Sen. Ricardo Lara, a Democrat from Bell Gardens, aims to force doctors to use the Controlled Substance and Utilization Review and Evaluation System (CURES) database.

Even though CURES is the oldest such system in the nation, legislators believe that few doctors consult it before writing prescriptions for opioids, which are highly addictive and are often associated with slower recovery periods for injured workers.

Under the measure, doctors authorized to prescribe, order, administer, furnish or dispense a controlled substance, would be required to check CURES no earlier than 24 before writing a prescription for a Schedule II, Schedule III or Schedule IV controlled substance for the first time – and at least annually thereafter.

Doctors who knowingly fail to check the database before writing a prescription would be referred to their licensing board for administrative sanctions.

The measure has already been passed by the State Senate and two committees in the Assembly (in unanimous votes) and looks like it will have a smooth ride on the Assembly floor thanks to amendments that were made in June.

Employers and insurers are encouraging passage of the bill.

The American Insurance Association says that CURES and other prescription drug monitoring programs have been shown to be effective in controlling the practice of “doctor shopping”, whereby patients will visit different doctors to obtain prescriptions for addictive medications. The association also said it will protect patients and improve outcomes.

Additionally, the California Chamber of Commerce says that SB 482 would discourage doctor shopping and identify the handful of physicians who write the majority of inappropriate prescriptions for opioids.


Addictive Medications

Schedule II: Substances that have a high potential for abuse which may lead to severe psychological or physical dependence.

Types: : Methadone, meperidine (brand name Demerol), oxycodone (brand names OxyContin, Percocet), fentanyl, morphine and high-strength codeine.

Schedule III: : Substances with a potential for abuse less than substances in Schedule II, and abuse of which may lead to moderate or low physical dependence or high psychological dependence.

Types: : Hydrocodone (brand name Vicodin), codeine (Tylenol with Codeine).

Schedule IV: Substances in this schedule have a lower potential for abuse than schedule III drugs.

Types: : Brand names Xanax, Soma and Valium.


The study

The study, released in June by the Workers’ Compensation Research Institute, found “significant” decreases in the amount of opioid prescriptions being written for injured workers.

Fourteen of the 25 states examined by the institute recorded decreases in opioid prescriptions of between 11% and 31% in the study period, which measured 24-month periods ending in March 2012 and March 2014.

Michigan saw the biggest drop (31%), followed by Oklahoma (29%) and Massachusetts (24%). Texas saw a drop of 19%; Connecticut, 17%; California, 12%; and Pennsylvania, 4%. Just four states saw increases.

The institute noted that the decreases coincided with various states enacting legislation aimed at reducing the abuse of opioids by improving prescription drug monitoring programs and adopting more stringent treatment guidelines and drug formularies.


Pharmacist in pharmacy (Digital Composite)

Pharmacist in pharmacy (Digital Composite)

Workers’ Comp Medical Costs Fall in Wake of Reforms

workers comp construction

The workers’ comp reforms in 2013 have generated surprising cost savings in treating injured workers in California, with overall medical costs per claim falling 8% over a three-year period.

That’s in contrast to the years of inflation before the reforms, when the average medical costs per claim were increasing by an average of 6.5% a year. The new study by the Workers’ Compensation Insurance Rating Bureau of California dissected claims costs between July 2012 and June 2015, finding the medical cost savings were greater than originally anticipated.

SB 863 increased benefits effective January 1, 2013 and January 1, 2014 and provided for a number of structural changes to the California workers’ compensation benefit delivery system.

In total, based on the most current information available, the WCIRB estimates the impact of SB 863 is an annual net savings of $770 million, or 4.1%, of total system costs.

The new study, released in early December, looked at the effects of the legislation on the medical costs associated with treating injured workers. The Rating Bureau had anticipated that reforms would cut medical costs, but it underestimated the effects.

These cumulative savings were primarily driven by changes to the physician fee schedule and pharmacy services, which collectively represent around 61% of all medical service payments. The use of medical services also dropped, due to a more stringent regimen of independent medical review (IMR) of claims.

Additional savings were generated by outpatient facilities and medical equipment providers, which when combined, represent roughly 16% of all medical service payments.

Medical-legal and inpatient hospital services, when taken together, represent approximately 23% of all payments and were the only services to register increases in costs per claim over the three-year period.


Other findings of the study include:

  • Payments per claim via the physician fee schedule (46% of all medical costs) decreased by 9% over the three-year study period. This decline was due in part to the introduction a new and more accurate fee schedule that is widely used in many states. That fee schedule took effect on Jan. 1, 2014.
  • Costs per claim for pharmaceuticals (which account for 15% of all medical costs) declined by 22% during the study period. But the legislation did not address drug costs, and the decline was largely the result of a drop in medical service usage – or utilization – due to the increased use of IMR.
    This reduction in utilization had a particular effect on the prescriptions of highly addictive drugs called opiates, such as OxyContin, the outlays for which fell 48% during the study period.
  • Inpatient hospital costs (12% of all medical costs) increased by 14% on a cost-per-claim basis over the study period. The costs declined in the first half of 2013 likely due to the elimination of payments for duplicate surgical hardware enacted by SB 863.
  • Costs per claim for outpatient facilities (7% of all medical costs) dropped 7% during the study period. Since the majority of these payments are to ambulatory surgical centers (ASCs), the primary driver of the savings was the reduction in reimbursements to ASCs enacted by SB 863.
    That said, outpatient facility cost payments started inching higher in 2015 due to upward adjustments in the Medicare ASC fee schedule as well as changes in the types of outpatient services these facilities provide.
  • Costs under another fee schedule for a variety of services like durable medical equipment, prosthetics and orthotics, fell 12% over the study period. The reforms had nothing to do with this, but rather, the costs were affected by changes to Medicare fee schedules.


Despite these results, the Rating Bureau noted that the trend may be reversing. It said payments per claim for all medical services increased 4% in the first half of 2015 from the same period the year prior.


New Legislation Aims to Cut Workers’ Comp Drug Costs

Gov. Jerry Brown is expected to sign recently passed legislation that could further reduce workers’ comp claims costs in California.

The Legislature in September passed AB 1124, which would establish a new drug formulary that would limit the types of medications that can be used to treat injured workers.

The law is seen as vital to controlling costs as the cost of some medications – particularly off-label, compound medications and specialty drugs – continues to rise at a quickening pace.

Also, because California’s workers’ comp system lacks a drug formulary, payers have often complained of price-gouging for certain pharmaceuticals, like compound medications.

California insurance experts are optimistic that a new workers’ compensation prescription drug formulary will help injured workers and reduce claims costs.

Both insurers and employers have expressed optimism about the effects of the legislation if signed into law.

Over the past decade, the workers’ comp spend on prescription drugs has increased more than 250% through the first two years of treatment and accounts for some 13% of a claim’s overall medical costs, according to the California Workers’ Compensation Institute, which has studied the issue. The share goes higher as claims age, and often accounts for 20% of the medical costs in a claim.

The institute’s research suggests that a formulary could save California employers anywhere from $124 million to $420 million a year, depending on how restrictive the Division of Workers’ Compensation (DWC) makes the formulary.

The estimate is based on the experience of Texas and Washington states when they adopted a workers’ comp formulary to stem double-digit increases in spending on prescription drugs.

Not only that, but the increasing prevalence of doctors prescribing highly addictive opioid medications is also a concern for employers and insurers. While the drugs are not particularly expensive, overuse and abuse can lead to worse workers’ comp outcomes, such as longer times away from work.

Mark Pew, senior vice president for Prium, told the news website workcompcentral.comthat potential savings will follow from the most important role of a formulary, that is, “to make sure injured workers are only taking drugs that are appropriate for their conditions. Cost savings are a side effect of doing the right thing for the patient from a clinical standpoint.”

Pew said that for many providers and patients, prescribing or taking drugs is the easiest way to try to address pain.

However, a lot of patients receiving powerful narcotic painkillers don’t report any improvement in function or quality of life, and they are still reporting pain at a six, seven or eight on a 10-point scale, he added. The medications are not doing anything to address the root causes of the pain, the injured worker doesn’t return to work, dosages increase and new drugs are required to deal with side effects.

Pew said there might be some situations in which a strong opioid is appropriate for non-malignant cancer pain, and a formulary would still allow injured workers access to these drugs in such situations.

The legislation does address this issue by requiring the DWC to include in the formulary guidance how an injured worker can access drugs for off-label use “when evidence-based and medically necessary.”


Drug Testing in Workers’ Comp Skyrockets

Drug testing of injured workers by treating doctors has skyrocketed over the past seven years as painkiller abuse continues and physicians want to monitor their patients for staying with their prescribed drug regimen.

The use of urine drug testing on injured workers in California increased 2,431% between 2007 and 2014, according to the California Workers’ Compensation Institute (CWCI).

During that period, urine drug tests grew from 10% to 59% of all California workers’ compensation laboratory services, while drug testing reimbursements increased from 23% to 77% of all lab payments in the system.

The rapid increase reflects the growing concern among workers’ comp insurers and employers about workers getting hooked on high-strength pain medications known as opioids, and similar pain drugs.

Other studies by the institute have found that adding opioids into the picture can greatly increase the time an injured worker is away from work recovering, as well as the cost of the claim.

Also, doctors are increasingly using the tests to ensure injured workers are taking the medicines they prescribe. The downside is that the cost of the testing continues to increase and can easily be a few thousand dollars, adding significantly to the cost of claims.

And the trend is not unique to California. In a recent multi-state study by the Workers’ Compensation Research Institute on injured workers with long-term opioid use, the percentage of workers who received at least one drug test increased from 16% to 25%.

Not only are more injured workers being tested, but workers themselves are being tested more, as well.


Here are some other significant findings from the study:

  • Between 2003 and 2012, the average number of drug testing service dates for injured workers who received these services increased by 9% at 12 months post-injury; 35% at 24 months post-injury; and 350% at 36 months post-injury.
  • Among the injured workers who were drug tested, the average number of tests per employee more than tripled from 4.5 in 2007 to 14.9 in 2014, driving the average amount paid per date of service from $96 in 2007 to $307 in 2014 – a 220% increase.
  • The number of providers who were paid for testing injured workers climbed from 428 in 2008 to 876 in 2014. Much of that growth is attributed to a migration towards physician in-office testing, because testing equipment has drastically come down in price.
  • The amount paid for drug tests in California workers’ comp are based on Medicare billing rules. These rules were revised in 2010 and 2011, after Medicare determined there were questionable billing practices for drug tests taking place.
    The CWCI study found that after those changes were made, the mix of tests used on injured workers changed. Drug screens, which are used to identify the presence or absence of a drug, accounted for a smaller share of tests.
    Meanwhile, quantitative tests, which are used to measure the amount of a drug sample, increased sharply. The CWCI notes quantitative tests are not subject to the tighter Medicare billing rules, perhaps explaining the increase.


Is it necessary?

Drug testing is in part related to the increasing costs and prescriptions for drugs in the workers’ comp system, as well as the fact that testing has shifted from labs to doctors’ offices, which can now afford testing equipment that was too expensive in the past.

Several medical treatment guidelines do call for doctors prescribing opioids to also test for illicit drug use under certain circumstances, such as when addiction or abuse is detected or when patients are at risk for overdose and death, sources said.

Doctors need to identify patients abusing drugs because it is inappropriate to provide them opioids and it can change the treatment required for them.

Proponents of drug testing say it helps keep injured workers’ medicinal intake in check to ensure they are sticking with their drug regimens and also not abusing prescription pain medications.

Tests revealing that patients are using drugs for other than “clinical health” can also help workers’ comp payers arguing before a judge or hearing officer regarding their responsibility for the claimant.

The purpose of testing is to assist in medical management. Still, testing should be done based on medical necessity related to a claimant’s medical presentation, dispensed drugs and evidence-based medicine protocols.


Court Lets Injured Workers Sue for Their Opioid Addictions

A new state supreme court decision allowing patients to sue doctors and pharmacies for contributing to their opioids addiction could spill over to the workers’ comp arena, legal experts say.

Workers’ comp experts told the trade publication <i>Business Insurance</i> that insurers and employers should put measures in place to reduce the chances of overprescribing of the highly addictive and potent painkillers to injured workers.

In the case at hand, 28 people filed eight lawsuits in West Virginia, alleging that medical centers and doctors had prescribed and dispensed drugs that led them to abuse and become addicted to opioids, according to court documents.

The doctors allegedly prescribed drugs like Lortab, Oxycontin and Xanax to the plaintiffs, who had been injured in automobile accidents or at work.

The state’s Supreme Court of Appeals ruled that plaintiffs could sue the medical centers and the physicians for contributing to their addictions to prescription opioids.

Interestingly, the court made the decision despite the fact that the patients admitted to abusing these drugs prior to going to these medical centers, and that they had engaged in “illegal activities associated with the prescription and dispensation of controlled substances.”

The defendants had filed a motion for summary judgment asking that the cases be thrown out based on the “wrongful conduct” rule, which states that a person can’t sue “when his or her unlawful conduct or immoral act caused or contributed to their injuries.” The court rejected the argument.

While the decision opens up the clinics, doctors and pharmacies to lawsuits, experts say that it could have an effect on workers’ comp payers. If injured workers who are addicted to painkillers and are overprescribed can sue as well, it could make settling their claims more difficult and costly.

And it could open up employers to lawsuits outside the workers’ comp system. If that is the case, employers could be swept up in legal disputes that their workers’ comp insurance may not cover.

Besides the new threat of lawsuits, opioids can often have a detrimental effect on workers’ comp claims in general. It’s been noted in a number of studies that the opioids can interfere with an injured worker’s recovery.


Why You Should Be Concerned

  • Opioids account for 23% of all prescriptions in California workers’ comp cases, according to the California Workers’ Compensation Institute (CWCI).
  • Opioid prescriptions account for 24% of all prescription costs in California, according to the CWCI.
  • The average cost of claims with a short-acting opioid (Percocet, for example), is $39,000, compared to just $13,000 for claims without an opioid prescribed, according to the National Council on Compensation Insurance (NCCI).
  • The average claim cost with a long-acting opioid – e.g., OxyContin – is $117,000 (900% above the average), according to the NCCI.
  • Between 2001 and 2008, narcotics prescriptions as a share of all drugs used to treat workplace injuries jumped 63%, according to the NCCI.
  •  When prescriptions for certain opioid painkillers were included in workers’ comp claims, it was nearly four times more likely that a catastrophic claim would develop. This is according to the study “The Effect of Opioid Use on Workers’ Compensation Claim Cost in the State of Michigan.”
  • Claims involving long-acting opioids were 3.94 times as likely to have a total cost of $100,000 or more compared with claims without any prescriptions.



What you can do

If you have an injured worker who is being prescribed opioids by the treating physician, you should work with us, the insurer’s claims adjuster and the doctors to make sure that the physician is using a prescription drug monitoring program, in order to see whether other doctors are also prescribing opioids to the same worker.

If the treating physician is not accessing an abuse database, they are failing to abide by best practices for deterring opioid abuse.



The Most Prescribed Opioids*

  • Vicodin (hydrocodone with acetaminophen)                    46.1%
  • Ultram (tramadol)                                                                         14.7%
  • Percocet (oxycodone with acetaminophen)                      13.6%
  • OxyContin (oxycodone)                                                                8.3%
  • Tylenol with codeine (acetaminophen with codeine)        3.8%
  • All others                                                                                            13.5%


Source: Express Scripts Inc.

* 2013