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How much will opioids really cost you?

A lot more than you think.
I met with a large workers comp payer recently to discuss (among other things) their strategy regarding long term work comp claims; they have over forty thousand claimants that have been on opioids for extended periods.
The research strongly suggests most of these claimants are addicted/dependent. Others may be diverting, and still others may be hyperalgesic (much more sensitive to pain as a result of long-term usage of opioids).
None of these are good, and most have serious and very costly implications for claim costs.
– very few individuals on opioids are going back to work (while on drugs)
– very few payers are screening for addiction, so they really don’t know if/how many of their claimants are addicted – and therefore don’t know how the potential financial implications (either pay for opioids forever, settle at a very high cost, or treat and successfully resolve the addiction)
– claimants using opioids are at much higher risk for death; one client identified almost sixty claimants that died last year that appeared to die as a result of prescription drugs prescribed for their work comp injury.
– I get the sense that most payers haven’t adequately reserved for these claimants, although the stiff stance of CMS may force them to do so if they have any hope of settling some portion of the block of claims.
This doesn’t have to inevitably become a financial disaster for insurers or employers, although it undoubtedly will for those who don’t take action.
Payers must work with their PBMs to dramatically reduce their exposure. This requires both parties to:
a) identify long-term users,
b) mine their data to determine which claimants may be abusing/misusing/diverting and involve SIU where appropriate,
c) channel appropriate claimants to addiction screening, allocate the resources necessary for weaning and recovery and recognize this will include behavioral therapy will find they can.

What does this mean for you?
These claims are NOT going to resolve themselves. You own it, and you’re going to own it until you’ve got an effective, working plan in place.

6 thoughts on “How much will opioids really cost you?”

  1. Joe, I think you missed the costs associated with those that die from the opiate use. A couple of cases recently found carriers liable for death claims for workers who died as a result of their opiate use. I’m fairly confident none of those claims are adequately reserved should they convert to death claims.

  2. Sounds like there is not much use of “utilization review” by claim adjusters or file review of physician practices to stem the excessive prescription of addictive drugs by physicians. Wouldn’t bill review companies notice such anomalies?

  3. Joe,
    Very timely post and certainly a call to action for PBMs and payors alike. Perfect segue to a presentation I will be doing at PRIMA called Drug Diversion: A New Type of Risk (
    Also, if your readers are not aware of an FDA program called Risk Evaluation and Mitigation Strategy (REMS encourage them to follow this program. Established in 2008 it has been slow to start but I am seeing positive effects mainly because certain new opioids like Abstral and Onsolis are entirely absent from my database! These drugs are similar to Actiq and Fentora but the REMS program has effectlively restricted their use to a registry of patients suffering from cancer pain. As of last week, Actiq and Fentora are also covered uncer REMS but it will be difficult to undo the damage done – there is no magic bullet and these patients will have to be treated (detox/weaning/counseling) on a case by case basis, but it can be done. The effect of REMS on long-acting opioids remains to be seen. REMS is significant because 1) the FDA is acknowledging that opioids fall into a category of dangerous drugs, and 2) the FDA has wisely placed the burden of developing these programs back on Pharma!

  4. Joe, thanks for bringing this to light. Ralph has an excellent point, the partnership with a company that knows what to look for is very important. Many TPA’s and self-insured clients have their hands full with managing claims, leaving them with little time and resources to learn and/or stay current with the necessary knowledge and expertise to know what to look for, how to address, and how to monitor for prescription utilization issues, including over utilization and improper use of opiates. I strongly encourage those involved to partner with a company who has taken the necessary steps and spent the time and resources to understand and master the nuances of this specialized area. It has been my experience that any claim with multiple opiates and/or more than three medications with dates of injury more than two years ago, are typically (not always) candidates for some type of intervention.
    In this economy, we could save every dollar possible.

  5. Great post, Joe, and excellent information on REMS, Phil! I will definitely check it out.
    I work for aa self-insured/self-administered employer in Colorado. In addition to multi-narcotic prescriptions, I am also starting to see clmt’s using “medical MJ” (which is legal in CO). Marijuana is not a drug, therefore not accepted under WC benefits, but we have MD’s that are prescribing the narcotics on top of the clmt’s use of MJ. Other than questioning the doctor about whether that type of care is within the accepted standard of care amoung occ med docs, I’m not sure that we have much control outside of a costly and lenthy UR process.
    Is anyone aware of an insurer filing a 3rd party action against a doctor when a clmt dies due to a combination of inappropriately prescribed medications (other than the MichaelJackson case, of course)?

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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