Opioids are a class of drugs that include both illegal and legal substances. Most people are familiar with the illegal substance known as heroin; however, many powerful pain relievers are available legally by prescription. Some of these are known generically as oxycodone, hydrocodone, codeine, morphine, and fentanyl, among several others. According to the Center for Disease Control and Prevention (CDC), the current opioid epidemic began in the 1990s, driven by a dramatic increase in the prescribing of such drugs for chronic pain. While the CDC recognizes that prescription opioids can help manage some types of pain, they also state, “there is not enough evidence that opioids improve chronic pain, function, and quality of life. Moreover, long-term use of opioid pain relievers for chronic pain can be associated with abuse and overdose, particularly at higher dosages.” According to guidelines by American College of Occupational and Environmental Medicine and the Official Disability Guidelines, opioid effectiveness plateaus after 60 days of use. Yet it remains, according to the National Council on Compensation Insurance, that narcotics prescriptions account for one fourth of all Workers’ Compensation prescription drug costs nationwide and prescription drugs represents 1/5th of the cost on average of a Workers’ Compensation claim.

Beyond the direct monetary cost of opioid prescriptions, there are other less direct costs that impact the employer. Addicted workers may abuse the system by malingering and staying out of work longer than the injury would normally dictate. Opioid addiction often delays the worker’s return to work. Even if the worker is returned to work, it remains that workers may be too impaired to safely return to work. This may prohibit the employer from returning the worker to their previous job and thus forcing the employer to cover those job duties with another employee. If the employee is returned to their same position, it may create a safety issue for others resulting in further workers compensation claims and/or liability claims.

As professionals responsible for claims management, we need to keep an eye out for red flags on our files and report those files over for investigation when warranted. When dealing with potential drug addicted workers, we want to look out for doctor and pharmacy shopping, especially pharmacies that are out of the PBM network. We want to look out for frequent early refills of prescriptions wherein the worker uses excuses such as the medicine was lost or stolen, especially if non-opioid prescriptions are not being refilled at the same time. We want to look out for treatment patterns wherein the worker is taking pain medications, but frequently missing other key elements of their treatment plan, such as chiropractic and/or physical therapy appointments. We want to look out for workers who routinely visit emergency rooms resulting in prescriptions of opioids.

While there have been many substantial and proven reforms around opioid abuse in the Workers Compensation system, the prevalence of addiction remains today and so do the costs to the insurance companies and to the employers. It is essential to look at these claim files where abuse of opioids may be occurring and investigate. Surveillance on a worker who habitually misses essential medical appointments may uncover a pattern of behavior consistent with drug addiction or even drug diversion. A background and social media search may uncover information pertaining to the workers addiction. A medical check of doctors and pharmacies can uncover a pattern of prescription filling. Investigating red flags can lead you to uncovering an addicted employee and allow you to get them the help they need at the same time as you reduce the cost of the overall claim.

Partner with Capital Investigating to mitigate your risk potential through our investigations. Contact Capital Investigating to discuss working with us as your investigative partner.