This document discusses the financial impact of opioid abuse on employers. It identifies the primary causes of increased healthcare costs related to opioid abuse as well as simple steps employers can take to reduce risks and costs. The document explains that prescription drug abuse can impact employers even if they are not currently dealing with issues in their workplace. It provides context on the costs of chronic pain and revenue from opioids. The document examines how cultural factors led to increased opioid prescribing and abuse. It discusses challenges in predicting outcomes for different patients prescribed opioids. Finally, it outlines guiding principles for employers to address opioid abuse, including education, enforcement, oversight, and statutory action if needed.

1. The Financial Impact to
Employers
April 10-12, 2012
Walt Disney World Swan Resort

2. Accepted Learning Objectives:
1. Identify the primary causes for increased
health care costs as it relates to opioid abuse.
2. Outline simple steps that employers can
implement within their work place to reduce
their risks, lower their costs and improve
productivity.
3. Explain why employers should be
concerned about prescription drug abuse
even if they are not currently dealing with an
abuse-related issue in their workplace.

3. Disclosure Statement
• All presenters for this session, Michael
Gavin and Dennis Jay, have disclosed
no relevant, real or apparent personal
or professional financial relationships.

4. The Cost of Pain
A 2011 report from the Institute of
Medicine estimated the total cost of
dealing with chronic pain is between
$560 and $635 billion per year.
That same year, drug manufacturers
generated $11 billion in revenue from
opioids.

5. How did we get here?
Culture of Treatment
Harder Answers: Easier Answers:
• Lose weight • Surgical intervention
• Change diet • Prescription drug therapy
• Exercise
• Sleep hygiene
• Socioeconomic /
psychosocial factors
• 74% of all physician office visits result
in a prescription1
• 15-20% of all physician office visits
result in a prescription for an opioid2
1 Source: Centers for Disease Control and Prevention
2 Source: IMS Health

6. How did we get here?
Culture of Treatment (cont.)
• $11 billion in annual sales
• Case study: Oxycontin
‒ A substantial and sustained marketing effort begun in the late
1990s led to significant growth in the use of the drug
‒ Sales of Oxycontin in 1996: $45 million
‒ Sales of Oxycontin in 2009: $3 billion
‒ Purdue Pharma ad from 1998 titled I got my life back
1 Source: Substance Abuse and Mental Health Services Administration (SAMHSA)
2 Source: CDC Vitalsigns publication, November 2011

7. How did we get here?
Culture of Treatment (cont.)
• More than 50M Americans suffer from chronic pain1
• Pain reliever abuse more than tripled, from 6.8% in 1998 to 26.5% in
2008 (Treatment Episode Data Set)1
• 15,000+ Americans died in 2008 from prescription drug overdose2
• 12,000,000+ Americans (12 years or older) in 2010 reported non-
medical use of prescription drugs within the past year2
• 500,000+ ER visits in 2009 from abuse or misuse of prescription drugs2
• $72,500,000,000+ in annual costs to health insurers for non-medical
use of prescription drugs2
• Enough prescription drugs were prescribed in 2010 to medicate
every American adult around-the-clock for one month2
1 Source: Substance Abuse and Mental Health Services Administration (SAMHSA)
2 Source: CDC Vitalsigns publication, November 2011

8. How did we get here?
Lack of Predictability
John, Joe, and Jim
• All 42 year old males
• All office-based knowledge workers
• Chronic low back pain
• Failed back surgery
• Failed conservative therapy
• NSAID trial ineffective
• Trial of low dose opioid

9. How did we get here?
Lack of Predictability (cont.)
John Joe Jim
• Pain relief • Tolerance • Tolerance
• High functioning • Dose escalation • Dose escalation
• No dose escalation • Switch to Oxycontin • Switch to Oxycontin
• Eventually moves to • Dependence • Dependence
as needed for the • Out of work • Out of work
opioid prescription • Addiction • Addiction
• Detox/rehab • Detox/rehab
• Motivated to get • Unmotivated to
healthy and back to return to work
At the outset, it s work • Would rather game
difficult to distinguish • Supportive family the system
John, Joe, and Jim • Engaged in
treatment

10. How did we get here?
Treatment of Co-morbidities
Acute Sub-Acute/Transitional Chronic Pain Syndrome
(1-3 months) (3-6 months) (>6 months)
PAIN PAIN PAIN
• Insomnia • Insomnia • Sexual
• Atrophy • Atrophy dysfunction
• Fear of • Depression • Addiction
movement • Weight gain
Source: Dr. Gary Mills, Pacifica Pain Management Services

11. How did we get here?
Treatment of Co-morbidities (cont.)
Chronic Pain Syndrome
(>6 months)
PAIN Oxycontin (… then Fentanyl?)
• Insomnia Ambien
• Atrophy Soma
All of this makes the
• Depression Cymbalta pain harder to
• Weight gain identify and treat
Surgery?
• Sexual dysfunction Viagra
• Constipation Doc-Q-Lace
• Addiction
Source: Dr. Gary Mills, Pacifica Pain Management Services

12. What to do?
Match Case and Context
Current medical treatment is sub-optimal,
Biomedical
what s needed is better medical treatment
Employee is receiving inappropriate treatment;
Medical / Legal
what can be done (by jurisdictional rule)?
Identify what s driving the employee behavior
Bio-psycho-social
and address root cause
Legal Employee is engaging in fraud/abuse; involve
law enforcement for remediation

13. What to do?
Have a Plan
Biomedical
These options aren t mutually
exclusive – good utilization
Medical / Legal management and employee
assistance programs can
mitigate risk
Bio-psycho-social

14. What to do?
Guiding Principles
DISCUSSION
EDUCATION
ENFORCEMENT
OVERSIGHT
STATUTORY ACTION

15. What to do?
Guiding Principles
EDUCATION
• Employee by employee, doctor by doctor, case by case
• Multiple areas of education:
‒ Clinical (pharmacology, interactions, alternative
therapies)
‒ Claims (best practices, centers of excellence, statutory
rules)
‒ Issues (welcome to the first annual National Rx Abuse
Summit!)
• Multiple stakeholders:
‒ Doctors, nurses, claims executives, patients, and
attorneys

16. What to do?
Guiding Principles
DISCUSSION
• Engage the treating physicians / prescribers
• Conversation should be:
‒ Peer to peer
‒ Collegial
‒ Evidence-based
• Not a typical peer review … how can we help?
• Incorporate the psycho-social element

17. What to do?
Guiding Principles
DISCUSSION (cont.)
1. Has the patient signed an opioid treatment agreement or narcotic contract?
2. Does the provider have the patient undergo regular urine drug monitoring?
3. Does the provider have the patient fill out a pain scale questionnaire on
every visit?
4. Did the provider consult a prescription drug monitoring database (PDMP)
prior to writing the prescription(s)?
5. Has an opioid risk assessment been completed on this patient to evaluate
the possibility of the patient s developing medication use/abuse problems?

18. What to do?
Guiding Principles
DISCUSSION (cont.)
5. Does the provider consult the prescription drug monitoring system database
(CURES) prior to prescribing any medications for this patient?
6. What are the specific treatment goals for this patient given the patient s current
objective findings and level of function?
7. Are there any generic equivalents or more cost-effective alternative equivalents
that can be used for the medications that are recommended for continuation?
8. For any recommendations to continue a medication, please state a
recommended timeframe for re-evaluation of the medical necessity of those
medications.
9. If agreement is reached to continue a medication (generic, name brand,
therapeutic equivalent), is a reduction in dosage or the number per
month/day possible without reducing efficacy?

19. What to do?
Guiding Principles
ENFORCEMENT
• Integration with the Pharmacy Benefit Manager is critical
• Don t settle for reporting alone; demand solutions
• Recognize the short-term lack of incentive to remove drugs
from a patient s regimen
• Demand solutions (and outcomes)

20. What to do?
Guiding Principles
OVERSIGHT
• Even when DISCUSSION goes well, consistent oversight is
needed to ensure implementation of treatment changes
• Should be nurse-led
• Focus on reinforcing the evidence-based recommendations
and agreements with treating physicians
• Engage with the claimant to make a psychosocial
assessment of the likelihood of success:
‒ Motivation?
‒ History of substance abuse?
‒ Environment?

21. What to do?
Guiding Principles
STATUTORY ACTION
• When the hand shake doesn t work, deploy the hammer
• In work comp, the tools vary by jurisdiction:
‒ Utilization review (UR)
‒ Independent Medical Exam (IME)
‒ Directed care
‒ Dispute resolution (work comp boards, ALJ, etc.)
• In group health, the tools vary by contract

22. What to do?
Guiding Principles
DISCUSSION
EDUCATION
ENFORCEMENT
OVERSIGHT
STATUTORY ACTION

23. Questions?
Michael Gavin
Chief Marketing Officer, PRIUM
Email: mgavin@prium.net
Website: www.prium.net
Blog: http://prium-evidencebased.blogspot.com/