The Opioid Epidemic in the U.S. is discussed and debated in many corners of the healthcare market. One of the possibly less apparent markets that affect opioid use is Workers’ Compensation. Trends in how opioid prescriptions are reviewed (Pharmacy Utilization Review) in Workers’ Comp cases are important to monitor. They give a pulse on opioid use at a broader level. Before reviewing the trends in Workers’ Comp, it’s important to understand the history of opioid use and abuse.

The History of Opioid Use

Even in the early 1900s, the U.S. had an opioid problem. They were considered “wonder drugs” that were used as effective pain relievers. By the 1920s, physicians were aware of the addictive properties of opioids and tried to avoid prescribing them. At that time, opioids were used mainly to give relief to terminal patients or for a very short-term use immediately after surgery.

This changed in the early 1980s when articles began to report low incidence of addictive behavior with non-cancer patients. But there was no real, credible research on the effects of long-term use of opioids to help chronic pain. Because of a growing focus on pain management, pain was birthed as a 5th vital sign that was mandatory to ask patients. That’s why if you’re at a doctor’s office or hospital, you’re often asked (numerous times) to “describe your pain on a scale of 1 to 10.”

Fast forward to the late 90s and early 2000s and Purdue Pharma was investing heavily in marketing OxyContin as safe for chronic pain. The number of prescriptions grew from 8 million to 11 million after a series of video ads were released featuring physicians promoting OxyContin. It didn’t help the issue when the Joint Commission – a nonprofit that sets standard and accredits hospitals and medical centers –  released a book (sponsored by Purdue Pharma) that dismissed doctors’ concerns about the addictive side effects of OxyContin.

This is certainly not an exhaustive history, but it gives you an idea of how easily opioid misuse became such an issue. The statistics are alarming:


The good news is that awareness around opioid misuse in the last few years has helped ignite change. There are new treatments available for opioid abuse that weren’t available 10 years ago. And since 2011, opioid prescriptions have continued to decline, with a 10% decline most recently in 2017.

So how does all of this relate to Workers’ Compensation? Pharmacy Utilization Review.

Opioid prescriptions directly correlate to a longer length of disability and higher claim costs. In response to rising costs of the opioid epidemic, multiple states have used evidence-based guidelines like the Official Disability Guidelines (ODG) to develop drug formularies that control unnecessary opioid prescriptions.

If a Workers’ Comp prescription is submitted, there are non-opioid treatments called “Y drugs” or in CA called “exempt drugs” (like Motrin) that don’t have to go through an approval process when a doctor prescribes them. These are considered an appropriate first line of treatment.

Heavier opioid drugs, like OxyContin, are labeled as “N drugs” or “non-exempt drugs” and must go through some form of approval process like Pharmacy Utilization Review. These are considered a second line of treatment and requires preauthorization. In simple terms, any time an opioid is prescribed for a Workers’ Comp claim, it requires further review.

Pharmacy Benefit Managers (PBMs) are seeing promising results from implementing programs that more closely monitor opioids like drug formularies.

  • Optum reported a 2.6% decline in opioid prescriptions and a 6.8% reduction in the amount of Morphine Equivalent Dosing (MED) per claim in 2017.
  • Express Scripts reported opioid spending down 13.4% for Workers’ Comp Payers but acknowledge that it’s still the highest utilized class of drugs.
  • MyMatrixx reported a decline in >30-day opioid prescriptions from 24.6% in 2016 to 22% in 2017.


The drug formularies and guidelines can be complicated and difficult to implement without experience. Shearwater’s UR Clinicians have experience in Pharmacy Utilization Review and can assist PBMs, TPAs, and Managed Care companies in adapting to this new pharmacy landscape.

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