1. Opioid Misuse: An Employers Path Forward
August 25, 2016 1

2. Overdose deaths per 100,000 2003-2014: County level data9
Image Source: NYT adaptation of data from “Drug Poisoning Mortality: United States, 2002–2014” by Lauren M. Rossen, Brigham Bastian, Margaret Warner, Diba Khan and Yinong Chong, and from the National Center for Health Statistics, Centers for Disease Control and Prevention, accessed via the-us.html?_r=0 on May 3, 2016

3. Why Should Employers Care?
Big Money: In 2014, opioid-related absenteeism and presenteeism costs U.S. Employers an estimated $10 Billion ($1.71 pmpm)
Higher Utilization: these Employees cost almost 2x as much in healthcare expenses than similar, non-abusing individuals
Disproportionate Drivers of Healthcare Costs: opioid-abusers make up only 4.5% of those with an Rx, yet drive 40% of all opioid spending and 32% of all Rx’s written
National Epidemic Drivers: opioid abuse costs the U.S. economy approx $56 Billion in 2015
Source: NBGH, Castlight, Integrated Benefits Institute, National Center for Health Statistics, CDC Wonder

4. OPIOID MISUSE: WHAT EMPLOYERS CAN DO

5. METHODOLOGY
Primary source of information: medical and prescription claims reporting
Opioid prescriptions analyzed across demographic categories and annual medical healthcare spending
Analyses restricted to de-identified and aggregated prescription opioid claims received between 2011 and 2015.
“Abuse” was defined as meeting the following conditions:
Receiving greater than a cumulative 90-day supply of opioids
Receiving an opioid prescription from four or more providers over the five-year period between 2011 and 2015
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6. KEY FINDINGS
Research on opioid abuse in the workplace provides employers with a more accurate picture of the extent and depth of this ongoing crisis:
PRESCRIPTIONS
MEDICAL SPENDING
AGE
One out of every three (32%) opioid prescriptions is being abused.
Opioid abusers cost employers nearly 2X as much in healthcare expenses on average than non- abusers.
Baby boomers are 4X more likely to abuse opioids than Millennials.
BEHAVIORAL HEALTH
INCOME
PAIN
GEOGRAPHY
Individuals living in America’s lowest income areas are 2X as likely to abuse opioids as those living in the highest income areas.
Patients with a behavioral health diagnosis of any kind are 3X more likely to abuse opioids than those without one.
Opioid abusers have 2X as many pain-related conditions as non- abusers.
Opioid abusers are more likely to live in the rural South than in other regions.
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7. 4.5% 32% 40% KEY FINDINGS: PRESCRIPTIONS
One out of every three (32%) opioid prescriptions is being abused.
Percent of opioid prescriptions received by abusers
32%
4.5%
Percent of individuals
who received an opioid prescription that are abusers
Percent of opioid prescription spending attributed to abusers
40%
Confidential 19

8. KEY FINDINGS: MEDICAL SPENDING
Opioid abusers cost employers nearly 2X as much ($19,450) in healthcare expenses on average annually as non-abusers ($10,853).
The difference in total medical costs for 2015 between opioid abusers and
non-abusers
Confidential 20

9. KEY FINDINGS: AGE
Baby boomers are 4X as likely to abuse opioids as Millennials.
Age
group
Relative share
of abusers (%)
Abuse
rate (%)
0-19
0.3%
0.1%
20-24
1.9%
1.0%
25-29
3.3%
1.8%
30-34
6.2%
2.9%
35-39
7.8%
3.8%
40-44
10.2%
4.7%
45-49
13.0%
5.8%
50-54
17.7%
7.1%
55-59
17.6%
7.4%
60-64
13.6%
7.3%
65+
8.4%
8.9%
Millennials 2.0%
Baby Boomers 7.4%
Confidential 21

10. KEY FINDINGS: INCOME
Individuals living in America’s lowest income areas are 2X as likely to abuse opioids as those living in the highest income areas.
Relative share of abusers (%)
Lowest (less than $40,000) Low ($40,000 - $48,000)
Middle ($48,000- $60,000) High ($60,000 - $84,000)
Highest (greater than $84,000)
26.3
24.8
21.3
14.8
12.8
Abuse rate (%)
6.3
5.7
4.7
3.3
2.7
Confidential 22

11. 8.6% 3% KEY FINDINGS: BEHAVIORAL HEALTH CONDITIONS
Individuals with a behavioral health diagnosis of any kind are 3X more likely to abuse opioids than those without.
8.6%
Percent of people, with a behavioral health diagnosis, abusing their opioid prescription 3%
Percent of people, without a behavioral health diagnosis, abusing their opioid prescription
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12. KEY FINDINGS: PAIN-RELATED CONDITIONS
Opioid abusers have 2X as many pain-related conditions as non-abusers.
Age group
Relative share of abusers (%)
Abuse rate (%)
Joint pain
43.4%
14.6%
Neck pain
34.2%
12.6%
Abdominal pain
16.1%
11.7%
Back pain
77.1%
11.3%
Arthritis
28.9%
11.0%
Fracture
35.9%
9.4%
Nephrolithiasis (Kidney stones)
9.9%
Cholelithiasis (Gallstones)
6.6%
9.0%
Sickle cell
0.4%
8.6%
Chest pain
62.4%
8.3%
Non-fracture injury
58.9%
7.1%
Dental/jaw pain
7.0%
Pelvic
18.6%
6.4%
Note: The abuse rate is defined as
the share of prescription holders that abuse.
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13. Employers Path Forward Top 10 Recommendations for Preventing, Mitigating and Providing evidence-based treatment for people living with addition to opioids

14. Recommendation #1: Introspection
1. Refrain from Judgement – Compassion Over
Conviction
Addiction IS NOT a moral failure. It is a medical issue plaguing our nation that requires Compassion rather than conviction. Partnering with a Behavioral Health partner is an important step in the right direction. 31

15. Recommendation #2: Analyze Prescription Opioid Related Claims
2. Work with your PBM and health plans to analyze
prescription opioid-related claims.
Look at claims data to identify opioid prescription trends and opioid-related health care use in your population. Identify patients with multiple prescriptions and multiple opioid-related emergency room visits and hospitalizations. 31

16. Recommendation #3: Employee Education
3. Educate employees, and cover and/or require
alternative pain management options.
Promote educational resources like Consumer Reports Health’s Surprising Things You Need to Know About Prescription Painkillers and Avoid Opioids for Most Long-Term Pain.
Encourage alternative approaches to pain management, including lifestyle adjustments, behavioral therapy, acupuncture and massage. The Business Group’s resource, Non-Invasive Treatments for Low Back Pain provides several examples on page 4.
Consider reducing cost sharing on alternative pain management therapies for patients with a
history of addiction or opioid abuse. 32

17. Recommendation #4: Health Plan Outreach to Providers
4. Encourage your health plans and hospitals to conduct
provider outreach on appropriate opioid use.
Health plans should contract with providers who agree to be follow new CDC guidelines on opioid prescribing.
Health plans can help implement physician decision-support tools that help providers make
evidence-based decisions about pain management.
Identify providers whose high prescription rates – this may indicate inappropriate prescribing. Your PBM and health plan should contact high prescribers to discuss appropriate vs. inappropriate opioid use. 33

18. Recommendation #5: Utilization Management
5. Implement prior authorization, step therapy and
quantity limits.
Step therapies should require documented pain evaluations and non-opioid and generic treatments before covering opioids for long-term chronic pain.
Quantity limits (e.g. only reimbursing for a limited number of pills per prescription fill) reduce
the likelihood that patients will stockpile medication, whether intentional or not.
Ensure that dispensing pharmacies cannot override rejected claims without a doctor’s requested exception. 34

19. 6. Work with your PBM to craft formularies that
Recommendation #6: Use Formularies that Promote Safe and Efficient Painkillers
6. Work with your PBM to craft formularies that
promote safe and efficient painkillers.
One formulary strategy prioritizes the use of generic prescription opioids, instead of higher-cost brand-name medications.
Alternatively, you can use your formulary to promote the use of new abuse-detterrant formulations (ADFs) that prevent some methods of opioid abuse. They do not fully remove the ability to abuse the drug, but they make it more difficult.
Talk to your PBM about excluding coverage of new powerful and long-acting oral opioid
therapies that have raised concerns from public health and health care professionals. 35

20. Recommendation #7: “Lock-in” and Opioid Medication Agreements
7. Consider implementing “lock-in” and opioid
medication agreements for high utilizers.
Consider a “lock in” policy for individuals suspected of “doctor-shopping.” This requires them to use a single pharmacy and/or single prescriber for prescription opioids.
Employers may ask patients to commit to following their physician’s care plan for chronic use of opioids prior to filling a prescription by having them sign a patient contract. 36

21. Recommendation #8: Safe disposal of unused pills.
8. Encourage employees to safely dispose of
unused pills.
Promote the safe disposal of unused medications to prevent children, pets or others without a prescription from ingesting them.
Support pharmacy medication take-back programs that allow people to return unused medications to some of their locations. Connect employees to local governments that run waste management and law enforcement, as many of them run medication disposal programs as well. 37

22. 9. Implement robust access to mental health services
Recommendation #9: Access to mental health services and employee assistance programs
9. Implement robust access to mental health services
and employee assistance programs (EAPs).
Create robust networks of behavioral health providers to help plan members who struggle with addiction to opioids and other substances to receive evidence-based services. As heroin use increases, it is critically important to not just prevent the abuse of prescription opioids, but help individuals who become addicted, sometimes via legitimate prescriptions.
Communicate the importance of addressing mental health needs, especially around major health conditions or “episodes” (e.g. surgery.) Stress, mental illness, alcohol abuse and long-term post- surgical recovery can contribute to patients becoming dependent on prescription painkillers.
Encourage employees to take advantage of an EAP that offers counseling and/or screening from a specialist provider who can help monitor the employee’s drug use and offer resources to help with their addiction, including connecting them to appropriate providers. 38

23. Recommendation #10: Act Now!
10. See It, Own It, Solve It, Do It!
Once A Leader KNOWS MORE; they MUST DO MORE! Act now in pulling together your Integrated Health Management Team and confirm your next steps. 36

24. Additional Resources NBGH: Preventing Opioid Misuse and Abuse
NBGH: Evidence-Based Treatments for Low Back Pain Castlight Health: The Opioid Crisis in America’s Workforce Consumer Reports: 5 Surprising Facts on Prescription Painkillers Consumer Reports: Avoid Opioids for Most Long-Term Pain
Office of National Drug Control Strategy: 2015 National Drug Control Strategy CDC: Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
Pew: Curbing Prescription Drug Abuse With Patient Review and Restriction Programs National Safety Council: The Proactive Role Employers Can Take: Opioids in the Workplace National Safety Council: Prescription Pain Medicines: A Fatal Cure for Injured Workers

25. Troy Ross President & CEO www.machc.org @MidAmHealth

26. Appendix 36

27. Understanding the Epidemic
More people died from drug overdoses in 2014 than in any year on record.
The majority of drug overdose deaths (more than six out of ten) involve an opioid.
And since 1999, the rate of overdose deaths involving opioids (including prescription opioid pain relievers and heroin) nearly quadrupled.
From 2000 to 2014 nearly half a million people died from drug overdoses.
78 Americans die every day from an opioid overdose.
Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, yet there has not been an overall change in the amount of pain that Americans report.
Deaths from prescription opioids—drugs like oxycodone, hydrocodone, and methadone—have also quadrupled since 1999. 6
Image Source: June 4, 2015 cover of TIME Magazine, accessed via on May 3, Statistics Source: “Drug overdose deaths in the United States hit record numbers in 2014,” accessed via on May 3, 2016

28. Hydrocodone (e.g., Vicodin) Oxycodone (e.g., OxyContin, Percocet)
What Are Opioids?
Hydrocodone (e.g., Vicodin)
Oxycodone (e.g., OxyContin, Percocet)
Morphine (e.g., Kadian, Avinza)
Codeine 7

29. Definitions Abuse Misuse Diversion
Taking any substance, including a prescription drug,
for recreational purposes (i.e., to get “high”)
Misuse
Taking any medication not as prescribed (i.e., twice a day when the prescription says once a day)
Diversion
Unlawful channeling of a regulated pharmaceutical
from a legal source (intended patient) to an illegal source (giving to a friend, relative, neighbor, etc., or – more overtly – selling for profit) 8

30. National Overdose Deaths Number of Deaths from Rx Drugs
30,000
Total
Female
Male
25,000
20,000
15,000
10,000
5,000
Source: National Center for Health Statistics, CDC Wonder

31. National Overdose Deaths Number of Deaths from Prescription
Opioid Pain Relievers
20,000
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
Total
Female
Male
Source: National Center for Health Statistics, CDC Wonder

32. National Overdose Deaths Number of Deaths from Benzodiazepines
9,000
Total
Female
Male
8,000
7,000
6,000
5,000
4,000
3,000
2,000
1,000
Source: National Center for Health Statistics, CDC Wonder

33. National Overdose Deaths Number of Deaths from Cocaine
8,000
Total
Female
Male
7,000
6,000
5,000
4,000
3,000
2,000
1,000
Source: National Center for Health Statistics, CDC Wonder

34. National Overdose Deaths Number of Deaths from Heroin
12,000
Total
Female
Male
10,000
8,000
6,000
4,000
2,000

35. National Committee on Evidence-Based Benefit Design
The National Committee on Evidence-Based Benefit Design seeks to:
•Identify solutions to help employers align plan design, communications, and health programs with available clinical evidence.
•Ensure employees are incentivized to seek appropriate, high quality care.
The Committee meets twice a year in Washington, DC, bringing together large employers, clinical leaders, and strategic partners. Membership is free to employers. 4