Stan* was a long-time employee at a major technical manufacturer in a safety-sensitive job. When a work injury required knee surgery, he was prescribed an opioid to deal with post-operative pain. He found that in addition to helping with the knee pain, his prescription also helped him cope with lingering post-traumatic stress disorder (PTSD) from his military reserve experience. When he needed the medications long after the pain in his knee had subsided, his doctor stopped prescribing. Although Stan found another doctor, this new doctor also eventually refused to prescribe. When he couldn’t find a third doctor to prescribe, he turned to buying street drugs.
Stan was addicted to opioids long before the condition manifested itself into issues at work. Eventually, he became irritable and had missed so much work that he was close to being disciplined or terminated.
Finally, Stan hit a brick wall, called into work suicidal and asked for help. His employer was able to get him into a program with Homewood Health Centre where he went through medically supervised detoxification to come off pills and simultaneously entered into treatment for the addiction and underlying PTSD issues. Stan was off work for several months on short-term-disability and was able to return to his job after treatment.
What would have been the outcome if Stan hadn’t disclosed his situation and asked for help? What if there had been an “early detection system” that could have identified his addiction?
Read: Narcotic abuse and drug diversion inside your plan
Canada’s abuse crisis
Canada is the world’s second largest per capita consumer of prescription opioids after the U.S. (see chart below), says an International Narcotics Control Board report. And other research indicates that non-medical use of prescribed opioids is now the fourth most prevalent form of substance use in Canada behind alcohol, tobacco and cannabis. A report from the Canadian Centre on Substance Abuse says this may be due, in part, to the 203% increased use of prescription opioids between 2000 and 2010.
Source: International Narcotics Control Board
Death from opioid use is also a reality. Research from 2012 indicates that overdose deaths due to medical and non-medical drug use are the third leading cause of accidental death in Ontario, with a significant proportion attributed to opioids. Research from B.C. indicates that 256 deaths in 2013 in that province were caused by opioid overdose.
Read: Missed understanding
Workplace worries
As in Stan’s case, opioid use can carry into the workplace—with detrimental effects. Recent U.S. research estimates the annual cost of the non-medical use of prescription opioids to be more than $50 billion, with lost productivity accounting for 61% of this amount.
And healthcare costs for opioid abusers are steep. An article by Alan G. White et al. in the Journal of Managed Care Pharmacy determined that patients who are opioid abusers have healthcare costs more than eight times higher than those of non-abusers. Another study conducted by U.S. private payer WellPoint Inc. found that it paid $41 in related medical claims for every $1 it paid in narcotic prescriptions for suspected abusers.
Because opioids are prescribed by a physician, there is a perception of safety associated with these medications. Although these drugs have therapeutic purposes, they have a high tendency for misuse because of their psychoactive properties and associated risk for psychological and physical dependence.
Although employers may not think they have a risk for narcotic misuse or dependence among their employee population, drug use can begin innocently enough with a valid prescription to manage pain from an injury or surgery and spiral quickly into dependency. Psychologist Dr. Ann Malain, executive vice-president, Stay at Work Services, with Homewood Human Solutions, says opioid addiction can happen to anyone; however, an underlying mental health issue or family history of addiction makes one more susceptible to developing an addiction. Initially the addicted employee may not demonstrate any outward symptoms. “Employees can be addicted for quite some time before it comes to the attention of the employer through workplace behaviour,” explains Malain.
In response to the critical situation posed by misuse of opioids and other prescription drugs, in March 2013, the National Advisory Council on Prescription Drug Misuse launched First Do No Harm: Responding to Canada’s Prescription Drug Crisis. It is a 10-year plan aimed at managing prescription drugs that may be legal, but have a high potential for abuse and misuse, while also ensuring that those who legitimately need the medications can still access them.
There are a wide variety of tools and programs used by insurance carriers and pharmacy benefit managers to monitor prescription drug use and identify potential cases of abuse, misuse or fraud. “When it comes to managing opioid use, there is a greater focus on plan member safety and ensuring appropriate drug use, not cost savings,” explains Jean-Michel Lavoie, director, pharmaceutical benefits, with Sun Life Financial.
Read: Combating drug abuse and diversion: the right approach
An innovative tool
Most programs track use of narcotics by either dollar amount or quantity. Both can be ineffective since there may be wide discrepancies in prices between narcotics, or there can be differences in low- and high-potency narcotics.
Pharmacy benefit manager TELUS Health has introduced an innovative approach to managing overall narcotic consumption in private drug plans based on the use of morphine equivalent dosing (MED).
Various narcotic medications with differing potencies are approved in Canada. MED is the process of converting doses of various narcotic analgesics to a morphine equivalent. Originally used as a guide to switch patients from one narcotic drug to another, MED also allows standardization to a single narcotic analgesic for tracking and utilization purposes (see table below). Simon Lee, manager, pharmacy services with TELUS, offers an analogy: “Just like most foreign currencies are referenced to the American dollar to simplify exchange, in MED, narcotics are referenced against a 30-milligram morphine equivalent to allow for accurate comparison.” This can be an “early warning system” to help identify plan members who may be on the path to addiction before the addictive behaviours have a negative impact on the workplace.
Morphine Equivalent Dosing (MED) Equivalence to morphine 30 mg | |
| Morphine | 30 mg |
| Codeine | 200 mg |
| Oxycodone | 20 mg |
| Hydromorphone | 6 mg |
| Meperidine | 300 mg |
Source: Adapted from a report by the National Opioid Use Guideline Group
As a standard, TELUS Health already uses a first level of Drug Utilization Review (DUR) edits at the point of sale. The DUR is conducted in real time when prescription medications are dispensed to plan members and are performed against all pharmacies where the plan member has used their drug card. Each prescription drug is reviewed against a series of criteria, based on the plan member’s medical drug history within the last 100 days—to be sure the prescription drug is being taken appropriately.
With the new morphine equivalency functionality, payers will more accurately track medication abuse, regardless of the number of doctors who prescribe or how many pharmacies the plan member is using. MED provides payers with the option of second and third levels of management. For Level 2, plans can implement limits at the point of sale based on the MED value, which is better aligned with clinical experience than a dollar or quantity limit. For the third level, payers can use MED post-claim analysis in combination with other elements within a case management approach to identify and manage high-risk individuals. This technique will contribute to reduce the risk of overdose and misuse of narcotics.
In addition to using claims analysis, Malain also suggests that front-line supervisors be trained to look for signs that their employees are struggling and be provided coaching on how to handle an initial conversation with the employee and offer help.
Managing Canada’s prescription drug abuse crisis will require collaboration from all stakeholders. For private payers, MED is an innovative prescription drug monitoring tool that can act as an early warning system. Although Stan is just one example, there are many other employees who are also struggling with an addiction. Perhaps if MED had been in place, Stan’s addiction might have been identified earlier and support could have been offered before he spiralled into suicidal despair.
* Stan is a fictitious person and his story is based of a collection of patient histories from Homewood Health.
Suzanne Lepage is a private health plan strategist based in Kitchener, Ont. The views expressed are those of the author and not necessarily those of Benefits Canada.