Zero Stigma. Zero Deaths.

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EXECUTIVE SUMMARY

The opioid epidemic impacts employers, employees, and dependents in the Commonwealth and the nation. Substance use problems, especially related to alcohol, have been a long-standing concern in the workforce. The opioid epidemic has brought addiction concerns in the workforce to the forefront. While the Commonwealth is a leader in its public health approach to the crisis, the issue of opioids in the workplace has not received the attention it demands. This issue brief examines the extent, cost, and consequences of the problem; current employer-provided benefit offerings; innovative interventions from employers/organizations; and best practices and recommendations. Primary themes include employers’ uncertainty regarding how to address the opioid epidemic in the workplace; the need for tailored, workforce-specific solutions, promoted by leadership; and the importance of reducing stigma.

Extent, Cost, and Consequences

The statewide prevalence of opioid use disorder (OUD) dramatically increased in the past two decades. Although declining in recent years, opioid-related deaths increased over 450% from 1999 to 2016, from 379 to 2,089 confirmed deaths. One estimate of the annual costs of prescription opioid misuse on Commonwealth employers is roughly $1.7 billion, which was extrapolated from a 2013 CDC study of the national costs of prescription opioid “abuse, dependence, and overdose.” The actual cost is likely significantly higher, due to difficulty of capturing unseen and indirect costs.

Nationally and in the Commonwealth, the opioid crisis is taking its toll on individuals, families, communities, and employers are starting to feel these effects directly. In addition to raising health care costs, OUD limits employees’ availability and reduces worker productivity. Roughly half of prime-age white men who were out of the labor force report chronic pain and daily use of opioid pain medications. The majority of persons with OUDs are full-time employees. The use of prescription opioids may negatively affect the performance of safety-sensitive tasks at work: people using opioids have a significantly increased risk of motor vehicle crashes, unsafe driving activities, and falls. The cost of workers’ compensation claims is also markedly higher for workers who receive opioid prescription than those who were not prescribed these drugs. Fully 37% of non-elderly persons with an OUD are covered by commercial insurance, largely through employer sponsored plans.

Not all employers are impacted equally, and they vary in their awareness of the problem and the programming they provide employees and dependents. Industries and occupations with high rates of work-related injuries are particularly hard hit. Contract employees, a growing part of the economy, may also be differentially impacted; however, little has been written regarding OUD in this population. For example, in the Commonwealth, construction workers had an incidence of opioid-related overdose deaths nearly five times the state average, and agriculture, forestry, fishing and hunting workers had an incidence over four times the state average. Stigma is also a major impediment to identifying and treating OUD and to creating a workplace conducive to long-term recovery. Targeted workplace anti-stigma interventions, as well as preventive interventions aimed at limiting workplace injuries and reducing opioid prescribing to injured workers, may lead to improved employee health.

Benefits and Treatment

Most employers purchase and subsidize health benefits for employees and dependents. For OUD, these benefits typically include inpatient, outpatient and rehabilitation treatment programs. Employers report significant concerns about the quality of opioid treatment. Services offered for treatment of OUD include Medications for Addiction Treatment (MAT, traditionally defined as Medication Assisted Treatment), which provides opioid pharmacotherapy (such as buprenorphine/naloxone, extended-release naltrexone, and methadone) to reduce or eliminate cravings and withdrawal symptoms, and more traditional non-medication or “abstinence-based” programs. Scientific evidence strongly supports MAT as an evidence-based treatment for OUD. MAT, which is offered in general medical or specialty behavioral health settings, is underutilized nationally and in the Commonwealth. The reasons for this likely concern access/capacity issues; a shortage of treatment and workforce capacity; low perceived reimbursement rates; patient experiences; opposition from some labor unions; and stigma and misunderstanding among patients, providers, and employers.

Innovative Interventions

In the Commonwealth, some employers/organizations have developed innovative ways to address opioid issues in the workplace. Many employers and health plans removed barriers to treatment, particularly copayments or prior authorization for MAT. Others are using toolkits and working with health plans and providers to increase access to effective treatment. This report highlights five innovative entities, including Boston Medical Center, Fishing Partnership Support Services, Seafood Sam’s, General Electric/the GE Foundation, and the New England Carpenters Benefit Fund. While they differ in terms of origins and offerings, common elements include:
-The importance of senior leadership sponsorship and buy-in
-Careful analysis and attention to the unique needs of each workplace
-Attentiveness to the voices and needs of managers, workers and families
-Support for a stigma-free and recovery-friendly workplace
-Willingness to engage with health plans and treatment providers to influence the quality of treatment provided
-Developing programs internally to meet the unique nature of their workforce

Best Practices and Recommendations

Increased employer engagement is necessary to address the crisis – and employers need targeted tools and resources do so. Employer-sponsored health plans and ancillary benefits are underused resources. Employers could work more closely with health plans and use de-identified data to better understand the prevalence and incidence of OUDs among their employees and their dependents. Employers could encourage the greater use of screening and intervention tools for OUD and other co-occurring SUDs and mental health conditions. Employers could work more closely with health plans to limit exposure to opioids and reduce barriers to treatment. Pharmacy benefit managers (PBMs) could be engaged in this process to identify problematic opioid prescribing patterns and encourage appropriate prescribing. Employers could encourage plans to use targeted case management and cover the cost of recovery coaches. They could support the coverage of alternative pain management options, such as acupuncture, chiropractic care, and physical therapy, and encourage the use of exercise and other non-pharmaceutical interventions.

Most importantly, employers could offer benefit designs that minimize or eliminate barriers to treatment, including MAT, which is the gold standard for OUD treatment. Ensuring that MAT is offered as one of a number of treatment options is critical. Employers could work with their health plans to remove prior authorization for OUD treatment, including both the counseling and pharmacotherapy components of MAT; eliminate copayments or placing MAT drugs on the tier with the lowest cost sharing; and eliminate copayments for counseling or adjunctive services associated with MAT.

Employee Assistance Programs (EAPs) are an underutilized resource and have the potential to provide education and evidence-based referrals. Employers can ask their EAPs for tailored programs designed to prevent OUD and direct employees and their dependents needing treatment to providers using evidence-based practices. The involvement of leadership is a key component of increasing utilization of EAPs. Employers could also use targeted, comprehensive disability management interventions aimed at employees receiving workers’ compensation or disability insurance, who have an elevated risk of developing an OUD.

Additional interventions employers may consider include:
-Conducting pre-employment screenings and conduct drug tests as they deem appropriate, in coordination with clearly-defined organizational policies and protocol
-Creating a culture in which the entire workforce feels invested in creating a safe, healthy, and drug-free environment
-Educating and training managers and employees in how to safely use and dispose of opioid prescriptions
– Understanding the signs of overdose and OUD and undergoing naloxone training. Some interviewees – particularly those in industries with high rates of fatal opioid overdose, such as construction and fishing, but also, more recently, Blue Cross Blue Shield of Massachusetts – provide naloxone kits and/or training at the workplace.
-Communicating the basics of effective OUD treatment, namely that detoxification alone is not treatment and that community-based treatment is more effective and safer than using potentially low-quality out-of-state, out-of-network treatment centers.

-Creating a recovery-friendly workplace that allows employees to take time off for appointments and support groups, and that reduces stigma for employees returning to work from treatment for OUD and other SUDs.
-Examining their health benefits, EAP programs, and workers compensation insurance to ensure the use of integrated and evidence-based approaches to combatting opioid misuse and OUD. For many individuals, OUD occurs with polysubstance use, and interventions need to incorporate appropriate treatment to meet these needs.27
-Using employer toolkits – such as those developed by the National Safety Council, Boston Medical Center, Shatterproof, and the Society for Human Resource Management – to better understand and communicate with their employees concerning opioid use and OUD.

Conclusion

The opioid epidemic is a public health and economic emergency for the Commonwealth. The crisis affects every aspect of life including the workplace. It is creating workforce shortages, increasing turnover, absenteeism, presenteeism, and costing millions in health care costs. The problem of stigma impedes identification and treatment of the problem. Progress requires effort from all stakeholders, including employers, employees, unions, health plans, providers, and the Commonwealth. The shared goal is prevention and access to effective treatment and recovery. The good news is that there are promising interventions. The opportunity is to build on innovation and coordinate across relevant stakeholders. The challenge will be to evaluate interventions and expand what works to a broader group of employers in coordination with health plans, providers and state public health efforts.