Opioid Abuse & Workers' Compensation

An epidemic of prescription pain medicine abuse has resulted in serious issues to both the health of injured employees as well as to the overall cost to the workers’ compensation system. The damaging impact can be seen in a variety of ways, including skyrocketing medical and prescription costs, longer treatment periods and claim settlement expenses.


The Fund has implemented an aggressive and comprehensive Drug Management Program.  The goal is to prevent inappropriate use of potentially harmful and addictive medications for injured employees and to control the costs associated with these prescriptions. The Fund accomplishes this goal through agreements with the treating physician, the use of technology to monitor the injured employee’s claim and by utilizing the procedures outlined in the MI Health Care Service Rules (HCSR).


Opioids are prescribed to manage acute and chronic pain complaints.  It can be difficult to recognize when the course of treatment moves from “acute care” to “chronic care.” The Michigan Health Care Service Rules has given employers, providers, TPA’s and Carriers, the necessary guidelines to help establish the acute from the chronic care.  Managing a Michigan WC claim with opioid involvement should have the following objectives:

  • Identify claims within the criteria of chronic pain (>90 days usage)
  • Educate the treating physician regarding the requirements under the new HCSR
  • Employ available tools to ensure that continued use of opioid medication falls within the acceptable parameters as outlined by the HCSR
  • Provide a system of continued monitoring that works towards the discontinuation of opioid medication therapy.


The Fund’s guidelines along with the HCSR changes have allowed us to address the problem of long-term abuse of opioids by injured workers. The intent is to lower the projected pharmaceutical costs associated with Medicare Set-Asides, and help reduce the over-all medical costs for the State’s job providers. In a recent review of a large sample of 2016 Michigan WC claims, involving prescribed opioid’s for pain management, the results show that the pharmaceutical costs can easily exceed $2,000 a month.  


Managing Occupation Injuries - What are some of the early warning signs?

  1. Any opioid prescription with a supply over 14-days, within the first 30 days of treatment
  2. Any opioid prescription lasting longer than 45 days - post surgery
  3. Any opioid prescription lasting longer than 90-days
  4. Pain management consultation within 45-days of the injury
  5. More than one Pharmacy being utilized, simultaneously
  6. Injured employee frequently runs out of medications
  7. Increased or exaggerated pain complaints during the course of treatment


In summary, when managing injured employees with opioid issues, your Fund utilizes the following action items:  direct the medical care the first 28 days of treatment; if opioids are being prescribed, consider an Independent Medical Evaluation to assist in guiding the treatment plan; consider the use of a Nurse Case Manager to help guide the employee and physician away from utilizing opioids for chronic care and in certain cases involve communication with a trusted WC Defense Attorney to outline short and long-term strategies that adhere to state guidelines.


The Fund aggressively manages its cost while providing injured employees the benefits and services they need to return to full employment. For more information on how the Fund can help your business manage its costs and benefit you by being an owner, contact RPS Regency at 800-686-6640 extension 2732.

This article was provided by Frank Schmidt, MBA, York Risk Services Group, the Fund’s claim adjusting service partner.