According to the National Survey on Drug Use and Health (NSDUH), 19.7 million American adults struggled with a substance use disorder (SUD) in 20171. In terms of cost, the American Addiction Centers estimate that drug abuse and addiction cost American society more than $740 billion each year in lost workplace productivity, health care expenses and crime-related costs. While there has been a great deal of progress in recent years with educating the public and removing the stigma surrounding substance abuse and addiction, employers still struggle to find ways to openly and effectively deal with the issue within their companies.

With alcohol and opioid pain relievers being two of the most abused substances, it is no surprise that many affected adults can be found in the workforce. Both products have legitimate and safe uses, but dependence on them can develop after either misuse or prolonged use. This can lead to absenteeism, turnover and increased health care costs. The following will explain SUD from a clinical disease perspective in order to better understand addiction and why it should be considered a chronic disease rather than a result of a lifestyle choice. Lastly, the article will cover SUD’s impact on employers and employees alike and discuss available opportunities to develop effective policies and plan designs to help patients.

What is Substance Use Disorder?

Two common types of SUDs encountered in the workforce are alcohol use disorder (AUD) and opioid use disorder (OUD). AUD affects about 14 million1 people in the U.S., and it can be difficult for people to distinguish social and binge drinking from alcohol dependence and addiction. The same goes for OUD, which impacts about 2 million Americans2. While opiates are commonly prescribed to help treat acute and chronic pain, people can develop a physical and mental dependence on these products. Together, alcohol and opioid misuse cost about $200 billion3 in lost workplace productivity and about $50 billion4 in health care costs.

From a clinical standpoint, it is important to realize that both AUD and OUD involve addiction, which is a chronic disease. With addiction, there is an uncontrollable urge to seek and use these substances despite the mental, physical and social problems that come with their use. Unfortunately, people with addiction cannot simply just stop using and be cured. Ongoing care and treatment are needed to successfully cure a SUD. The reason behind this is that alcohol and opioids change how the brain works, specifically targeting areas that are responsible for reasoning, decision-making, basic drives, urges, pleasures and rewards. Over time, both substances stimulate the reward system in the brain which causes people to repeatedly seek this feeling of pleasure despite the negative effects.

Physically, people with SUD are at risk of a range of health problems. For alcohol users, this could lead to brain damage, liver disease, cancer and increased risk of heart disease5. Opioids can worsen breathing, exacerbate mental illness and in cases of overdose, can lead to death6. Regrettably, the feelings of euphoria that come with substance abuse supersede the potential risks. People with SUD develop tolerance over time which means they require increased amounts of the substance to gain the same effects they are seeking. Once they discontinue the medication, they may undergo withdrawal symptoms which include anxiety, nausea, vomiting, depression and even seizures which makes stopping abruptly difficult. This is a vicious cycle which drives people to seek these substances to avoid both the short-term mental and physical problems they experience by not using.

How is SUD Treated?

Consequently, treatments for SUD usually require both a chemical (drug) and a behavioral (counseling) component for optimal results known as medication-assisted treatment (MAT). Drugs are specifically developed to attach to the same receptors that alcohol and opioids target. This means that some of these products may also be controlled substances or opioids as well, which may be counterintuitive to many people7.

So how does giving more of a controlled substance help with SUD? These chemicals are designed to compete or block the same sites that alcohol and opioids target to help reduce the symptoms of withdrawal, dampen the rewarding feeling and lower the dependence on the products over time8, all without the negative health effects. These less potent versions have little to no abuse potential and have been evaluated by the Food and Drug Administration (FDA) to be safe and effective. Due to the chronic nature of SUD, patients will typically have to take these medications over a prolonged period, and for some patients treatment may be ongoing indefinitely to reduce the risk of relapse. Doctors will work closely with patients and other appropriate health care members to ensure that the right dosing and amounts are prescribed based on individual needs.

The other key component of MAT is the behavioral counseling. Specialized counseling and psychotherapy can help with changing behavior, thoughts, emotions and how affected people see and understand situations. By improving their mental health, this allows people a better chance to use other strategies to aid their recovery, such as being adherent to the MAT medications. Early treatment can be very beneficial, so it is important to offer options for both medications and therapies from the start.

Examples of FDA-approved MAT Medications

Opioid Use Disorder
Generic Brand
Buprenorphine Subutex®
Suboxone®
Zubsolv®
Methadone Dolophine®
Methadose®
Naltrexone ReVia®
Vivitrol®
Alcohol Use Disorder
Generic Brand
Acamprosate Campral®
Disulfram Antabuse®
Naltrexone ReVia®
Vivitrol®

What Can Employers do?

The first step is education. Informing all levels of your company on substance abuse helps reduce the stigma and ensures people understand that this is a chronic disease. The goal of educating employees is to help them recognize SUD both in themselves or loved ones. Not all employees are aware of the plan benefits surrounding SUD and some may be afraid to seek them out. Being open with this health topic can help workers feel they are cared for and may hopefully encourage them to explore SUD resources such as counseling through employee assistance programs (EAPs).

Involving key stakeholders and decision makers in this process can greatly enhance the policies and plan designs within the company. While a clear drug-free policy is essential, it is also important to review how your company provides access to SUD resources, how and what MAT options are covered and how return-to-work and fitness-for-duty policies work for those undergoing treatment.

In terms of resources, benefits professionals can help connect affected employees and plan participants to a host of community options:

  • inpatient/outpatient treatment,
  • detoxification centers,
  • mental health services and
  • support groups.

For a more comprehensive approach, some employees may benefit from being referred to a center of excellence (COE )9. COEs allow for a holistic approach which involves counseling, primary care and medications all provided by a coordinated health care team.

Employers can work with both medical and pharmacy insurance providers to ensure there is comprehensive coverage for the different settings of care that may be involved in treating people with SUD. Removing or reducing patient cost share for MAT medications can be very beneficial in supporting patients with initiation and adherence to treatment. Nonadherent members incur significantly greater health care costs and are more likely to relapse10. Some plans have taken the option to remove patient cost sharing with generic MAT options, like buprenorphine and naltrexone, to address this issue. Reviewing your claims data for metrics such as opioid prescription claims11, high dosage opioids, alcohol- and opioid-use disorder diagnoses from your health plan or pharmacy benefit manager (PBM) can help identify possible trends and provide insight on your current population. Comparing these metrics over time to industry or peer benchmarks can indicate if the implemented strategies are effective.

Lastly, always feel free to consult experts who advise on AUD and OUD policies to identify best practices for your plan. This is an ongoing issue, and employers are tackling it in many innovative ways based on their industry and size. Employers Health is always listening and working with our clients and PBM partners to discover best ways to manage SUD from a clinical, legal and operational standpoint. For additional resources, feel free to reach out to the clinical team at Employers Health.

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About the Authors

Kevin Wenceslao, PharmD

Kevin Wenceslao, PharmD

Clinical Advisor

Kevin works closely with the director of pharmacy to serve as a clinical resource for our members’ benefit professionals on topics of new drugs, plan design recommendations and overall trends.


Matthew Harman, PharmD, M.P.H.

Matthew Harman, PharmD, M.P.H.

Senior Director of Pharmacy

In his role at Employers Health, Matthew is primarily responsible for monitoring and evaluating the pharmacy plan performance of member organizations that participate in the collective strategy purchasing programs with CVS Caremark and OptumRx.

References

  1. Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www. samhsa.gov/data/
  2. https://www.cdc.gov/drugoverdose/training/oud/accessible/index.html
  3. Sacks JJ, Gonzales KR, et al. 2010 national and state costs of excessive alcohol consumption. Am J Prev Med. 2015;49(5):e73-e79.
  4. Florence CS, Zhou C, Lou F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016;54(10):901-6
  5. National Institutes of Health. National Institute on Drug Abuse. Easy-to-read drug facts: effects of alcohol on brains and bodies. https://easyread.drugabuse/gov/content/effects-alcohol-brains-and-bodies. Accessed March 26, 2020.
  6. National Institutes of Health. Prescription opioids. https://www.drugabuse.gov/publications/drugfacts/prescription-opioids. Accessed March 26, 2020.
  7. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1(1):13-20.
  8. https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat
  9. Elrod JK, Fortenberry JL Jr. Centers of excellence in healthcare institutions: what they are and how to assemble them. BMC Health Serv Res. 2017;17(Suplp1):15-24.
  10. https://www.ajmc.com/journals/issue/2017/2017-vol23-n6/heterogeneity-of-nonadherent-buprenorphine-patients-subgroup-characteristics-and-outcomes
  11. Kentuckiana Health Collaborative. Opioids and the workplace: an employer toolkit for supporting prevention, treatment, and recovery. https://ww.khcollaborative.org/wp-content/uploads/2019/04/Opioids-and-the-Workplace-Print-Version-1.0.pdf. Accessed March 25, 2020.