While opioid analgesics can be very effective in controlling the pain caused by an injury, the long-term use of opioids has been associated with potentially serious side effects. Despite these risks, over the past two decades, there has been a dramatic increase in the use of opioids to treat chronic pain. This increased utilization has led to an escalation in the misuse and abuse of opioids, including overdoses and deaths, so much so that the Center for Disease Control (CDC) has characterized the issue as an epidemic.


A recent report by the CDC illustrates the impact - 46 people die every day from an overdose of prescription painkillers in the U.S. In 2012, 259 million prescriptions for painkillers were written—enough for every American adult to have a bottle of pills. The CDC’s report, CDC Grand Rounds: Prescription Drug Overdoses - a U.S. Epidemic (2012), states that for every opioid-related death, there are more than 150 people who abuse or are dependent on opioids. This is of particular concern in the workers’ compensation industry where 70% of injured workers take opioid analgesics. And workers’ compensation claims with opioid prescriptions cost on average $20,000 more than those claims without opioids.

O​ur perspective

Optum proactively manages opioid utilization, ensuring the safe and appropriate usage of this potent medication. We have deliberately designed our products and services to mitigate the risk associated with opioid utilization. Our global utilization management strategies:

  • Emphasize prevention from the first fill, because it is always more difficult to change behavior or therapy regimens after-the-fact.

  • Limit utilization of long-acting opioid analgesics until 90-days post injury based on evidence-based medicine and accepted medical guidelines. This helps to reduce early morphine equivalent dose (MEDs) and long-term spend, as well as mitigates potential misuse or abuse situations.

  • Provide actionable data and insight.

  • Use technology to facilitate timely, secure communication and claim management.

 Outlined below are some of the more noteworthy program components.

Medication plans and formularies
All retail prescription transactions flowing through our network follow one of three paths - the prescription is approved and is filled, the prescription requires additional information or prior authorization before being filled, or the prescription does not fall within the program criteria and is not filled. Medication plans and formularies, along with drug utilization review criteria, and program business rules, guide transactions along these paths. This is accomplished by using a sophisticated algorithm that contemplates body part, nature of injury, injury date, and state of jurisdiction to ensure that injured persons receive the right medication at the right time. For example, long-acting opioid analgesics might not be appropriate for a laceration or during the acute phase of an injury. By customizing your formulary, we can make sure that inappropriate opioid usage is avoided.

Medication review
Our medication review service provides a comprehensive review of an injured person’s medication profile that delivers a detailed analysis and list of action items. The review assists claims professionals in the proper management of injured person care with an emphasis on the appropriate use of opioid medications. It compares actual versus recommended use and can identify potential therapeutic duplications and drug-to-drug interactions, as well as other therapeutic concerns and intervention needs.

Early intervention and high-risk profiling
At Optum, we proactively capture data and identify potential misuse or abuse situations before they disrupt recovery or otherwise cause harm. By doing this, we can detect concerns, such as high doses of medication, duplication of opioid therapy, and the use of multiple prescribers. These are all potential indicators of misuse or abuse. If such issues arise, we offer a variety of intervention programs to address the concern, from letters to the prescriber to peer-to-peer outreach. Through our state-of-the-art claim management portal, we can also provide clinical escalation alerts to claims professionals, raising awareness of potential therapeutic concerns. Our services allow the identification of possible therapeutic concerns earlier in the claim to facilitate communication with all of the stakeholders in order to optimize therapy.

Drug testing and monitoring
Drug testing and monitoring ensures that injured persons are taking their medications as prescribed. Our drug testing and monitoring (DTM) service is an on-going monitoring program for high-risk injured persons. This intervention helps eliminate drug misuse and abuse while promoting appropriate use of medications by facilitating urine drug testing at the prescriber level. Our ​DTM program has helped reduce opioid usage, successfully driving down the utilization of high-risk medications and reducing medication misuse factors.

Influencing ​policy
We believe it is our responsibility to act as an influential voice for positive change. We monitor state and national issues regarding opioids, providing expert opinions and testimony, and keeping our clients informed.

By working collaboratively with our clients and other industry stakeholders, we are effectively bending the curve away from high-cost misuse and abuse situations and toward brighter outcomes.