Anton C. Bizzell, MD Fellow, U.S. Chamber of Commerce

1. Businesses, Employees and Opioid Use Anton C. Bizzell, MD Fellow, U.S. Chamber of Commerce Chief Executive Officer, The Bizzell Group, LLC Lanham, MD | Rockville, MD | Atlanta, GA

2. America’s Addiction Epidemic • In 2017, 47,600 overdose deaths occurred from opioids; 70,237 overall overdose deaths from all drugs • In 2016, enough opioid pills were prescribed for every person in the US to have 36 pills • 174 Americans die of a drug overdose every day • 246 Americans die of alcohol misuse every day • The opioid crisis has cost employers over $700 billion in lost work hours • Drug overdose deaths have nearly doubled in the past 10 years • Shatterproof.org/workplace. Accessed October 10, 2019

3. The Opioid Epidemic The opioid epidemic is destroying communities and families across America. Addressing a crisis of this scope and magnitude requires everyone who has a stake to be part of the solution, including the business community. Businesses are a vehicle to help solve the problem.

4. What are Opioids? • Opioids are powerful medications that • are prescribed for many types of pain. • Some prescription opioids are derived from the poppy plant, while others are synthetic. • Street drugs like heroin and illicit fentanyl are also opioids.

5. The Opioid Epidemic • Prescription opioids are highly addictive and are often overprescribed. • Prescription opioid misuse can lead victims to dangerous street drugs and result in overdose or death. • The deadliest drug crisis in American history. • Every day, 115 Americans die from an opioid overdose, including heroin and prescription opioids.

6. Common Prescription Opioids • Codeine • Fentanyl (Actiq, Duragesic, Fentora) • Hydrocodone (Lorcet, Lortab, Vicodin) • Hydrocodone and Acetaminophen (Lorcet, Lortab, Norco, Vicodin) • Hydromorphone (Dilaudid, Exalgo) • Meperidine (Demerol) • Methadone (Dolophine, Methadose) • Morphine (Avinza, Kadian, MS Contin, Ora-Morph SR) • Oxycodone (OxyContin, Oxyfast, Percocet, Roxicodone) • Oxycodone and Acetaminophen (Percocet) • Oxycodone and Naloxone (Targiniq ER)

7. The Opioid Epidemic • Opioid misuse affects everyone, not just people with a substance use disorder. Across the country, misuse of opioid pain medication, heroin, and fentanyl has taken a staggering toll. • Only 1 in 10 Americans with a SUD receives treatment (CASA Columbia) • 1.4 Million people used prescription painkillers non-medically (NSDUH) • The average age for prescription drug painkiller use is 21.2 yo (NSDUH)

8. The Opioid Epidemic • 50.5 of people who misused prescription drugs go them from a friend or relative for free, and 22.1 percent got them from a doctor • 4 out of 5 people who are addicted to heroin report that their addiction started with pain pills (ASAM)

9. US Drug Overdose Deaths: Waves 1-3

10. US Drug Overdose Deaths: Kansas

11. Opioid Prescriptions: Kansas

12. The Opioid Epidemic

13. Economic Burden of Opioid Abuse • Nonmedical use of opioid pain relievers cost insurance companies up to $72.5 billion annually in health-care cost • Social & economical consequences • Cost of prevention and treatment • Increased incidences of opioid overdose deaths • Safety risk to the public due to drug affected driving • Environmental contamination due to inappropriate disposal and illicit cultivation • Loss of productivity at work • Neonatal abstinence syndrome Volkow, Nora. "Prescription Opioid and Heroin Abuse." National Institute on Drug Abuse (NIDA). N.p., 29 Apr. 2014. Web. 26 Jan. 2017. Available at: https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/prescription-opioid-heroin-abuse

14. Economic Burden of Opioid Abuse • In a 2017 National Safety Council survey, 70% of employers reported suffering the negative effects of prescription drug misuse; noting positive drug tests, absenteeism, injuries, accidents, and overdoses [Hersman 2017]. • In 2013, the total U.S. societal costs of prescription opioid use disorder (OUD) and overdoses were $78 billion. Of that, about $2.8 billion was for treatment [Florence et al. 2016].

15. Economic Burden of Opioid Abuse • In 2016, individuals with insurance coverage received $2.6 billion in services for treatment of opioid addiction and overdose, a dramatic increase from $0.3 billion in 2004 (based on claims data from large employers). • $1.3 billion was for outpatient treatment • $911 million was for inpatient care • $435 million was for prescription drugs [Cox et al. 2018]. • Employers may save up to $2,607 per worker annually by getting workers into treatment [NSC et al. 2016; NORC]. • 80% of individuals in need of treatment for a SUD in 2016 did not receive treatment [CBHSQ 2017].

16. The Opioid Epidemic The Best Treatment is Prevention • Medication Assisted Treatment • Buprenorphine • Methadone • Naltrexone Counseling & Behavioral Therapies • Individual and group counseling • Inpatient and residential treatment • Intensive outpatient treatment • Case or care management • Recovery support services • 12-step fellowship • Peer supports

17. What Can You Do to Prevent Opioid Misuse?

18. The Opioid Epidemic • Science has proven that Opioid Use Disorder is a chronic brain disease that can be managed with medical treatment • Medication-Assisted Treatment programs provide a safe and controlled level of medication to overcome the use of an opioid (SAMHSA)

19. Breaking the Epidemic: Approach • Primary Prevention: prevent new cases of opioid dependence. Education, outreach, community prevention programs, etc. • Secondary Prevention: provide interventions and ready access to treatment • Tertiary Prevention or Supply Control: law enforcement and medical board interventions to reduce over-prescribing and black-market availability. Relapse prevention to keep individuals from returning to active addiction

20. “EVERY PROBLEM HAS IN IT … THE SEEDS OF ITS OWN SOLUTION” - Norman Vincent Peale

21. An estimated • 2 MILLION • workers • are not in the labor force each year due to opioid abuse Workers with substance use disorders miss nearly 50% more work days than their peers – up to six weeks annually – and absenteeism leads to losses in productivity.

22. Breaking the Epidemic: Approach • Construction, entertainment, recreation and food service sectors have twice the national average of employees with SUDs. • Industries dominated by women or older adults had a two-thirds lower rate of substance abuse. • Industries that have higher numbers of workers with alcohol use disorders also had more illicit drug, pain medication and marijuana use disorders. National Safety Council, 2017

23. What Employers are Saying? • 32.5 million businesses in the US • 28.8 million small businesses in the US • 56.8 million employees. • Small businesses (defined as businesses with fewer than 500 employees) account for 99.7% of all business in the U.S. • Communities across the nation rely on small businesses for jobs, goods, services, and general economic well-being. US. SBA, 2017

24. Employers were most concerned about the costs of benefits (95%), ability to hire qualified workers (93%) and costs of workers' compensation (84%), but less concerned over drug misuse (67%) and illegal drug sale or use (61%). • Workers in recovery have lower turnover rates and are less likely to miss work days, less likely to be hospitalized and have fewer doctor visits. National Safety Council, 2017

25. How Employers Can Make a Difference? • Ensure that work is safe and working conditions do not lead to worker injury or illness, or contribute to painful chronic conditions. • Identify clinics that provide evidence-based treatment for injured workers, including the adherence to opioid prescribing guidelines. • Provide adequate leave and other benefits after workplace injury including flexibility in scheduling and receiving medical care, support during recovery, and return to work. • Take steps to manage workplace stressors and job insecurity to the extent possible. • Take steps to decrease the stigma associated with substance misuse through awareness building and supervisor training.

26. How Employers Can Make a Difference? • Educate workers about how drugs impair work activities, including driving, and encourage them to notify their employers if they are taking medications that may affect their ability to work safely so that a safe solution can be determined. • Develop and communicate clear drug-related workplace policies that include an offer of assistance to workers with OUD. • Offer comprehensive treatment options to workers with OUD, including healthcare coverage that provides MAT. • Work with health plan providers and pharmacy benefit managers to attend to inclusion of such coverage in employer health plans.

27. How Employers Can Make a Difference? • Employers should also consider the following steps when arranging services for their workers, or when working with others to select an MAT program or provider: • Ensure that the MAT program is licensed or certified by your state. • Verify that the MAT program offers FDA-approved medications to treat OUD. • Check if the provider can offer or refer for psychological, social, and family support in the treatment program. • Look for independent evidence that the program offers effective and proven treatment whenever possible [SAMHSA 2019].

28. How Employers Can Make a Difference? Among employers with a drug-free workplace policy, 43% also have a “first offense forgiveness” policy, which connects the employee to treatment rather than immediate termination after the individual’s first substance- use -related workplace incident. Ridgley L. Opioids in the Workplace. Survey Report. National Business Group on Health. https://www.businessgrouphealth.org/pub/?id=CC2C67F5-E2AD-87F6- 797E-9293C4EDB3CC. Accessed February 27, 2018.

30. Businesses Sharing Solutions

31. Businesses Combat Opioid Crisis Library

32. Employer & Employee Resources

33. State-Specific Resources

34. SAMHSA Locators for Provider Identification and Access to Opioid SUD Services http://dpt2.samhsa.gov/treatment/directory.aspx http://buprenorphine.samhsa.gov/bwns_locator/

35. SAMHSA Physician DATA Waivers http://buprenorphine.samhsa.gov/

36. Supporting Employees Employer drug misuse prevention and treatment initiatives are keeping employees and their families healthy and safe.

37. Supporting Employees • CEO pledge to take the stigma out of addiction (Roger Krone, Leidos) • Industry groups make construction safer (Construction Coalition for a Drug- and Alcohol-Free Workplace) • Rehabilitation costs covered by company (Belden) • Educating employees on signs of opioid misuse (The Hartford) • Opioid forum for employers (GE) • Training managers to stop drug abuse (National Association of Home Builders)

38. Supporting Employees

39. Changing Business Practices Companies in the healthcare pipeline are making operational changes to mitigate and prevent opioid misuse.

40. Changing Business Practices • Disposing unused medications safely (CVS Health) • Limiting excessive opioid prescriptions (Walmart) • New clinics for individuals with SUD (BCBS)

41. Anthem’s Response to the Epidemic • With over 74 million people served by its affiliated companies, Anthem is taking a leadership role in addressing the epidemic by supporting prevention, treatment, recovery, and deterrence. • Reached the company’s collective goal of reducing prescribed opioids filled at pharmacies by 30% since 2012 – 2 years earlier than the initial goal. • Anthem will double the number of consumers who receive MH and SUD services as part of Medication-Assisted Therapy (MAT) for opioid addiction by 2019.

42. Anthem’s Response to the Epidemic • Preventing Unnecessary Prescribing & Overprescribing of Opioids • Aligned pharmacy benefit management strategies with CDC Guideline for Prescribing Opioids for Chronic Pain • Short-acting: Initial prescriptions limited to 7 days: Maximum of 14 day supply • Long acting: Prior authorization • Pharmacy Home Programs • One Pharmacy and/or One Provider

43. Anthem’s Response to the Epidemic • Supporting Early Identification, Treatment and Recovery • Removed prior authorization MAT (oral & sublingual) • No prior authorization for Naloxone • Improving MAT access in rural and underserved areas through MD recruitment & training to achieve 1 MAT trained MD in each primary care practice • Extending availability of care & treatment via telehealth services • Partnering with NICU facilities for newborns with NAS • Focusing on non-opioid pain management

44. Anthem’s Response to the Epidemic • Strategies to identify and address instances of opioid waste, fraud, and abuse, as well as diversion including: • Monitoring of claims for potential fraudulent or abusive behavior • Data mining for top prescribers • Review of pharmacies when identified for high volume dispensing of controlled substances • Monitoring cases of potential “doctor shopping”.

45. Applying Core Competencies Business are using their resources, expertise, and relationships to create solutions to combat the opioid epidemic.

46. Applying Core Competencies • Cutting edge treatment for all (Optum) • Public private partnership engages students (Discovery Education & Drug Enforcement Agency) • Bringing together people from nonprofits, business, government and health care (Amazon Web Services (AWS) Opioid Crisis Council) • Opioid response center for business (Kentucky Chamber Foundation)

47. Engaging Communities Corporate philanthropic efforts and community relations programs enable partnerships that support drug misuse prevention and treatment.

48. Engaging Communities • Helping local groups through philanthropy (AmerisourceBergen) • Training to staffers at libraries and Ys on recognizing overdose & naloxone administration (Adapt Pharma; Emergent Solutions) • Social media (Facebook)

49. Suggest a Resource or Business Story

50. “It always seems impossible until it’s done” - Nelson Mandela