The workers compensation sector’s decade-long push to reduce opioid prescribing has sharply curtailed use of the drugs. The harder task, though, is determining whether changes in pain treatment are helping injured workers recover and return to work while avoiding new risks and costs.

Ten years after the Centers for Disease Control and Prevention issued its first opioid prescribing guideline, insurers and claims administrators have expanded pharmacy reviews, nurse case management and treatment options ranging from physical therapy to behavioral care.

Pain “has been and will continue to be a central part of an injured worker’s journey,” said Jon Sinclair, Boca Raton, Florida-based executive director and actuary for the National Council on Compensation Insurance, which found that pain management treatments account for about 30% of annual medical costs in workers comp.

“The way pain is treated has changed … (but) no single pain treatment has replaced opioids,” he said. “Instead, there is now a wider variety of treatment options used, including physical therapy and increased use of topical medications.”

Pain management matters because it affects recovery and a worker’s ability to return to the job, ultimately influencing claim costs, said Ramona Tanabe, president and CEO of the Workers Compensation Research Institute. Differences in opioid prescribing across states prompted WCRI’s early research, and changes in prescribing rules, guidelines and utilization management have given researchers further areas to examine, she said.

Prescription data illustrates the shift. In Enlyte’s analysis of retail and mail-order pharmacy transactions billed through its workers compensation pharmacy benefit management program, opioids accounted for 19.8% of prescriptions in 2025, down from 30.1% in 2016. Average daily morphine-equivalent dose per opioid prescription declined 35.6% over the same period.

Whether those changes consistently translate into better recovery is harder to establish. Workers who have taken opioids for years also continue to pose some of the most difficult treatment decisions (see related story below).

Measuring recovery

Regulations have helped reshape prescribing practices. Sixteen states have drug formularies for injured workers, according to WCRI, and many states have prescribing limits or controlled-substance tracking.

The number of states with laws limiting opioid prescribing or dispensing rose from 10 in 2016 to 39 by the end of 2019, according to a study published in Addiction in 2021.

The CDC’s 2016 guideline focused on primary care prescribing for chronic pain outside active cancer treatment, palliative care and end-of-life care. Its recommendations were voluntary, although governments and payers incorporated opioid controls into their own policies. The agency’s 2022 update expanded its scope to acute, subacute and chronic pain in adult outpatients and warned against treating dosage guidance as rigid limits or abruptly discontinuing treatment.

That distinction remains important in claims handling, experts say.

 

Some administrative processes have been slower to move away from hard authorization thresholds, said Dr. Scott Cherry, Houston-based chief medical officer of Axiom Medical. Clinical recommendations can become inflexible coverage decisions when an individual worker’s circumstances receive insufficient attention, he said.

Maintaining the controls that reduced inappropriate prescribing remains essential, said Joe Paduda, Skaneateles, New York-based president of CompPharma.

“What needs to be done is continue to focus on the programs and processes and clinical approaches that have been successful in the past,” he said.

The challenge is extending that oversight to assess what happens after an opioid is avoided or reduced, experts say.

The industry has stronger evidence of declining opioid use than of corresponding improvements in return-to-work rates, Dr. Cherry said. Employers should examine disability duration by diagnosis and compare outcomes across treatment approaches.

“The most important thing is function in each injured employee,” he said.

Success increasingly includes faster return to work, lower total claim costs and better outcomes for injured workers, said Michael MacAulay, Mount Laurel, New Jersey-based president of Lodestar Claims & Risk Services.

“Effective pain management is about balancing recovery and function and safety,” he said.

That can mean accepting higher treatment costs initially, said Emily Drew, Boston-based president and CEO of Helmsman Management Services, Liberty Mutual Insurance’s third-party administrator. Physical therapy may cost more than a prescription, but an earlier return to work and less time receiving indemnity benefits can change the overall result, she said.

“You also have to look at something other than pure cost,” Ms. Drew said.

Scrutinizing alternatives

Lower opioid spending has not eliminated pharmacy cost pressures.

Prescription payments per medical claim increased in most of the 31 states examined by WCRI between the first quarters of 2022 and 2025, even as per-claim opioid payments continued to decline in nearly all study states. The study examined prescriptions filled within three years of injury on non-COVID-19 claims.

Dermatological agents accounted for 23% of prescription payments in the median state in early 2025 and more than 30% in 12 states. Physician dispensing and delivery pharmacies accounted for more than 70% of dermatological payments in 20 states.

The search for opioid alternatives has created opportunities for effective treatments, but also expensive variations of existing products, said Nikki Wilson, Omaha, Nebraska-based senior director of clinical pharmacy services for Enlyte.

Topicals can be appropriate when supported by evidence and indicated for the condition, she said. Her concern is products that command higher prices without offering additional clinical value, including new strengths of familiar drugs such as ibuprofen and gabapentin.

“If you’re going to have a new drug, make sure it’s got efficacy,” she said.

The same scrutiny should extend to how alternatives are combined. Replacing an opioid with separate prescriptions for pain, muscle spasms, sleep and anxiety can leave a worker with several medications requiring close review, said Scott Westman, Jacksonville, Florida-based senior vice president and chief claims officer of Lodestar.

Those prescriptions must be considered alongside medications taken outside the claim, he said.

Regular contact with workers and prescribers can also identify treatments that continue without a clear need, said Mina Nakhla, Philadelphia-based assistant vice president of pharmacy and ancillary programs for Gallagher Bassett. A worker receiving topical medications, for example, may no longer be using them, while long-term use of other drug classes warrants reassessment, he said.

Coordinating care

Closer coordination among providers can sometimes simplify treatment.

For workers with nerve pain and depression, pharmacists may discuss with the pain provider and psychiatrist whether one medication could address both conditions, said Andrew Newhouse, Rochester, Michigan-based director of clinical pharmacy for Sedgwick.

“We’re treating the workers more as a whole versus just focusing on opioids,” he said.

That requires recognizing the psychological effects of an injury, including the loss of self-worth that can accompany being unable to work, Mr. Newhouse said.

Historically, concerns about accepting an additional condition on a claim have made behavioral and psychological issues uncomfortable territory for insurers, said Jen Laabs, Merrill, Wisconsin-based claim director, workers compensation, for Church Mutual Insurance. Those concerns should not prevent attention to factors affecting recovery from the work injury, she said.

Even workers with similar physical injuries may need different support. An underlying condition or responsibilities such as caring for a disabled child can affect the treatment experience, said Taylor Kostroski, Church Mutual’s Merrill, Wisconsin-based senior nurse case manager for workers comp.

“Health care is so hard to navigate, and then you add the complexity of workers comp, and it gets even scarier for so many claimants,” she said.

Education and advocacy help workers understand their choices and participate in treatment, Ms. Kostroski said.

Identifying those needs earlier is a priority for claims administrators. Predictive models can flag claims with potential for prolonged disability, chronic pain or excessive pharmacy use, Mr. MacAulay said.

At Helmsman, the tools deliver relevant information to adjusters who may be managing more than 100 files, helping them identify claims that need closer attention, Ms. Drew said. The purpose is to prompt consultation or connect a worker with appropriate resources sooner.

The models already exist, but the industry needs to do more with the information they provide, Mr. Westman said.

“We have to do a better job as an industry trusting that data, right, and acting on it,” he said.

For employers, support can begin with a supervisor’s early check-in to help maintain a worker’s connection to the workplace without probing medical details, Dr. Cherry said. Case managers can coordinate that contact and bridge gaps between the worker, employer and treating providers.

Those relationships matter as much as prescription decisions, he said. The continuing task is helping the person receiving care recover and return to daily life.

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Tapering drug use requires individualized approach for best outcomes

Reducing opioid prescribing for newly injured workers has helped the workers compensation sector avoid some long-term treatment problems, but claimants who have taken the drugs for years often need a slower, more individualized approach.

These legacy claimants may have persistent pain, have undergone multiple surgeries and have medication regimens that were established before today’s prescribing controls. Their care can require coordination among treating physicians, pain specialists, pharmacists, nurses and behavioral health providers.

Long-term opioid use can lead to physical dependence, but dependence alone does not establish addiction or opioid use disorder, according to the Centers for Disease Control and Prevention.

Many older claims began with high opioid doses, and some workers have reduced their use without being able to discontinue treatment, said Andrew Newhouse, Rochester, Michigan-based director of clinical pharmacy for Sedgwick.

“Overall, we may not be able to get them completely off the opioids, but can we get them to the next lower level if they’re doing better?” he said.

As workers age, medications for conditions such as diabetes or high blood pressure can complicate existing treatment, Mr. Newhouse said. Alternatives also require review for potential adverse effects and interactions.

Treatment changes should begin with understanding why the worker remains in pain, said Dr. Frank Tomecek, Tulsa, Oklahoma-based medical director of Precision Motion Health and a neurosurgeon.

“Pain is not a diagnosis, it’s a symptom,” he said.

Persistent symptoms after back surgery, for example, may warrant evaluation for an unresolved or new structural problem. Other patients need specialist management of chronic pain, alongside physical reconditioning and other care, Dr. Tomecek said.

Ending coverage abruptly before another treatment is available can leave workers without support, said Dr. Scott Cherry, Houston-based chief medical officer of Axiom Medical.

“You really don’t want to stop one treatment before the next treatment is scheduled,” he said.

The treating provider should direct the treatment plan, claims staff should arrange timely authorizations and case managers should coordinate the transition, Dr. Cherry said.

The CDC’s 2022 guideline advises against abrupt discontinuation or rapid dose reductions unless there is a life-threatening concern. Tapering should reflect the patient’s circumstances and may take months or years.

The agency also recommends weighing the risks of tapering against those of continued treatment and integrating behavioral and nonopioid pain therapies.

Older claims often need more frequent reviews, nurse involvement and education because workers may be afraid to try another treatment, said Mina Nakhla, Philadelphia-based assistant vice president of pharmacy and ancillary programs for Gallagher Bassett.

“I think a lot of them are too afraid to try anything else,” he said.

The difficulty of changing established treatment reinforces the importance of early intervention, said Nikki Wilson, Omaha, Nebraska-based senior director of clinical pharmacy services for Enlyte.

“Once the patient has been on it for a number of years, it is really challenging to try to turn the ship once it sets sail,” she said.

For those already receiving long-term treatment, improved daily functioning may be a more useful immediate goal than complete discontinuation, Mr. Newhouse said. Reviewing medications, supporting activity and reassessing what helps remain ongoing responsibilities.