Sober, clear-headed workers can mean life or death on a construction jobsite.

So last month’s recommendations from the Food and Drug Administration for more restrictions on hydrocodone-containing painkillers is good news for construction employers and workers: the FDA wants to upgrade hydrocodone’s status from a schedule 3 narcotic—the classification for low-dose codeine-containing drugs—to a schedule 2 narcotic, the category for methadone, hydromorphone, and fentanyl.

The new status would reduce the number of refills allowed before checking in with a doctor. It would require patients to bring prescriptions to a pharmacy in person rather than the doctor calling it in.

“It becomes a big issue for workers’ compensation insurance because hydrocodone is the number one product prescribed for an injury,” says John Malley, a senior vice president in health and benefits consulting at Aon Hewitt, Chicago, Ill.

“I don’t think the medical community and government had been dialed into the level of abuse until recently,” he says.

Experts agree that many workers first encounter opioid painkillers in the emergency room or at a primary care physician’s office.

According to Kim Ferris, senior utilization review nurse at FutureComp of USI Insurance Services, West Springfield, Mass., injured workers who go to their primary care physicians for treatment instead of to an occupational health specialist are more likely to be prescribed an opioid painkiller without a medical history review or psychological evaluation.

These painkillers are highly effective and highly addictive. While research does not show how likely a worker is to continue abusing opioids after returning to work, a Workers’ Compensation Research Institute study of narcotic use between 2006 and 2008 found that in New York, 15% of injured workers who received narcotics in the first quarter after the injury were still receiving them almost two years later.

Workers’ compensation laws in many states permit physicians to dispense medications directly to patients.

Physician dispensing “is a newer development within the last five years or so, and this is a problem that is exclusive to workers’ compensation,” says Mark Walls, workers' compensation research leader for broker Marsh. “There were loopholes in workers’ compensation statutes that some people chose to exploit.”

“The government has looked to pharmacies for intervention” on opioid prescribing, “but they are not in a position to question a physician; they’re covered from a malpractice and moral side,” says Malley.

Physician dispensing is one cause of the increasing prescription costs in workers’ compensation systems, especially when it comes to opioid prescriptions. For example, a study by the WCRI shows that a pill of hydrocodone covered by workers’ compensation in Maryland cost, on average, 37 cents when purchased from a pharmacy and $1.46 when purchased at a physician’s office dispensary.

In Iowa, the cost of hydrocodone from a physician’s office dispensary has increased, on average, 32% per year since 2008. It now costs $1.37 on average per pill from a dispensary, versus an average of 50 cents per pill from a pharmacy—the same price since 2008.

Federal prescription reform was intended to be part of Pres. Barack Obama’s Affordable Care Act, particularly provisions that would have allowed for the importation of prescription drugs at lower prices from Canada. However, such provisions drew opposition from the domestic pharmaceutical industry and e-mails published by the New York Times indicate that they were abandoned in order to gain the industry’s support.

Experts have plenty of advice for employers who want to help cut workers’ compensation costs and prevent opioid abuse. Ferris, who has worked as a workers compensation nurse for a decade, recommends that workers seek treatment at a designated occupational health facility because of the lower likelihood of receiving an unnecessary narcotics prescription.

Marsh’s Walls adds that employers should focus on accident prevention and getting people back to work, “on things that they can work on with their carrier or their third-party administrator to help control the cost of the claims that they have.”

How would employers know a worker was taking a drug like hydrocodone?

“For a contractor or employer, the only way of controlling [opioid abuse] is random drug testing like the [National Football League],” suggest Malley.