What to do when a claimant presents with medication dependency
Managing substance use disorder and medication misuse on insurance claims
Published: 3 April 2026 | Updated: 3 April 2026
The dependency challenge
A claimant started on opioids for legitimate pain management. Over months or years, their relationship with the medication changed. They're now seeking medications more frequently than prescribed. They've lost pills or run out early. They're doctor shopping to obtain additional supply. Their treating doctor thinks they have a dependency problem but isn't sure what to do. Your concern has shifted from managing pain to managing an emerging substance use disorder.
Medication dependency on claims is a clinically complex and emotionally charged issue. The claimant started with a legitimate injury and legitimate medication. The dependency that developed wasn't necessarily their intention. But the fact remains: they're now dependent on medications in ways that are harming them and significantly increasing your claim liability. You need a clear strategy to address it.
Medication dependency isn't a moral failing or something to be punished. It's a clinical problem requiring a clinical solution. Your role is to identify it, understand its drivers, and work with the treating team to establish a structured management approach that protects the claimant, manages the claim, and addresses the underlying dependency.
Key understanding: Medication dependency on claims is typically iatrogenic (caused by medical treatment). It requires compassionate management within a structured clinical framework, not blame or punishment.
Step 1: Recognise the signs of medication dependency
Medication dependency can look different depending on which medication is involved and the claimant's behaviour. Know what to watch for:
| Red flag behaviour | What it suggests | Action needed |
|---|---|---|
| Claimant reports lost or damaged scripts; early refills requested repeatedly | Possible non-compliance with intended dosing or diversion | Request full pharmacy record; investigate pattern of early refills |
| Claimant sees multiple doctors for the same medication or similar medications | Seeking additional supply beyond prescribed amount | Cross-reference prescribers via prescription monitoring program |
| Claimant becomes distressed or aggressive when medication is delayed or changes are suggested | Medication has become central to their emotional regulation | Refer for clinical assessment of psychological dependency |
| Pain reports escalate when claimant isn't granted medication requests | Pain reporting may be driven by medication-seeking rather than actual pain changes | Seek independent pain assessment |
| Claimant reports withdrawal symptoms or increased symptoms if medication is delayed even slightly | Physical or psychological dependency has developed | Refer for medical assessment of withdrawal risk |
| Medication use continues despite documented harm to employment, relationships, or health | Dependency has become primary driver of medication use | Urgent assessment needed; consider structured management plan |
The key distinction: dependence is physical adaptation to a medication. Addiction is compulsive use despite harm. A claimant might have physical dependence without addiction. But if they're actively seeking additional medications despite harm, or if medication use is impacting function and relationships negatively, addiction may be present.
Step 2: Refer for specialist assessment
If you suspect medication dependency, don't manage it yourself. This requires specialist assessment. Refer the claimant for assessment by a doctor experienced in substance use disorder, or by a medication review pharmacist experienced in dependency management. What you're looking for is:
- Confirmation of whether dependency exists and what type (physical, psychological, or both)
- Assessment of the original clinical need for the medication versus current dependency driver
- Evaluation of whether the claimant can safely reduce or stop the medication
- Recommendations for a structured management approach
- Advice on what level of monitoring and support is needed
Be explicit with the specialist about your concerns. Say something like: "I'm seeing early refills, multiple prescribers, and escalating requests. The claimant started on legitimate pain management, but I'm concerned medication dependency may have developed. Can you assess this and advise on appropriate management?"
Step 3: Understand the causation question
When a claimant develops medication dependency during their claim, a critical question arises: is the dependency a compensable injury consequence, or is it a separate issue? This question affects how you manage the claim going forward.
In most cases, if a claimant received legitimate medications for a compensable injury and subsequently developed dependency on those medications, the dependency is causally linked to the injury and its treatment. That doesn't mean you pay for unlimited medication use. It means the dependency is an injury-related complication that requires appropriate clinical management as part of the claim.
However, there are situations where dependency isn't directly injury-related. If the claimant has pre-existing substance use disorder that has been activated or exacerbated by injury-related medications, that's a complicating factor but doesn't necessarily remove your obligation to manage the claim. If the dependency is clearly driven by medication-seeking unrelated to pain management, that's a different issue. These distinctions matter for how you structure your response.
Step 4: Develop a structured dependency management plan
Once you've confirmed medication dependency, work with the treating team to develop a structured management plan. This plan should include:
Essential components of a dependency management plan
- Single prescriber and single pharmacy: Consolidate all prescribing to one responsible doctor and dispensing to one pharmacy. This eliminates opportunities for doctor shopping or duplicate acquisition.
- Documented treatment agreement: The claimant signs an agreement understanding the management approach, the reasons for it, and the expectations for compliance.
- Regular monitoring: Specify frequency of monitoring (typically monthly or more frequently initially), what will be monitored (urinalysis, medication counts, pharmacy records), and consequences of non-compliance.
- Clear medication protocol: Document exactly which medications are approved, dose, frequency, and when the plan will be reviewed.
- Gradual reduction timeline: If the goal is to reduce dependency, establish a realistic timeline with specific dose reduction milestones and monitoring points.
- Support services: Identify what supportive services will be in place (counselling, psychology support, addiction specialist input) to help the claimant manage reduction.
- Review points: Specify when the plan will be formally reviewed and what indicators would trigger plan modification.
This isn't punishment. It's creating a structure that helps both the claimant and the claims team manage a difficult situation. Many claimants with medication dependency actually appreciate having clear, explicit structure. It removes ambiguity and provides a pathway forward.
Step 5: Address the underlying pain or function issue
Medication dependency often persists because the claimant still has legitimate pain or dysfunction that the medication was originally managing. You can't simply remove the medication without addressing what it was treating. Your management plan should include:
- Assessment of current pain levels and whether they're genuinely elevated or medication-seeking-driven
- Non-medication approaches to pain management: physiotherapy, exercise, psychology support
- Evaluation of whether the original injury still warrants pain medication or whether dependency has become the primary issue
- If pain reduction is part of the plan, coordination with treating team on how that will be approached
Often, claimants with medication dependency will resist deprescribing because they're convinced they can't function without it. Sometimes that's true; sometimes it's dependency talking. A structured approach with medical oversight helps distinguish between the two. If the claimant reduces medications gradually with proper support and function improves rather than declines, that's valuable information that the dependency had become the primary driver.
Step 6: Monitor for compliance and progress
Once a management plan is in place, monitoring is critical. Specify what you're monitoring and how frequently:
| Monitoring element | Frequency | What you're assessing |
|---|---|---|
| Pharmacy records | Monthly | Is claimant filling prescriptions on time? Are there gaps suggesting stockpiling? Any early refills? |
| Prescription monitoring program | Quarterly | Are there scripts from other prescribers or medications not in the plan? |
| Treating doctor report | Every 4-6 weeks initially, then quarterly | How is the claimant doing? Are they compliant with the plan? Any concerns about progression or regression? |
| Urine drug screening | As specified in plan (often monthly initially) | Is claimant taking medications as prescribed? Are there undisclosed substances? |
| Claimant interview | Every 2-4 weeks | How is claimant managing? Any withdrawal symptoms? Any difficulty complying with plan? |
Document compliance clearly. If the claimant is adhering to the plan and progressing (gradually reducing medications, improving function, engaged in support services), document that. If there are breaches (additional scripts from other doctors, early refills, positive urine tests for undisclosed substances), document those too. This record is important if the claim later deteriorates or if you need to escalate management.
Specific dependency scenarios
Opioid dependency
Opioid dependency on claims is increasingly common. Management involves consolidating prescribing, establishing clear dose protocols, regular monitoring, and supporting gradual dose reduction if appropriate. Some claimants may require opioid maintenance therapy long-term; others can successfully deprescribe. The management plan should clarify which is being pursued and why. Involve pain management and addiction medicine specialists if possible.
Benzodiazepine dependency
Benzodiazepine dependency is particularly challenging because withdrawal can be dangerous. Never attempt rapid benzodiazepine reduction without medical oversight. Management involves establishing exactly what dose the claimant is taking (through pharmacy records and supervised baseline assessment), then very gradual reduction (typically reducing by 5-10% per week to monthly, depending on duration of use and dose). Psychological support is critical because benzodiazepine withdrawal includes significant anxiety and mood symptoms.
Combination dependency
Some claimants are dependent on multiple medications: opioids, benzodiazepines, and possibly other sedating agents. This is the most complex scenario. Reduce only one medication at a time. Typically, one medication is identified as the priority for reduction, while others are maintained at stable doses during the initial reduction phase. After the first medication is stabilised at a reduced dose, then consider reducing the second agent.
Addressing non-compliance
If a claimant breaches the management plan (obtains medications from other doctors, runs out of medication early, tests positive for undisclosed substances), respond promptly but proportionately. Minor first breaches might warrant a conversation and reminder of the agreement. Repeated or significant breaches require escalation.
Escalation might involve: increasing monitoring frequency, involving psychology or addiction specialist, referral to a substance use disorder program, or in serious cases, requiring that all medications be prescribed by a specific doctor and dispensed by a specific pharmacy with restrictions on early dispensing. In extreme cases, you may need to consider whether the claimant's management is compatible with continued unrestricted medication access.
Summary: Your action plan
When you suspect medication dependency, refer for specialist assessment. Confirm the dependency and understand its drivers. Develop a structured management plan with single prescriber, single pharmacy, clear medication protocols, monitoring, and support services. Address the underlying pain or function issue. Monitor compliance actively. Distinguish between physical dependence (adaptation) and addiction (compulsive use despite harm), and manage each appropriately. Be compassionate but firm about structure and accountability.
Medication dependency on claims is challenging but manageable when approached systematically. The key is early identification, specialist input, clear structure, and ongoing monitoring. With these in place, many claimants can either stabilise on appropriate medication or successfully reduce and move toward independence from medication.
Medication dependency requires expert clinical management
IMM's pharmacists are experienced in identifying and managing medication dependency on insurance claims. We develop structured dependency management plans, provide monitoring oversight, and support claimants through gradual medication reduction when appropriate. Our approach balances compassion with clinical accountability.
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