Substance Use Disorders and Mental Health

Substance Use Disorders and Mental Health

The mind and body are inextricably linked – both suffer and drive costs when patients are not receiving the support and resources that they need. The connection between mind and body is illustrated by the following proof points:

  • 35 percent of Americans with physical illness also have mental health disorders.1
  • Nearly 70 percent of adults in the United States with mental illness also have physical illness.2
  • 30 percent of adults in the United States with a chronic health condition also have symptoms of depression.3

In light of this connection, we are committed to finding novel ways to encourage customers experiencing stress, anxiety, depression, loneliness, or substance use disorders (SUDs) to connect with their health care providers and to build resiliency.

Removing Stigmas and Creating Necessary Dialogue on Mental Health

Cigna was an early leader in viewing physical health and mental health holistically. In 2020, we strengthened our commitment to behavioral health through our transformative model of health care, which elevates whole person health and puts the patient at the center.

Our approach to addressing whole person health has become even more important: With COVID-19, it is critical for both individuals and businesses to understand the connection between physical and mental health. At present, one in four Americans has struggled with depression since stay-at-home orders; 47 percent feel lonelier due to social isolation and fewer social interactions; 30 percent have developed generalized anxiety disorders; and two times more Americans in 2020 said they considered suicide than did in 2018.4,5,6

Americans need help with behavioral health support

Case Study: Helping Employees and Employers Navigate Caregiving

In 2020, Cigna explored the impacts of caregiving on employees and employers. This is particularly relevant as COVID-19 has turned many employees into caregivers. Our research showed that 30 percent of American adults care for a sick or disabled relative and 20 percent of these individuals are employees.1,2

Extraordinary times now more than ever

1 in 4 struggles with depression since stay-at-home orders

47 percent feel lonelier due to social isolation and fewer social interactions

30 percent have develop generalized anxiety disorders

2x more people in 2020 said they considered suicide than did in 2018

Our approach to support workplace health and well-being, called Health Accelerated: Life ConnectedSM [PDF], is a way for us to help clients and their employees by addressing their whole health needs. Leveraging the Health Accelerated: Life Connected approach, we can help drive better health, greater resiliency, and increased productivity by looking at the following five dimensions of well-being:

  • Physical Health: Putting Fitness and Nutrition at the Forefront
  • Emotional Health: Coping with Stress
  • Environmental Health: Improving Creativity
  • Financial Health: Prioritizing preparation and Peace of Mind
  • Social Health: Staying Connected and Engaged

Talking About Loneliness and its Root Causes

Loneliness is a rising public health problem in the United States.7 Research shows that chronic loneliness leads to poorer health outcomes.8 It has been correlated with increased risks for diabetes,9 heart disease,10 depression,11 suicide, substance use disorders, and even dementia. It is as deadly as smoking 15 cigarettes a day.12 As such, improving people’s sense of connection to others will improve their overall health and functioning. In 2018, Cigna released results from a groundbreaking national survey exploring the impact and the potential underlining root causes of loneliness in the U.S. The survey of more than 20,000 U.S. adults age 18 and over, conducted in partnership with market research firm Ipsos, revealed that most American adults are considered lonely, and that the youngest generation of adults is the loneliest of all.

Cigna’s 2020 Loneliness Index showed that America’s loneliness epidemic is getting worse, with three in five adults (61 percent) reporting they are lonely, a seven percentage-point increase from 2018. These results come against the backdrop of a rising mental health crisis in America, with more than 46 million people living with a mental illness.13 Importantly, because Cigna’s loneliness study was concluded by the end of 2019, the results of Cigna’s 2020 loneliness study did not account for the unprecedented isolation that occurred as a result of COVID-19. In response to the results of the 2020 Loneliness Study, Cigna is taking action to help communities across the country proactively reduce the risks of mental illness and improve mental well-being overall.

Understanding Resilience

In 2020, Cigna released the findings from the Cigna Resilience Index, the largest study of resilience in the U.S. to date. The study found that resilience was at risk for 60 percent of Americans.

Resilience, commonly defined as the ability to quickly recover from challenges, has was a key theme of 2020 and will be moving forward. The Cigna Resilience Index, developed in partnership with the Resilience Research Centre, evaluated two cohorts: school- and university-age communities (students age 5 - 17 and their parents, and young adults age 18 - 23) and the American workforce (age 18+).

Among the robust findings from the Cigna Resilience Index, the data shows that children entering their early pre-teen years (age 11 - 13) often experience a sharp decline in resilience that continues through age 23, with most acute levels of low resilience occurring between the ages of 18 and 23.

Results also show that only 37 percent of full-time workers have high resilience; that full-time workers with lower resilience are 16 times less likely to say that people like to spend time with them (95 percent versus 6 percent); and that workers with access to expanded mental health services are more likely to be resilient than those without access (48 percent versus 35 percent). Moreover, one-third of full-time workers (33 percent) and one-third of essential workers (32 percent) say they almost never have workplace discussions about the impact of COVID-19 on them, their families, and their mental health.

The consequences of low resilience can have lasting effects on people and businesses. Children with lower resilience are more likely to have lower self-esteem, perform worse in the classroom, have lower educational aspirations, and require treatment for a mental or behavioral health issue. In adult workers, low resilience has a direct impact on business outcomes because as it is correlated to lower job satisfaction, engagement, performance, and retention. Without the ability to cope with challenges, adults are also more likely to experience stress, anxiety, and depression and resort to negative coping strategies, such as social withdrawal or substance abuse.14,15

The results of the study prompted Cigna to launch GROW FORTH: A Cigna Approach to Building Greater Resilience as a free resource to help people learn more about the various aspects of improving resilience. Cigna also introduced a toll-free School Community Support Line within Miami-Dade County and Nashville school districts for the 2020 - 2021 academic year to help build resilience and improve well-being in students.

Cigna Takes Action

Cigna is combatting loneliness and helping people build resilience to improve mental health at home, in the workplace, and in our schools. Cigna is taking several steps, which include:

  • Redefining and broadening the services available to address and deliver support for mental health needs.
  • Expanding access to our comprehensive network of more than 170,000 behavioral health care providers who are dedicated to helping customers improve their well-being and navigate issues such as loneliness, stress, depression, anxiety, and addiction. Cigna is also creating preferred provider networks to target areas of the country where the behavioral provider industry faces a significant supply and demand issue.
  • Committing to uncover and understand how factors such as loneliness can impact stress, so that we can develop solutions to address these factors holistically.
  • Making it easier and quicker for customers to connect with mental health specialists virtually through our own broad network of 18,000 virtual providers, and schedule appointments online through MDLIVE®16, an Evernorth℠ business. Virtual care helps customers overcome stigmas as well as scheduling and accessibility barriers, while giving people peace of mind, privacy, and convenience.
  • Creating a path forward for future generations, Cigna is partnering with clients and school districts in select areas to provide a School Support Line for junior high or high school (grades 7–12) students, staff, and parents for the 2020–2021 school year. The dedicated phone line is provided at no charge and is staffed by Cigna advocates who are trained in how to interact with students, parents, and staff.
  • The Cigna Foundation committed $3 million over three years in 2019 to support mental health well-being in schools, as part of our broader $25 million dollar initiative, Healthier Kids for Our Future®.

Our Efforts to Combat the Opioid Epidemic

Achieving Our Target to Reduce Opioid Use

In 2016, we committed to reducing opioid use among our customers by 25 percent in three years. We met our target ahead of schedule by partnering with over one million prescribing physicians as well as dentists, pharmacists, advocacy groups, employers, and regulators to change overprescribing patterns and reduce prescribed opioids to customers. Our engagement with these key stakeholders early on helped us to identify near- and long-term approaches that increased safeguards in the opioid prescribing process, enhanced support and counseling, and made it easier for patients and customers to access treatments for SUDs.

Target to Combat Opioid Overdoses

In response to the increase in overdose deaths, in 2018 Cigna set a goal to reduce overdoses among our customers in targeted communities by 25 percent by 2021.

To meet our 2021 overdose reduction goal, our initial focus has been on targeted U.S. communities where a sizable number of Cigna customers reside and where there are higher incidences of overdose. These communities include Connecticut, Maryland, New Jersey, Virginia, Chicago, New York City, Philadelphia, and Washington, D.C. We are using a multifaceted approach to achieve our new target, including identifying and managing opioid use; providing chronic pain support for those who are suffering; intervening through connective care coordination; and collaborating with stakeholders who can help us drive positive change.

Over 81,000 drug overdose deaths occurred in the United States in the 12 months ending in May 2020, the highest number of overdose deaths ever recorded in a 12-month period – 38 percent higher than the previous 12 months.17 Although overdose deaths were already increasing prior to COVID-19, the numbers from spring 2020 suggest an acceleration of overdose deaths during the pandemic.

Prior to COVID-19, we were on track to meet this target. In 2020, we continued to be on track in our target markets as opioid overdoses were down 18 percent vs. our 2018 baseline. That said, our customers are facing the isolation and economic uncertainties that people all over the country are facing -- factors that are accelerating opioid abuse and overdose trends.18 We are continuing to work hard to improve the care of customers at risk due to opioids, and we believe that we can still hit our target, but there is risk from the pandemic that may impact our ability to reduce overdoses 25 percent by the close of 2021.

Interventions and Advocacy to Prevent Opioid Use and Abuse

Identifying At-Risk Customers and Providing Interventions

Cigna uses a variety of methods to identify customers who may be at risk for substance use disorders, such as behavioral assessments during chronic health and other coaching sessions; predictive analytics driven by our medical, behavioral, and pharmacy data; and hospital or treatment facility admittance, which triggers a notification that we quickly act on to ensure effective ongoing treatment after discharge. Our pharmacy benefit manager (PBM) plays a key role in the company’s efforts to help clients guard against opioid misuse. Express Scripts’ Advanced Opioid Management monitors and measures consumption, stepping in with first-time-user education and controls; reviewing for appropriate use; reducing patients’ quantity on hand through utilization management, safe disposal, and prescriber alerts; deploying our behavioral health experts to quickly support our customers in need; and collaborating with. In September 2019, we enhanced the program with added utilization management touchpoints and functionality, staying current with evolving market needs. As a result of our continued work in this area, which includes the distribution of 3.2 million member education letters on opioids and the distribution of specialized disposal bags, we facilitated the disposal of 33.5 million pills and prevented 4.5 million days’ worth of opioid pills from being dispensed as of the end of 2020. Additionally, we achieved a 55 percent reduction in average day supply of short-acting opioids per claim for first-time opioid users and a nearly 92 percent success rate in limiting first-time adult opioid users to a 7-day supply (or less) of short-acting opioids.

We are also working to prevent opioid abuse affecting the pediatric patient population that we serve. With our enhancements, we achieved a 91 percent success rate in limiting first-time pediatric opioid users to a 3-day supply (or less) of short-acting opioids.

Providing chronic pain support to patients is another tool that we are using to reduce opioid prescribing and overdoses. One in five people in the U.S. is living with chronic pain.19 By reviewing data across benefits, we are identifying customers who may be struggling with daily pain and letting them know about support programs, including our integrated pain case management and our comprehensive pain management programs. Cigna’s integrated pain case management program is made up of trained case managers who counsel customers on pain management options other than opioids, such as physical therapy and behavioral health. Our comprehensive pain management program equips primary care providers (PCPs) with evidence-based resources and tools to manage the complex needs of customers with back pain. PCPs leverage guidelines for when to refer customers to pain providers, physical therapy, and behavioral health care in the community, including selecting preferred pain management specialists. We are also reducing overdoses through five intervention models:

  • Substance Use Coaching Program: A team of case managers who specialize in SUDs follow and support patients through their recovery journey. The program encourages behavioral changes and necessary first steps, such as outpatient treatment at a designated substance use treatment provider. It also includes care coordination with PCPs.
  • Pharmacy Oversight Intervention: When pharmacy or other interventions identify a customer who may be struggling with opioid use disorder, we bring in our behavioral team as well as care coordination assistance to listen and provide education.
  • Predictive Overdose Model: Using proprietary algorithms and integrated pharmacy, medical, and behavioral health data, we leverage our predictive analytic capabilities to identify patients at highest risk of overdose in the next 30 days. Representatives from our behavioral health team then actively reach out to these customers to intervene with connections to counseling and other local support. The model uses integrated claims data and analytics to detect opioid use patterns that suggest possible misuses that may lead to overdose within the next 30 days.
  • Medication-Assisted Treatment (MAT): Prescribed by a medical or behavioral provider, MAT can include a combination of therapy and medications to help those identified with opioid use disorder. We have increased our network by more than 66 percent since 2017 and waived prior authorizations for Cigna Pharmacy customers.
  • Virtual Access: Created specifically for patients who are living in low-access areas or who may not be willing or able to seek in-person care or professional counseling, such as during a natural disaster or the COVID-19 pandemic, this intervention is particularly effective because it meets patients where they are. We’re working to provide models of care that consist of complete substance use treatment programs that are almost entirely virtual.

Driving Change through Advocacy

To fight opioid overdoses we are also teaming up with stakeholders with a mutual interest in driving positive change. We have engaged prescribers since the start of the epidemic and are continuing to expand this relationship. We offer providers data, tools, and support to help them deliver effective care. High-risk alerts go out annually to 145,000+ prescribers whose patients have a hazardous pattern of opioid prescription use, and providers are notified when their patients reach a high daily narcotic potency level to help with intervention and pain management options. We also partner with Centers of Excellence (COE), which are Cigna-contracted behavioral facilities that have earned top rankings for patient outcomes and cost efficiency based on our methodology. Additionally, we are working closely with communities to fight opioid overdoses. Over the last five years, we have donated more than $400,000 to Shatterproof™, a nonprofit organization committed to giving those living with addiction, and their families, resources and information to overcome addiction. We are also part of Shatterproof’s Substance Use Disorder Task Force.

Cigna is also advocating for policy solutions at state and federal levels that advance prevention and optimal treatment. We are partnering with policymakers to modernize the sharing of addiction treatment records, which will allow providers to treat substance use disorders in a coordinated way, like other chronic diseases. We are also working with policymakers to provide health plans access to state prescription drug monitoring programs (PDMPs). PDMPs collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by pharmacies and practitioners. Access to PDMPs would greatly enhance the ability of regulators, providers, pharmacies, and insurers/health plans to monitor and manage opioid utilization. Additionally, we are working with policymakers to expand Medicare coverage for alternative pain treatments. Coverage of alternative pain treatments and therapies could reduce demand for opioids to address chronic pain. We are also pushing to expand coverage for the full range of substance use disorder treatment levels. Lastly, we are collaborating with researchers in the hopes of uncovering new insights and evidence-based treatments.

Our opioid-reduction strategy is continuing to evolve. We are continuing to aid at-risk populations through support mechanisms, care coordination, and integrated contracting strategies; going deeper locally; focusing support for clients and caregivers; and issuing earlier notifications to enable more timely care coordination.

1Milliman. 2/2018, “Potential economic impact of integrated medical-behavioral healthcare.”

2Modern Healthcare, Addressing behavioral health to improve all health; Special Report – Behavioral Health: Fixing a system in crisis, by Steven Ross Johnson, May 27, 2017.

3WebMD, Dealing With Chronic Illnesses and Depression, August 2018.

4Mental Health America, Data Shows Impacts of COVID-19 on Mental Health, June 2020.

5TIME, COVID-19 Is Making America's Loneliness Epidemic Even Worse, May 2020.

6CDC, Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, August 2020.

7Loneliness in the Workplace Can Be a High Cost For Employers, American Psychiatric Association (APA) Center for Workplace Mental Health, 2018; http://workplacementalhealth.org/News-Events/Blog/January-2018/Loneliness-in-the-Workplace-Can-Be-a-High-Cost.

8Loneliness and social isolation as risk factors for mortality: a meta-analytic review.

9Socially Isolated Individuals Are More Prone to Have Newly Diagnosed and Prevalent Type 2 Diabetes Mellitus – the Maastricht Study, BMC Public Health, 2017; https://bmcpublichealth.biomedcentral.com/articles/%2010.1186/s12889-017-4948-6.

10Loneliness and Social Isolation as Risk Factors for Coronary Heart Disease and Stroke: Systematic Review and Meta-Analysis of Longitudinal Observational Studies, BMJ Journals Heart, 2016; http://heart.bmj.com/content/102/13/1009.info.

11Unraveling the Role of Loneliness in Depression: The Relationship Between Daily Life Experience and Behavior, Interpersonal and Biological Processes, 2017; https://www.tandfonline.com/doi/full/10.1080/00332747.2016.1256143.

12Testimony before the US Senate Aging Committee, Julianne Holt-Lunstad, Ph.D., 2017; https://www.aging.senate.gov/imo/media/doc/SCA_Holt_04_27_17.pdf.

13National Institute of Mental Health (2019, February). Mental Illness. Retrieved from https://www.nimh.nih.gov/health/statistics/mental-illness.shtml

14Ponte, K. (2020, April 20). Coronavirus: Building Mental Health Resilience. Retrieved September 09, 2020, from https://www.nami.org/Blogs/NAMI-Blog/April-2020/Coronavirus-Building-Mental-Health-Resilience

15How to build resiliency. (2020, May 15). Retrieved September 09, 2020, from https://www.mayoclinic.org/tests-procedures/resilience-training/in-depth/resilience/art-20046311.

16Cigna acquired MDLIVE in 2021. MDLIVE is now an Evernorth business.

17Overdose Deaths Accelerating During COVID-19: Expanded Prevention Efforts Needed. CDC NEWSROOM, Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.htm.

18National Institute of Environmental Health Sciences. (2020). OPIOIDS AND THE WORKPLACE: PREVENTION AND RESPONSE. Https://Tools.Niehs.Nih.Gov/Wetp/Public/Hasl_get_blob.Cfm?ID=12121.

19Dahlamer, James, et al. “Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults.” CDC Morbidity and Mortality Weekly Report, Center for Disease Control, 14 Sept. 2018, www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm?s_cid=mm6736a2_w.