Improvements like this don't happen by chance. Newer, more expensive drugs continue to exert upward pressure on pharmacy costs, so workers' comp insurers and claims administrators have to be vigilant to make sure claimants get just the drugs they need for good treatment.

Again at the top of the list is OxyContin, a powerful timed-release narcotic used for moderate-to-severe pain. OxyContin is designed for long-term use and frequently is appropriate for patients with certain workers' comp injuries.

Unfortunately, though, the drug's potent narcotic effects and its high street value provide a big potential for diversion. The Food and Drug Administration, the U.S. Drug Enforcement Administration and OxyContin's manufacturer–Perdue Pharma–have been working together to try to curb its abuse. We do our part by remaining vigilant to indications that the drug is not being used as intended.

Not surprisingly, drugs to control pain dominate the list, accounting for 20 of the top 25. They break down into four groups–non-steroidal anti-inflammatory drugs (NAIADS); short-acting narcotics; long-acting narcotics; and drugs to support or augment pain relief. The list also includes anti-depressants such as Zoloft, sleeping pills such as Ambien, and muscle relaxants such as Skelaxin.

Pain management is a complex matter. With so many drugs available, I worry that some physicians subscribe to a “newer is better” philosophy, routinely putting patients on new and trendy drugs when more established medications may have a lower risk and lower cost.

A case in point is the COX-2 inhibitors like Celebrex (number three on the list), Vioxx (number seven despite being withdrawn from the market in September) and Bextra (number six). The FDA's recalls and warnings for these newer drugs suggests more changes may be coming, and early 2005 data shows a drop-off in prescribing patterns for the COX-2 drugs. Aspirin and Ibuprofen are two of the older, non-steroidal medications often successfully used to treat many of the same conditions as the COX-2 inhibitors, and this may boost their use.

Oxycodone, a short-acting narcotic, is new to the list this year at number 17. Also new are Mobic (number 24) and Endocet (number 25)–both non-steroidal anti-inflammatory drugs. Although not yet on the top-25 list, we're watching Palinode–a newly available, sustained-release version of Hydrocodone that may replace OxyContin to some degree in the future.

Our list of the top-25 drugs prescribed for workers' comp in 2004 indicates that significant off-label drug use continues, despite widespread negative publicity. Off-label involves the use of drugs in ways not approved by the FDA.

One such drug is Actiq–a powerful painkiller approved by the FDA for cancer patients with breakthrough pain. Actiq jumped from number 15 in 2003 to number nine in 2004. The increasing number of patients receiving this drug and the increasing number of prescriptions those patients are receiving strongly suggests it is being used for a much wider range of pain than the FDA intended. The narcotic is administered in a lollipop or lozenge and takes just minutes to enter the bloodstream, giving it a high potential for diversion and abuse.

Another drug, Neurontin, remained at number two on the list in 2004–although its manufacturer, Pfizer, paid more than $430 million to settle state and federal charges relating to the drug's promotion and marketing to physicians for non-FDA approved uses.

The drug–originally launched by Warner-Lambert, which Pfizer later acquired–is approved by the FDA only to treat seizures in epilepsy and pain following shingles outbreaks (post-herpetic neuralgia). These conditions are relatively infrequent in workers' comp, but its numbers suggest considerable off-label use of the drug.

While the cost of prescription drugs continues to rise, The Hartford has kept its pharmaceutical inflation rate down through continuous cost management efforts–including careful monitoring, negotiated prices and other controls, as well as the use of a pharmacy benefits manager.

One important factor in controlling costs is our proprietary lists of drugs commonly used to treat certain workers' comp-related medical conditions. When we receive a request for a drug that is not on our list, we refer the request to a nurse for clinical review to determine whether the requested drug actually is related to the injury.

There are times when an unusual drug may be appropriate. Often, though, the drug is for a medical condition not associated with the workers' comp claim but which the pharmacy erroneously processed under the workers' comp account.

Additionally, when refill patterns for certain drugs are excessive, our case review may turn up indications of misuse, including fraud, drug diversion and addiction.

Every injured worker deserves the good care and appropriate medicine to treat their injury. Our vigilance in monitoring the drugs used in workers' care helps ensure they get it. We think Ms. Poppins would be pleased.

Robert E. Bonner, MD and Master of Public Health, is medical director for The Hartford Financial Services Group Inc.

Flag: Bitter Pills

Head: The Hartford's Top 25 WC Drugs

Drugs to control pain dominate the list, accounting for 20 of the top 25. Significant 'off-label' use of drugs in ways not approved by the FDA is a key cost driver, The Hartford says.

Cover Caption:

Doctors often prescribe expensive drugs in unapproved ways when cheaper alternatives are available, sending workers' comp bills soaring unnecessarily.

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“I worry that some physicians subscribe to a 'newer is better' philosophy, routinely putting patients on new and trendy drugs when more established medications may have a lower risk and lower cost.”

Dr. Robert E. Bonner