Are WC MDs Overprescribing Narcotics?

A study of workers' compensation drug prescription costs by The Hartford has found evidence that narcotic pharmaceuticals continue to be overprescribed, according to an executive with the company.

Dr. Rob Bonner, medical director for The Hartford, said the findings were especially surprising "given there have been several evidence-based treatment guidelines published over the past several years that recommend very limited use of narcotics for musculo-skeletal conditions."

About 40 percent of The Hartford's spending on workers' comp pharmaceutical claims is for narcotics, he said.

The doctor's unit with the company has prepared a listing of which drugs are most responsible for pharmaceutical treatment costs.

Although the number-one ranked medicine is Lidoderm, a non-narcotic pain medicine, Dr. Bonner explained that OxyContin would actually be in first place if it were coupled with its generic substitute Oxycodone.

Oxycodone is third on The Hartford list of the top 25 drugs in 2006 ranked by total costs, and OxyContin, which held first place between 2001 and 2005, is now fifth in the rankings.

The continuing high level of prescription of OxyContin is also surprising given the recent negative publicity.

Dr. Bonner mentioned that two months ago the drug's manufacturer, Stamford, Conn.-based Purdue Pharma, and three top executives were slapped with a $635 million fine. Federal authorities in Virginia, after an investigation, found the company had staged a fraudulent marketing campaign portraying the drug as less addictive than other pain killers.

The physician also noted the relatively high seventh-place position on the list of the fast acting oral narcotic, Actiq.

"That's of concern to us because Actiq is only approved by the FDA (Food and Drug Administration) for breakthrough pain in cancer patients," he said.

Usage of Actiq, he said, is normally reserved for pain that a baseline dose of narcotics fails to quell. "Actiq is for excruciating pain when other medications don't manage it."

Dr. Bonner said he was also concerned over the long-term usage of high-dose narcotics such as OxyContin, explaining that medical science has only tracked its use for three-to-six months. The potential effects for longer periods can only be extrapolated.

It is a question, he said, of whether "that's an appropriate way to manage non-cancerous, non-malignant pain."

The doctor said The Harford still managed to keep its increase in pharmacy spending for 2006 to 3 percent compared with 2005, in spite of significant increases in the cost of named drugs. The cost per prescription of Actiq, for example, has gone up 70 percent, he said.

"Our goal is to make sure we only approve payment for drugs appropriate to the workers' compensation injury," he advised. "We often ask physicians to explain why they want to prescribe a drug if there is a question--especially with regard to narcotics and off-label drugs."

The Hartford has this focus since several evidence-based treatment guidelines published this year recommend very limited use of narcotics for musculo-skeletal conditions, the company said.

Off-label, Dr. Bonner explained, means prescription drugs given to a patient to treat a condition different from the use approved by the Federal Drug Administration.

Among other changes noted in this year's listing of drugs, by percentage of total costs to the insurer, was the downward movement of Mobic from eighth place to 15th.

The non-narcotic, non-steroidal pain medication is believed to have dropped because of the introduction of a generic equivalent, Meloxicam, Dr. Bonner said.

"We've also seen where the medication Neurontin has fallen out of the top 25 and been replaced with the generic, Gabapentin," Dr. Bonner said of the antiseizure medication.

The Hartford 25 top ranked drugs by total costs for 2006 were in order:

Lidoderm, Hydrocodone, Oxycodone, Celebrex, OxyContin, Gabapentin, Actiq, Lyrica, Fentanyl, Ambien, Skelaxin, Tramadol, Duragesic, Cyclobenzaprine, Mobic, Oxyco/Apap, Carisoprodol, Cymbalta, Topamax, Naproxen, Tizanidine, Avinza, Effexor, Percocet and Kadian.

This article updated July 27, 2:08 p.m. EDT