Narcotic abuse and drug diversion inside your plan

• In Year 1, this plan member claimed for 3,700 tablets of Percocet, a moderate-potency combination narcotic that contains 5mg of oxycodone (the same ingredient as OxyContin) and 325mg of acetaminophen (Tylenol). Percocet is not intended to treat significant chronic pain conditions—these patients need to be moved up the ladder to higher potency narcotics.

• In Year 2, this plan member claimed 4,850 Percocet tablets—the equivalent of 13.25 tablets per day. That works out to over 4.3 grams of Tylenol daily. Doses of Tylenol above 4 grams per day for any extended period of time can lead to liver failure, and can be fatal.

• Generic Percocet is dirt cheap and will never flag as a high cost drug (it’s approximately 15 cents per tablet), but if abused, the results can be devastating. Hard to believe that a patient could receive enough Percocet through the plan in one year to join Larry Hagman (circa 1994) on the transplant list.

• On the positive side, the CMAJ article only quoted the street value of Percocet in 1998 at an average of $4 per tablet, so this isn’t going to contribute to an enormous retirement nest egg if in fact this person was smart enough to protect their liver by selling and not consuming most of the 4,850 tablets.

In all three cases above, I am not suggesting that there was not a valid prescription for each claim. I’m sure there was.. One can assume all claims processors will at least validate the existence of a legitimate prescription. That is not the concern. The problem is that for those people seeking out multiple narcotic prescriptions from one or more physicians that lead to extremely high or dangerous patterns of utilization, the system as it is structured today is not catching and addressing these problems.

The issues here for plan sponsors are significant. A major side effect of narcotic abuse is sedation. This can be a health and safety issue for some plan sponsors that operate in a manufacturing or manual labour based industry. There is also a potential legal liability issue if a plan is allowing its members to claim and receive as many narcotics as they choose.

Solutions
The solution is very simple: take a look at your blinded claims data (i.e. no personal information included) to determine if suspect cases of narcotic or control drug abuse exist, and in what form. Develop a targeted therapeutic limit program that will only ever be encountered by a fraction of one percent of plan members that provides an opportunity for plan member education (i.e. cases where a plan member with significant chronic pain needs to be moved up to a more potent narcotic), discussion with the prescribing physician(s) in those cases where utilization is very suspect, and suspension of coverage for narcotics in cases where the utilization is not warranted and supported by the physician.

Too often these days it seems like stakeholders in benefits management and administration get distracted discussing macro-level topics like proposed changes to government legislation, and don’t bother focusing on critical issues like this happening in plans across the country as you read this. These are issues where practical, easy to implement solutions exist. If narcotic abuse is happening in your plan, you need to be aware of it, and you need to have a practical solution to address the problem in a responsible and respectful manner.

Mike Sullivan is President of Cubic Health Inc., a Toronto-based drug plan management company.

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