Highlights of Noteworthy Decisions

Decision 2157 14
S. Netten
  • Health care (necessary)
  • Health care (medical aid) (drug formulary)

The worker was injured in an assault in 1978. The Board granted a 20% pension for chronic pain disability. The worker appealed a decision of the Appeals Resolution Officer denying payment for the medications Tramacet and Tridural.

Tramacet is the brand name of an opioid analgesic consisting of acetaminophen and tramadol, for short-term management of acute pain. Tridural is the brand name for the opioid analgesic tramadol, in an extended release formulation for management of moderate to moderately-severe pain.
The Board's Drug Advisory Committee recommended against drug formulary coverage for tramadol, in favour of other comparators. The use of an expert committee to review medical literature on the efficacy, safety and cost-effectiveness of prescription medication is a reasonable method to determine the general necessity, appropriateness and sufficiency of medications. However, generally applicable conclusions do not need to apply in every case.
In this case, the worker had a longstanding pain condition. He had tried a number of other medications, which produced side effects that were intolerable for the worker. He found that Tramacet and Tridural to be effective, with limited side effects. In the circumstances, the Vice-Chair found that the Tramacet and Tridural were necessary for the worker. The worker was entitled to payment for the two medications.
The appeal was allowed.