The Pew Charitable Trusts

In the wake of October's anthrax attacks in Florida, New York and Washington, D.C., states and insurers have seen an increased request for antibiotics like Ciprofloxacin or Cipro, as it's known. Maine and Virginia have now stepped up education for doctors on antibiotic use, while Georgia officials are asking doctors to justify why they are prescribing the drug.

As Maine's human services commissioner, Kevin Concannon had his hands full before the Sept 11 attacks managing prescription drug programs, child support collections and welfare reform. Since that day, his job has become even busier.

Concannon's department is now the hub of the state's anti-bioterrorism efforts, keeping health care workers and the public up-to-date on the threat of weapons like anthrax. More than 110 "suspicious" items have turned up in Maine since Sept. 11, Concannon says. None of the items have tested positive for anthrax.

Maine hasn't seen an increase in requests for prescriptions for Ciprofloxacin HCL or Cipro, as it's known, the antibiotic of choice for treating possible anthrax exposure. Nevertheless, it is something the commissioner is monitoring. "If there's been an increase in requests for Cipro, I haven't heard anything," he says.

Concannon and his staff are attempting to ward off unwarranted requests for antibiotics like Cipro by providing regular health updates to doctors and hospitals across the state. "Our focus is on educating physicians through a weekly e-mail and a hard mail advisory note. We're advising people not to put patients on antibiotics unless there's a reason to do so," he says.

In Virginia, officials from Trigon Blue Cross Blue Shield, a health insurance company that serves two million residents, including state and federal employees and postal workers, say there's been a 15 percent increase in Cipro requests since the attacks.

"Before September 11, we had 1,898 Cipro prescriptions per week. Between October 6 and October 12, the number climbed to 2,178 per week," says Trigon spokesperson Stacey Bates.

Bates says company executives aren't too concerned. "Our numbers show no cause for alarm," she says. Even so, Trigon has beefed up communication with doctors and other health care workers.

"Our company has several (ways) to communicate with our providers, so we've proactively put those to good use," Bates says. Trigon recently sent out an alert to doctors on the use of doxycycline, an antibiotic also used to treat anthrax, tucking an extra information sheet in with regular billing statements. In addition, the company has a monthly newsletter that includes anthrax-related updates for physicians.

Georgia health officials opted to take a harder line on potential antibiotic over-use. Department of Community Health officials recently saw Cipro requests by Medicaid patients and state employees double. Nearly 200 Cipro prescriptions were written in the Medicaid program in September. As of Oct. 21, the monthly prescription total was 376, says Martin Smith, spokesperson for the state's Department of Community Health.

At a cost of $600 per prescription, Smith says officials decided to take quick action to make sure all the Cipro requests were valid. Accordingly, the department issued a bulletin to all pharmacies on Oct. 23 that the state now requires approval on Cipro prescriptions when the quantity requested is more than 30 tablets. "Prescriptions issued for (patients) to have on hand in the event of possible future exposure to anthrax are not deemed a medical necessity and as such are not covered," the bulletin says.

Which approach is more efficient? Drug industry officials prefer that states and insurers educate doctors before adding administrative hurdles to the prescription drug process. "We always support physician education before a state imposes another decision-maker between a doctor and a patient," says Marjorie Powell, assistant general counsel at Pharmaceutical Research and Manufacturers of America(PhRMA), a trade group that represents some of the nation's biggest drug companies.

"I can understand why Georgia would be concerned about over-prescribing a particular antibiotic... (but) it's not clear that prior authorization is the most effective" way to go, she says.

Powell says antibiotic overuse is a topic that's always good to discuss. "Every so often, we see articles about the frequency of doctors prescribing antibiotics and how that occurrence builds antibiotic resistance across the population. It's a perfect chance for states and health plans to do more physician educating, which could potentially" help the United States on an overall level, she says.

Maine's Concannon, who is typically at odds with PhRMA on prescription drug matters, agrees. "Maine hasn't prior-authorized Cipro and I would hesitate to do that" if we started to see an increase in prescriptions, he says. "I'd still try and work more on educating physicians. We want to be sensitive to the anxiety that's out there."