OBJECTIVES: To examine utilization of various narcotic analgesics that are used in pain management of occupational injuries among West Virginia Worker's Compensation claimants. METHODS: We reviewed all claimants (N=20,282) who had any narcotic analgesic prescription reimbursement during a period between July 1, 1997 and June 30, 2002. This accounted for 8% of all injury claimants (N=253,841) and 53.5% of all claimants with any prescription reimbursements (N=37,903). We analyzed all narcotic analgesic claims by types of drug, extent, and duration of use and cost of the drug. We also studied the trend and pattern of utilization of these medications between fiscal years FY1998 and FY2002. RESULTS: The proportion of claimants with narcotic analgesic prescription reimbursements increased by almost 3 times from 7.8% in FY1998 to 24.4% in FY2002. During the same period, total costs of narcotic analgesics increased by 18 times. Most of the narcotic analgesics were utilized in claimants who had a diagnosis of multiple musculoskeletal sprains (40.8%), multiple injuries (21.2%), severe trauma (20.6%) and back injury (7.0%). Twenty-nine percent of cases utilized more than one narcotic analgesic. The most frequently prescribed narcotic analgesic was hydrocodone with acetaminophen (40.8%), followed by propoxyphene napsylate (12.6%), Ultram (11.8%) and Oxycontin (8.9%). Although Oxycontin was utilized in 8.9% of the claimants, it accounted for 34.8% of the total narcotic analgesic expenditure in this population. Of all the narcotic analgesics, Oxycontin had the highest median cost ($453 per claimant) and median duration of use per claimant (97 days). CONCLUSION: Cost and utilization of narcotic analgesics have dramatically increased over the past five years among WV Workers Compensation claimants. Almost 90% of narcotic analgesic utilization is concentrated in claimants with diagnosis of musculoskeletal sprains, severe trauma, back and multiple injuries. High utilization and duration of use of Oxycontin needs attention due to its highly addictive nature and cost implications.