The study encompassed the years since the onset of the opioid epidemic, but before the issuance of the CDC guideline on opioid prescribing in 2016. The variation among counties “suggests inconsistent practice patterns and a lack of consensus about appropriate opioid use and demonstrates the need for better application of guidance and standards around opioid prescribing practices,” the authors wrote.
To perform the study, the authors obtained prescribing information from a national medical data collection company, whose database contains information from approximately 59,000 pharmacies and from 88% of the prescriptions written in the US.
From 2006 to 2010, prescribing rates for opioids increased from 72.4 to 81.2 prescriptions per 100 people. They remained at that level through 2012, and then declined to 70.6 per 100 people by 2015.
In 1999, opioid prescriptions totaled 180 morphine milligram equivalents (MME, commonly used to compare doses among opioids) per capita nationwide. The new study revealed that figure had risen to 782 MME by 2010, and fallen to 640 MME by 2015, still 3.5 times the 1999 level.
The authors suggested that two prescribing changes may account for the drop in the quantity of opioids prescribed per capita in recent years. First, the daily dose in the average prescription fell. They note that the largest decrease in the average daily MME per prescription occurred between 2010 and 2012, concurrent with two national guidelines, one from the American Pain Society and American Academy of Pain Medicine, and the other from the Department of Veterans Affairs, that defined “high-dose” prescribing as more than 200 MME per day. At the same time, studies were published showing that opioid overdose deaths correlated with prescription opioid use. Second, the prescribing rate fell, perhaps due to “a growing awareness among clinicians and patients of the risks associated with opioids,” according to the study.
However, the authors of the study noted, those changes were opposed by a countervailing trend to write longer prescriptions. “This pattern, along with the trends in overall numbers of opioid prescriptions, might reflect fewer patients initiated on opioid therapy after 2012, whereas patients already receiving opioids were more likely to continue receiving them,” the authors suggested. That may be problematic, they argued, since research has shown that patients receiving opioids for more than five days are at risk for long-term use, and those receiving them for more than 90 days are unlikely to discontinue, “highlighting both the importance of minimizing unnecessary initial opioid exposure and potential challenges in reducing opioid use among patients already receiving them,” they concluded.
The national patterns were a composite of widely varying state- and county-wide trends that in many cases ran in the opposite direction. Between 2010 and 2015, the study found, “half of counties in the US experienced reductions in the amount of opioids prescribed,” while the other half experienced an increase (22.6% of counties) or no change (27.8%), despite the nationwide increase in awareness of this health epidemic. The states of Florida, Ohio, and Indiana experienced statewide decreases in MMEs prescribed per capita, while increases were the rule in northern New York and Vermont, large portions of Wyoming, and many counties in Iowa, among other locations.
The total number of opioids prescribed varied dramatically by county. The average MME per capita in the quartile of counties with the highest per capita MME was more than six times as high as that in the quartile with the lowest: 1,319 MME vs. 204 MME. That dramatic prescribing difference may be explained by much less dramatic, but still statistically significant, differences between these counties in multiple aspects of socioeconomic and health status. In the highest-MME counties, diabetes was diagnosed in 12.1% of residents, and arthritis in 26.3%, versus 11.1% and 24.8% in the lowest-MME counties. The highest-MME counties also had lower income, higher poverty, less education, a higher proportion of Medicaid-eligible residents (23.3% vs. 20.6%), and a higher proportion of non-Hispanic whites (83.6% vs. 80.1%), and were more likely to include urban clusters with population between 10,000 and 50,000.
The authors suggested the wide variation in prescription patterns reflects differences in awareness and application of opioid prescribing guidelines. They recommend primary care clinicians treating adult patients with chronic pain pay wider attention to the CDC Guideline for Prescribing Opioids for Chronic Pain. “The guideline can help providers and patients weigh the benefits and risks for opioids according to best available evidence and individual patients’ needs and safely taper opioids if risks outweigh benefits. The Guideline recommends the use of non-opioid therapies, such as acetaminophen, nonsteroidal anti-inflammatory medications, exercise therapy, and cognitive behavioral therapy for chronic pain.
“Given the associations between opioid prescribing, opioid use disorder, and opioid overdose rates, states and local jurisdictions can use these findings to target high-prescribing areas for interventions such as academic detailing for clinicians or individual educational visits to clinicians, and increased access to medication-assisted treatment for patients with opioid use disorder. Innovative approaches, such as virtual physical therapy sessions with pain coping skills training, can be used to improve access to effective treatment for chronic pain. In addition, states can consider policies that can reduce opioid overdose, including mandated PDMP use and pain clinic laws. Changes in opioid prescribing can save lives. The findings of this report demonstrate that substantial changes are possible and that more are needed,” the authors said.