SAFE GC Coalition: A Few Providers Prescribe Half of Opioids

A recent study conducted by the National Institute of Drug Abuse (NIDA) reported that only 1 percent of the providers who prescribe opioids account for almost half of all opioid doses prescribed and one-quarter of opioid prescriptions written in the U.S. This pattern has persisted for a decade. These top prescribers write opioid prescriptions that far exceed dose and duration thresholds recommended by the Centers for Disease Control and Prevention (CDC) and the vast majority of prescribers are following suggested guidelines, and interventions to promote appropriate opioid prescribing should target high prescribers and focus on improving care for patients with complex pain management needs.

According to NIDA, opioid prescribing remains high in the United States compared with other countries, despite concerted efforts to educate providers and enforce evidence-based and appropriate prescribing practices. To better understand who in the United States is prescribing opioid medication, researchers conducted a large, nationwide retrospective study of opioid prescribing practices from 2003 to 2017. They found that a small proportion of providers are responsible for a large percentage of all opioids prescribed.

Researchers analyzed information on 134 million opioid prescription claims from the Optum Clinformatics Data Mart, which contains data from a national private insurance provider that covered about 60 million nationally representative patients over the time period analyzed. For each prescriber in the database, the researchers examined the daily dose of opioids prescribed, the number of opioid prescriptions filled, and the opioid dose for each prescription. Their analysis excluded buprenorphine prescribed for opioid use disorder and opioid drugs that are not usually prescribed in an outpatient setting, such as injectable or intravenous opioids. For comparison, they also analyzed prescribing patterns of benzodiazepines.

Findings indicated prescriptions were unevenly distributed and the researchers noted huge variations in prescribing practices. Specifically, nearly half (49 percent) of the opioid doses and 27 percent of the opioid prescriptions were from the top 1 percent of providers. This skewed pattern in opioid prescribing was consistent from 2008 to 2017 and across all states.

Additionally, the top 1 percent of providers prescribed much higher opioid doses, with up to 49 percent of prescriptions exceeding the CDC-recommended daily threshold of 50 Morphiene Milligram Equivalent (MME) and up to 98 percent of prescriptions written for longer than the recommended threshold of 7 days. The top 1 percent of opioid prescribers were mostly specialized in family medicine, physical or pain medicine and rehabilitation, anesthesiology, and internal medicine. Particularly, physical or pain medicine and rehabilitation specialists as well as anesthesiologists were highly over-represented among high opioid prescribers; while each specialty accounts only for about 1 percent of all providers, they each represented 14 percent of the top opioid prescribers.

Researchers also looked at the patients who received the opioids. They found that the top 1 percent of patients received 28 percent of all opioids prescribed, most commonly for back problems. More than two-thirds of these patients received their prescriptions from the top 1 percent of opioid prescribers, often remaining with the same provider over multiple years.

Based on their findings, there are implications to modify prescribing practices. Interventions aimed at promoting responsible opioid prescribing should target primarily high opioid-prescribing providers. These providers often prescribe higher opioid doses than recommended by CDC and for longer periods of time, which may place patients at increased risk of overuse, addiction, and overdose. The vast majority of U.S. providers are prescribing opioids consistent with CDC guidelines. This suggests that previous policies have largely worked and that future policies should not be based on thresholds but instead focus on the few high-prescribing providers and patients receiving opioid prescriptions.

Additionally, the researchers noted that many of the top prescribers are from specialties that already receive training on appropriate opioid prescribing practices and seem to have established long-term relationships with their patients that focus on managing complex pain. Therefore, findings suggest the need to move beyond just enforcement and focus on improving patient care, management of patients with complex pain, and reducing comorbidities.

The National Institute on Drug Abuse (NIDA) is a United States federal-government research institute whose mission is to "lead the Nation in bringing the power of science to bear on drug abuse and addiction”. For more information please visit www.drugabuse.gov.

The SAFE Glen Cove Coalition is conducting an opioid prevention awareness campaign entitled. “Keeping Glen Cove SAFE,” in order to educate and update the community regarding opioid use and its consequences. To learn more about the SAFE Glen Cove Coalition please follow us on www.facebook.com/safeglencovecoalition or visit SAFE’s website to learn more about the Opioid Epidemic at www.safeglencove.org.