Nation-Wide Opioid Prescribing Changes

Meron Mezgebe, Mercer University College of Pharmacy

The national opioid crisis has reached epidemic levels, with 33,091 drug overdose deaths involving an opioid in 2015. [1] The estimated economic burden of prescription opioid overdose, abuse, and dependence was estimated to be $78.5 billion in 2013. [2] The exposure to prescription opioids was found to be a strong risk factor opioid use disorder among individuals with a new episode of a chronic non-cancer pain condition in a 2000-2005 database analysis [3] Accordingly, in 2016 the Center for Disease Control’s (CDC) Guidelines for Prescribing Opioids for Chronic Pain outline specific criteria for the initiation and continuation of opioids for chronic pain. [4]

Vital Signs: Changes in Opioid Prescribing in the United States [5]
Design Population database analysis
Objective To assess changes in national-level and county-level opioid prescribing during 2006-2015
Study Groups N/A
Methods The QuintilesIMS Transactional Data Warehouse provided data on the number of opioid prescriptions dispensed based on a sample of approximately 59,000 pharmacies in the United States. Data included overall opioid prescribing rates, high-dose prescribing rates, and prescribing rates by days’ supply (≥30 days and <30 days). High-dose prescribing rates include prescriptions with daily dosage ≥90 morphine milligram equivalents (MME). Cold and cough products containing opioids and buprenorphine products indicated for conditions other than pain were excluded.

Changes in opioid prescribing at the national level were analyzed from 2006 to 2015. A change of ≥10% was considered an increase or decrease, whereas changes <10% were considered stable.

County characteristics were obtained from the U.S. Census Bureau; American Community Survey; U.S. Diabetes Surveillance System; Dartmouth Atlas of Health Care; Centers for Medicare and Medicaid Services; Behavioral Risk Factor Surveillance System; and the Area Health Resource File.

Duration 2006-2015
Primary Outcome Measure Annual opioid prescribing rates in the United States
Baseline Characteristics
  Lowest quartile Second quartile Third quartile Highest quartile p value
Average MME per capita 202.9 528.5 76.9 1,318.7
Age group, years (%)
< 35 43.2 44.6 43.3 42.1
35-64 38.6 38.7 38.9 39.0
³ 65 18.2 16.7 17.7 18.9
Race/Ethnicity, n (%)
Non-Hispanic white 76.9 78.3 81.8 83.6 < 0.001
Non-Hispanic black 9.3 9.4 9.3 8.0
Hispanic 9.5 8.3 5.3 4.8
Other 4.4 4.0 3.7 3.6
Insurance status, n (%)
Uninsured 15.3 14.3 14.5 15.7 < 0.001
Medicare 17.2 15.8 16.7 17.7
Medicaid 19.2 19.3 20.7 23.3 < 0.001
Education level
No high school diploma 17.3 15.9 16.1 18.4 <0.001
Employment level
Unemployed 6.7 7.3 7.9 8.5 < 0.001
Income
Income below the Federal poverty level (%) 15.3 14.5 15.2 17.1 0.08
Median annual income, dollars 22,339 23,747 22,612 21,216
Urban/Rural (%)
Metropolitan 29.5 47.9 41.9 34.7 0.003
Micropolitan 13.6 20.2 24.9 27.6 <0.001
Noncore 56.9 31.9 33.2 37.7
Provider density per 100,000 residents, n
Primary care physician 44.1 57.4 59.5 60.0 <0.001
Dentists 30.5 41.5 41.3 39.5 <0.001
Disease/Condition prevalence (%)
Diagnosed diabetes 10.2 10.6 11.4 12.1 <0.001
Diagnosed arthritis 23.7 23.9 25.4 26.3 0.009
Disabled 14.4 13.5 15.3 17.4 <0.001
Selected death rate, n
Suicides per 100.000 7.7 15.1 13.5 9.0 <0.001
Results
Percentage of counties with changes in opioid prescribing – United States, 2010-2015
Opioid prescribing measures Decrease (%) Stable (%) Increases (%)
MME per capita 49.6 27.8 22.6
Overall prescribing rate 46.5 33.8 19.6
High-dose prescribing rate 86.5 6.7 6.9
Average daily MME per prescription 72.1 25.7 2.2
Average days’ supply per prescription 1.1 25.4 73.5
Adverse Events N/A
Study Author Conclusions The amounts of opioids prescribed remains high relative to 1999 levels and varies substantially at the county-level.

Variations in opioid prescribing patterns across the United States suggests a lack of consensus and demonstrate the value of greater implementation of evidence-based guidelines such as CDC’s Guideline for Prescribing Opioids for Chronic Pain. Opioid prescription appropriateness was not analyzed and a limitation of this report since clinical outcomes and prescription indications were not included. As such, appropriateness of opioid prescriptions could not be assessed. Finally, the QuintilesIMS data used to provide estimates on opioid dispensing, have not been validated.

References

[1] Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 30;65(5051):1445-1452.

[2] Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care. 2016 Oct;54(10):901-6.

[3] Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014 Jul;30(7):557-64.

[4] Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain–United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45.

[5] Guy GP Jr, Zhang K, Bohm MK, Losby J, Lewis B, Young R, Murphy LB, Dowell D. Vital Signs: Changes in Opioid Prescribing in the United States, 2006-2015. MMWR  Morb Mortal Wkly Rep. 2017 Jul 7;66(26):697-704.

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