According to published data, there has been a 10-fold increase in the misuse of opioid painkillers in the United States over the past 2 decades. Questions remain, however, about the causes that are driving this trend. “Some researchers and experts have suggested that small groups of high-volume prescribers working in so-called ‘pill mills’ are among the main reasons for the opioid overdose epidemic in the U.S.,” explains Anna Lembke, MD. “Despite this belief, opioid overprescribing is more than just a problem of a small group of high-volume prescribers,” adds Dr. Lembke.
Taking a Closer Look
In a research letter published in JAMA Internal Medicine, Dr. Lembke and colleagues examined data from individual prescribers using the 2013 Medicare Part D claims data set created by CMS. Medicare data provide the opportunity to address the issue of opioid prescribing patterns across the nation. Medicare Part D covers about 68% of the roughly 50 million people on Medicare.
For the more than 800,000 prescribers assessed in the study, data were examined on each drug prescribed, the total number of claims, and total costs. Data were available on both location and specialty of practice, and represented nearly 1.2 billion claims for approximately $81 billion.
The analysis focused on schedule II opioid prescriptions containing hydrocodone, oxycodone, fentanyl, morphine, methadone, hydromorphone, oxymorphone, meperidine, codeine, opium, or levorphanol. The authors then calculated the cumulative claims for schedule II opioids from the top individual prescribers relative to the total claims for all prescribers. For comparisons, this exercise was repeated for prescription costs, for all drugs, and for each state.
The study showed that the largest group of opioid prescribers was primary care physicians (PCPs). Family practice physicians issued approximately 15.3 million prescriptions whereas internal medicine physicians issued 12.8 million (Figure). “This finding should be expected because there are many more PCPs in the U.S. than other types of specialists,” says Dr. Lembke. The study also found that nurse practitioners wrote 4.1 million prescriptions for opioids while physician assistants ordered up 3.1 million.
Based solely on claims-per-prescriber, pain specialists led the way in opioid prescribing, followed by practitioners in pain management, anesthesiology, and physical medicine and rehabilitation. Importantly, the study showed that the top 10% of Medicare prescribers accounted for a smaller proportion of opioid claims than for all Medicare prescriptions. Minimal regional variations were observed across provider states.
Excluding hydrocodone— which was a schedule III opioid prior to 2014—the authors observed similar trends with the same top three prescribing specialties and about 58% of claims from the top 10% of prescribers. “Opioid prescriptions are concentrated in specialty services in pain, anesthesia, and physical medicine and rehabilitation,” says Dr. Lembke. “By sheer volume, however, total prescriptions are dominated by general practitioners.”
A Widespread Issue
The study notes that the data represent a comprehensive national population of Medicare Part D prescribers, but do not necessarily reflect clinicians’ complete practices, patient factors, or medication dosing to inform morphine equivalents.
Overprescribing is a national concern, according to Dr. Lembke, and mitigation efforts should not be oversimplified or targeted to a select few prescribers. “Interventions to reduce the burden of the opioid epidemic should not simply targeted only particular regions of the country or specific patient populations or communities,” she says. “Clinicians in all patient care settings need better education on the proper prescribing of opioids, and need clear direction on when these therapies are truly safe and effective.”
Dr. Lembke adds that increased oversight, follow-up, and accountability in opioid prescribing and patient care are necessary. This includes greater efforts to educate patients and communities and to increase awareness of the opioid epidemic. “Efforts to curtail national opioid overprescribing must address a broad collection of prescribers in order to be effective,” Dr. Lembke says.
Throughout the U.S., institutions are conducting interventions to further the education of healthcare professionals on appropriate opioid use. In fact, the CDC is soon planning to release guidelines for primary care providers on appropriate opioid use. Initiatives are also needed to increase consideration for less habit-forming treatment alternatives for pain whenever possible.
When managing pain, clinicians should strive to reserve prescribing opioids for those who truly warrant these powerful drugs, Dr. Lembke says. “There are many other treatment options that can be used to manage pain,” she says. “Clinicians need to collaborate with patients and ensure that the safest, most effective treatments are used. Only then can we make a significant impact on the burden of the opioid epidemic.”
Readings & Resources (click to view)
Chen JH, Humphreys K, Shah NH, Lembke A. Distribution of opioids by different types of Medicare prescribers. JAMA Intern Med. 2015 Dec 14 [Epub ahead of print]. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=2474400.
Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical overdose deaths, United States, 2010. JAMA. 2013;309:657-659.
Rosenau AM. Guidelines for opioid prescription: the devil is in the details. Ann Intern Med. 2013;158:843-844.
Betses M, Brennan T. Abusive prescribing of controlled substances: a pharmacy view. N Engl J Med. 2013;369:989-991.
ReedWJ. The Pareto, Zipf, and other power laws. Econ Lett. 2001;74:15-19.