Prescribing Patterns and the Opioid Epidemic

September 7, 2017

While the factors driving the opioid epidemic are complex, there is broad recognition among leading public health authorities that opioids have been overprescribed — a trend that began in the 1990s and continues to this day. As the broader healthcare industry looks to reverse and prevent another epidemic in the future, there is greater focus on how to effectively curb overprescribing while balancing the legitimate and diverse health needs of patients across the country.

Wholesale distributors recognize the importance of the patient-provider relationship. Yet, as logistics providers, distributors cannot and should not interfere with clinical decision-making. Our responsibility is to ensure the safe and efficient distribution of medicines to licensed pharmacists and healthcare providers. That’s why our industry strongly supports mandatory prescriber education and greater awareness regarding the safe use of prescription medicines and pain treatments — both of which reflect the efforts from the Centers for Disease Control and Prevention (CDC), leading medical organizations and professional societies that are working to reduce the prevalence of overprescribing across the country.

Historical Prescribing Practices

• According to the CDC, opioid prescribing in the U.S. hit its highest point in 2010 with providers writing 81.2 prescriptions per 100 persons. 

• A 2011 study by leading public health experts found that approximately 56 percent of opioid prescriptions were dispensed to patients who had already filled another opioid prescription within the past month. 

• As prescriptions hit their peak, the Drug Enforcement Administration (DEA) simultaneously approved higher opioid and controlled substance production quotas in the market.

Problems Persist

• Total volume of opioids prescribed remains high. While the number of opioid prescriptions dropped more than 13 percent between 2012–2015, the CDC found that the amount of opioids prescribed in 2015 was still enough for every American to be medicated around the clock for three weeks. In fact, recent government data estimate that close to 92 million people (38 percent of the population) used prescription opioids in 2014–2015, pointing to the continued prevalence of overprescribing.
  
  
• Patients with an opioid prescription receive more medication than they need. Researchers from Dartmouth Hitchcock estimated “patients actually need only 43 percent of the opioid pain medications they are generally prescribed and that surgeons can reduce the amount of narcotics patients usually receive after some surgeries.”
  
  
• Patients of “high-intensity” prescribers are more likely to have long-term reliance on opioids, creating serious risk of misuse or overdose.
  
  
  • An analysis from the New England Journal of Medicine tracked roughly 375,000 Medicare patients from 2008–2011 who visited an emergency room and the frequency of opioid prescriptions written by the doctors who treated them. Providers identified as “high-intensity” prescribers sent one in four patients home with opioids. Those patients who saw a high-intensity prescriber were 30 percent more likely to become long-term users.
    
    
  • A report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General identified about 400 providers who had written opioid scripts to Medicare Part D beneficiaries in extreme amounts or to those who appeared to be doctor shopping over the course of 2016, putting them at serious risk of misuse or overdose.

Challenges Facing Providers

• Inconsistent treatment guidelines. In one of the first reports examining the factors driving chronic pain treatment decisions among providers, researchers found that “optimal chronic pain management is constrained by the fact that treatment guidelines are often inconsistent across specialty areas, give insufficient consideration to common comorbidities (e.g., depression), and lack strong supporting [clinical] evidence.”
  
  
• Complicating chronic conditions. This lack of clear clinical guidance exacerbated the opioid challenge in areas with high prevalence of chronic disease. Indeed, the CDC found that high-prescribing counties share similar characteristics, including an increased prevalence of patients managing chronic or long-term conditions, like diabetes, arthritis or disabilities. Treating these conditions and any associated pain can pose significant complications for providers, particularly if patients demonstrate multiple symptoms.
  
  
• Lack of coverage for alternative treatments. A National Institute on Drug Abuse analysis found that, “pain relief was most commonly cited as the reason for the misuse of opioids.” With limited insurance coverage for alternative pain treatments — such as physical therapy, acupuncture, or other types of medicines — patients have few choices beyond opioids to treat their symptoms.

What Can Be Done Now: New Prescribing Guidelines, Mandatory Provider Training

• New prescribing guidelines gain adoption. New prescribing guidelines from the CDC as well as recommendations from organizations such as the American College of Physicians (ACP) have led to greater awareness and self-regulation of opioid prescribing among the medical community.
  
  
  • Notably, ACP strongly urged “physicians to consider opioids as a last option for treatment” for patients suffering from low back pain, and “only in [those] who have failed other therapies, as [opioids] are associated with substantial harms, including the risk of addiction or accidental overdose.”
    
    
  • This sentiment was echoed in July 2017 by former HHS Secretaries Kathleen Sebelius and Tommy Thompson, who urged “doctors, dentists, and other providers take immediate steps to end overprescribing…”
• Mandatory provider training can make a difference. Public health organizations and advisory boards recommend mandatory provider training as a critical step to stem the tide of over-prescribing. A critical part of these education efforts is recognizing that it’s possible to adequately treat patients’ pain needs with fewer opioids.
  
  
  • In its recent report, the National Academies of Sciences, Engineering, and Medicine called for a fundamental shift in the nation’s approach to prescribing practices” by “improv[ing] awareness of the risks and benefits of opioids.” The committee called for “enhancing education for both health professionals and the general public including mandating pain-related education for all health professionals who provide care to people with pain, requiring and providing basic training in the treatment of opioid use disorder for health care providers, and training prescribers and pharmacists to recognize and counsel patients who are at risk for opioid use disorder or overdose.”
    
    
  • This recommendation was echoed by a Food and Drug Administration advisory board that unanimously called on doctors who prescribe opioids to complete mandatory training on the risks and safe use of these treatments. “We need to teach people to use these drugs sparingly,” said committee member Dr. Jeanmarie Perrone, a professor of emergency medicine and toxicologist at the University of Pennsylvania.