Vital Signs

Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines

United States, 2012

Leonard J. Paulozzi, MD; Karin A. Mack, PhD; Jason M. Hockenberry, PhD


Morbidity and Mortality Weekly Report. 2014;63(26):563-568. 

In This Article

Abstract and Introduction


Background. Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation.

Methods. CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines.

Results. In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone.

Conclusions. Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety.

Implications for Public Health. State policy makers might reduce the harms associated with abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.


Persons in the United States consume opioid pain relievers (OPR) at a greater rate than any other nation. They consume twice as much per capita as the second ranking nation, Canada.[1] Overprescribing of opioid pain relievers can result in multiple adverse health outcomes, including fatal overdoses.[2] Opioid pain relievers were involved in 16,917 overdose deaths in 2011; in 31% of these deaths, benzodiazepine sedatives were also cited as contributing causes (CDC WONDER, unpublished data, 2014). High rates of prescribing these controlled substances are important determinants of rates of fatal overdose and drug abuse.[3,4] Overall state prescribing rates of OPR vary widely.[5] Variation in prescribing rates for higher-risk opioid prescriptions (e.g., those for long-acting or extended-release [LA/ER] formulations) or those for high daily dosage have not been examined. LA/ER OPR are more prone to abuse, and high-dose formulations are more likely to result in overdoses, so they deserve special attention. Benzodiazepines are commonly prescribed in combination with OPR, even though this combination increases the risk for overdose.[6] Interstate variation in prescribing rates for benzodiazepines has not been measured.

Information on local prescribing rates can alert authorities to atypical use and can prompt action. Such authorities include state and local health departments, law enforcement agencies, health-care systems, and licensure boards. States have the authority to track prescribing and dispensing and regulate medical practice within their borders. They can influence the rate of prescribing of controlled prescription drugs by various measures. These include passing regulations related to use of state prescription drug monitoring programs and the operation of pain clinics.