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

Conclusions and Comment

The rates of use of pain relievers and benzodiazepine sedatives showed about three- to five-fold variation from the highest to lowest states. Variation was greater for the LA/ER and high-dose formulations of OPR. Higher OPR and benzodiazepine prescribing rates in the South presented in this report are similar to the findings of higher prescribing rates for other drugs in the South, including antibiotics,[7] stimulants in children,[8] and medications that are high-risk for the elderly.[9] Previous studies have found that regional prescribing variation cannot be explained by variation in the prevalence of the conditions treated by these drugs.[5,7] Other research indicates that wide variation in rates of surgery and hospitalization also cannot be explained by the underlying health status of the population.[9,10] Wide variation in the use of medical technology, including pharmacotherapy, usually indicates a lack of consensus on the appropriateness of its use.[9] Therefore, one possible explanation for the results of this study is the lack of consensus among health-care providers on whether and how to use OPR for chronic, noncancer pain.[2]

Research on small-area variation in health care indicates that high rates of use of prescription drugs and medical procedures do not necessarily translate into better outcomes or greater patient satisfaction. In fact, high rates of use might produce worse outcomes.[11,12] In this case, greater use of opioids and benzodiazepines might expose populations to greater risks for overdose and falls.[2,3,13,14] Greater use is also associated with abuse,[4] although such use might both cause and be caused by abuse. The wide variation in rates of use for LA/ER opioids, in particular, might reflect the demand for these drugs in the drug-using community and their selective prescribing, often in combination with sedatives and muscle relaxants, by unscrupulous pain clinics.[14] Factors that might explain why some states have consistently lower rates of prescribing also need to be identified in future research.

The findings in this report are subject to at least four limitations. First, IMS estimates have not been validated, and they do not include prescriptions dispensed by prescribers, hospital/clinic pharmacies, or health maintenance organization pharmacies, potentially biasing rates downward. Second, prescriptions might be dispensed to nonstate residents, as commonly occurred in Florida during the previous decade.[14] Third, prescribing rates cannot be correlated with rates of outcomes, such as overdoses with these drugs, because drug-specific overdose data are not available for most jurisdictions. Finally, the prescribing rates shown for a state might conceal large differences in rates within the state.[15]

Evaluating and modifying state prescribing patterns is particularly important in states with the highest prescribing rates for drugs prone to abuse. States can determine the factors driving their high prescribing rates by using data from their prescription drug monitoring programs (PDMPs), systems that record all prescriptions for drugs prone to abuse. They can also use PDMPs to evaluate the impacts of policy changes. Recently, a few states have been able to change prescribing patterns by increasing prescriber use of their PDMPs. New York and Tennessee, for example, mandated prescriber use of the state PDMP in 2012. They subsequently used their PDMPs to document declines of 75% and 36%, respectively, in the inappropriate use of multiple prescribers by patients.[16]

States can take other actions that will affect prescribers. Developing or adopting existing guidelines for prescribing OPR and other controlled substances can establish local standards of care that might help bring prescribing rates more in line with current best practices. State Medicaid programs can manage pharmacy benefits so as to promote cautious, consistent use of OPR and benzodiazepines. In addition, a number of states have passed laws designed to address the most egregious prescribing excesses. Florida, for example, enacted pain clinic legislation in 2010 and prohibited dispensing by prescribers in 2011. It subsequently experienced a decline in rates of drug diversion[17] and a 52% decline in its oxycodone overdose death rate.[18] Guidelines, insurance strategies, and laws are promising interventions that need further evaluation. Patients in all states deserve access to safe and effective evidence-based medical care, and prescribers should carefully consider the balance between risks and benefits in any pharmacotherapy.