Opioid Overprescribing Not Limited to a Few Bad Apples

Megan Brooks

December 16, 2015

An analysis of national Medicare data discounts the notion that a small group of prolific prescribers operating out of corrupt "pill mills" are driving the opioid overdose epidemic in the United States.

The bulk of prescriptions for opioid painkillers are made by the broad swath of general practitioners, not by a limited group of specialists, according to a study from researchers at Stanford University School of Medicine in California.

"It's nice to see what I had always suspected was true, which is that the problem is not isolated to a few prolific prescribers. It's really a systemic problem," senior author Anna Lembke, MD, noted in an interview with Medscape Medical News.

"I think most of us had a sense that was true, but it's nice to have confirmatory data, especially since most media coverage has focused on a few rogue prescribers or just frankly nefarious doctors out there prescribing insane amounts of opioids in pill mills," Dr Lembke said.

The findings were published online December 14 a research letter in JAMA Internal Medicine.

Focus on Pill Mills Insufficient

The researchers examined Medicare prescription drug claims data from 2013 for 808,020 individual prescribers, including physicians, nurse practitioners, physician assistants, and dentists. For each prescriber National Provider Identifier number, the data identify each drug prescribed, total number of claims, and total costs. The researchers focused on schedule II opioid prescriptions containing hydrocodone, oxycodone, fentanyl, morphine, methadone, hydromorphone, oxymorphone, meperidine, codeine, opium, or levorphanol. The data represent more than 1.18 billion claims totaling nearly $81 billion.

On the basis of claims per prescriber type, it was determined that opioid prescriptions were concentrated in interventional pain management (1124.9 prescriptions, on average, per prescriber) and pain management (921.1), followed by anesthesiology (484.2) and physical medicine and rehabilitation (348.2).

From an analysis of total claims, it was determined that in 2013, most opioids were prescribed by healthcare providers in family practice (15.3 million prescriptions) and internal medicine (12.8 million), followed by nurse practitioners (4.1 million) and physician assistants (3.1 million).

The researchers say the top 10% of opioid prescribers accounted for 57% of all opioid prescriptions, similar to the prescribing pattern for all drugs for which there are Medicare data: the top 10% of all drug prescribers accounted for 63% of all drug prescriptions.

Efforts by law enforcement to shut down pill-mill prescribers are "insufficient to address the widespread overprescribing of opioids," lead author Jonathan Chen, MD, PhD, an instructor of medicine and Stanford Health Policy VA Medical Informatics Fellow, notes in a statement. "Efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective."

Public Health Crisis

"The reason this is a public health crisis is in a large part because it's become a commonality to prescribe opioids for a lot of different things," Dr Lembke told Medscape Medical News.

"What was really interesting," she noted, "was the number of nurse practitioners prescribing opioids. These 'physician extenders' are really the future of medicine, so from a public health intervention point, we can't just focus on pain doctors. We've got to focus on all doctors, and even non-MDs, dentists, and nurse practitioners."

Cynthia Campbell, PhD, MPH, from Kaiser Permanente Division of Research, in Oakland, California, who was not involved in the study, agrees. "Providers on the whole healthcare team that manages patients need more education around prescribing opioids," she noted in an interview with Medscape Medical News. She pointed out that the US Department of Veterans Affairs (VA) has recently developed some initiatives that focus on opioid prescribing in primary care.

Dr Campbell said this new study is an "important" contribution to the literature and that the issue of prescription opioid abuse "remains a high concern."

The study was supported in part by the VA's Office of Academic Affiliations, the VA Health Services Research and Development Service, the National Institute of General Medical Sciences, and the Peter F. McManus Charitable Trust. The authors have disclosed no relevant financial relationships.

JAMA Intern Med. Published online December 14, 2015. Full text

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