Opioid Overprescribing Down, but Still Room for Improvement

Batya Swift Yasgur, MA, LSW

April 17, 2018

Opioid prescribing remains a significant cause of overdose deaths, but new data show that physicians are writing fewer prescriptions. Nevertheless, these drugs are still overprescribed in high-risk patients, and naloxone coprescribing is suboptimal.

Investigators found that rates of new opioid prescriptions to higher-risk patients taking benzodiazepines initially increased between 2005 and 2010 but then decreased from 2010 to 2015. However, opioid prescriptions were still administered to these patients more than to the general public. In addition, naloxone (multiple brands) was dramatically underprescribed.

"Although the general trend was encouraging, the coprescription of opioids with benzodiazepines remains a very important problem that needs to be recognized, considering that millions of Americans are taking benzodiazepines and are at high risk for overdose," senior author Joseph Ladapo, MD, PhD, of the Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, told Medscape Medical News.

"Also troubling is the underprescription of naloxone, something emphasized by the surgeon general's recent call for wider use to prevent opioid-related deaths," he said.

The study was published online April 12 in JAMA Psychiatry.

Pipeline to Long-term Use

Nearly half of the opioid overdose deaths that occurred in the United States in 2015 involved a prescription opioid. Evidence suggests that physician overprescribing contributed to this problem, the authors write.

Fatal overdoses "seem to cluster among patients who concurrently use benzodiazepines and opioids." Such patients are up to four times more likely to overdose than those who are not using benzodiazepines.

The initial prescription of opioids "represents a particularly important juncture in medical decision making because it increases the risk of future opioid use disorder and is preventable," they observe.

"Our study differs from previous research into these patterns because we are looking only at the first prescription, while most studies have looked at total prescriptions, any prescriptions, or renewals," Ladapo said.

He called the first prescription a "pipeline" to potential long-term opioid use and said the study was designed to explore whether clinicians' prescribing patterns have changed in light of overdose-related concerns.

To investigate the question, the researchers analyzed data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care for the period 2005-2015 for adults aged 20 years and older.

"Ambulatory visits with a new drug prescription...reflect the national volume of new prescriptions for that medication in ambulatory settings," the authors note.

Visits for outpatient procedures performed with sedation or prescriptions for opioid-containing cough medicines and buprenorphine were excluded, because these agents typically are not prescribed for pain.

The investigators identified reasons for the patient's pain (ie, cancer, back pain, headache, injuries, musculoskeletal, or other) and included in their analysis demographic information (age, sex, race/ethnicity, insurance status, US Census region), continuity of care, and comorbidities.

The Horse Has Left the Stable

The researchers studied 13,146 visits, representing 214 million visits nationally, that involved a new opioid prescription.

There was an increase of 5.7 million (from 7.3 million to 13.0 million) individuals who reported using benzodiazepines annually from 2005 to 2015.

By contrast, those who reported not using benzodiazepines during that time increased from 202.8 million to 216.1 million.

During the first 5 years (from 2005 to 2010), the rates of new opioid prescriptions among adults using a benzodiazepine increased from 189 to 351 per 1000 US persons (rate difference, 162; 95% confidence interval [CI], 29 - 295; P = .02).

But by 2015, the rate had decreased to 172 per 1000 persons (rate difference, -179; 95% CI, -310 to -48; P = .008).

Despite the encouraging trend, the researchers described these rates as "substantially higher" than the rates of new opioid prescription in the general population, which increased nonsignificantly from 78 to 93 per 1000 US persons between 2005 and 2010 (rate difference, 15; 95% CI, -3 to 33; P = .10) and decreased nonsignificantly to 79 per 1000 persons by 2015 (rate difference, −14; 95% CI, -38 to11; P = .28).

After adjusting for demographic characteristics, comorbidities, and pain diagnoses, the researchers found that individuals taking benzodiazepines were more likely to receive a prescription for opioids than persons in the general population (adjusted relative risk, 1.83; 95% CI, 1.56 - 2.15; P < .001).

The decrease in new opioid prescriptions for those taking benzodiazepines following an initial increase in prescriptions "suggests that the recent increase in opioid-related deaths may be associated with factors other than physicians writing new opioid prescriptions," the authors state.

However, the finding that these patients received more prescriptions than persons in the general population "represents an important opportunity to improve the quality of care for patients experiencing pain," they remark.

They note that these results "may be of particular interest to psychiatrists," because adults with chronic pain are more likely to have mental illness.

"It is important to keep in mind that even though, overall, there seems to have been a general decline in opioid prescribing for these patients in recent years, it's a decline from a rate that's really high, and the rate remains higher than in the general population," said Ladapo.

"It is a good trend, but the horse is out of the stable," he said.

Include Naloxone

A second pattern the researchers explored was the degree to which clinicians are coprescribing naloxone as a way to prevent opioid-related death.

"There are several reasons for the higher risk of overdose in people using benzodiazepines, including benzodiazepine-induced impaired memory that might lead to a person forgetting that they took their medication and taking it again, leading to many accidental overdoses where naloxone could be helpful," Ladapo explained.

The researchers found that naloxone was coprescribed with opioids in <1% of visits made by patients using a benzodiazepine.

Ladapo added that patients should be made aware of the greater risk for overdose when opioids and benzodiazepines are coprescribed and that naloxone should be "more widely used."

He emphasized that naloxone should not be prescribed as a stand-alone measure to prevent overdose but "as part of a multicomponent strategy."

Other components include nondrug approaches to pain management, such as physical therapy, occupational therapy, acupuncture, and cognitive-behavioral therapy, "all of which have good evidence and are sustainable, safe ways for people to have improved quality of life and less pain."

However, "we need economic policies that support these alternative methods, such as reduced copays," he said.

Increase Access to Nondrug Options

Commenting on the study for Medscape Medical News, Anupam B. Jena, MD, PhD, Ruth L. Newhouse Associate Professor, Harvard Medical School, Boston, Massachusetts, said that it "tackles an important but understudied issue of concurrent prescribing of opioids with benzodiazepines, which is an important contribution because it raises awareness that opioid prescribing shouldn't happen in isolation."

He called the drop in prescriptions "surprising" and suggested that it "may reflect increased awareness of the harms of concurrent prescribing, or simply increased awareness of opioid-related adverse events alone."

By contrast, Jena said, the low rates of naloxone prescribing were "not surprising" because it is "not standard practice for most physicians who prescribe an opioid to prescribe naloxone at the same time."

Ladapo added that nondrug options "are healthier, more sustainable, better for our country, and better for our society than these medications, which have a lot of downsides for most people and are a poor long-term solution," so efforts should be made on a systemic basis to increase access to these options.

The study was supported grants from the National, Heart, Lung, and Blood Institute, the National Institute on Minority Health and Health Disparities, the Robert Wood Johnson Foundation, the National Institute on Drug Abuse, and other institutions. The original article contains a full listing of funding and of the authors' relevant financial relationships. Dr Jena has disclosed no relevant financial relationships.

JAMA Psychiatry. Published online April 12, 2018. Full text

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