June 25, 2020

A study entitled “Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study” published on January 29, 2020 in the British medical journal BMJ reported: “In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs [morphine milligram equivalents]—nearly 1000 times more than the middle 1% … 81% to 98% of prescriptions written by the top centile of providers were for more than seven days.” Nonetheless, the study reported “Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing.”

“At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.”

“More than half of the top centile of opioid prescribers are in family medicine (24%), physical or pain medicine and rehabilitation (14%), anesthesiology (14%), or internal medicine (13%); about one third are classified as other (17%) or unknown (14%). Physical or pain medicine and rehabilitation and anesthesiology are the most over-represented specialties in the top centile, with each accounting for just 1% of providers across all centiles. Family medicine and internal medicine are slightly over-represented in the top centile, and account for just 13% and 8% of providers, respectively, across all centiles. Hospice and critical care specialists accounted for less than 1% of both the top centile group and across all providers.”

“Among the top centile of patients receiving opioids, the most common recent primary diagnostic indication was a “back problem,” followed by “other connective tissue disease,” “other aftercare,” “other nervous system disorders,” and “unclassified” … Less than 20% of patients in the top centile receiving opioids had any diagnosis of malignant cancer during the study period (including patients with cancers currently in remission).”

Opioid prescribing in the United States quadrupled from 1999 to 2010. The study reported that one national pharmacy chain identified 42 providers, out of nearly one million, who prescribed excessive levels of opioids and had a high number of patients who paid cash. The national pharmacy chain requested documentation justifying their level of prescribing but only six responded with medically justified reasons. The national pharmacy chain did not allow opioid prescriptions to be filled by the remaining 36 providers who did not respond or did not provide justification.

The researchers reported: “Between 2003 and 2017, an average of 8.2 billion MMEs were prescribed by 669 495 providers to 3.9 million patients a year … These prescribing patterns correspond to an average of more than 700 MMEs daily for each provider, more than 120 MMEs daily for each patient, more than 50 MMEs daily for each prescription, and 8.9 million opioid prescriptions a year.”


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