Deaths from opioid overdoses have increased dramatically over the last decade. In 2017, the latest year for which the U.S. government has statistics on the trend, more than 47,000 Americans died of opioid overdoses.
One major factor contributing to the rising number of people who get addicted to opioids and die from overdoses is the increasing number of prescriptions written by doctors to treat pain. Overdose deaths related to such prescriptions increased five times from 1999 to 2017.
But according to the latest study looking at opioid prescribing patterns, published in the New England Journal of Medicine, recent efforts to address the rising number of prescriptions may be working to limit the number of opioids that doctors dispense.
In the study, researchers led by Wenjia Zhu, a fellow in the department of health care policy at Harvard Medical School, and Nicole Maestas, an associate professor also in the department, found that new prescriptions for opioids dropped by about half from 2012 to 2017. The researchers analyzed national claims data from Blue Cross-Blue Shield from more than 86 million people to monitor prescriptions for opioids. They calculated the monthly incidence of new opioid prescriptions as the percentage of enrollees getting a prescription for an opioid who had never received such a prescription or who had not received one in the previous six months. During the study period, the monthly incidence of opioid prescriptions dropped by 54%, and the number of doctors prescribing opioids for the first time to patients or to people who had not had them prescribed in the last six months also declined, from 114,043 to 80,462.
However, Maestas and her team found that physicians who continued to prescribe opioids were more likely to prescribe them for longer periods and at higher doses than the Centers for Disease Control and Prevention (CDC) guidelines currently recommend for first-time users.
“On the one hand, we are very much encouraged,” says Maestas. “The study does suggest that every month, fewer people are being started on opioids, which means the risk of developing opioid addiction and other adverse outcomes is lower because of that. Our enthusiasm is a bit tempered, however. One group of providers didn’t seem to get the message.”
The research team focused on the time period between 2012 and 2017 because in 2016, the CDC issued revised guidelines designed to address the burgeoning opioid epidemic, advising doctors that opioids should not be the first drugs used to treat most cases of pain and advising how to prescribe the drugs in ways that might reduce the risk of addiction. For people prescribed opioids for the first time, the CDC recommends starting with a three-day supply and at the lowest dose. In the study, among the doctors who continued to prescribe opioids, 57% were prescribing them for longer than three days and at higher doses to first-time users.
By focusing on first-time prescriptions, or prescriptions for people who hadn’t been given opioids in the last six months, the team revealed areas where recent efforts to control opioid abuse are falling short. Programs to monitor prescriptions by doctors, for example, are mostly centered at hospitals, and Maestas found that many of the physicians continuing to prescribe outside of the CDC guidelines were primary care doctors in private practice; 80% of them prescribed opioids for longer than three days and at higher doses for people getting the painkillers for the first time.
Initial prescriptions are a reasonable place to focus in trying to control the opioid epidemic, she says, since legitimate prescriptions for the drugs are often the gateway to addiction and abuse. “We’re looking at the beginning of the road and saying, ‘Let’s stop that person who just had surgery from having a bottle of leftover pills sitting in the medicine cabinet,’” she says.
The study also raises another concern about the effect that more awareness about opioid abuse is having on the treatment of pain. Rather than prescribing at lower doses and for shorter periods of time, about 30% of doctors did not prescribe opioids at all to people who had not used them before. The study did not delve into whether these people were provided with other options to manage their pain, but Maestas says the pendulum may be swinging from one extreme of over-prescribing opioids to perhaps, in some cases, under-managing pain.
“We have been [too] light on opioid control policies for a long time,” she says, adding that the current study’s results should help to refine such advice in coming years. “It’s good news that some providers are changing their behavior, but not all providers are. The data suggest that that some could use additional education around this issue.”