Just a few hundred prescribers responsible for half of U.S. opioid doses

(Reuters Health) - The top 1% of opioid prescribers in the U.S. are responsible for 49% of all opioid doses and 27% of all prescriptions, according to a study that suggests efforts to combat overuse of prescription painkillers should concentrate on these heavy prescribers.

FILE PHOTO: A full syringe, empty syringe and spoon sit on the roof of the car in which a man in his 20's overdosed on an opioid in the Boston suburb of Lynn, Massachusetts, U.S. August 14, 2017. REUTERS/Brian Snyder/File Photo

The study authors examined data on 8.9 million opioid prescriptions for 3.9 million patients from 2003 to 2017, based on records from an average of 669,495 providers each year.

By 2017, the top 1% of providers prescribed a yearly average of 748,000 “morphine-milligram equivalents” (MMEs), a standardized way of describing doses of different types of opioids. That volume was roughly 1,000 times more than the providers in the middle percentiles, researchers report in The BMJ.

“We did not know that opioid prescribing was so extraordinarily concentrated in the U.S., well beyond what we see for other medications,” said co-author Keith Humphreys of Stanford University in California.

Guidelines from the Centers for Disease Control and Prevention recommend no more than 50 MMEs per day for less than seven days to treat chronic pain, the study team notes. The prescribing pattern of the top 1% of prescribers adds up to an average of 700 MMEs daily for each provider and more than 120 MMEs daily per patient, they calculate.

“On the positive side, our study also showed that most U.S. physicians are now prescribing consistent with guidelines,” Humphreys said by email. “Taken together, these findings suggest that safer prescribing initiatives can be much more focused on the most prolific prescribers.”

There are two main ways policies can try to curb opioid prescribing, Humphreys and colleagues note.

Broad policies aimed at all medical providers might limit things like total MMEs prescribed and total doses per patient.

Narrow policies aimed just at heavy prescribers, by contrast, might require certain providers to document medical exams and follow-up visits before and after prescribing opioids to cut down the potential for providers to run so-called “pill mills.”

The findings suggest targeted policies might make a big dent in over-prescribing without limiting the ability of the vast majority of providers to prescribe reasonable amounts of opioids to manage pain, the study team concludes.

Researchers lacked medical records to determine whether some instances of prolific prescribing might be medically appropriate. However, family medicine practitioners were the most common specialty in the top 1%, suggesting at least some prescriptions might not be needed or might be for higher doses than necessary.

That’s because people with severe pain after injuries or operations would be more likely to get high-dose opioid prescriptions from specialists.

It’s also possible the sickest patients go to certain providers, concentrating high-dose opioid prescribing among a handful of clinicians, said Brendan Saloner, of the Johns Hopkins Bloomberg School of Public Health in Baltimore, who wasn’t involved in the study.

Variation takes place across all types of medical practice, and some of this is clinically appropriate, Saloner said by email.

“It is undeniable that opioid prescribing also reflects a fair amount of prescriber discretion,” he added.

A very small number of prescribers are probably reckless in their prescribing, and that can place patients at unnecessary risk, Saloner said. This might include some of the top 1% of providers in the study.

“That said, there are probably also some prescribers that are too reluctant to prescribe opioids to patients who could use pain relief,” Saloner added. “It’s impossible to know the exact breakdown with this study because clinical appropriateness was not assessed.”

SOURCE: The BMJ, online January 29, 2020.