The volume of prescription opioids dispensed in retail pharmacies in the United States has declined 21% in recent years as attempts have been made to reduce unnecessary pain reliever use, but the rate of decline has varied widely by patient type and species of the doctor, according to a study.
In a brief report published December 28 by the Annals of Internal Medicine, researchers with the nonprofit RAND Corp reported an analysis of opioid prescriptions for two periods, 2008–2009 and 2017–2018.
The researchers tried to rate total opioid use rather than just tracking the number of pills dispensed. Therefore, they used the daily requirement and total daily dose to calculate morphine milligram equivalents (MME) per capita for opioid prescriptions, write Bradley D. Stein, MD, PhD, MPH, the study’s lead author and senior medical researcher at RAND Corp, and its co-authors in their work.
For the study, the researchers used data from the consulting firm IQVIA, which they claim to cover around 90% of US prescriptions. Total opioid volume per capita based on prescriptions redeemed at retail pharmacies decreased from 951.4 million
(In 2020, IQVIA separately said that prescription opioid use per adult in this country rose from an average of 16 pills, or 134 MME, in 1992 to a high of about 55 pills per person, or 790 MME, in 2011. By 2019 the Opioid use per adult had decreased to 29 tablets and 366 MME per capita.)
The RAND report found significant differences in opioid volumes across insurance types, including a 41.5% decrease (636.5 MME to 372.6 MME) for those covered by commercial health insurance. This exceeded the 27.7% decrease seen in Medicaid members (646.8 MME to 467.7 MME). The decrease was smaller (17.5%; 2780.2 MME to 2294.2 MME) for those on Medicare who used the most opioids as the group.
“Works almost like a Rorschach test”
The causes of the decline are easy to guess, although definitive conclusions are impossible, Stein told Medscape Medical News.
Considerable work has been done in recent years to change the mindset of doctors, researchers, and lawmakers about opioid prescribing. The aggressive promotion of prescription pain relievers, particularly OxyContin from Purdue Pharma, in the 1990s is often cited as the trigger for the national opioid crisis.
In response, states created databases known as prescription drug surveillance programs. The Centers for Disease Control and Prevention issued guidelines in 2016 aimed at reducing the unnecessary use of opioids. The guidelines identified how other medicines could treat chronic pain without increasing the risk of addiction. The Choosing Wisely campaign, run by a foundation of the American Board of Internal Medicine, also offered recommendations on how to limit opioid use. And insurers have limited access to opioids due to the prior approval process. As a result, based on their own experience and research interests, researchers will make their own guesses about the causes of the decline in opioid prescriptions, Stein said.
“It works almost like a Rorschach test,” he said.
Stein’s group also looked at trends in medical specialties. They found the greatest reduction between 2008–2009 and 2017–2018 among emergency doctors (70.5% decrease from 99,254.5 MME to 29,234.3 MME) and psychiatrists (67.2% decrease from 50,464.3 MME to 16,533.0 MME) ) and oncologists (59.5% decrease from 51,731.2 MME.). 20,941.4).
In terms of surgeons, the RAND researchers found a decrease of 49.3% from 220,764.6 to 111,904.4. For dentists, they found a decrease of 41.3% from 22,345.3 to 13,126.1.
Among pain specialists, they found a decrease of 15.4% from 1,020,808.4 MME to 863,140.7 MME.
Among adult primary care clinicians, Stein and his colleagues found a 40% decrease from 651,489.4 MME in 2008–2009 to 390,841.0 MME in 2017–2018.
However, one of the groups tracked in the study increased the volume of opioid prescriptions issued: Advanced practice providers that included scripts for the drugs increased 22.7% from 112,873.9 MME to 138,459.3 MME.
Stein said he suspects this increase reflects a shift in the nature of primary care practice, with nurses and medical assistants taking a more active role in treating patients. Some of the decline seen among primary care doctors treating adults may reflect a shift in how medical staff at a practice issue opioid prescriptions.
Still, the trends generally seen by Stein and co-authors are encouraging, even if further study of these patterns is needed, he said.
“This is one of those papers that I think raises as many questions as it offers answers,” he said.
Nobody takes less opioids. I can safely say that. You only get them from other sources.
What is missing
Maya Hambright, MD, a family doctor in New York’s Hudson Valley who was primarily addictive in response to the opioid overdose crisis, observed that the decrease in the total amount of prescription pain medication prescribed does not necessarily translate into a decrease in opioid use
“Nobody is taking less opioids,” Hambright told Medscape Medical News. “It’s easy to say. You only get it from other sources.”
CDC data supports Hambright’s view.
An estimated 100,306 people in the US died of drug overdoses in the 12 months ended April 2021, a 28.5% increase from the 78,056 deaths for the same period last year, according to the CDC.
Hambright said more doctors need to be involved in prescribing drug-assisted treatment (MAT).
The federal government last year relaxed restrictions on a requirement known as an X-Waiver. Certain clinicians have been exempted from training requirements, as explained on the Frequently Asked Questions page on the Substance Abuse and Mental Health Service (SAMHSA) website.
(SAMHSA says laws are needed to abolish the waiver. By December 30, 2021, more than half of the members of the U.S. House of Representatives were listed as sponsors of the Mainstreaming Addiction Treatment (MAT) Act (HR 1384), which concluded X waiver. The bill is backed by 187 Democrats and 43 Republicans.)
Too many doctors right now are shy of offering MAT, Hambright said.
“People are still scared of it,” she said. “People don’t want to deal with addicts.”
But Hambright said the initial time is well worth investing in having the necessary conversations with patients about MAT.
“After that, it’s so easy. People feel better. They are healthier. It’s amazing,” she said. “You change life.”
The research was supported by grants from the National Institutes of Health. Stein and co-authors reported no relevant financial relationships.
Anna Intern Med. Published online December 28, 2021. Summary
Kerry Dooley Young is a freelance journalist based in Washington, DC. She is the key topic leader on patient safety issues for the Association of Health Journalists. Young previously covered health policy and federal budget for the Congressional quarterly / CQ call and the pharmaceutical industry and food and drug administration for Bloomberg. Follow her on Twitter at @kdooleyyoung.
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