Dr. Feel Good: Just a few Hundred Prescribers Responsible for Half of U.S. Opioid Doses

            My first reaction was ‘who are these nuts?’ But then I think, heck, this could be you, could me, could be our colleagues etc. The article reports on a study and reports:

“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”.

            The study comes from the British Medical Journal titled “Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study (2).” The study examined data on 9 million opioid prescriptions (benzodiazepines and opiates) for 4 million patients from 2003 – 2017 from the records of 670,000 providers. The study identified ‘high prescribing opioid providers and suggested that interventions targeted at high prescribing opioid providers should be prioritized for three reasons:

  1. most of the prescriptions written by the majority of providers (not the high prescribing providers) are below recommended thresholds, suggesting that most US providers prescribe opioids carefully, thus potentially burdensome, constraints on this set of providers are unlikely to be beneficial – the majority of opioid prescriptions by this group are probably appropriate, any increase in restrictions is more likely to reduce appropriate use rather than prevent those of concern
  • the top centile of providers is stable over time, which suggests that interventions targeted at this group will produce sustained results.
  • the top centile of providers accounts for a disproportionate number of patients receiving high amounts of opioids , and interventions targeted here will reach these high risk patients efficiently.

Guidelines from the Centers for Disease Control and Prevention (3) recommend no more than 50 Morphine Milligram Equivalents (MMEs) per day for less than seven days to treat chronic pain. The study found that 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. This likely a combination of having the sickest patients and a small number of providers who are reckless in their prescribing. And then there is the patient for whom you just filled the script, but whose cat happened to knock the bottle of Vicoden into the sink, ate half, and the other half went down the drain. Aka – the drug-seeking patient which the study didn’t account for. While the study did find a small portion of providers account for a highly disproportionate proportion of opioids, it also found that most of the prescriptions written by the majority of providers are below recommended thresholds.

Disclaimer: Use of the term ‘provider’ was used only because both the article and actual study used it and didn’t denote whether or not it was physicians or mid-level providers prescribing. I know how many of my physician colleagues feel about the term.

References:

  1. https://www.reuters.com/article/us-health-opioids-prescribing/just-a-few-hundred-prescribers-responsible-for-half-of-u-s-opioid-doses-idUSKBN2002VZ
  2. https://www.bmj.com/content/368/bmj.l6968)  
  3. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm

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Robert Duprey MD

Robert P. Duprey Jr studied medicine as a 2nd career medical student who went to medical school in his 40’s after honorable discharge and ‘retirement’ from 25 years in the US Military (USCG & US Army). He was a registered nurse (RN) with specialty training as a psychiatric RN in the US Army for 15 years. During this time he also became a Master’s level psychotherapist in 2002. While on US Army active duty he also became a Psychiatric Nurse Practitioner while working full time in 2011. He served as a Psych NP on active duty, to include a combat tour in Iraq, until his ‘retirement’ in 2014 and moved to Philippines with his 3 children. At this time he started medical school overseas at Oceania University of Medicine based out of Samoa accredited by Philippine Accrediting Association of Schools, Colleges and Universities (PAASCU). He continued to work as a Psych NP throughout medical school to support his children and to not have to take out loans for medical school tuition. Originally from Rhode Island, he completed medical school clerkship rotations throughout the USA with a graduation in May 2019 earning the esteemed credential of MD. He has successfully completed USMLE Steps 1, 2CS, and 2CK. He will take Step 3 this September as he applies for Psychiatry Residency. Having been and RN, NP and now MD, he is a believer of Physician led multidisciplinary healthcare teams