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Interview

How Geographic Location Impacts Opioid Prescribing


June 06, 2019

By Julie Gould

lynaA recent study, published online in JAMA Network Open, examined how opioid prescriptions changed by state between 2006 and 2017 across the United States.  

According to the study findings, over the 12 years, “prescription duration increased in all states, averaging approximately 18 days; nearly 1 in 5 (18.1%) prescriptions were filled for a short term of 3 or fewer days, decreasing by 5.2% annually; approximately 1 in 3 prescriptions (33.6%) were filled for 30 or more days, increasing 3% annually; and high-dose prescriptions decreased by 53%, but half of these were still filled as extended-release and long-acting formulations.”

Lead study author, Lyna Schieber, MD, DPhil, epidemiologist on the Health Systems Team in the Division of Unintentional Injury Prevention, CDC, recently spoke with Pharmacy Learning Network and discussed current opioid addiction prediction models and highlighted knowledge gaps that still exist between opioid prescriptions and geographic location.  

To begin, please tell us a little about yourself and your research interests.  

I am an epidemiologist on the Health Systems Team in the Division of Unintentional Injury Prevention, CDC. This unit is where much of the opioid problem is being addressed within CDC.  My particular work has been on opioid prescribing in the United States and risk of HIV, viral hepatitis B or C infection with opioid addiction and overdose. I am passionate about clinical and scientific issues in public health and recognize the importance of addressing culture diversity when responding to the opioid epidemic. 

I received my MD degree from the Medical College of University of South China in 1986.  Subsequently, I served as an obstetrician and Gynecologist in China for 4 years. I became a medical research scientist at Oxford University in the U.K. from 1991 to 2004, earning a DPhil (equivalent to a PhD in the U.S.) in Obstetrics and Gynecology research in 1997 and worked on human genomic epidemiology of infectious diseases after that until 2004, when I was invited to join the CDC as a public health career development fellow.  Since then, I studied human genomics on influenza and viral hepatitis and integrated this into CDC policies.   

Can you briefly discuss what is used to predict opioid addiction among patients that receive a prescription?

We do know from other studies that the risk of opioid use disorder (commonly called “addiction”), overdose, and death increases as prescription opioids are taken in higher daily dosages, for longer periods of time, or as extended-release/long-acting formulations. The duration of use appears at this time to be the strongest predictor of opioid use disorder and overdose.  Each additional week of use has been associated with a 20% increased risk in the development of an opioid use disorder or occurrence of an overdose. Dosage is also important. Overdose risk is dosage-dependent, doubling as a person increases their dose from 50 to 99 morphine milligram equivalents (MME) per day.  The risk of overdose increases up to nine times as high at ≥100 MME per day compared at ≤20 MME per day. Use of extended release/long-acting agents also increases risk of overdose.  Unintentional overdoses are twice as likely to occur in those starting opioid therapy with extended-release/long-acting compared with those starting therapy with immediate-release opioids.  

How large is the patient population addicted to opioids? How do opioid prescriptions and geographical area compare?

In 2017, 3 million (1.5%) Americans aged 12 or older were addicted to opioids.  Most of these, 2.5 million (1.2%), were addicted to prescription opioids. Resource: https://www.samhsa.gov/data/report/slides-2017-nsduh-annual-national-report 

I am sharing data from SAMHSA on state comparison of percentage of population aged 12 or older addicted to prescription opioids in 2016 and 2017. 

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Resource: https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHsaeMaps2017/NSDUHsaeMaps2017.pdf 

Can you briefly highlight the findings of your study? 

  1. An estimated all-state average of 233.7 million (state-by-state range from 191.2 to 255.2 million) opioid prescriptions were filled in retail pharmacies in the U.S. for all ages and sex each year between 2006 and 2017.
  2. Across these 12 years, duration per prescription significantly increased by an average of 3% per year in all states and the District of Columbia. The prescribing rate per 100 people for prescriptions filled for ≥ 30 days increased significantly in 39 states by an average 3% per year.   
  3. Between 2006 and 2016, the amount of opioids prescribed in morphine milligram equivalents (MME) per person for states first increased, and then fell back to 2006 level.  It then declined by 13% as a one-year drop from 2016 to 2017.  
  4. All-state analysis indicated that nearly one in five prescriptions were filled short-term for ≤ 3 days.  Short-term prescription fills decreased by about 40% over these 12 years.  Meanwhile, about one in three prescriptions were filled for ≥ 30 days, and these increased by more than one third during this period. 
  5. High-dose prescriptions (≥ 90 MME/day) decreased 53%, but many were for extended-release or long-acting formulations.  These formulations accounted for nearly one in ten (9.2%) of all opioid prescriptions filled.
  6. Substantial (two-to-three-fold) variation was found among states for five of the six key prescribing metrics studied.

What knowledge gaps still exist between opioid prescriptions and geographic location?

There is substantial variation among states for these key metrics of prescription-writing. The variation among states is 2-3 fold, depending on the metric. Additional research would be needed to determine which state laws and regulations, if any, were most responsible for the changes we reported.  Physician opioid awareness and education especially should be studied, as well as other factors.

What are the major takeaways health care providers can learn from the findings of your study?

This study offers some good news on national efforts to reduce the overprescribing of opioids. Several measures decreased significantly, in agreement with the CDC Guideline.

The good news is that the amount of opioids prescribed in MME per person declined in 22 states and the District of Columbia by an average of 13% between 2006 and 2017.

But this was not true for long-term prescriptions ≥ 30 days.  About one in three prescriptions were filled for long-term opioids, significant increased for 39 states.  This is of great concern. Approximately 20% of individuals receiving long-term opioid therapy develop addiction.

There is growing evidence that prescription opioids are not superior to non-opioid treatment strategies for chronic pain.  Opioid treatment did not reduce pain more than non-opioid treatments. 

Clinicians generally do find time to read about new studies and recommendations.  As new information about opioids and their recommendations are published, clinicians should continue to consider the use of opioids in their practice, especially how they might improve patient pain management and incorporate recommendations for non-opioid modalities such as such as exercise and cognitive behavioral therapy.

How can they take these findings and implement them into practice? Specifically, how can a pharmacist help address opioid prescriptions and opioid abuse in their state/location?  

Knowing a state’s opioid prescribing trends according to these specific metrics could help state health officials modify and expand their opioid misuse prevention and treatment programs through legislation, regulations, enforcement, surveillance, and education. The magnitude, severity, and chronic nature of the opioid epidemic in the U.S. is of serious concern to healthcare providers, and clinicians and pharmacists are on the front line of breaking this epidemic.  The government and general public are also important. Clinicians should constantly strive to improve a patient’s pain management, including opioid prescribing and non-opioid modalities. 

Is there anything else you would like to add?

It’s important to separate deaths from prescription opioids vs. illicit opioids (e.g., heroin, illicitly-manufactured fentanyl), although both can cause death.  The number of opioid-related deaths from all sources increased dramatically since 2012, but the number of deaths each year associated with use of prescription opioids alone has not increased since then.  

This may be partly due to an overall decline in the amount of opioids prescribed.  Meanwhile, the relatively recent rise in opioid-related deaths may be due to greater use of illicit drugs, especially if less costly than prescription opioids. Death may then result either from the use of an illicit drug itself, or taking illicit drugs in combination with prescription opioids.  As indicated in a CDC MMWR overdose death report in 2017, people died from taking heroin or fentanyl either alone (59%) or combined with prescription opioids (19%). 

Prescription opioids are often the “gateway” drugs for those heroin users. Studies have shown that 66% to 83% of new heroin users report that their addiction began with the misuse of a prescription opioid. Accordingly, both illegal and illicit street drugs and prescription opioids need to become less available.  This highlights the complexity of solving the current epidemic.  Closing the path to opioid use disorder and stopping the epidemic will require addressing over-prescription of legal opioids, reducing the availability of illicit and illegal opioids, and getting patients with opioid use disorder into treatment. 

Reference: 

Schieber LZ, Guy GP, Seth P, et al. Trends and Patterns of Geographic Variation in Opioid Prescribing Practices by State, United States, 2006-2017 [published online March 15, 2019]. JAMA Netw Open. 2019;2(3):e190665. doi:10.1001/jamanetworkopen.2019.0665

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