A national call for restraint in opioid prescribing has yielded dramatic progress in clinician prescribing patterns, with some notable room for improvement, according to a study by the Harvard Medical School showing a 54% drop in monthly opioid prescribing for patients who have never used these drugs or who had been off of them for at least six months.
Despite this decrease, the researchers note, a subset of physicians has persisted in prescribing opioids at concerning dosages and lengths. At the same time, others have ceased any new prescriptions for opioid pain relief, raising the question of whether some patients might be getting less than adequate treatment for their pain.
The study was based on an analysis of more than 86 million privately insured patients across the United States between 2012 and 2017. Of the nearly 11 million initial opioid prescriptions the study examined, 20% were written by dentists. While these prescriptions were indicated for dental pain, the study did not identify specific dental procedures for these claims.
First-time prescriptions are deemed an important gateway to long-term opioid use and misuse and have become a target for risk reduction, the researchers said, adding that their results are reassuring because of the significant drop though alarming because of the persistence of potentially inappropriate prescribing in some cases and undertreatment in others.
“The challenge we have in front of us is nothing short of intricate—curbing the opioid epidemic while ensuring that we appropriately treat pain,” said Nicole Maestas, PhD, senior investigator of the study and associate professor of healthcare policy in the Blavatnik Institute at Harvard Medical School. “It’s a question of balancing the justified use of potent pain medications against the risk for opioid misuse and abuse.”
The researchers cautioned that, because the insurance claims they examined lacked details about key specifics of the clinical encounter, their analysis was not designed to determine the appropriateness of physicians’ decisions to prescribe or withhold opioids. Still, they said, the patterns of prescribing raise some concerns.
Between 2012 and 2017, the monthly incidence of initial opioid prescriptions declined by more than half, from 1.63% to 0.75%, with fewer clinicians initiating opioids for patients who have never used these drugs or who have been off of them for at least six months, also known as opioid-naïve patients. The number of providers who prescribed opioids for these patients dropped by nearly 30%, from 114,043 to 80,462.
Among the shrinking number of physicians who did initiate opioid prescriptions, risky prescribing—defined as either a morphine-equivalent dose of 50 milligrams per day or more, or any dose prescribed for longer than three days—persisted at an average rate of more than 115,000 high-risk prescriptions per month out of 15.9 million opioid-naïve individuals.
A small portion of these high-risk prescriptions were particularly alarming, the researchers noted. More than 7,700 exceeded 90 morphine milligram equivalents per day, a dose that places patients at a substantially higher risk of both nonfatal and fatal overdose.
With the United States in the midst of a crippling opioid epidemic, spurred in large part by overuse of prescription opioids, the researchers set out to analyze trends in the rate at which opioid therapy was initiated among commercially insured patients. During the years covered by the study, physicians and policymakers were paying more attention to the dangers of opioids.
One major turning point during this time was the prominent release of prescribing guidelines in 2016 by the Centers for Disease Control and Prevention, which were meant to cut back on prescriptions of high-dosage and long-duration courses of opioids, the researchers said.
The researchers used de-identified insurance data clams from BCBS Axis, the largest collection of commercial insurance claims, medical-professional, and cost of care information. They estimated the percentage of opioid-naïve individuals receiving a new opioid prescription, the percentage receiving a long-duration or high-dose opioid prescription, and the number of clinicians who started any opioid-naïve patient on opioid therapy.
The sample consisted of 15,897,673 opioid-naïve patients each month, representing a total of 63,817,512 opioid-naïve individuals over the five-year study period. Above all, the researchers said, the findings underscore the need for further analysis into how clinical decisions are made about whether to use opioids and, if so, at what dose and for how long.
“The ultimate goal should be creating interventions that promote safer prescribing by balancing the importance of pain relief with the risks of opioid treatment, rather than an all or nothing approach,” said Maestas.
The study, “Initial Opioid Prescriptions Among US Commercially Insured Patients, 2012-2017,” was published by The New England Journal of Medicine.