Cutbacks by Some Doctors Halved New Opioid Prescriptions Over 5 Years

By Gene Emery

(Reuters Health) - The rate of first-time opioid prescriptions declined 54% between 2012 and 2017 in the U.S., largely because many doctors stopped prescribing the painkillers, according to a study of more than 86 million people covered by private insurance.

The number of prescriptions for three days' worth of an opioid - the recommended amount for an initial prescription - fell 57% during those five-and-a-half years and there was a 68% decline in the number of prescriptions offering seven days of opioid therapy.

The decline came because the number of doctors willing to prescribe an opioid drug to a patient for the first time dropped 29% during that period, researchers reported March 13 online in the New England Journal of Medicine.

Nonetheless, a core group of physicians continued to write high-risk prescriptions - with higher doses or covering more than seven days - for people who had never used opioids before.

"This study offers some much-needed good news about opioids," lead author Wenjia Zhu of Harvard Medical School in Boston told Reuters Health in a telephone interview. The substantial decline "says that a large number of providers have responded to the opioid crisis by changing their behavior."

"We are making progress. That's something that can give hope to many people," senior study author Nicole Maestas, an economist and associate professor of healthcare policy at Harvard said. "Providers are getting the message. We can quibble about who's getting how much of the message and who's getting too much of the message. But the top-level point here is that some progress is being made here."

Analyzing U.S. insurance claims data for people over age 15, the researchers identified nearly 64 million without a previous opioid prescription and tracked the proportion of these from month to month who received a first-time opioid prescription. In July 2012, 1.63% of these patients got a new prescription. By December 2017, the rate had dropped to 0.75%. Overall, nearly 11 million people received their first opioid prescription during that time span.

The bad news seems to be that some doctors haven't throttled back on the opioid prescribing patterns while others appear to have been spooked into not prescribing the painkillers at all when they might be useful, albeit in lower doses or for shorter durations.

The overall decline "is probably a good thing. At the same time, it's not clear the optimal place is no opioid therapy," Maestas told Reuters Health. "What we were hoping to see is a large number of providers moving to safer prescribing with low doses and short duration."

It's hard to overstate the seriousness of the opioid epidemic.

By 2016, opioid overdoses were claiming 115 lives each day, and people taking prescription opioids to relieve pain were a key part of the problem. Most heroin users start with prescription opioids, and using an opioid for only six days increases the odds of becoming addicted.

In March 2016, the Centers for Disease Control and Prevention issued guidelines encouraging doctors to generally limit patients to a three-day supply. It also advised caution in prescribing more than 50 morphine-milligram equivalents per day.

The CDC advisory did have some effect. While 4.3% of the insured population was getting opioids from July 2012 to March 2016, the rate had declined by 16% to 3.6% in December 2017.

They "didn't seem to produce a big decline. The declines really preceded the CDC guidelines by a lot," Maestas said. "They may have crystalized the direction everyone was trying to head, amplifying the message that opioid prescription can be dangerous."

One drawback to the study was the team couldn't tell if an opioid prescription was appropriate for the patient's pain.

"It is difficult to ascertain the severity of pain from claims data alone, and prescriptions that deviate from the CDC guidelines are not necessarily medically inappropriate, although, as the CDC notes, they are associated with a higher risk of adverse outcomes," they said.

SOURCE: https://bit.ly/2VMTWMD

N Engl J Med 2019

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