Opioid prescriptions see drop
CDC says can’t link fewer prescriptions to illegal drug use
WASHINGTON — The amount of opioid painkillers prescribed in the United States peaked in 2010, a federal analysis has found, with prescriptions for higher, more dangerous doses dropping the most sharply — by 41 percent — since then.
But the analysis by the federal Centers for Disease Control and Prevention also found that the prescribing rate in 2015 remained three times as high as in 1999, when the nation’s problem with opioid addiction was just starting. And there is still tremendous regional variation in how many opioids doctors prescribe, with far more prescribed per capita in parts of Maine, Nevada and Tennessee, for example, than in most of Iowa, Minnesota and Texas.
Overall, the analysis found that the amount of opioids prescribed fell 18 percent from 2010-2015, though it increased in 23 percent of the counties.
“We still have too many people getting medicine at too high a level and for too long,” said Dr. Anne Schuchat, acting director of the CDC. She noted that the quantity of opioids prescribed in 2015 would be enough to provide every American with roundthe-clock painkillers for three weeks.
A flurry of recent attempts to tamp down opioid prescribing — including CDC guidelines issued last year on prescribing the drugs for chronic pain and new state and insurer limits on how many pills doctors can prescribe — are not reflected in the analysis, which did not look beyond 2015.
But earlier actions, like state crackdowns on pain clinics and prescribing guidelines released by the Department of Veterans Affairs in 2010, may have contributed to the declines. The quantity of prescribed opioids fell in 85 percent of Ohio counties from 2010-2015, for example, as the state tightened regulations for pain clinics and started requiring clinicians to check databases to see whether patients were getting opioid prescriptions elsewhere.
The decline documented in the analysis also coincided with the federal government’s tightening of prescribing rules in 2014 for one of the most common painkillers: hydrocodone combined with a second analgesic, like acetaminophen.
In many states, including Ohio, restrictions on prescribing have coincided with staggering increases in overdose deaths from heroin and its far more powerful, synthetic relative, fentanyl. But Schuchat, pointing to several studies, said the CDC had found no clear-cut evidence that tighter prescribing played a role in the rising use of illicit opioids.
“We do know that when you start people on prescription opioids, the risk of unintended consequences and illicit use goes up,” Schuchat said. “But our staff has done intensive analyses to see whether changing policies for prescription drugs shifts people into illicit use, and the answer is no.”
While the analysis found that the amount of opioids prescribed per capita remained extremely high in many counties in 2015, some experts warned that averages could be misleading.
“An enormous amount of opioid volume is driven by a very small number of prescribers,” said Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. “They need to be intervened upon, targeted with educational outreach and, if necessary, professional or regulatory sanction. My sense is that’s not yet happening enough.”
Attempts to restrict opioid prescribing have upset many patients with chronic pain who say their needs are being ignored in the rush to stamp out the addiction epidemic.
“One group I think that has been affected without question is patients who are compliant with their regimen, who have a clear diagnosis and have been managed appropriately, but now find they can’t continue to receive opioids that allowed them to continue to function,” said Dr. Daniel Carr, director of Tufts Medical School’s program on pain, research education and policy.
But others say there is very little evidence to suggest opioids are effective for chronic pain that is not caused by cancer. The CDC prescribing guidelines published last year, which were opposed by many pain doctors and drug industry groups, recommend that doctors first try ibuprofen or aspirin to treat pain. The guidelines, which are nonbinding, also recommend limiting opioid treatment for short-term pain to less than a week.
“If you are on opioids longer than three months, your risk of being addicted increases by 15-fold,” Schuchat said.
One challenge in cutting opioid use, Alexander said, is that while insurers are placing new restrictions on opioid prescribing, many are strictly limiting or not yet covering alternative treatments for pain, such as physical therapy and acupuncture, or even other types of medication that could help.
Despite the national decline in the amount of opioids prescribed, the analysis found that the average number of days that opioid prescriptions were meant to last actually increased in 73 percent of the counties from 2010-2015. Overall, the average supply grew about 14 percent, to 17.7 days’ worth from 15.5. Schuchat said that could be because fewer doctors were starting new patients on opioids — initial prescriptions are often smaller — and doctors instead were prescribing largely to longtime pain patients.
The top-prescribing counties as measured by the amount of opioids prescribed per capita — including Surry County, N.C., and Claiborne County, Tenn. — prescribed six times more opioids per capita in 2015 than the lowest-prescribing counties.
One weakness of the study, as Carr and the CDC researchers pointed out, was that it could not evaluate the reasons for prescriptions, and how often they were given for chronic pain versus acute or end-of-life pain.
The analysis also did not include opioid prescribing data from about 13 percent of the nation’s counties because it was either incomplete or unavailable.
This file photo shows hydrocodone-acetaminophen pills, also known as Vicodin, arranged for a photo Feb. 19, 2013, at a pharmacy in Montpelier, Vt.