TAYLOR PASKEY, BS
ASIF ILYAS, MD, MBA, FACS
Despite recent decreases in opioid prescribing, significant variation in prescribing based on geography and specialty persist nationwide.
The top 5 prescribers of opioids overall by Physician-type are: Family Practitioners (20.5%), Internists (15.7%), Nurse Practitioners (9.9%), Physician Assistants (9.3%), and Dentists (8.6%).
The top 5 prescribers of opioids (based on number of prescriptions per provider annually) are Pain Medicine (1314), Physical Medicine & Rehabilitation (1023), Orthopaedics (438), Family Medicine (428), and General Practitioners (328).
Between 2012 and 2018, despite a decrease in opioid prescribing by physicians by 17% there has been a paradoxical 71% increase in opioid prescribing by physician extenders.
Since 2012, the average U.S. opioid prescribing rate has decreased by more than a third. Nevertheless, the opioid epidemic remains a public health crisis with over 1.6 million opioid prescriptions dispensed in 2018 alone. The 2018 U.S. Prescribing Rates published by the Centers of Disease Control and Prevention (CDC) indicate that some counties have rates six times higher than the overall U.S. opioid prescribing rate, with upwards of 300 opioid prescriptions dispensed per 100 persons annually,1 as depicted in FIGURE 1. However, the geographical variation in prescribing rates is not the only pattern worth investigating. Ordering providers initiate every opioid prescription—so when comparing specialties side by side, how do they measure up?
Levy et al. analyzed opioids dispensed from 90% of U.S. pharmacies from July 1, 2016 to June 30, 2017 using the IQVIA Prescriber Profile. The data reflected 970,902 opioid prescribers, demonstrated in TABLE 1. The most represented specialty groups were internal medicine, dentists, nurse practitioners, and family medicine. The distribution of dispensed opioid prescriptions indicated family medicine physicians were the highest prescribers overall, responsible for 20.5% of dispensed opioid prescriptions, followed by internal medicine (15.7%), nurse practitioners (9.9%), physician assistants (9.3%), pain medicine (8.9%), and dentists (8.6%). The average number of opioid prescriptions per prescriber was an estimated 215.8 prescriptions. Notably, the top 4 specialties having the highest average number of prescriptions per provider were pain medicine, physical medicine and rehabilitation, orthopaedics, and family medicine.2 (TABLE 1) This study also compared opioid prescribing from 2012 to 2018 among specific providers. Primary care physicians had demonstrable improvement in prescribing patterns, as their opioid prescriptions decreased from 44.5% in 2012 to 37.1% in 2018. However, among non-physician opioid prescribers, opioid prescriptions almost doubled from 11.2% of dispensed opioid prescriptions in 20122,3 to 19.2% in 2018.2
A subset analysis of the above study was published by Nataraj et al. It identified the top 10% of opioid prescribers (~10,000 of the 970,902 prescribers in the above dataset), and clustered them based on prescriber specialty and region. Of the top 10%, specialties prescribing the most opioids were family medicine (32%), internal medicine (23%), and orthopaedics (11%).4 According to this 2018 review, emergency medicine had already begun trending down in its opioid prescribing patterns by 2012 and had some of the lowest median total opioid prescriptions as well.3,4 Examining geography, this analysis demonstrated consistent high-volume cross-specialty opioid prescribing in southern regions with opposite patterns in northeastern regions.4
In summary, cross-specialty prescribing patterns still merit exploration. Indeed, analyzing these patterns will help determine placement for supplemental targeted education and guided interventions. Nonetheless, recent years have welcomed progress; in 2018, the opioid prescribing rate was the lowest it had been in 13 years.1 However, there has been a paradoxical increase in opioid prescribing by physician extenders. Ongoing national interventions have included standardized prescribing guidelines, opioid tapering protocols, multi-modal pain strategies, and enhanced patient and provider (physician and non-physician) education, bringing us closer to conquering the opioid epidemic.
1. Centers for Disease Control and Prevention. (2020, March 5). U.S. Opioid Prescribing Rate Maps. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html.
2. Guy GP Jr.,, Zhang K. Opioid Prescribing by Specialty and Volume in the U.S. Am J Prev Med. 2018;55(5):e153-e155. doi:10.1016/j.amepre.2018.06.008
3. Levy, B., Paulozzi, L., Mack, K. A., & Jones, C. M. (2015). Trends in Opioid Analgesic– Prescribing Rates by Specialty, U.S., 2007–2012. American Journal of Preventive Medicine, 49(3), 409–413. https://doi.org/10.1016/j.amepre.2015.02.020
4. Nataraj, N., Zhang, K., Guy, G. P., & Losby, J. L. (2019). Identifying opioid prescribing patterns for high-volume prescribers via cluster analysis. Drug and Alcohol Dependence, 197, 250–254. https://doi.org/10.1016/j.drugalcdep.2019.01.012