John Waters, BS Jenna Adalbert, MPH Asif Ilyas, MD, MBA, FACS
SUMMARY POINTS:
Understanding patterns of prescription distribution is key for targeting harm reduction efforts in the opioid epidemic.
Since implementation of the PDMP, annual opioid prescriptions across Pennsylvania has dropped by a third.
Consistent with national trends, Pennsylvania’s women receive more opioid prescriptions than men, and individuals over 65 years of age received the most opioid prescriptions..
Unlike national trends, Pennsylvania private insurers pay for the majority of opioid prescriptions followed by Medicare.
Introduction
In 2014, enough opioid analgesics were prescribed to medicate every person in the United States (US).1 The overall U.S. opioid prescribing rate has steadily declined since 2012, including in Pennsylvania where the Commonwealth from being the 6th highest prescribing state in 2012 to the 26th highest by 2018.2 However, despite the decrease in opioid prescribing nationwide since 2012, opioid overdose deaths have more than doubled since 2010, particularly involving older Blacks and Hispanics in metropolitan areas.2,3 While opioid misuse continues to rise, a number of studies have indicated that policies restricting opioid prescription may ultimately be impacting the number of overdoses.4
Gaining an understanding of prescription opioid distribution patterns can allow for better targeting of laws and regulations as well as harm reduction strategies.5 Prescription Drug Monitoring Programs (PDMP) have been created by all states across the US to aid in these efforts.5,6 The Pennsylvania PDMP was initiated in 2016. This analysis will examine the age, gender, and form of payment for opioid prescriptions among Pennsylvania residents from 2016 through the first quarter of 2020. Trends within each of these groups will be correlated to relevant state and federal policies, as well as changes to prescription guidelines and investigate what policies may have been effective to decrease opioid prescriptions.
Overall Opioid Prescription Rates
There was an overall 33% decrease in overall quantity of opioids prescribed in Q1 2017 compared to Q1 2020.
Prescription Rates Between Males and Females
Figure 1 identifies prescription trends by gender between males and females. Limited information was available for individuals who are classified as neither male nor female. The rate at which men and women are prescribed opioids from 2016 to 2020 is similar, but women tend to receive more prescriptions than men. This is consistent with national data that women are more likely than men to be prescribed opioids.7,8 The explanation for increased rates in women is unclear, but it is suspected it may be due to greater healthcare utilization, perceptions of pain, and greater prevalence of chronic conditions in women as compared to men.8,9
Figure 1. Prescriptions of opioids per 100,000 people by gender.
Prescription By Age Cohort
Figure 2 shows prescriptions by 100,000 population by age cohorts. Similar to trends in gender, prescriptions by age cohort for Pennsylvania residents are consistent with national data.10 Over the past decade, the 65 and older cohort has had the smallest decrease in opioid prescription of only 16% and are more than twice as likely to receive opioid prescriptions than those in the 15-24 age cohort. 11,12
Figure 2. Prescriptions of opioids per 100,000 people by age cohort.
The sudden decrease in prescriptions around 2017 in both Figure 1 and Figure 2 is likely in tandem with the Department of Health and Human Services (HSS) recognizing the rising rate of opioid overdoses as a public health emergency in 2017.13 The effect of this declaration is consistent in most states as opioid prescriptions by physicians have decreased by a third.1
Prescription By Payment Type
Figure 3 details Pennsylvania patients means of payment for prescriptions ranging from private insurance, uninsured (out-of-pocket), Medicaid, Medicare, workers compensation, military benefits, and unknown sources of payment. The number of opioid prescriptions by health plan is consistent with the number of people in each health plan (i.e. ~50% of opioid prescriptions are given to persons with private insurance and ~50% of the population is covered by private insurance).
Forms of payment had similar decreasing trends to age and gender cohorts in 2017, but the greatest impact was evident in the private insurance and Medicare populations. Nationally, Medicaid has been the most common payor for opioids, and prior to the HSS public health emergency declaration, nearly a third of Medicaid Part D beneficiaries were receiving opioids.14 In contrast in Pennsylvania, most opioids prescriptions were paid for with private insurance. Pennsylvania prescription guidelines appears to have had a major impact on private insurance paid opioid prescriptions.16 Inconsistencies in Medicaid-paid opioid prescriptions in Pennsylvania compared to other states was likely dependent on Medicaid-expansion being independently and variably implemented from state to state.
Figure 3. Prescriptions of opioids per 100,000 by means of payment.
Discussion
Analysis of the Pennsylvania PDMP demonstrates a number of findings. Most prominently, there has been a one third decrease in annual opioid prescribing in Pennsylvania during the first 3 full years of its implementation. Consistent with national data, Pennsylvania’s women receive more opioid prescriptions than men, and individuals over 65 years of age received the most opioid prescriptions. Unlike national trends, Pennsylvania private insurers pay for the majority of opioid prescriptions followed by Medicare-paid.
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