There are probably few health care professionals who are unaware of the concerns about the apparent overprescription of opioids. However, we have had only limited information on how good a job physicians may actually be doing in prescribing these medications.
The report of a new study by the pharmacy benefit manager Express Scripts provides a useful picture of how opioids are currently being prescribed in the US.1 The study examined the pharmacy claims of 6.8 million patients who filled at least one prescription for an opioid between 2009 and 2013. Sadly it offers very little good news about prescription of these drugs and many reasons to be concerned about what physicians are doing and their level of knowledge.
The only piece of what could be considered good news is that between 2009 and 2013 there was a 9.2% decrease in the number of patients filling prescriptions for opioids. Although at first glance this may appear to be a positive step, it is impossible to determine whether this was due to physicians being more appropriately discerning in prescribing these drugs or whether they are denying patients who may benefit from these drugs because of fears of drawing attention from regulatory authorities. That it might at least to some degree involve the latter is the finding that the reduction occurred among patients receiving prescriptions for a shorter term, defined by the study as the drugs being taken for less than 30 days over the course of the year. There was little change in the number of patients taking opioids for 30 or more days, considered by the study to be longer-term users.
Of great concern is the finding that 47% of new opioid users who were taking these medications for more than 30 days continued using them for at least 3 years. There is currently a debate over whether extended use of opioids is beneficial for chronic pain; there is limited evidence to support that it is. Findings from the Express Scripts study indicate that in many cases physicians are not reevaluating whether the opioid is effective but are simply continuing to prescribe it. It also raises the very real issue of the possibility that some of this ongoing use is due to addiction to the drugs.
That abuse and addiction is a problem is highlighted by the finding regarding the benefits of prescription drug monitoring programs. Only one state, Missouri, has not instituted such a program. (A New York Times article reported that opposition to doing so was led by a state senator who is also a family physician; he argues that drug monitoring programs are an invasion of privacy.2 The article also noted that this same physician-senator had expressed the not exactly enlightened opinion that if substance abusers “overdose and kill themselves, it just removes them from the gene pool.”) The report notes that residents of the 7 states neighboring Missouri filled opioid prescriptions in Missouri at 4 times the rate that residents of Missouri filled such prescriptions out of state. This suggests that those out-of-staters might be trying to avoid their opioid use being monitored even though doing so would provide useful information to their caregivers.
In the Express Scripts study, among patients taking opioids for more than 30 days, the use of codeine, OxyContin (long-acting oxycodone), and fentanyl declined approximately 14% for each drug. In contrast, in this same group of patients, prescriptions for short-acting oxycodone products increased more than 7% and prescriptions for tramadol increased more than 32%.
The report does not offer explanations for these findings, but I believe that there are probable explanations for at least some of the findings. The decline in OxyContin use and the increase in short-acting oxycodone use may be due to the widespread publicity about the abuse potential of the former resulting in its use being replaced with the latter either because physicians are concerned about possible abuse or because they do not want to draw the attention to themselves from regulatory authorities by continuing to prescribe OxyContin.
The increase in tramadol prescriptions may reflect physician anxi-ety about prescribing opioids that are Drug Enforcement Administration schedule II or III and instead turning to tramadol, a schedule IV drug. Tramadol is now the second most prescribed opioid, although its share of the market, at 14.7%, is dwarfed by that of hydrocodone with acetaminophen (Vicodin), at 46%.
1. The Express Scripts Lab. A Nation in Pain: Focusing on U.S. Opioid Trends for Treatment of Short-Term and Longer-Term Pain. An Express Scripts Report; December 2014. http://lab.express-scripts.com/publications/a-nation-in-pain. Accessed March 18, 2015.
2. Schwarz A. Missouri alone in resisting prescription drug database. New York Times. July 20, 2014. http://www.nytimes.com/2014/07/21/us/missouri-alone-in-resisting-prescription-drug-database.html?_r=0. Accessed March 18, 2015.