Opioid Prescribing Rates Drop in Wake of CDC Guidelines

Release of guidelines by the Centers for Disease Control and Prevention (CDC) in March 2016 coincided with a sharp sustained monthly decline in opioid prescriptions, according to an analysis of prescribing practices published earlier this year in the Annals of Internal Medicine. Yet researchers were reluctant to state that the guidelines were responsible for the drop.

In an abstract of the full study, one researcher noted that several opioid prescribing practices were decreasing before the guidelines were issued, although the time of the report’s release was associated with a greater decline and therefore the “guidelines may be effective in changing prescribing practice.”

Seeking to test the hypothesis that the CDC-released Guideline for Prescribing Opioids for Chronic Pain  corresponded to declines in specific opioid prescribing practices, researchers undertook an interrupted timed series analysis of monthly prescribing measures from 2012 to 2017. They found that the overall opioid prescribing rate was 6,577 per 100,000 people in January 2012 and declined by nearly 24 prescriptions each month before the guideline was released and by nearly 57 per month afterward.

The causes of the nation’s opioid epidemic are manifold. One study, published in the Journal of the American College of Surgeons in February 2018, noted that one in 16 surgical patients prescribed opioids becomes a long-term user. Over-prescribing opioids after surgery is common, and the lack of multidisciplinary procedure-specific guidelines contributes to the wide variations in prescribing practices. This led researchers to hypothesize that a single-institution, multidisciplinary expert panel could establish consensus on ideal opioid prescribing for common surgical procedures.

To test their hypothesis, researchers reviewed 20 surgical procedures and found that the expert panel never recommended opioid tablets. Rather, ibuprofen was recommended for all patients unless medically contraindicated. This led them to conclude that: “Procedure-specific prescribing recommendations may help provide guidance to clinicians who are currently overprescribing opioids after surgery. Multidisciplinary, patient-centered consensus guidelines for more procedures are feasible and may serve as a tool in combating the opioid crisis.”

The American Medical Association (AMA) also weighed in, with a report issued in May 2018, which found that opioid prescribing decreased for the fifth consecutive year in every state. The report, Physicians’ progress to reverse the nation’s opioid epidemic, found that the number of opioid prescriptions decreased by more than 55 million—just over 22 percent—between 2013 and 2017. The AMA also found that:

  • Use of state prescription drug monitoring programs (PDMP) continues to increase, with healthcare professionals accessing state databases more than 300 million times in 2017, up 121 percent from 2016.
  • Naloxone prescriptions continue to rise, more than doubling in 2017 from 3,500 to 8,000 dispensed weekly—a trend that has continued into 2018.
  • Physicians certified to provide buprenorphine in office for the treatment of opioid use disorders increased across all 50 states, up more than 42 percent in the past 12 months to more than 50,000 by May 2018.

“While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose,” said Patrice A. Harris, MD, MA, Chair AMA Opioid Task Force, in a press release announcing the AMA’s report. “What is needed now is a concerted effort to greatly expand access to high quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end.”

The report found that, despite the largest decrease in opioid prescriptions in 25 years, the number of deaths is rising. Specifically, deaths related to heroin, illicit fentanyl and prescription opioids have continued climbing. While the AMA report did not address where patients were obtaining the drugs, Harris did call for public and private insurers, policymakers, public health infrastructure and communities to work together to find a solution.

To that end, the AMA issued a series of recommended actions designed to remove barriers to care for pain and substance use disorders, including ensuring formularies include all FDA-approved forms of medication assisted treatment and removing prior authorization and other administrative barriers to treatment. Increased oversight and enforcement of parity laws for mental health and substance use disorders, ensuring patient access to affordable non-opioid pain care, and ending the stigma associated with substance use were also recommended.

“We encourage policymakers to take a hard look at why patients continue to encounter barriers to accessing high quality care for pain and for substance use disorders,” said Dr. Harris, adding that the AMA report “underscores that while progress is being made in some areas, our patients need help to overcome barriers to multimodal, multidisciplinary pain care, including non-opioid pain care, as well as relief from harmful policies such as prior authorization and step therapy that delay and deny evidence-based care for opioid use disorder.”

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