Doctors are writing fewer opioid prescriptions than they were in 2010, when such prescriptions hit their peak, but the amount of opioids prescribed is still three times higher than it was in 1999, according to a new report from the Centers for Disease Control and Prevention (CDC).

The amount of opioids being prescribed also varies widely at the county level across the United States, with counties that are predominantly nonurban, white and low-income having the highest prescription rates.

CDC officials urge states and counties to use the findings in this report to educate physicians on the appropriate use of opioid painkillers and to help people get better access to treatments for opioid addiction.

The Affordable Care Act (ACA) made addiction treatment available to many opioid addicts through its expanded Medicaid program. The Republican plan to replace the ACA, which is now stalled in the Senate, would reportedly give states $45 million to spend on opioid treatment programs, but addiction experts say that amount won’t make up for the plan’s deep cuts to Medicaid.

A major health crisis

The United States is in the midst of a massive opioid epidemic, and prescription opioids have played a key role in that epidemic. As background information in the CDC report points out, an estimated 2 million Americans are addicted to prescription opioids, and those drugs were involved in approximately 15,000 — or about half — of the opioid-related overdose deaths in 2015. 

But even that number disguises the contribution of prescription opioids to the ongoing opioid health crisis. Many people who die from an overdose of a nonprescription opioid, such as heroin, turned to the illegal drug after first becoming addicted to a prescription painkiller given them by their doctor.

The rise in opioid prescriptions since 1999 “was primarily because of an increase in the use of opioids to treat chronic noncancer pain,” the CDC researchers explain. “Previously, opioids had primarily been reserved for severe acute pain, postsurgical pain, and end-of-life care.”

Key findings

For their new report, the researchers analyzed data on opioid prescribing patterns in the U.S. from 2006 to 2015, including prescribing at the county level from 2010 through 2015.

Some of the trends revealed by the data are encouraging, while others are troubling. First, the positive trends:

• After rising at an alarming rate for many years, the annual prescribing rate for opioids by U.S. doctors has begun to decline. The rate rose to 81.2 prescriptions per 100 persons in 2010, after which it held steady for a couple of years. Then, between 2012 and 2015, the rate fell 13.1 percent — to 70.6 prescriptions per 100 persons.  
• Doctors are less likely to prescribe high doses of opioids than they were a few years ago. The prescribing rate of high doses of opioids fell from 11.4 prescriptions per 100 persons in 2010 to 6.7 in 2015 — a drop of 41.4 percent.
• The overall amount of opioids prescribe by doctors has also declined — from 782 morphine milligram equivalents (MME) per person in 2010 to 640 MME per person in 2015. That’s a drop of 18 percent.

Here are the troubling trends from the report:

• The overall amount of opioids prescribed by U.S. doctors in 2015 remains about three times as high as in 1999.
• Doctors are increasingly giving patients prescriptions for opioids that last for 30 days or more. The prescribing rates for these longer supplies of the drug jumped 58.9 percent between 2006 and 2012, from 17.6 to 28 prescriptions per 100 persons. The rates have not increased — but nor have they decreased — since then. This trend is troubling, for research has shown that the risk of becoming addicted to prescription opioids increases with each day of use, starting as soon as the third day.

County-level differences

The new CDC report also uncovered widely varying opioid prescribing patterns at the county level. In 2015, six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing ones.

The high-prescribing counties can be found across the country, including in Minnesota, particularly in the state’s northeastern region.

Nationally, counties with the highest rates of opioid prescriptions were more likely to be predominantly white and “micropolitan” (having an urban center of at least 10,000 residents but not more than 50,000). They also tended to have higher unemployment and Medicaid enrollment than the low-prescribing counties, as well as more residents diagnosed with diabetes and arthritis.

Despite recent declines, opioid prescribing is still high and inconsistent across the U.S.

There are several possible reasons why micropolitan counties might have more opioid use, including “less access to quality health care and other treatments for pain, such as physical therapy,” write the CDC researchers.

“In addition, persons in rural areas might travel to micropolitan areas, which often serve as an anchor community for a much larger rural region, to receive medical care and pick up medications.” (The data in the CDC report reflect where prescriptions were picked up, not necessarily where the residents lived.)

Needed: substantial change

The wide variation in opioid prescribing patterns at the county level “suggests inconsistent practice patterns and a lack of consensus about appropriate opioid use [and] demonstrates the need for better application of guidance and standards around opioid prescribing practices,” write the CDC researchers.

In 2016, the CDC issued opioid prescribing guidelines for chronic pain, which included three key recommendations:

• Use opioids only when benefits are likely to outweigh risks.

• Start with the lowest effective does of immediate-release opioids.

• Reassess benefits and risks when considering dose increases.

“Changes in opioid prescribing can save lives,” the current CDC report concludes. “The findings of this report demonstrate that substantial changes are possible and that more are needed.”

That statement seems like an understatement, given that today — and tomorrow and each day after that — an average of 41 Americans will die from overdosing on prescription opioid painkillers.

FMI: The new CDC report appears in the July 7 issue of Morbidity and Mortality Weekly Report, where it can be read in full.