Trends and Patterns of Geographic Variation in Opioid Prescribing Practices by State, United States, 2006-2017

Abstract

Importance: Risk of opioid use disorder, overdose, and death from prescription opioids increases as dosage, duration, and use of extended-release and long-acting formulations increase. States are well suited to respond to the opioid crisis through legislation, regulations, enforcement, surveillance, and other interventions.

Objective: To estimate temporal trends and geographic variations in 6 key opioid prescribing measures in 50 US states and the District of Columbia.

Design, setting, and participants: Population-based cross-sectional analysis of opioid prescriptions filled nationwide at US retail pharmacies between January 1, 2006, and December 31, 2017. Data were obtained from the IQVIA Xponent database. All US residents who had an opioid prescription filled at a US retail pharmacy were included.

Main outcomes and measures: Primary outcomes were annual amount of opioids prescribed in morphine milligram equivalents (MME) per person; mean duration per prescription in days; and 4 separate prescribing rates-for prescriptions 3 or fewer days, those 30 days or longer, those with a high daily dosage (≥90 MME), and those with extended-release and long-acting formulations.

Results: Between 2006 and 2017, an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year. For all states combined, 4 measures decreased: (1) mean (SD) amount of opioids prescribed (mean [SD] decrease, 12.8% [12.6%]) from 628.4 (178.0) to 543.4 (158.6) MME per person, a statistically significant decrease in 23 states; (2) high daily dosage (mean [SD] decrease, 53.1% [13.6%]) from 12.3 (3.4) to 5.6 (1.7) per 100 persons, a statistically significant decrease in 49 states; (3) short-term (≤3 days) duration (mean [SD] decrease, 43.1% [9.4%]) from 18.0 (5.4) to 10.0 (2.5) per 100 persons, a statistically significant decrease in 48 states; and (4) extended-release and long-acting formulations (mean [SD] decrease, 14.7% [13.7%]) from 7.2 (1.9) to 6.0 (1.7) per 100 persons, a statistically significant decrease in 27 states. Two measures increased, each associated with the duration of prescription dispensed: (1) mean (SD) prescription duration (mean [SD] increase, 37.6% [6.9%]) from 13.0 (1.2) to 17.9 (1.4) days, a statistically significant increase in every state; and (2) prescriptions for a term of 30 days or longer (mean [SD] increase, 37.7% [28.9%]) from 18.3 (7.7) to 24.9 (10.7) per 100 persons, a statistically significant increase in 39 states. Two- to 3-fold geographic differences were observed across states, measured by comparing the ratio of each state's 90th to 10th percentile for each measure.

Conclusions and relevance: In this study, across 12 years, the mean duration and prescribing rate for long-term prescriptions of opioids increased, whereas the amount of opioids prescribed per person and prescribing rate for high-dosage prescriptions, short-term prescriptions, and extended-release and long-acting formulations decreased. Some decreases were significant, but results were still high. Two- to 3-fold state variation in 5 measures occurred in most states. This information may help when state-specific intervention programs are being designed.

Figure 1.. Changes in Annual Amount of Opioids Prescribed in Morphine Milligram Equivalents (MME) per Person, and Mean Duration per Prescription From Years 2006, 2010, and 2017

Data were calculated from the IQVIA Xponent database in the years 2006, 2010, and 2017. The annual amount of opioids prescribed in MME per person and mean duration per prescription were calculated from all opioids prescribed for each state and the District of Columbia in that year. We used 2010 quartiles as the break points for part A and the break points that optimize the visual differences among states between maps for part B. The dark color indicates a higher MME per person or a longer duration. In the boxplots, the bottom border of the boxes indicates the 25th percentile; middle line, the 50th percentile; top border, the 75th percentile across all states; whiskers, the full range across states; and circles, the national mean for MME per person (A) and mean duration per prescription (B).

Figure 2.. Changes in Rates per 100 Persons of Opioids Prescribed of Duration of 3 or Fewer Days and 30 or More Days From Years 2006, 2010, and 2017.

Data were calculated from the IQVIA Xponent database for the years 2006, 2010, and 2017. Rates of opioids prescribed for a duration of 3 or fewer days (A) and for 30 days or longer (B) were determined from all opioids prescribed for each state and the District of Columbia in that year. The 2010 quartiles were used as the break points for both parts. Dark colors indicate the higher-risk prescribing practices—higher prescribing rate of opioids for a duration of 30 days or longer or 3 or fewer days. In the boxplots, the bottom border of the boxes indicates the 25th percentile; middle line, the 50th percentile; top border, the 75th percentile across all states; whiskers, the full range across states; and circles, the national mean for rates per 100 persons of opioids prescribed for a duration of 3 or fewer days (A) and 30 days or longer (B).

Figure 3.. Changes in Rates per 100 Persons of Opioids Prescribed of High Dosages (≥90 MME/d) and Extended-Release and Long-Acting Formulations From Years 2006, 2010, and 2017

Data were calculated from the IQVIA Xponent database for the years 2006, 2010, and 2017. Rates of opioids prescribed in high dosages (A) and as extended-release and long-acting formulations (B) were determined from all opioids prescribed for each state and the District of Columbia in that year. We used the break points that optimize the visual differences among states between maps for part A and 2010 quartiles as the break points for part B. The darker colors indicate higher-risk prescribing practice—higher prescribing rates of opioids in high dosages or as extended-release and long-acting formulations. In the boxplots, the circles indicate the national mean for rates per 100 persons of opioids prescribed in high dosages (A) and as extended-release and long-acting formulations (B). See the caption to Figure 2 for definitions of the other elements.