Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study

Abstract

Objective: To examine the distribution and patterns of opioid prescribing in the United States.

Design: Retrospective, observational study.

Setting: National private insurer covering all 50 US states and Washington DC.

Participants: An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017.

Main outcome measures: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions.

Results: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.

Conclusions: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.

Fig 1

Distribution of standardized doses and prescriptions for opioids and benzodiazepines across all providers in 2017. Dotted lines show top 1%, 5%, 10%, and 50% of providers for each type of drug along with proportion of opioids distributed by each of these groups

Fig 2

Proportion of standardized doses and prescriptions prescribed by top 1% of providers for opioids and benzodiazepines, 2003-17

Fig 3

Volume of opioid and benzodiazepine doses transacted between provider and patient centile groups, 2017

Fig 4

Persistence of top centile of providers, patients, and provider-patient pairs over time.