US Opioid Crisis: Prescribing Practices and 5 Things Healthcare Practitioners Can Do

It is no secret that the United States (US) is facing an opioid crisis of epidemic proportions. Provisional counts of deaths from drug overdose for 2016 released by the Centers for Disease Control and Prevention (CDC) stands at 64,070, a 21% increase over figures for 2015. A report published by the Police Executive Research Forum shows that this figure is more than the number of persons who died in the Vietnam war.

In the July 2017 Vitalsigns report, the CDC highlighted the issue of opioid prescribing, noting that despite peaking in 2010 and decreasing thereafter through 2015, prescribing remains high and is inconsistent across the country. Some points of note from the report include:

• The amount of opioid prescribed per person was 3x higher in 2015 than in 1999
• In 2015, providers in the highest prescribing counties prescribed 6 times more opioids per person compared with providers in the lowest prescribing counties
• Counties with higher opioid prescribing tend to be small cities or large towns, have a higher percent of white residents, have more people who are uninsured or unemployed, among other factors
• The amount of opioids prescribed in 2015 was enough to medicate every American around the clock for 3 weeks
• Prescriptions are being given for too long a duration – the average days supply per prescription increased from 2006 to 2015
• Prescriptions are being given in too high doses – the average daily MME (morphine milligram equivalents) per prescription is still too high despite declining nationwide

For its role, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) is aiming to fight the crisis presented by the epidemic of opioid abuse and deaths in the US, while also addressing its priority of protecting Medicare beneficiaries from prescription drug abuse. Towards this end, the OIG embarked upon a study to investigate prescriptions under Medicare Part D (optional prescription benefits) which covered 43.6 million beneficiaries in 2016. The study provides baseline data on the scope of the issue of beneficiaries receiving extreme amounts of opioids, apparently ‘doctor shopping,’ and prescribers with questionable prescribing patterns.

Some of the key findings from the study are:

• One in three Medicare Part D beneficiaries received a prescription for opioids in 2016
• Half a million Part D beneficiaries received high amounts of opioids in 2016 (excluding beneficiaries with cancer or in hospice care)
• Approximately 70,000 beneficiaries received extreme amounts of opioids (more than two and a half times the level CDC recommends avoiding) for the entire year
• A little more than 22,000 beneficiaries appeared to be doctor shopping – received high amounts of opioids and had multiple prescribers and multiple pharmacies
• About 2000 beneficiaries received extreme amounts of opioids and also appeared to be doctor shopping
• Almost 90,000 beneficiaries are at serious risk of misuse or overdose based on those that received extreme amounts of opioids and those that appeared to be doctor shopping
• 401 prescribers were found to have questionable prescribing patterns – ordered opioids for the highest numbers of beneficiaries at risk

The numbers presented by this OIG study are alarming and lend support to the CDC’s report of high levels of opioid prescribing in the US. Healthcare organizations and practitioners have an active role to play in helping to stem the epidemic of opioid misuse and abuse in the US.

What can healthcare organizations and prescribers do?

1. Review opioid prescribing policies for conformity with recommended prescribing guidelines
2. Use the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations on prescribing opioids such as using opioids only when the benefits are likely to outweigh the risks
3. Utilize the prescription Drug Monitoring Program (PDMP) for your state to help you identify if a patient is at risk of addiction or overdose
4. Ensure staff is educated on and are complying with the policies
5. Organizations and the prescribers themselves need to evaluate prescriber patterns and take necessary steps to address any questionable patterns found

The opioid crisis is real and will only continue to worsen without serious intervention. As with any epidemic, healthcare practitioners and organizations must play an active role in stemming the opioid crisis in the US. In addition to the above five points, practitioners and organizations should brainstorm and come up with their own ideas of how they can contribute to lowering the incidence of opioid misuse and abuse. Without the input of all stakeholders, the crisis will continue, and more people will die from opioid overdose.