"Range of opioid prescribers play important role in epidemic, study finds"

A cross-section of opioid prescribers that typically do not prescribe large volumes of opioids, including primary care physicians, surgeons and non-physician health care providers, frequently prescribe opioids to high-risk patients, according to a new study by researchers at the Johns Hopkins Bloomberg School of Public Health. The findings suggest that high-volume prescribers, including "pill mill" doctors, should not be the sole focus of public health efforts to curb the opioid abuse epidemic. The study also found that "opioid shoppers," patients who obtain prescriptions from multiple doctors and pharmacies, are much less common than other high-risk patient groups, suggesting why policy solutions focused on these patients have not yielded larger reductions in opioid overdoses.
"This crisis has been misconstrued as one involving just a small subset of doctors and patients," says senior author G. Caleb Alexander, MD, associate professor in the Department of Epidemiology at the Bloomberg School and founding co-Director of the Johns Hopkins Center for Drug Safety and Effectiveness. "Our results underscore the need for targeted interventions aimed at all opioid prescribers, not just high-volume prescribers alone."
The study, which will be published on Nov. 29 in Addiction, comes as America's opioid crisis continues to worsen. Opioids include not only the recreational, poppy-derived drug heroin, but also many newer and much more potent synthetic painkillers available by prescription, such as fentanyl and oxycodone. Opioids tend to be highly addictive and when overdosed can stop a user from breathing. Drug overdose deaths in the US, which now mostly involve opioids, surged from about 52,000 in 2015 to more than 64,000 in 2016.
Alexander and colleagues have found in previous, smaller-scale studies that a small minority of doctors can account for an inordinately high proportion of opioid prescriptions: just 4 percent of opioid prescribers in Florida, for example, accounted for 40 percent of all opioid prescriptions in that state in 2010.
For this study he and his team, including first author Hsien-Yen Chang, PhD, an assistant scientist in the Bloomberg School's Department of Health Policy and Management, examined the relationship between high-volume prescribers and high-risk patients more closely. "While we and others have demonstrated that opioid prescribing tends to be concentrated among a relatively small group of providers, in the current study, we wanted to examine how commonly high-risk patients are prescribed opioids by low-volume prescribers," says Chang. "We were also interested in whether we could identify systematic differences in the doses and durations prescribed by different groups of doctors caring for the same patients."
The study covered more than 24 million opioid prescriptions in 2015 by more than 4 million residents of California, Florida, Georgia, Maryland, or Washington, as recorded in a nationwide pharmacy database, QuintilesIMS' LifeLink LRx.
A key finding was that the high-volume prescribers—those who stayed in the top 5 percent, in terms of total opioid volume, during every quarter of 2015—were far from being the only prescribers for high-risk patients. Across the five states studied, the remaining, low-volume prescribers accounted for 18 to 56 percent of all opioid prescriptions to high-risk patients, depending on how such patients were defined.
"The point here is that ordinary, low-volume prescribers are routinely coming into contact with high-risk patients—which should be a wake-up call for these prescribers," says Alexander. "We need to build systems to help prescribers better identify these patients, screen them for opioid use disorders, and improve the quality of their pain management."
The analysis also revealed that "opioid shoppers," the patient group most commonly thought of as being at high-risk for non-medical use, represent only small fraction of all opioid users. The researchers defined opioid-shoppers in the study as those receiving prescriptions from more than three prescribers and three pharmacies during any 90-day period. They found that this group made up just 0.1 percent of the 4 million patients covered in the study.