In 2012, U.S. health care professionals wrote 259 million prescriptions for opioids. "That is enough for every American adult to have their own bottle of pills," said CDC Director Thomas Frieden, M.D., M.P.H., during a July 1 conference call(www.cdc.gov) held to mark the release of July's CDC Vital Signs report(www.cdc.gov), titled "Opioid Painkiller Prescribing." A Morbidity and Mortality Weekly Report (MMWR) issued the same day also addressed national opioid pain reliever prescribing rates(www.cdc.gov).
Opioid Prescribing Rate Variance
According to the MMWR report, the United States far exceeds every other nation in per capita opioid consumption, with a rate double that of second-ranked Canada.
In 2012, prescribers wrote 82.5 opioid pain reliever (OPR) and 37.6 benzodiazepine prescriptions per every 100 people in the United States. Long-acting/extended-release (LA/ER) OPRs accounted for 12.5 percent and high-dose OPRs accounted for 5.1 percent of the estimated 259 million prescriptions written that year. Prescribing rates varied widely by state for all drug types.
Other key findings in the report:
- A recently published Morbidity and Mortality Weekly Report (MMWR) focused on national opioid pain reliever prescribing rates.
- Among the report's findings is that in 2012, clinicians wrote prescriptions for 82.5 opioid pain relievers and 37.6 benzodiazepines per every 100 people in the United States.
- A second MMWR report focused on Florida's recent success in reversing its rising drug overdose trends, which appears to have been driven largely by legislation and enforcement activities aimed at combating the state's opioid abuse epidemic.
- Overall, Southern states -- Alabama, Tennessee and West Virginia, in particular -- racked up the most painkiller prescriptions per person.
- The Northeast, especially Maine and New Hampshire, had the most prescriptions per person for LA/ER OPRs and high-dose OPRs.
- Among all prescription painkillers, variation by state was greatest for oxymorphone prescriptions. Nearly 22 times as many prescriptions for oxymorphone were written in Tennessee as were written in Minnesota.
Robert Rich, M.D., who chaired the AAFP opioid and pain management workgroup for the Academy's Commission on Health of the Public and Science, said there is a possible connection between higher prescription rates in Southern and rural states and the fact that more people in those areas have chronic pain problems attributable to years of manual labor in physically challenging occupations.
"In North Carolina, on a per capita basis, we have higher prescription rates for opioid pain relievers in some of our rural counties," Rich told AAFP News. "The reasons for that are complex because some of that reflects lifestyle and occupational hazards. As a rural practitioner, I see patients who have had typical bad backs, knees and hips from injuries through the years."
Legislation at the state and federal levels constitutes one piece of the puzzle to help combat opioid abuse, and Frieden noted during the conference call that the number of states with laws in place to address painkiller misuse rose from three in 2010 to 11 in 2013.
"There are other states that have laws that address some parts of the pill mill or pain clinic law legislation," said Frieden. "But I think that there are programs at the state level that can make a really big difference." For example, he said, prescription drug monitoring programs, which are actively monitored and capture all patients in real time, have proven helpful.
Family Physician's Perspective
For his part, Rich said that focusing solely on legislation is a counterproductive way of addressing the opioid abuse crisis, and it may not achieve the goal of reducing abuse levels.
"We need to devote a great deal of emphasis for our family docs in terms of looking at guidelines and best practices, promoting best practices, and increasing the availability of that information to them," he told AAFP News.
One such resource is the pain management and opioid abuse position paper created by the AAFP opioid and pain management workgroup Rich chaired.
Rich also encourages family physicians to re-examine the principles of safe prescribing. He suggested, for example, reviewing updated policies from the Federation of State Medical Boards, such as its Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain(www.fsmb.org), published July 2013, and Model Policy on DATA 2000 and Treatment of Opioid Addition in the Medical Office(www.fsmb.org), which was released in April 2013.
As for more comprehensive interventions, Rich said he knows state-based programs to combat opioid abuse can see significant results -- he's been a part of one.
The North Carolina Experience
Recognizing that they had a problem with overdose deaths from prescription medications and other substances, officials in Wilkes County, North Carolina, took action. In 2008-09, they created Project Lazarus(www.projectlazarus.org), a community coalition of medical professionals, hospital officials, law enforcement agents, members of the faith community, and social services and education representatives. The groups used a multifaceted approach that included
- community activation and coalition-building,
- epidemiologic surveillance and monitoring,
- prevention of overdoses through medical education and other means, and
- use of rescue medication to reverse overdoses.
The results were remarkable, according to Rich. "This rural county was able to reduce its overdose deaths down to basically zero," he said.
The North Carolina Medicaid program, administered by nonprofit Community Care of North Carolina, subsequently adopted the project and, since 2012, has been in the process of rolling Project Lazarus out to all of the counties in North Carolina.
Now working as a regional medical director for Community Care of North Carolina, Rich said that one of his duties is to visit practices and talk with health care professionals about the tenets of safe prescribing of opioids as highlighted in the Project Lazarus provider toolkit.
Rich begins his visits by explaining the importance of recognizing substance abuse, behavioral health problems and other issues that need to be addressed and, if needed, prescribing medication and executing treatment plans that may include consultations with specialists. Some patients who are experiencing physical pain also have emotional pain, which must be evaluated and treated, he noted.
Instead of prescribing OPRs as first-line therapy, Rich recommends greater use of nonsteroidal anti-inflammatory drugs along with other modalities that can include antidepressants and muscle relaxants, if appropriate, as well as adjunctive treatments such as physical therapy and acupuncture.
Florida's Success Story
A second MMWR report released on July 1(www.cdc.gov) focused on Florida's success in reversing its rising drug overdose trends, revealing a correlation between new legislation and enforcement activities intended to combat the state's opioid abuse epidemic and a subsequent significant reduction in related deaths.
Between 2003 and 2009, drug overdose deaths in Florida increased 61 percent, according to the report. Pain clinics proliferated in the state, and, in 2010, Florida was home to 98 of the 100 U.S. physicians who dispensed the highest quantities of oxycodone directly from their offices.
In 2010, the Florida legislature began creating laws requiring pain clinics to register with the state. The DEA and Florida law enforcement agencies began conducting statewide raids and closing pain clinics found to be operating illegally the same year. By 2013, about 250 such pain clinics had been shut down.
In addition, Florida began requiring mandatory prescriber reporting to its newly established prescription drug monitoring program in 2011. Other laws and programs have since been created by the state to help battle opioid abuse.
Overall, the results were significant: From 2010-2012, the number of drug overdose deaths in the state decreased by more than 16 percent, with deaths from oxycodone dropping the most at more than 52 percent, according to the report.
Although Rich lauded the progress Florida has made in combating its opioid abuse problem, he noted difficulties in extrapolating that experience to other states. He said the Florida laws focused on unscrupulous free-standing pain clinics, which are not common in many other states. In addition, the Florida clinics actually dispensed controlled substances themselves, which also is uncommon in other parts of the country.
"Each state must examine the opioid abuse issues that they are experiencing, find the source of their specific problems and tailor solutions to fit each problem," Rich said. "Those solutions, to be effective, must involve the entire community, not just the family physician's office."