A new study by Stanford University has found that most prescriptions for opioid painkillers are handed out by general practitioners, not by a few prolific prescribers with connections to “pill mills,” as suggested by previous studies.
“The bulk of opioid prescriptions are distributed by the large population of general practitioners,” said lead author Jonathan Chen, M.D., Ph.D., an instructor of medicine and Stanford Health Policy VA Medical Informatics Fellow.
“These findings indicate law enforcement efforts to shut down pill-mill prescribers are insufficient to address the widespread overprescribing of opioids. Efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective.”
Those prescribing the most Schedule II opioids in 2013 were family practice doctors (15.3 million prescriptions), internal medicine doctors (12.8 million), nurse practitioners (4.1), and physician assistants (3.1 million prescriptions).
Schedule II drugs are those approved by the FDA for medical use but carry a high potential of abuse. This includes the commonly abused opioid drugs hydrocodone, codeine, and fentanyl.
“Being a physician myself, I am acutely aware of the emotional angst that can occur when deciding whether to prescribe opioids to a patient who may have simultaneously developed a chronic-pain and substance-dependence problem,” said Chen. “The public health epidemic of opioid overuse is perhaps not surprising given the tenfold increase in volume over the past 20 years.”
The findings also show that the top 10 percent of opioid prescribers account for 57 percent of opioid prescriptions. This prescribing pattern is similar to that found in the Medicare data for prescribers of all drugs: The top 10 percent of all drug prescribers account for 63 percent of all drug prescriptions.
This is also in contrast to a 2011 study by the California Workers’ Compensation Institute suggesting that one percent of prescribers account for one-third of opioid prescriptions, and that the top 10 percent account for 80 percent of prescriptions.
The new Stanford study used a different set of data. Instead of California workers’ compensation prescriptions, it looked at prescriber data from the 2013 Medicare prescription drug coverage claims and investigated whether such disproportionate prescribing of opioids occurs in the national Medicare population.
“This data set indicates no special distinctions in the concentration of opioid prescribing among Medicare prescribers,” said Chen. “The earlier study suggests potentially aberrant behavior among those extreme outlier prescribers, while implying the remaining majority do not contribute much to the problem — and now we know this is not the case.”
The Centers for Medicare and Medicaid Services data included all prescribers and represented all Medicare prescription drug coverage claims for 2013: 808,020 prescribers and 1.18 billion claims. The researchers focused on Schedule II opioids: 381,575 prescribers and 56.5 million claims.
The study is published in JAMA Internal Medicine.