Disproportionate prescribing patterns

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The top 1% of prescribers accounted for 49% of all opioid doses and 27% of all opioid prescriptions, US study finds

A retrospective, observational study has examined the distribution and patterns of opioid prescribing in the United States. 

Researchers from the Stanford University School of Medicine and Harvard Medical School in the US identified 134 million opioid prescriptions from the large database of a national private insurance provider. 

Data showed an annual average of 669,495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017. 

In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. 

These disproportionate prescribing patterns persisted after accounting for prescription length, number of patients for each provider, and number of prescriptions for each provider. 

In absolute terms, the top 1% of providers prescribed an average of 748,000 morphine milligram equivalents (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. 

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. Source: BMJ

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, the researchers found. 

More than half of the top centile of opioid prescribers were in general practice (24%), physical or pain medicine and rehabilitation (14%), anesthesiology (14%), or internal medicine (13%); about one third were classified as other (17%) or unknown (14%).

“Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing,” said the researchers. 

“Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden.” 

They say 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. 

The Australian Department of Health has previously written letters to the top 20% of opioid-prescribing doctors in the country to highlight their prescribing patterns. 

“One of the things we’re doing with the medical community is to ensure that we have control over the opioid use in Australia,” Health Minister Greg Hunt said in 2018. 

“We know that 2000 people lost their lives over a five-year period to opioid abuse, whether it’s oxycodone, morphine, fentanyl.

“But the AMA and the College of GPs are working with us to make sure that doctors know exactly how many prescriptions they’ve been giving, whether or not they are at the outer edges of prescriptions and therefore they can better moderate and regulate their own actions to protect patients,” said Minister Hunt. 

“This means that they’re working to ensure that all doctors know where they sit, whether or not they may have inadvertently become over-prescribers, but the vast and overwhelming majority of Australian doctors do the right thing, and overwhelmingly we have the best doctors in the world.” 

See the full article in the BMJ

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