The Supply of Prescription Opioids: Contributions of Episodic-Care Prescribers and High-Quantity Prescribers

Ann Emerg Med. 2018 Jun;71(6):668-673.e3. doi: 10.1016/j.annemergmed.2017.10.016. Epub 2017 Dec 21.


Study objective: We determine episodic and high-quantity prescribers' contribution to opioid prescriptions and total morphine milligram equivalents in California, especially among individuals prescribed large amounts of opioids.

Methods: This was a cross-sectional descriptive analysis of opioid prescribing patterns during an 8-year period using the de-identified Controlled Substance Utilization Review and Evaluation System (CURES) database, the California subsection of the prescription drug monitoring program. We took a 10% random sample of all patients and stratified them by the amount of prescription opioids obtained during their maximal 90-day period. We identified "episodic prescribers" as those whose prescribing pattern included short-acting opioids on greater than 95% of all prescriptions, fewer than or equal to 31 pills on 95% of all prescriptions, only 1 prescription in the database for greater than 90% of all patients to whom they gave opioids, fewer than 6 prescriptions in the database to greater than 99% of patients given opioids, and fewer than 540 prescriptions per year. We identified top 5% prescribers by their morphine milligram equivalents per day in the database. We examined the relationship between patient opioid prescriptions and provider type, with the primary analysis performed on the patient cohort who received only short-acting opioids in an attempt to avoid guideline-concordant palliative, oncologic, and addiction care, and a secondary analysis performed on all patients.

Results: Among patients with short-acting opioid only, episodic prescribers (14.6% of 173,000 prescribers) wrote at least one prescription to 25% of 2.7 million individuals but were responsible for less than 9% of the 10.5 million opioid prescriptions and less than 3% of the 3.9 billion morphine milligram equivalents in our sample. Among individuals with high morphine milligram equivalents use, episodic prescribers were responsible for 2.8% of prescriptions and 0.6% of total morphine milligram equivalents. Conversely, the top 5% of prescribers prescribed at least 29.8% of prescriptions and 48.8% of total morphine milligram equivalents, with a greater contribution in patients with high morphine milligram equivalents.

Conclusion: Episodic prescribers contribute minimally to total opioid prescriptions, especially among individuals categorized as using high morphine milligram equivalents. Interventions focused on reducing opioid prescriptions in the episodic care setting are unlikely to yield important reductions in the prescription opioid supply; conversely, targeting high-quantity prescribers has the potential to create substantial reductions.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Analgesics, Opioid / supply & distribution*
  • California / epidemiology
  • Cross-Sectional Studies
  • Databases, Factual
  • Drug Utilization Review
  • Emergency Service, Hospital / statistics & numerical data
  • Episode of Care*
  • Humans
  • Morphine / supply & distribution
  • Practice Patterns, Physicians'*
  • Prescription Drug Misuse / statistics & numerical data*


  • Analgesics, Opioid
  • Morphine