Initial Opioid Prescriptions among U.S. Commercially Insured Patients, 2012-2017

Abstract

Background: The United States is undergoing a crippling opioid epidemic, spurred in part by overuse of prescription opioids by adults 25 to 64 years of age. Of concern are long-duration and high-dose initial prescriptions, which place the patients and their friends and relatives at heightened risk for long-term opioid use, misuse, overdose, and death.

Methods: We estimated the incidence of initial opioid prescriptions in each month between July 2012 and December 2017 using administrative-claims data from across the United States (accessed through Blue Cross-Blue Shield [BCBS] Axis); monthly incidence was estimated as the percentage of enrollees who received an initial opioid prescription among those who had not used opioids (i.e., no opioid prescription or a diagnosis of opioid use disorder in the 6 months before a given month). We then estimated the percentage of enrollees initiating opioid therapy who received a long-duration or high-dose initial opioid prescription in each month during this period. We also calculated the number of providers who initiated opioid therapy in any patient who had not used opioids in each month and examined monthly trends in the duration and dose of initial opioid prescriptions in prescriber and patient subgroups. Our study sample included 63,817,512 enrollees who had not used opioids (mean, 15,897,673 per month).

Results: The monthly incidence of initial opioid prescriptions among enrollees who had not used opioids declined by 54%, from 1.63% in July 2012 to 0.75% in December 2017. This decline was accompanied by a decreasing number of providers (from 114,043 in July 2012 to 80,462 in December 2017) who initiated opioid therapy in any patient who had not used opioids. Nonetheless, among the shrinking subgroup of physicians who initiated opioid therapy in such patients, high-risk prescribing (i.e., prescriptions for more than a 3-day supply or for a dose of 50 morphine milligram equivalents per day or higher) persisted at a monthly rate of 115,378 prescriptions per 15,897,673 enrollees who had not used opioids.

Conclusions: As the opioid crisis progressed between July 2012 and December 2017, many providers stopped initiating opioid therapy. Although the number of initial opioid prescriptions declined, a subgroup of providers continued to write high-risk initial opioid prescriptions. (Funded by the National Institute on Aging and a gift from Owen and Linda Robinson.).

Figure 1.. Prevalence and Incidence of Opioid Prescriptions (July 2012–December 2017).

Prevalence was estimated as the percentage of enrollees who received any opioid prescription in each month during the study period (July 2012 through December 2017). The denominator was 86,258,528 enrollees (mean, 24,277,964 per month) who were 15 years of age or older, resided in the United States, and had primary medical and prescription coverage in any month. Incidence was estimated as the percentage of enrollees who received an initial opioid prescription in each month during the study period, among those who had not used opioids (defined as those who satisfied the above criteria and also had been continuously enrolled for at least 6 months and had no recorded opioid prescription or diagnosis of opioid use disorder during those 6 months). The denominator was 63,817,512 enrollees (mean, 15,897,673 per month), among whom 10,893,788 were identified as having received an initial opioid prescription during this period. The dashed and solid vertical lines represent when the Centers for Disease Control and Prevention (CDC) issued opioid-prescribing guidelines in draft form and final version, respectively. The inset shows the same data on an enlarged y axis.

Figure 2.. Incidence of Long-Duration or High-Dose Initial Opioid Prescriptions (July 2012–December 2017).

Shown is the percentage of enrollees who received a long-duration (>3-day and >7-day supply) or high-dose (≥50 and ≥90 morphine milligram equivalents [MME] per day) initial opioid prescription in each month from July 2012 through December 2017. The denominator was 63,817,512 enrollees (mean, 15,897,673 per month) who had not used opioids, among whom 10,874,869 were identified as having received an initial opioid prescription during this period. The dashed and solid vertical lines represent when the CDC issued opioid-prescribing guidelines in draft form and final version, respectively. The inset shows the same data on an enlarged y axis.

Figure 3.. Providers Who Initiated Opioid Therapy in Any Patient Who Had Not Used Opioids (July 2012–December 2017).

Shown are the numbers of providers who initiated opioid therapy and who initiated long-duration or high-dose initial opioid therapy in any patient who had not used opioids. The sample comprised 710,698 providers (mean, 95,449 per month) with identifiable National Provider Identifiers who wrote initial opioid prescriptions to patients who had not used opioids. The dashed and solid vertical lines represent when the CDC issued opioid-prescribing guidelines in draft form and final version, respectively.

Figure 4.. Duration and Dose of Initial Opioid Prescriptions and Percentage of Long-Duration or High-Dose Initial Opioid Prescriptions (July 2012–December 2017).

The sample comprised 10,874,869 patients who had not used opioids but received an initial opioid prescription during the study period. The dashed and solid vertical lines represent when the CDC issued opioid-prescribing guidelines in draft form and final version, respectively.