Rates of Physician Coprescribing of Opioids and Benzodiazepines After the Release of the Centers for Disease Control and Prevention Guidelines in 2016

Abstract

Importance: The Centers for Disease Control and Prevention guidelines in 2016 recommended avoiding concurrent use of opioids and benzodiazepines.

Objective: To determine whether the release of the guidelines was associated with changes in coprescription of opioids and benzodiazepines.

Design, setting, and participants: This retrospective cohort study used claims data obtained from a US national database of medical and pharmacy claims for 3 598 322 adult commercially insured patients and 1 299 142 Medicare Advantage (MA) beneficiaries with no recent history of cancer, sickle cell disease, or hospice care who ever used prescribed opioids during the study period, January 1, 2014, through March 31, 2018.

Exposures: Overlapping opioid and benzodiazepine prescriptions filled.

Main outcomes and measures: The extent (proportion of person-months with any overlapping days of prescription of opioids and benzodiazepines) and intensity (proportion of days with opioids prescribed where benzodiazepines were also available) of coprescription.

Results: Of 4 897 464 patients (with 13.4 million person-months of opioid use), the total number of unique commercially insured individuals was 3 598 322 (1 974 731 women [54.9%]), and the total number of unique MA beneficiaries was 1 299 142 (770 256 women [59.3%]). Among 128 576 participants experiencing chronic pain episodes, more than one-half of person-months of long-term opioid use occurred in women (52.7% of person-months among those with commercial insurance and 62.4% of person-months among MA beneficiaries). The median (interquartile range) age of the participants was 51 (41-58) years for patients in the commercial insurance group and 70 (61-77) years for those in the MA group. The mean (SE) extent of coprescription was 23.0% (0.18%) for the commercial insurance group and 25.7% (0.18%) for the MA group. The extent of coprescription decreased in the targeted guideline population-individuals with long-term opioid use-after the guideline release (postguideline slope, -0.95 percentages point per year [95% CI, -1.44 to -0.46 percentage points per year] for the commercial insurance group and -1.06 percentage points per year [95% CI, -1.49 to -0.63 percentage points per year] for the MA group). Nontargeted short-term episodes of opioid use were associated with no change or small declines in trend (for the MA group, postguideline slope of 0.47 percentage point per year [95% CI, 0.35-0.59 percentage point per year]; for the commercial insurance group, postguideline slope of -0.05 percentage point per year [95% CI, -0.12 to 0.02 percentage point per year]). High coprescribing intensity was seen, with 79.3% (95% CI, 78.9%-79.6%) of opioid prescription days in the commercial insurance group and 83.9% (95% CI, 83.7%-84.2%) in the MA group overlapping with benzodiazepines. There was no change in the intensity of coprescribing. Intensity of coprescription was higher when the same clinician prescribed opioids and benzodiazepines.

Conclusion and relevance: This study observed a reduction in the extent but not intensity of coprescribing of benzodiazepines for patients with long-term opioid use.

Figure 1.. Extent of Coprescription of Opioids and Benzodiazepines Before and After the Centers for Disease Control and Prevention Guideline Release

Adjusted proportion of person-months with overlapping opioid and benzodiazepine prescriptions in the population of commercially insured individuals (A) and Medicare Advantage beneficiaries (B). Statistical significance was set at P = .05. Statistical significance for change in level is indicated next to dashed line, which denotes release of opioid guidelines. Statistical significance for change in trend (line slope) is indicated further to the right of the statistical significance of the change in level. Point estimates and 95% confidence intervals are shown in eTable 6 in the Supplement.

Figure 2.. Intensity of Coprescription of Opioids and Benzodiazepines Before and After the Centers for Disease Control and Prevention Guideline Release

Adjusted proportion of opioid prescription days with overlapping benzodiazepine prescriptions in the population of commercially insured individuals (A) and Medicare Advantage beneficiaries (B). Statistical significance was set at P = .05. Statistical significance for change in level is indicated next to the dashed line, which denotes the release of the opioid guidelines. Statistical significance for change in trend (line slope) is indicated further to the right of the statistical significance of the change in level. Point estimates and 95% confidence intervals are shown in eTable 6 in the Supplement.

Figure 3.. Difference in Intensity With Same vs Different Physicians Prescribing Opioids and Benzodiazepines

Error bars denote 95% confidence intervals, and column height indicates the percentage point increase in the rate of coprescribing (overlap days in month per opioid prescription days in month). For example, in the commercial population using long-term opioids before the guideline release, the regression-adjusted proportion of opioid prescription days with overlapped benzodiazepines was 80.5% with the same physician prescribing and 76.6% with different physicians prescribing. The absolute difference is 80.5% − 76.6% = 3.9%. All differences were statistically different from 0 when adjusted for a familywise error rate of 0.05. Point estimates and differences with 95% confidence intervals are provided in eTable 15 in the Supplement.