2017-07-06 14:01:03
Opioid Prescriptions Fell Over 5 Years, but No Easy End to Addiction Crisis

WASHINGTON — The amount of opioid painkillers prescribed in the United States peaked in 2010, a new federal analysis has found, with prescriptions for higher, more dangerous doses dropping most sharply — by 41 percent — since then.

But the analysis by the federal Centers for Disease Control and Prevention also found that the prescribing rate in 2015 remained three times as high as in 1999, when the nation’s problem with opioid addiction was just getting started. And there is still tremendous regional variation in how many opioids doctors dole out, with far more prescribed per capita in parts of Maine, Nevada and Tennessee, for example, than in most of Iowa, Minnesota and Texas.

Overall, the analysis found that the amount of opioids prescribed fell by 18 percent between 2010 and 2015, though it increased in 23 percent of counties.

“We still have too many people getting medicine at too high a level and for too long,” said Dr. Anne Schuchat, the acting director of the C.D.C. She noted that the amount of opioids prescribed in 2015 would be enough to provide every American with round-the-clock painkillers for three straight weeks.

A flurry of recent attempts to tamp down opioid prescribing — including C.D.C. guidelines issued last year on prescribing the drugs for chronic pain and new state and insurer limits on how many pills doctors can prescribe — are not reflected in the analysis, which did not look beyond 2015.

But earlier actions, like state crackdowns on pain clinics and prescribing guidelines released by the Department of Veterans Affairs in 2010, may have contributed to the declines. The amount of prescribed opioids fell in 85 percent of Ohio counties from 2010 to 2015, for example, as the state tightened regulations for pain clinics and started requiring clinicians to check databases to see whether patients were getting opioid prescriptions elsewhere.

The decline documented in the analysis also coincided with the federal government’s tightening of prescribing rules in 2014 for one of the most common painkillers: hydrocodone combined with a second analgesic, like acetaminophen.

In many states, including Ohio, restrictions on prescribing have coincided with staggering increases in overdose deaths from heroin and its far more powerful, synthetic relative, fentanyl. But Dr. Schuchat said the C.D.C. has found no evidence that tighter prescribing has played a role in the rise of illicit opioids.

“We do know that when you start people on prescription opioids, the risk of unintended consequences and illicit use goes up,” Dr. Schuchat said. “But our staff has done intensive analyses to see whether changing policies for prescription drugs shifts people into illicit use, and the answer is no.”

While the analysis found the amount of opioids prescribed per capita remained extremely high in many counties in 2015, some experts warned that averages can be misleading.

“An enormous amount of opioid volume is driven by a very small number of prescribers,” said Dr. Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. “They need to be intervened upon, targeted with educational outreach and, if necessary, professional or regulatory sanction. My sense is that’s not yet happening enough.”

Attempts to restrict opioid prescribing have upset many patients with chronic pain, who say their needs are being ignored in the rush to stamp out the addiction epidemic.

“One group I think has been affected without question is patients who are compliant with their regimen, who have a clear diagnosis and have been managed appropriately, but now find they can’t continue to receive opioids that allowed them to continue to function,” said Dr. Daniel Carr, the director of Tufts Medical School’s program on pain, research education and policy.

But others say there is very little evidence to suggest opioids are effective for chronic pain that is not caused by cancer. The C.D.C. prescribing guidelines published last year, which were bitterly opposed by many pain doctors and drug industry groups, recommend that doctors first try ibuprofen or aspirin to treat pain. The guidelines, which are nonbinding, also recommend limiting opioid treatment for short-term pain to less than a week.

“If you are on opioids longer than three months, your risk of being addicted increases by 15-fold,” Dr. Schuchat said.

One challenge in cutting opioid use, Dr. Alexander said, is that while insurers are placing new restrictions on opioid prescribing, many are strictly limiting or not yet covering alternative treatments for pain, such as physical therapy and acupuncture, or even other types of medication that could help.

The C.D.C. analysis, which used retail prescription data from QuintilesIMS, also found that larger amounts of opioids were prescribed in “micropolitan” counties, which have urban clusters of between 10,000 and 50,000 people, and are often anchor communities for much larger rural regions. It also found larger amounts were prescribed in counties with a higher prevalence of diabetes and arthritis, and with larger white populations, higher unemployment and higher Medicaid enrollment.

Yet Dr. Schuchat pushed back against claims that the Affordable Care Act’s expansion of Medicaid, which started in 2014, has made the opioid crisis worse by increasing access to prescription painkillers. The overprescribing of opioids “predates Medicaid expansion by many years,” she said, adding that the states with the highest rates of opioid prescribing in 2015 tended to also have high rates in 2010 and earlier.

“It is likely that higher prevalence of disability, as well as socioeconomic factors, largely explain the findings related to Medicaid,” she said.

Despite the national decline in the amount of opioids prescribed, the analysis found that the average number of days that opioid prescriptions were meant to last actually increased in 73 percent of counties between 2010 and 2015. Overall, the average supply grew by about 14 percent, to 17.7 days’ worth from 15.5. Dr. Schuchat said that could be because fewer doctors were starting new patients on opioids — initial prescriptions are often smaller — and instead were prescribing largely to longtime pain patients.

The top-prescribing counties as measured by the amount of opioids prescribed per capita — including Surry County, N.C. (north of Winston-Salem) and Claiborne County, Tenn. (along the Kentucky border) — prescribed six times more opioids per capita in 2015 than the lowest-prescribing counties.

One weakness of the study, as Dr. Carr and the C.D.C. researchers themselves pointed out, was that it could not evaluate the reasons for prescriptions, and how often they were given for chronic pain versus acute or end-of-life pain.

The analysis also did not include opioid prescribing data from about 13 percent of the nation’s counties because it was not complete or available.

Dr. Bruce Psaty, an internist and researcher at the University of Washington who studies drug safety, said changes have to originate within individual health systems and doctors’ offices to be most effective. His own clinic now has pharmacists who closely monitor opioid prescriptions and “come to us and say, ‘I think this person’s on too much.’

“It’s the culture in the clinic that leads to the change,” he said.

Dr. Schuchat said that even if opioid prescribing continues to drop, it will not have an immediate effect on the addiction epidemic.

“It’s going to take a while to get out of this because so many are already addicted,” she said. “We’re all very impatient; we all see this as an emergency, but it’s going to take a while for it to get better.”