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Prescription narcotic abuse in the US rampant in some states

Robin Wulffson MD's picture
opiates, narcotics, abuse, overprescribing, underprescribing, state variation

Narcotics are opioids that are highly effective for relieving pain; however, they are also subject to abuse. A new study has found that opiates are over prescribed in some states and underprescribed in others. Researchers at the firm Abt Associates published their findings in the October issue of the Journal of Pain

The researcher estimated geographic variation among states and counties in regard to the prevalence of opioid prescribing. They reviewed a large (135 million) representative national sample of opioid prescriptions dispensed during 2008 by 37,000 retail pharmacies. The sample represented 66% of all prescriptions for the eight most frequently prescribed forms of opioids: codeine, fentanyl, hydrocodone, methadone, oxycodone, oxymorphone, tramadol, and propoxyphene (removed from the market in 2010). The authors used these prescriptions to estimate the total number of opioid analgesics prescribed that year and then grouped the estimates to the county of the prescribing physician. They used statistical analyses to estimate the extent to which county variation is explained by characteristics of resident populations, their healthcare utilization, proxy measures of morbidity, availability of healthcare resources, and prescription monitoring laws.

The researchers found that geographic variation in the prevalence of prescribed opioids was significant; furthermore, it was far greater than the variation observed for other healthcare services. They found that counties having the highest prescribing rates for opioids were disproportionately located in Appalachia and in southern and western states. They noted that the number of available physicians was by far the strongest predictor of amounts prescribed; however, only one-third of county variation was explained by the combination of all measured factors. They suggested that the wide variation in prescribing opioids reflects weak consensus regarding the appropriate use of opioids for treating pain, especially chronic non-cancer pain. They found that patients’ demands for treatment with opioids have increased, more potent opioids have become available, an epidemic of abuse has emerged, and calls for increased government regulation are growing. They noted that greater guidance, education, and training in opioid prescribing are needed for clinicians to support appropriate prescribing practices.

Prescription prevalence rates were expressed as milligrams prescribed and dispensed per 1,000 residents, with the weights of the eight opioids converted into morphine equivalents. The authors measured variation in opioid prescribing as the difference between the average amount in milligrams in all counties and the amount prescribed and dispensed in a particular county.

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Pike County, Kentucky is one of the many counties with high opioid use in Appalachia, which stretches from southwestern New York to the northern reaches of Mississippi, Alabama, and Georgia. The investigators also found large areas of intense opioid prescribing in states such as California, Arizona, and Florida. The authors noted that Florida has a profusion of pain-medicine clinics; however, prescriptions that were dispensed at such facilities were not included. The investigators ranked states in terms of milligrams of opioids in morphine equivalents per resident. Southern, western, and Appalachian states dominated the top-10 list:

(State - Average mg of Opioids/Resident - Relative to All-State Average (%))

Nevada - 1,150 - 210
Delaware - 973 - 178
Florida - 969 - 177
Kentucky - 893 - 163
Tennessee - 849 - 155
Arkansas - 834 - 153
West Virginia -821 -150
Utah -796 - 146
Alabama - 749 - 137
South Carolina -729 - 133

The range in prescription rate was huge. Residents of number-one Nevada used on average seven times more opioids by weight than the District of Columbia, which had the lowest rate. On a county-to-county basis, the greatest variation occurred with oxycodone, methadone, and oxymorphone. The top 25% of counties used 7.1 times as much oxycodone, 10.8 times as much oxymorphone, and 8 times as much methadone as the bottom 25%.

The authors concluded that the wide geographic variation in opioid prescribing does not reflect differences in the prevalence of injuries, surgeries, or conditions requiring analgesics. Thus, the study raises questions about opioid prescribing practices. They suggested that low prescription rates may indicate under-treatment, while high rates may indicate overprescribing and insufficient attention to risks of misuse.

Take home message:
This interesting study reports the wide range of opioid prescribing in the US. Doctors who overprescribe opiates can be found in most regions of the US and patients who are drug abusers discover them and pass the information on to their friends. However, this study notes that over-prescribers and drug-abusers are clustered in regions of the US. It also notes areas where these medicines are under-prescribed.

Reference: Journal of Pain
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