Intended for healthcare professionals


Opioid prescribing rates in US vary widely between states, CDC reports

BMJ 2014; 349 doi: (Published 04 July 2014) Cite this as: BMJ 2014;349:g4424
  1. Michael McCarthy
  1. 1Seattle

Healthcare providers in Alabama wrote almost three times as many prescriptions for opioid painkillers per person as those in Hawaii, the US Centers for Disease Control and Prevention (CDC) has reported.1

The report said that the states with the highest prescription rates of opioid pain relievers tended to be in the South: Alabama had the highest rate of prescriptions per 100 people, at 142.9; Tennessee had 142.8; and West Virginia had 137.6. The states with the lowest rates were California (57.0), New York (59.5), and Hawaii (52.0).

The variation in prescription rates for benzodiazepines was even wider, with a nearly fourfold difference between West Virginia, which had the highest rate (71.9), and Hawaii, which had the lowest (19.3). “Such wide variations are unlikely to be attributable to underlying differences in the health status of the population,” the CDC researchers noted.

Over the past two decades the number of prescriptions for opioid pain relievers has soared in the United States. In 2012 US healthcare providers wrote nearly 258.9 million prescriptions for opioid pain relievers—enough for one prescription for every adult in the country—and US residents consume opioid pain relievers at a higher rate than those of any other country. The figure was twice as high as in Canada, which ranked second.

As opioid prescriptions have increased in the US, so too have overdose related deaths: in 2011 opioid pain relievers were involved in nearly 17 000 overdose deaths in the US—more than from heroin and cocaine combined. In about a third (31%) of these deaths a benzodiazepine sedative was also involved. “Benzodiazepines are commonly prescribed in combination with [oral pain relievers], even though this combination increases the risk for overdose,” the CDC noted.

For the report CDC researchers analyzed data collected by IMS Health, a commercial company that tracks US prescribing trends. For this study “opioid pain reliever” included semisynthetic opioids, such as oxycodone and hydrocodone, and synthetic opioids, such as tramadol. It did not include buprenorphine (primarily used for substance abuse treatment), methadone distributed through substance abuse treatment programs, or opioid containing cough and cold formulations. The benzodiazepines in the study included alprazolam, clonazepam, clorazepate, diazepam, estazolam, flurazepam, lorazepam, oxazepam, quazepam, temazepam, and triazolam.

The researchers found that US healthcare providers wrote 82.5 prescriptions for opioid pain relievers for every 100 people (including both adults and children) and 37.6 benzodiazepine prescriptions per 100 people. The prescribing rates varied widely by state for all drug types but were highest for oxymorphone, a powerful opioid often prescribed in a long acting, extended release form, which was prescribed 22 times more often in Tennessee than in Minnesota.

The researchers wrote, “Wide variation in the use of medical technology, including pharmacotherapy, usually indicates a lack of consensus on the appropriateness of its use. Therefore, one possible explanation for the results of this study is the lack of consensus among healthcare providers on whether and how to use [opioid pain relievers] for chronic, noncancer pain.”

Variations in the use of long acting, extended release opioids may reflect the practices of “unscrupulous pain clinics” prescribing to people who used the drugs for substance abuse, they added.

States can affect their healthcare providers’ prescribing practices by developing or adopting guidelines, instituting prescription drug monitoring programs to track prescriptions for drugs prone to abuse, and using pharmacy benefit management programs to promote the more cautious use of opioid pain relievers and benzodiazepines, the researchers noted.

In a teleconference, Tom Frieden, CDC director, said, “All states, but especially those where prescribing rates are highest, need to examine whether the drugs are being used appropriately. What type of pain treatment you get shouldn’t depend on where you live, but on the condition that you have.”


Cite this as: BMJ 2014;349:g4424


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