After years of fitful efforts to get doctors to prescribe fewer opioid painkillers, the nation’s annual dose of the potentially addictive medications remained roughly three times higher in 2015 than it was in 1999, when overdose deaths began their historic climb in the U.S.
A new report from the Centers for Disease Control and Prevention shows that while prescription rates fell nationwide between 2010 and 2015, their availability either remained steady — or actually increased — in just over half of the U.S. counties for which data were available.
The CDC’s comprehensive report offers a mixed picture of progress in a national effort to reduce the availability of the prescription painkillers, which have been implicated in roughly half of the nation’s 33,000 opioid-related overdose deaths in 2015.
Researchers sorted American counties according to the average amount of opioids prescribed per person. This was measured in morphine milligram equivalents, or MMEs, to account for the fact that the drugs come in a variety of types and dosages.
In the counties with the top 25% of MMEs in 2015, patients were prescribed more than six times as much narcotic pain medicine as patients in the 25% of counties where such prescribing is lowest, according to the report in Friday’s edition of the Morbidity and Mortality Weekly Report. The counties in the top quartile were largely rural places where residents are overwhelmingly white, low-income and in poor health.
The 22.6% of counties that have seen increases in the prescribing of opioid painkillers were densely clustered in northern New York and Vermont’s Northeast Kingdom, along the border between North and South Carolina and scattered broadly across the rest of the states.
In California, two counties — Imperial in the state’s far southeast and Mariposa in the central region — saw increases in opioid prescribing between 2010 and 2015. Levels remained stable in eight counties — Inyo, Merced, Mono, San Bernardino, San Benito, San Diego, Siskiyou and Trinity — and declined everywhere else.
Florida, Ohio and Kentucky — all states that cracked down on high-prescribing doctors and clinics between 2010 and 2012 — saw opioid prescribing fall in 80%, 85% and 62% of their counties, respectively.
Given that rates of opioid prescribing are closely linked to addiction and overdoses, the CDC said that counties and states can use its detailed breakout of prescribing trends to increase the availability of addiction treatment.
Those efforts could be complicated by congressional Republicans’ efforts to repeal and replace the Affordable Care Act, which has made addiction treatment available to many opioid addicts through the expanded Medicaid program. Indeed, 23.3% of people in counties with the highest opioid prescription rates were insured by Medicare, compared with 19.2% of people in counties with the lowest prescription rates.
The CDC also urged states to use its analysis to target their efforts to educate physicians on the proper use of narcotic pain relief.
Often-painful conditions such as arthritis and diabetes are disproportionately common among the populations of counties in which opioid prescription rates remain high, CDC researchers found. But such conditions “explain only a fraction of the wide variation” in prescribing rates, the report said.
Mainly, the CDC said, it appears that many physicians have not absorbed a key message issued by federal agencies and professional medical societies alike: For common chronic afflictions such as back pain, arthritis and headache, the benefits of opioid pain relievers don’t outweigh the risk of addiction and death.
For patients with chronic pain not associated with cancer or end-of-life conditions, the CDC recommends medications such as acetaminophen (the active ingredient in Tylenol) and anti-inflammatory drugs such as ibuprofen (the active ingredient in Advil and Motrin), as well as exercise and cognitive behavioral therapy.
At least efforts to discourage opioid prescribing have not backfired. That’s been a key concern after one measure taken to curtail the epidemic — the development of abuse-resistant opioid drug formulas — appeared to steer many addicts to heroin and other street drugs.
Despite overall reductions in opioid prescribing, opioid-involved overdose death rates have continued to rise in recent years, the CDC acknowledged. These increases have been driven largely by use of illicit fentanyl and heroin, the new report said.
But “there is no evidence that policies designed to reduce inappropriate opioid prescribing are leading to these increases,” the researchers wrote.
Where states have cracked down on doctors and pain clinics that appeared to be easy sources of opioid prescriptions, the result was a decline both in prescriptions and in opioid-related deaths. Even overdose deaths attributed to heroin declined in these states, though the drop was too small for researchers to be sure it was more than a statistical fluke.
MORE IN SCIENCE