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July 16, 2014
States Vary Dramatically in Rates of Opioid,
Benzodiazepine Prescribing Atlanta—Prescribing of pain medications and sedatives varies widely across the United States, and the CDC is calling for a crackdown by states with the highest rates. “The rates of use of pain relievers and benzodiazepine sedatives showed about three- to five-fold variation from the highest to lowest states,” researchers from the CDC and Emory University, both in Atlanta, write in the article, published recently in the Morbidity and Mortality Weekly Report, adding that differences were greater for long-acting and high-dose formulations. “Research on small-area variation in health care indicates that high rates of use of prescription drugs and medical procedures do not necessarily translate into better outcomes or greater patient satisfaction,” study authors explain. “In fact, high rates of use might produce worse outcomes. In this case, greater use of opioids and benzodiazepines might expose populations to greater risks for overdose and falls.” Using a commercial database, the CDC study assessed the potential for improved prescribing of opioid pain relievers (OPR); long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines. The researchers found that prescribers wrote an average of 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States in 2012, twice as much per capita as the second ranking nation, Canada. States within the U.S. ranged dramatically in prescribing, meanwhile; overall, some states prescribed OPRs 2.7 times and benzodiazepines 3.7 times as much as others. For both drug classes, the CDC found higher rates in the South, with three Southern states two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast, and rates varied 22-fold for one type of OPR, oxymorphone. “Factors accounting for the regional variation are unknown,” according to the study. “Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety.” The CDC is calling on state policy makers to reduce potential abuse of the drugs in those high-prescribing states, noting, “States have the authority to track prescribing and dispensing and regulate medical practice within their borders. They can influence the rate of prescribing of controlled prescription drugs by various measures. These include passing regulations related to use of state prescription drug monitoring programs and the operation of pain clinics.” Prescribing rates varied widely by state for all drug types: • For all OPR combined, the prescribing rate in Alabama was 2.7 times the rate in Hawaii. • The high/low ratio was greater for LA/ER OPR and high-dose OPR compared with all OPR together: for high-dose OPR, state rates ranged 4.6-fold (Delaware vs. Texas), and for LA/ER OPR, state rates ranged 5.3-fold (Maine vs. Texas). • State rates ranged 3.7-fold (West Virginia vs. Hawaii) for benzodiazepines. • For both OPR and benzodiazepines, Alabama, Tennessee, and West Virginia were the three highest-prescribing states and were greater than or equal to two standard deviations (SDs) above the mean. • For LA/ER opioids, Maine and Delaware were greater or equal to two SDs above the mean. • For high-dose OPR, Delaware, Tennessee, and Nevada were greater than equal to two SDs above the mean. The rate for LA/ER OPR in Texas was the only one greater than or equal to two SDs below the mean for any category. Overall, the highest rate of prescribing all OPRs and benzodiazepines was in the South, with the greatest levels for high-dose OPR and LA/ER OPR in the Northeast, where 17.8% of OPR prescribed were LA/ER OPR. Elevated rates also were documented in individual states in the South and West for high-dose and extended-release formulations, and Southern states also ranked highest for all individual opioids except for hydromorphone, fentanyl, and methadone, for which the highest rates were in Vermont, North Dakota, and Oregon, respectively. The MMWR report points out that opioid pain relievers were involved in 16,917 overdose deaths in 2011, with benzodiazepine sedatives cited as contributing causes in 31% of those deaths. “Higher OPR and benzodiazepine prescribing rates in the South presented in this report are similar to the findings of higher prescribing rates for other drugs in the South, including antibiotics, stimulants in children, and medications that are high-risk for the elderly,” the CDC notes. “Previous studies have found that regional prescribing variation cannot be explained by variation in the prevalence of the conditions treated by these drugs.” Instead, “one possible explanation for the results of this study is the lack of consensus among health-care providers on whether and how to use OPR for chronic, noncancer pain.” The study also emphasizes that states can change inappropriate prescription rates by using prescription drug monitoring programs (PDMPs), citing, “New York and Tennessee, for example, mandated prescriber use of the state PDMP in 2012. They subsequently used their PDMPs to document declines of 75% and 36%, respectively, in the inappropriate use of multiple prescribers by patients.” Other recommended actions include: • Developing or adopting existing guidelines for prescribing OPR and other controlled substances to establish local standards of care and bring prescribing rates more in line with current best practices • Managing pharmacy benefits through state Medicaid programs to promote cautious, consistent use of OPR and benzodiazepines • Passing laws to address the most egregious prescribing excesses, such as Florida’s legislation on pain clinics in 2010 and prohibition of dispensing by prescribers in 2011.
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U.S. Pharmacist Social Connect
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