Baltimore, MD—To combat the nation’s opioid epidemic, the sole focus should not be on high-prescribing “pill-mill” clinicians, a new study suggests.

The study in the journal Addiction found that opioids often are prescribed to high-risk patients by primary-care physicians, surgeons, and nonphysician healthcare providers who, overall, are not high prescribers of narcotics.

And while pharmacists and other healthcare professionals have been alerted to the issue of “opioid shoppers”—patients who seek opioids from multiple doctors and pharmacies—those individuals are much less likely to show up to fill a prescription than other categories of painkiller users, according to study authors.

“This crisis has been misconstrued as one involving just a small subset of doctors and patients,” explained senior author G. Caleb Alexander, MD, associate professor in the Department of Epidemiology at the Bloomberg School and founding codirector of the Johns Hopkins Center for Drug Safety and Effectiveness. “Our results underscore the need for targeted interventions aimed at all opioid prescribers, not just high-volume prescribers alone.”

Researchers conducted a cross-sectional study using 2015 longitudinal, all-payer QuintilesIMS pharmacy claims from California, Florida, Georgia, Maryland, and Washington.

Among more than four million patients, the study team identified:
• 37,848 concomitant users, defined as filling more than 30 days of concomitant opioids and benzodiazepines 
• 150,814 chronic users, defined as using 100 morphine milligram equivalents (MMEs) or more per day for more than 90 days, and 
• 3,190 patients prescribed opioids by more than three prescribers and filling those scripts at more than three pharmacies during any 90-day period. 

At the same time, among 192,126 healthcare professionals, the researchers pinpointed 8,023 high-volume prescribers, who made up the highest fifth percentile of opioid volume during four calendar quarters.

Results indicate that low-volume prescribers accounted for 15% to 29% of opioid volume and 18% to 56% of opioid prescriptions for high-risk patients, compared with 28% to 37% and 53% to 58% for low-risk patients. 

After accounting for state of residence, comorbid burden, prescriber specialty, and care sequence, patients were more likely to receive higher doses (60.9 vs. 53.2 MMEs per day), longer supplies (22.1 vs. 15.6 days), more prescriptions (4.0 versus 2.6 prescriptions), and greater opioid volume (5.6 vs. 1.9 g) from high-volume rather than low-volume prescribers.

“In the United States, high-risk patients obtain a substantial proportion of prescription opioids from low-volume prescribers,” study authors conclude. “The differences in prescribing patterns between high- and low-volume prescribers suggest the importance of interventions targeting prescriber behaviors.”

“The point here is that ordinary, low-volume prescribers are routinely coming into contact with high-risk patients–which should be a wake-up call for these prescribers,” Alexander added. “We need to build systems to help prescribers better identify these patients, screen them for opioid use disorders, and improve the quality of their pain management.”
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