Study Shows Urgent Need for Improved Prescribing Practices; Opioid Abuse

Drug overdose is the leading cause of injury death in the United States. The death rate from drug overdose in the United States more than doubled during 1999 to 2013, from 6.0 per 100,000 population in 1999 to 13.8 in 2013. The increase in drug overdoses is attributable primarily to the misuse and abuse of prescription drugs, especially opioid analgesics, sedatives/tranquilizers, and stimulants. Information from state prescription drug monitoring programs (PDMPs) can be used to detect and measure prescribing patterns that suggest abuse and misuse of controlled substances, according to a recent CDC report.


This is the first multi-state report from the CDC and FDA-funded Prescription Behavior Surveillance System (PBSS), which analyzes data from state PDMPs. The eight states that submitted 2013 data—California, Delaware, Florida, Idaho, Louisiana, Maine, Ohio, and West Virginia—represent about a quarter of the U.S. population. Certain patients obtain drugs for nonmedical use or resale by obtaining overlapping prescriptions from multiple prescribers. The risk for overdose is directly associated with the use of multiple prescribers and daily dosages of >100 morphine milligram equivalents (MMEs) per day.


The study found that prescribing practices varied widely among states despite the fact that states are similar in the prevalence of the conditions these drugs are used to treat. Moreover, differences in population characteristics, such as ethnicity and social status, likely explain only a fraction of the variation in prescribing practices. The findings point to the urgent need for improved prescribing practices, particularly for opioids – which in all eight states were prescribed twice as often as stimulants or benzodiazepines.


Rates for opioids and benzodiazepine (tranquilizer) prescriptions were substantially higher for females than for males in all states. In most states, opioid prescribing rates peaked in either the 45–54 years or the 55–64 years age group. Benzodiazepine prescribing rates increased with age. The higher prescribing rates for opioids among women compared with men are consistent with a higher self-reported prevalence of certain common types of pain, such as lower back pain among women. The trend in opioid prescribing rates with age is consistent with an increase in the prevalence of chronic pain with age, but the increasing prescribing rates of benzodiazepines with age is not consistent with the fact that anxiety is most common among persons aged 30 to 44 years. Louisiana ranked first in opioid prescribing.


“Every day, 44 people die in American communities from an overdose of prescription opioids and many more become addicted,” said the CDC director Tom Frieden, M.D., M.P.H. “States are on the frontline of witnessing these overdose deaths. This research can help inform their prescription overdose prevention efforts and save lives.”


The study findings underscore the need to curb overprescribing. Prescribing rates varied widely by state: twofold for opioids, fourfold for stimulants, and nearly twofold for benzodiazepines. Among the study’s other findings:


  • A small minority of prescribers are responsible for most opioid prescriptions.
  • The top one percent of prescribers wrote one in four opioid prescriptions in Delaware, compared with one in eight in Maine.
  • People who receive opioid prescriptions often receive benzodiazepine prescriptions as well, despite the risk for adverse drug interactions.
  • The percentage of controlled substance prescriptions paid for in cash – an indicator of abuse – varied almost threefold among five states reporting this measure.


“A more comprehensive approach is needed to address the prescription opioid overdose epidemic, including guidance to providers on the risks and benefits of these medications,” said Debra Houry, M.D., M.P.H., director of the CDC’s National Center for Injury Prevention and Control.


The CDC works with states, communities, and prescribers to prevent opioid misuse and overdose by tracking and monitoring the epidemic and helping states scale up effective programs such as the Prescription Drug Overdose: Prevention for States program. The CDC also improves patient safety by equipping health care providers with data, tools, and guidance so they can make informed treatment decisions.


States can use their PDMPs as public health surveillance systems to generate timely population-based metrics for the prescribing of controlled substances and for behaviors that suggest their misuse. Tracking changes in these metrics over time can be useful in measuring the effect of policy changes designed to reduce prescription drug misuse. The calculation of similar measures in multiple jurisdictions can now be conducted, and such comparisons can help identify norms and determine whether patterns or trends in one state are attributable to state policies or the result of larger, national influences. Explaining the variation in prescribing from state to state is an important topic for future research.


See the CDC Announcement


See the CDC Report


See also Medical Law Perspectives, January 2014 Report: Prescription Painkillers: Risks for Patients, Pharmacists, and Physicians


See also Medical Law Perspectives, May 2013 Report: Drugs, Dosage, and Damage: Physician Liability for Prescribing or Administering Medication


See the Medical Law Perspectives October 8, 2014, Blog: Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double