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Rural Patients More Likely to Be Prescribed Opioids, CDC Says

Allison Inserro
Patients in the most rural areas had an 87% higher chance of receiving an opioid prescription than did patients in large urban areas, according to Thursday's CDC Morbidity and Mortality Weekly Report. 
This story has been updated with a comment about forthcoming CDC research.

A new CDC report that looks at opioid prescription data using national electronic health record (EHR) data from 2014 to 2017 finds a much higher percentage of patients were prescribed opioids in rural areas, but all parts of the country saw decreases after the 2016 release of federal chronic pain guidelines for primary care physicians.

Patients in the most rural areas had an 87% higher chance of receiving an opioid prescription than did patients in large urban areas, the study said.

The study used data from Athenahealth, a EHR vendor for about 100,000 health providers, serving about 86 million patients. The retrospective study used deidentified EHR prescription data from 31,422 primary health care providers serving approximately 17 million patients.

Patient-level data were aggregated by week over the 166 weeks from January 5, 2014, through March 11, 2017.  The study was divided into 3 timeframes: January 5, 2014, through January 3, 2015 (period 1); the next 63 weeks, ending March 19, 2016 (period 2); and the final 51 weeks, through March 11, 2017 (period 3).

Each patient-week was equivalent to each week that a patient had at least 1 Athenahealth record. For each patient-week, it was noted whether primary care providers prescribed 1 or more opioids; the percentage of patient-weeks during which an opioid prescription was written was considered equivalent to the percentage of patients receiving an opioid prescription during that time.

Overall, 128,194,491 patient-weeks of data were included in the analysis. At least 1 opioid was prescribed during 8,810,237 (6.9%) of these patient-weeks, decreasing from 7.4%  to 6.4% by the end of the last study period.

By county classification, the overall percentage of patients with opioid prescriptions ranged from 5.2% in large urban areas to 9.6% in the most rural areas.

Attempting to explain the possible difference between rural and urban areas, the report said higher odds of opioid prescribing in rural counties might stem partly from prescription drug use and misuse as well as a higher prevalence of chronic pain. In addition, rural areas also tend to have larger populations of older adults who have more chronic conditions associated with pain.

The CDC also suggested that opioid prescribing in rural areas "is strongly influenced by providers’ individual relationships with their patients, and can be inconsistent with opioid prescribing guidelines." In addition, rural areas have limited access to medication-assisted treatment facilities, if needed, or alternative therapies. There might also be state by state variations in the implementation of prescription drug monitoring programs and local laws, such as the regulation of pain-management clinics, the report said. 

Some doctors have criticized the CDC 2016 guidelines, saying they were never meant to apply to chronic pain patients, such as those suffering from rare diseases or even cancer pain. These patients now find themselves struggling to get medicine prescribed by their doctor. CMS and insurers have used the guidelines to create safety policies around opioids in an attempt to cope with rising rates of substance use disorder and overdose deaths, most of which come from illicit opioids such as heroin and fentanyl.

In an email to The American Journal of Managed Care®, a CDC spokeswoman said the agency is working to identify "the possible unintended consequences of opioid policies." The results of 1 forthcoming study, looking at whether more restrictive opioid prescribing practices is having the effect of increasing heroin use and overdose, are expected at the end of this year. The study will include patients from Kaiser Permanente Colorado and Colorado's Medicaid program, totaling about 2 million people in the state, or about 40% of the population. 

In the report, the CDC said the guidelines “can help providers and patients weigh the benefits and risks of prescribing opioids according to best available evidence and individual patient needs." It also said the study shows how EHR data can be used in addition to “traditional surveillance methods for monitoring trends in opioid prescribing and other areas of public health importance.”


García MC, Heilig CM, Lee SH, et al. Opioid prescribing rates in nonmetropolitan and metropolitan counties among primary care providers using an electronic health record system — United States, 2014–2017. CDC Morbidity and Mortality Weekly Report." ?rel=0" ?rel=0" ? Published January 17, 2019. Accessed January 17, 2019.

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