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Drops in First-Time Opioid Prescriptions Highlight Progress, but Also Some Concern

Jaime Rosenberg
Between July 2012 and December 2017, a significant proportion of providers stopped prescribing opioids; but while overall incidence dropped, a subgroup of providers continued to prescribe high-risk doses of opioids, and for long durations.
Growing recognition of and calls to put an end to the opioid epidemic in recent years have produced results, according to a new study that identified a significant drop in opioid prescribing for patients who never used opioids or who had been off them for at least 6 months.

However, while overall prescribing has dropped by more than 50%, there are still subgroups of providers that continue to write high-risk initial opioid prescriptions for these patients, according to researchers who included Michael E. Chernew, PhD, the Leonard D. Schaeffer Professor of Health Care Policy; director of the Healthcare Markets and Regulation Lab in the Department of Health Care Policy at Harvard Medical School; and co-editor of The American Journal of Managed Care®.

These findings come from an analysis of more than 86 million patients insured with Blue Cross-Blue Shield Axis between July 2012 and December 2017.

Over the 4.5 years, the rate of monthly opioid prescriptions among enrollees who hadn’t used opioids or were opioid naïve dropped by 54%, falling from 1.63% to 0.75%. During the period, the number of providers who prescribed initial opioids for these patients dropped 29%, from 114,043 in July 2012 to 80,462 in December 2012, suggesting that some providers responsed to the opioid crisis by stopping opioid prescriptions rather than prescribing them at lower-risk doses and durations.

The researchers noted that these declines started before the CDC finalized their draft guidelines in March 2016 that emphasized limiting the use, duration, and dose of opioids for first-time users, which the they said indicates the guidelines were not the sole driver of these declines.

The researchers also observed that as overall incidence declined, the incidence of long-duration and high-dose initial opioid prescriptions also decreased by comparable percentages, with initial prescription duration of more than 3 days falling by 57% and initial prescription duration of more than 7 days falling by 68%. At the same time, initial prescription doses of more than 50 milligram equivalents (MME) per day declined by 57% and incidence of initial prescription doses of more than 90 MME per day declined by 67%.

However, while the incidence of initial prescriptions dropped over the period, among providers who did initiate opioid therapy, the mean prescription duration increased from 6 days in July 2012 to 6.3 days in January 2013 before declining to 5.5 days in December 2013, where it remained consistent until dropping again to 5.1 days in December 2017.

“Strikingly, the percentage of long-duration or high-dose initial prescriptions remained high over the period, even after the release of the CDC guidelines,” wrote the researchers, who were alarmed to find that high-risk initial opioid prescriptions represented more than 115,000 prescriptions per month per 15,897,673 enrollees who had not used opioids.

More than 7000 of these prescriptions exceeded 90 MME per day, which the CDC said is rarely needed, if at all. But, the researchers did note that they were not able to gauge severity of pain from the claims data alone and these prescriptions that deviate from CDC guidelines are not necessarily inappropriate.


Zu W, Chernew M, Sherry T, Maestas N. Initial opioid prescriptions among US commercially insured patients, 2012-2017 [published online March 13, 2019]. N Engl J Med. doi: 10.1056/NEJMsa1807069.

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