From Pages to Practice

By Angela Castellanos, MD

Published March 20, 2019


As many current residents and new attendings were becoming physicians, an opioid epidemic developed in the United States. During our training, the professional conversations and education around opioid prescribing practices and pain management shifted beneath our feet. It’s hard to remember a time before the emphasis on nonopioid treatments for pain control, opioid consent forms, and prescription drug monitoring programs, although that era was not long ago. The Centers for Disease Control and Prevention (CDC) officially issued prescribing guidelines for opioid use in chronic pain in March 2016. What did opioid prescribing practices look like during this epidemic? Has the surge in public and professional awareness changed opioid prescribing practices in the U.S. during this time?

In an observational study recently published in NEJM, Zhu et al. examined trends in opioid prescriptions among privately insured enrollees in the U.S. between 2012–2017.  The results demonstrated a decline in the monthly incidence of initial opioid prescriptions and in the number of providers who initiated opioid therapy. Although these data show promising practice changes, they do not assess the direct clinical effect of such practices.

The following NEJM Journal Watch summary explains the study and its findings.


Nationwide U.S. Opioid Prescribing Trends

Fewer physicians prescribe opioids, but those who do are not changing their ways.

In the past decade, U.S. clinicians have been urged to rethink their opioid prescribing practices; the Centers for Disease Control issued formal guidelines to limit use, shorten duration, and lessen potency. How have clinicians responded? To examine recent nationwide trends in opioid prescribing, researchers probed data from a large commercial insurer's claims database. Among more than 86 million enrollees (age, ≥15), about 20 million received at least one opioid prescription between July 2012 and December 2017; about half of such patients were considered to be opioid-naive. Individuals with Medicare were excluded, as were those receiving methadone and buprenorphine.

Fifty percent fewer enrollees received new opioid prescriptions in December 2017 than in July 2012 (0.8% vs. 1.6%); almost 60% fewer prescriptions were written for >3-day supply, and 70% fewer were written for >1-week supply. Prescriptions for doses higher than 50 morphine milligram equivalents (MME) daily fell by about 60%. In addition, the number of clinicians who wrote new prescriptions fell by 30%, with reductions occurring across all provider specialties, and for all diagnostic codes. Throughout the study, dentists were least likely to write prescriptions for long courses of opioids, and primary care doctors were most likely. Among clinicians who continued to write opioid prescriptions, duration of prescriptions changed minimally, as did average daily dose and quantity of high-dose opioids (≥50 MME daily).

Comment: Without clinical correlation, we have no way of knowing if these data represent good news or bad. The overall decrease in opioid prescribing probably curbed a culpable excess but might also have caused a regrettable increase in patients with poorly controlled pain. Doctors who continue to prescribe opioids might be doing so for good reasons or just to avoid having very difficult conversations with dependent patients.

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Angela Castellanos is a general pediatrician and editorial fellow at the NEJM.