Recall that CWCI data indicates that 10% of prescribers are responsible for nearly 80% of the opioid prescriptions in the California work comp system (and 88% of opioid costs!). That's an astounding statistic and one that has led many observers and decision-makers to conclude that the solution to mitigating the opioid epidemic is to change the behavior of a small subset of prescribers that were driving the utilization of potentially dangerous medications. I've heard this from a multitude of sources: "It's a relatively small group of the prescribers who are really responsible for this problem. How do we change their prescribing behavior?"
The authors of this recent research letter decided to test whether the same ratio was exhibited in a much broader data set: all Medicare claims. Granted, this is a data set not representative of the work comp injured worker population, but it's still an interesting question: Do we see that 10% of prescribers to Medicare patients drive 80% (or more) of the opioid prescriptions? The answer would lend itself to opioid misuse and abuse mitigation strategies that go far beyond work comp and speak to the national effort to curb addiction and overdose deaths. What are we aiming for? 10% of prescribers? Or a broader group?
The answer: the top 10% of Medicare prescribers account for only 56.7% of all opioid claims. Not only is this far below the CWCI data point of 80%, but it's also significantly less than the percentage of overall prescriptions (opioids and non-opioids) written by the top 10% of overall Medicare prescribers (63%).
Does this mean the CWCI data is less accurate or less valuable to us? Absolutely not. On the contrary, the CWCI data should help focus our work comp specific strategies for opioid misuse and abuse. But for those of us concerned with the broader, national (and, increasingly, international) issue of opioid misuse and abuse, this JAMA research letter suggests that a broader, more comprehensive set of strategies that span a wider swath of prescribers will be necessary.
Perhaps of even greater consequence is the specialty make-up of the prescribers. The number of opioid claims in the Medicare data set are overwhelmingly from general practitioners (note that this chart is on a log scale... look at the actual numbers... family practice and internal medicine doctors are responsible for about 28 million opioid claims vs. a little over 3 million for pain management and interventional pain management combined).
1) We need broad-based strategies to confront the opioid epidemic, though in work comp our efforts may be focused on a smaller subset of prescribers.
2) These broad efforts need to focus on education for general practitioners. Chronic pain is fundamentally an issue of primary care and we would be wise to treat it as such.
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