Tuesday, December 15, 2015

It's Actually NOT 10% of Doctors Driving the Opioid Epidemic

A brief research letter in the Journal of the American Medical Association published just yesterday highlights a fascinating phenomenon in opioid prescribing and does so against the backdrop of workers' compensation data from the California Workers' Compensation Institute (CWCI).

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).  

Two conclusions:
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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  1. An interesting article overall. I'm a little surprised by the second paragraph as it seems to indicate that these results were unexpected. These two populations, Medicare and work comp, are completely different. The Medicare population actually has members where opioid prescribing is actually warranted as the population has a much higher prevalence of cancer and end-of-life care. The third paragraph does go on to mitigate the shock value of the previous.
    Overall, an interesting piece highlighting a broader perspective on a problem we are all familiar with. I wonder though if we are missing an important construct with opioids: how much of the prescribed pills are actually used? Myself, and anecdotally several people I know, have been prescribed opioids post-surgery and of the 20-40 initial pills (plus at least one refill available) only ended up using 1-5 and quickly switched to OTC pain relief. Understanding that behavior could help begin the process of change. Instead of all or nothing, lower the initial dispense and remove the allowance of unsupervised refills.
    Great thought piece, thanks for sharing.

  2. Very interesting research,thank you. Being involved in the work comp world, I had been following, as many of us do, the rise and out-of-controledness of opoids in our business, but I had yet to see a side-by-side comparison of Medicare prescribing trends and volumes.