Opioid Prescribing in America, has it Changed?

By M.K. Leach, a health care professional specializing in Substance Use Disorder and addiction recovery. He is a regular contributor to the healthcare website Addicted.org and a Certified Clinical Medical Assistant.

Opioid prescribing has been a major contributor to the number of opioid-involved overdose deaths across the United States. However, over the past ten years, opioid prescribing trends have changed nationally and on an individual state level. Amid the COVID-19 pandemic, overdose deaths connected to opioids continue to increase, and unfortunately, opioid prescriptions continue to contribute to numerous overdose deaths, despite declining nationally. States across the nation have taken extreme steps to reduce prescribing rates and provide more resources for people struggling with addiction. Yet, has it caused any change—the pandemic and excessive government restrictions placed on free society did contribute to the already rising overdose death rate. Opioid prescribing has decreased, but people are dying in record numbers. 

According to the Centers for Disease Control, after a steady increase in the overall national opioid dispensing rate beginning in 2006, the total number of prescriptions peaked in 2012 at more than 225 million. The dispensing rate was 81.3 prescriptions per 100 persons. Between 2012 and 2019, the opioid dispensing rate declined, and in 2019, it had fallen to the lowest in 14 years. However, in 2019, dispensing rates remained high in certain areas of the country. In approximately 5% of U.S. counties, enough opioid prescriptions were dispensed for every person to have one. The national prescribing rate in 2019 was 46.7 prescriptions per 100 people. Yet, some counties had a rate that was six times higher than that.

In 2019, nearly 50,000 people in the United States died from opioid-involved overdoses. The misuse of opioids includes prescription pain medication, heroin, and synthetic opioids. Unfortunately, roughly 21 to 29 % of people prescribed opioids for pain misuse them. Also, around 8 to 12% of people using opioids for chronic pain develop an addiction. Among 38 states with recorded overdose data, 17 states saw a decline between 2017 and 2018. However, in 2019, deaths began to rise again nationally, and once the pandemic hit, overdose deaths increased significantly.  In December of 2020, the CDC estimated that over 81,000 drug overdosed deaths occurred in the 12 months ending in May 2020.

Approximately 37 of the 38 U.S. jurisdictions with available data reported increases in synthetic opioid-involved overdose deaths. Moreover, 18 of these jurisdictions reported increases greater than 50%, and ten western states reported over a 98% increase in synthetic opioid-involved deaths. Overall, 32% of opioid-related deaths in 2018 involved prescription opioids, and this trend continues. Yet, there are significant regional disparities. For example, Virginia had one of the lower opioid prescription rates in the country at the state level.  However, at the county level, some counties saw death rates due to prescription opioids double.

Overall, trends indicate the total number of prescriptions dispensed had decreased by more than 22%, yet prescription opioids remain the leading cause of overdose death. Most people prescribed pain medication do not understand the risk for addiction. Pain medication is typically prescribed for short-term use, unless for chronic pain. However, the physical and psychological dependence becomes too much to manage, and more Americans are also prescribed benzodiazepines, sedatives, anti-depressants, and other drugs that increase the risk of overdose. In 2018, one in five Americans had an opioid prescription filled.

Additionally, more opioids were being prescribed in rural America. Between 2014 and 2017, the percentage of patients prescribed an opioid was higher in rural areas than in urban settings. In 2017, 14 rural counties were among the 15 counties with the highest opioid prescribing rates. More Americans are moving away from large urban centers to rural areas for various reasons, and prescribing rates have followed. Between January 1, 2009, and December 31, 2018, the number of prescriptions per 100 primary care patients decreased by 73.7%. However, regionally things are much different than what is happening nationally and could be what is driving the ongoing issue with overdose deaths. In 2018, Kentucky had one of the highest opioid prescribing rates at 79.5 per 100 persons, yet the overdose rate was 23.4 per 100,000 persons. West Virginia had a prescribing rate of 69.3 per 100 persons and an overdose rate of 42.4 per 100,000 persons.

Local insight is the key to controlling the problem, and more attention should be placed regionally than what is happening nationally. Some programs have proven success, like prescription drug monitoring programs, regulating controlled substances, licensed addiction care providers in rural areas, quick response to drug overdose outbreaks, and adequate public health insurance coverage and workers compensation programs. However, 2020 and 2021 have not been easy and will likely show the highest number of opioid deaths on record.