n~& “@_~“ &‘~

I Vital and Health Statistics of the National Center for Health Stat[sttcs Number 96 � March 14, 1984 

Q 

-.* 

PROPEm OF WE 

PUBLICATIONS
 i3MNCH 

EMTORWL LIBRARY 

Utilization of Analgesic Drugs


in Office=Based Ambulatory Care:


National Ambulatory Medical Care Survey,


1980-81


by Hugo Koch, Division of Health Care Statistics, and Deanne 

Introduction 

The purpose of this report is to describe the utilization 

‘analgesic drugs in office-based ambulatory care. The report 

]bines the 1980 and 1981 findings of the National Ambula­

*	 y Medical Care Survey, an annual, sample survey of otTicebased physicians conducted from 1973 through 198I by the 

National Center for Health Statistics. The National Ambulatory 

Medical Care Survey (NAMCS ) is scheduled to take the 

tleld again in 19S5and every third year following. 

The term utilisation is limited to the ordering or providing 

of an analgesic drug by the otllce-based physician in the 

course of an office visit. It does not include drugs ordered 

by phone contact, nor does it attempt to measure ultimate 

patient compliance with the doctor’s instruction. 

The drugs described are those classified as Central iVervous System Drugs: Analgesics and Antipyretics, according 

to the American Hospital Forrnulary Service Classitlcation 

System. ] Description centers on drugs of this class that were 

named by physician respondents in 1980–81. A list of the 

named analgesics appears in figure 1. Along with all ne}~t 

analgesics ordered or provided, the physician also recorded 

continued analgesics if the patient was specifically instructed 

during the visit to continue the medication. (However, the 

data base does not distinguish between the new and the 

continued medication. ) The listed agents appear as brand2 

or generic names, depending on the choice made by the 

physician in ordering the analgesic. They are divided into 

two subcategories:~ 

�Opioids: Produce analgesia by their interaction with specific opioid binding sites in the central nervous system. 

(The terms “opioid” and “opiate” are interchangeable). 

E. Knapp, Ph. D., National Center for Drugs and Biologics 

.	 Nonopioids: Do not bind to the opioid receptors. (Indeed, 

the exact mechanism of their analgesic action remains 

unknown}. 

By restricting its scope to an arbitrarily selected class 

of analgesics this study understates the overall use of pain-relieving drugs in office practice. For example, it does not 

account for the presence of analgesic ingredients in drugs 

primarily classified under other rubrics, as in the following 

cases: 

.Members with 

Drug class analgesic ingredients 

Psychotropic agents . . . such as Equagesic, Fiorina[ 

Skeletal muscle relaxants . such as Parafon forte, 

Soma compound 

Antihistamines . . . such as Synalgos 

Antitussives . , . . codeine combinations 

Antidiarrheal agents . . . . opium combinations 

Because the estimates presented in this report are based 

on a sample of office visits and drug mentions rather than 

the entire universe of visits and mentions. they are subject 

to sampling variability. The technical notes at the end of 

the report provide a brief description of the sample design, 

an explanation of sampling errors, and guidelines for judging 

the precision of the estimates. 

‘American Hospital Formulaq Senice Cla.@cation S~wem and Therapeutic


Ca/egory Codes: Copyright, 1980, American Society of Hospital Pharmacists,


Inc.


2The use of trade names is for identification only and does not imply


endorsement by the Public Health Service of the U.S. Department of Health


and Human Services.


‘Based on AMA Drug Eualuotions, Fifth Edition; Chapter 4: American


Medical Asscniation, 1983.

Opioids 

Aceta w/codeine Dilaudid pentazocine Aceta 

acetaminophen Dolacel Percocet-5 acetaminophen 

w/codeine Dolene Percodan Acetycol 

Anexsia-D Dolene Percodan-demi Aluprin 

Anexsia w/codeine compound-65 Phenaphen Amphenol 

Anodynos-DHC Dolophine w/codeine Anacin 

APAP w/codeine Dovaphen propoxyphene Anaprox 

aspirin, phenacetin, Duradyne DHC propoxyphene APAP 

caffeine, codeine Empirin wlcodeine compound 65 aspirin, phenacetin, 

Ascriptin w/codeine Empirin compound propoxyphene caffeine 

aspirin w/codeine w/codeine w/acetaminophen aspirin, phenacetin, 

B&O supprettes Empracet propoxyphene caffeine compound 

Capital w/codeine Innovar wIAPAP Arlhralgen 

Christodyne-DHC ‘, ‘“ Levd-dromoran SK-65 Arthritis pain 

Codap ‘ LiqlJix’ c SK-65 APAP formula 

cod6ine. ~,., 1 Mepergan SK-65 compound Arthrolate 

Copavin meperidine Stadol Atthropan 

Damason-P c methadone Talwin Ascriptin 

Darvocet-N morphine Talwin compound Aspergum 

DaNOfI Nubain Tylenol aspirin 

Darvon compound opium and w/codeine aspirin compound 

IMNOII w/A.S.A. belladonna Tylox Azolid 

Dawon-N opium extract Unigesic-A B-A 

Darvon-N w/A.S.A. P-A-C compound Vicodin Buffadyne 

Demerol w/codeine Wygesic 

Demerol-APAP 

Nonopioids 

Bufferin


Bufferin arthritis


strength 

Butazolidin 

Butezolidin alka 

Cama 

Capron 

choline salicylate 

Clrin 

Clinoril 

colchicine 

Colsalide 

Dasin 

Datril 

Dimindol 

Disalcid 

Ecotrin 

Empirin 

Empirin compound 

Esgic 

Excedrin 

Febrirrol . 

Fever reducer 

St. Joseph 

Gemnisyn phenylbutezone 

ibuprofen alka 

Indocin Ponstel 

indomethacin Presalin { 

Liquiprin SK-APAP 

Magan sodium 

Measurin salicylate 

Meclomen sulindac 

Mobidin Suppap 

Motrin Tandearil 

Nalfon Tempra 

Naprosyn Thiolate 

naproxen Thioral 

Neopap Thiosal 

Norgesic Tolectin 

Os-cal-gesic tolmetin 

Oxalid Trigesic 

P-A-C compound Trilisate 

Pabalate Tylenol 

Pain reliever-E Valacet 

Persistin Vanquish 

Phenaphen Zactirin 

Phencaset Zomax 

phenylbutazone 

NOTES: Included in the category Opioids are all opioid-nonopioid combinations: included in the category Nonopioids are nonopioid-nonopioid combinations. 

Drug namea are hsted in brand or generic form, according to actual swvey reaponsea. 

-.. . . . . ,., . . –—J----- ,,-,. —- ,.—. —. .s. -s, -.

Hgure 1. Analgeslc amgs namea Dy pnyslclan responaems: urmea =nes, I YISU-61 

Table 1. The 25 analgesic druga most frequently mentioned in officebased practice, by name of drug and number and percent distribution of 

mentians: United States, 1980-61 

General findings R Number 

a of 

According to findings from the National Ambulatory n mentions in Percent 

Medical Care Survey for 1980 and 1981 combined, an esti- k Name of drug thousands distribution 

mated 1,160,922,000 visits were made to physicians who 

identified themselves as primarily engaged in office-based, All analgesics . . . . . . .. . . . . . . . . . . . 116,641 100,0 

patient care practice. Of this total, 717,775,000 (62 percent) 25 drugs most frequently mentioned 

were drug visits; that is, visits at which one or more of 1 aspirin (includes A. S. A.) . . . . . 16,342 14.0 

any type of drug was ordered or provided. The total number 

of drug mentions for the 2-year span amounted to an estimated 

2 

3 

Motrin (ibuprofen) . . . . . . . . . . . . ,,. . 

Tylenol w/codeine 

(acetaminophen, cod&ine). . . 

11,786 

7,746 

10.1 

6.6 

1,330,746,000 mentions. 4 Tylenol (acetaminophen). . . . 7,086 6.1 

Visits involving the utilization of an inscope analgesic 

numbered 106,718,000, about 9 percent of the overall number 

5 

6 

7 

Clinoril (sulindac) . . . . . . . . . . . . . . . 

Naprosyn(naproxen) . . . . . 

Indocin (indomethacin). . . . . 

6,670 

6,431 

6,288 

5.7 

5.5 

5.4 

of office visits and about 15 percent of all drug visits. The 8 Darvocet-N (acetaminophen, 

total number of analgesic drug mentions was 1I6,641,000. 

Of these an estimated 31,380,000 (27 percent) were opioids. 9 

10 

propoxyphene) . . . . . . . . . . . . . . . 

Zomax(zomepirac) . . . . . . . . . . . . . . . 

Nalfon(fenoprofen) . . 

5,199 

3,495 

3,153 

4.4 

3.0 

2.7 

The remaining 85,261,000 (73 percent) were nonopioids. 11 Butazolidin alka (phenylbutezone, 

Table 1 lists the 25 analgesic products most frequently 

mentioned. They accounted for virtually nine-tenths of all 12 

aluminum hydroxide, magnesium 

trisilicate) . . . . . . . . . . . . . . . . ,.. . 

Norgesic (orphenadrine, aspirin, 

3,092 2.7 

analgesic mentions. The generic names most frequently rep- phenacetin, caffeine) . . . . . . 2,691 2.3 

resented among these 25 products are shown in the following 13 Empirin w/codeine (aspirin, 

codeine) . . . . . . . . . . . . . . . . . . . . 2,519 2.2 listing: 14 Ascriptin (aspirin) . . . . . . . . . . . . . . . . 2,368 2.0 

15 Percodan and Percodan-demi 

Number ofnrentjons (oxycodone, aspirin) . . . . 2,144 1.8 

16 Tolectin (tolmetin) . . . . . . . . . . . . 2,077 1.8 

aspirin .,, . . . . . . . . . . . . . . . . . . . 28,448 17 Demerol (meperidine) . . . . . . . 1,703 1,5 

acetaminophen . . . . . . . . . . . . . . . . . 21,318 18 Talwin(pentazocine) . . . . 1,505 1,3 

codeine, . . . . . . . . . . . . . . . . . . . . 12,794 19 Meclomen (meclofenamate) . . . 1,346 1.2 

ibuprofen, . 

sulindac, . . 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. . . 

. . 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

. 

11,786 

6,670 

20 

21 

Darvonand Darvon-N (propoxyphene) 

Phenaphen w/codeine (dcetaminophen, 

. . 1,298 1.1 

Generic name in thousands 

propoxyphene . . . . . . . . . . . . . . . . . . 6,497 codeine) . . . . . . . . . . . . . . . . . . . . 1,287 1.1
 naproxen . . . . . . . . . . . . . . . . . . . . 6,431


indomethacin ...,,.... . . . . . . . . . 6,288 22 Empirin compound wlcodeine


phenylbutazone . . . . . . . . . . . . . . . . 4,252 (aspirin, codeine) . . . . . . . . . . . . . 1,242 1.1


zomepirac . . . . . . . . . . . . . . . . . . . 3,495 23 Butezolidin (phenylbutezone) . . . 1,160 1.0


24 Bufferin (buffered a$pirin) . . l,t42 1.00 25 Tandearil (oxyphenbutazone) . . 1,051 0.9 
acktncedata 3 

Table2. Number andpercent d=tribution ofanalgeaic mentions by 

category ofanalgesiq according toselected drug dimensimw 

nited States, 1980-S1 

Ar?a/gesic mentions 

— Selected . 

drug dimensions All 

analgesics Opioids Nonopioids 

Number in thousands 

Total mentions . . . . . . 116,641 31,380 85,261 

Percent distribution 

100.0 100.0 100.0 

Entry status’ 

Generic name . . . . . . . . . . . 19.2 10.1 22.6 

Brand name . . . . . . . . . . . . 80.7 89.9 77.3 

Prescription status 

Prescription drug . . . . . . . . 72.8 100.0 62.8 

Nonprescription drug . . 27.2 37.1 

Federal control status 

Controlled by DEA2 . . . . . . 26.4 100.0 

Schedule lo . . . . . . . . . . . 5.7 21.1 

Schedule ill . . . . . . . . . . . 11.9 46,1 

Schedule IV . . . . . . . . . . 8.7 32.4 

Schedule V . . . . . . . . . . . ‘0.1 ‘0.4 

Non controlled . . . . . . . . . . . 73.5 100.0 

Composition status 

Single-ingredient drug . . . 74.4 21.2 93.9 

Combination drug. . . . . . . 25.6 78,8 6.0 

me form of the drug name (brand or generic) represents the choice of the 

ician in preparing the order. 

g Enforcement Administration. 

Drug dimensions 

Table 2 describes some key dimensions of the analgesic 

drugs. 

Entry status—In ordering an analgesic, physicians showed 

a strong tendency to favor brand name choices over their 

generic counterparts. About 4 of every 5 of the overall class 

were identified by trade name. The tendency was strongest 

in the opioid subclass; here, only 1 of every 10 mentions 

was generically identified. 

Prescription stares-The utilization of nonprescription 

drugs, apparent in 27 percent of analgesic mentions, was 

more than double their proportionate use in overall, officebased drug therapy (12 percent). 

Control status-Because of its opioid component, the 

analgesic family has a substantial proportion of controlled 

agents among its members. Controlled agents accounted for 

26 percent Of analgesic mentions, the majority of their number 

classified in Schedules III and IV. Thus the prescribing physician, faced with the need to moderate pain, also needs to 

weigh the desired therapeutic effect against the potential hazards of dependence or habituation. 

Composition status 

The proportionate use of combination products among Qanalgesics (apparent in about 26 percent of mentions)

onforms closely to the proportionate use of combinations 

throughout office-based drug therapy. By far the most common 

analgesic mixtures involved the combination of an opioid 

with a nonopioid, with codeine or propoxyphene appearing 

as the most common opioid ingredient. Ample support for 

the use of this type of analgesic combination is provided 

by the AMA Drug Et’aluations, Fzj?h Edition: 

The combination of an opiate or opioid with a nonopiate (analgesic-antipyretic) appears to be rational because the mechanism of action of each drug differs and 

the results of controlled studies have shown that the 

analgesic effects of the individual drugs are additive. 

Since the nonopiates have a ceiling analgesic effect and 

the dosage of opiates should be limited to prevent adverse 

effects, a combination of this type may provide greater 

pain relief with a minimum of adverse effects in a convenient form for the patient.4 

Apparent in only 6 percent of analgesic mentions, the combination of a nonopioid with another nonopioid is manifestly 

uncommon in the office-based utilization of analgesics, possibly because of the reason stated in AMA Drug Evaluations, 

F[~th Edition: “... it can be concluded that mixtures of 

analgesic-antipyretic drugs with or without caffeine have not 

been proved to be superior to optimal doses of their individual 

components.”~ 

Diagnosis 

By far the most intensive use of analgesic therapy occurs 

within two diagnostic groups: “Injuries” and “Diseases of 

the Musculoskeletal System” (table 3).5 This is demonstrated 

more clearly in the following listing of the specific conditions 

most frequenti y associated with analgesic utilization: 

Opioid therapy 

Rank Diagnosis and ICO-9-CM Codes 

1 . . . . . . . . . Back sprains and strains . . . . . . . . 847 

2 . . . . . . . . . Intervertebral disc disorders . . . . . 722 

3 Other and unspecified back disorders . . 724 

4::::::::: Sprains and strains of the sacroiliac . 846 

5 . . . . . . . . . Osteoatthrosis . . . . . . . ..’ . . . . ...715 

Nonopioid therapy 

Rank Diagnosis and ICO-9-CM Codes 

1 . . . . . . . . . Osteoarthrosis . . . . . . . . . . . . . ...715 

2 . . . . . . . . . Other and unspecified arthropathies . 716 

3 . . . . . . . . . Peripheral enthesopathies . . . . . . . . . 726 

4 . . . . . . . . . Rheumatoid arthritis . . . . . . . . . . . . 714 

5 . . . . . . . . . Acute upper respiratory infection . . 465 

In contrast to other drug classes, the rate of analgesic 

utilization in the category “Symptoms and ill-defined conditions” is relatively higher, documenting the physician’s tendency to respond to symptomatic pain in advance of a clearly 

established diagnosis. However, it would be a mistake to 

assume that an analgesic is automatically ordered whenever 

pain appears as a symptom. Indeed, according to another 

NAMCS study (in preparation), about 70 percent of nearly 

70 million newly encountered problems where pain was the 

chief presenting symptom did not involve the use of an 

inscope analgesic. 

‘AMADrag Erulaa2ions, op cit, p 10 I. 

TBa.wd on International Classification of l)iseases, 9th Revision, Clinical 

Modijkofion (lCD-9-CM ). 
4 admncedata 

Table 3. Number of office visits, number of analgesic mentions, and number of mentions per 1,000 visits, by principal diagnosis and problem catgories; ‘ 

and percent distribution by opioid and nonopioid mentions, according to principal diagnosis and problem category United States, 1980-81 

Analgesic mentions 

Number 

of 

visits Percent of Percent of 

in Number Rate per all all 

Principal diagnosis and thousands in 1,000 analgesic analgesic 

problem category thousands visits mentions mentions 

All principal diagnoses, . . . . . . . . . . . . . . 1,160,922 99,581 86 28.3 71,7 

Major diagnostic groups (selected) 

Infectious and parasitic diseases,. . . . . . . . . . . . . . . 37,714 2,451 65 21.9 78,1 

Neoplasm. , . . . . . . . . . . . . . . . . . . . . . . . 30.707 1,300 42 57.0 43.0 

Endocrine, nutritional, and metabolic 

diseases, and immunity disorders,, . . . . . . . . . . . . . . . . . . . . . 45,371 2,281 50 16.1 83.9 

Mental disorders ..,..... . . . . . . . . . 47,624 1,622 34 50.5 49,5 

Diseases ofnervoussystem and sense organs ,,. 109,573 4,465 41 43.1 56.9 

Diseasesofcirculatorysystem.. . . . . . . . . . . 112,344 8,142 72 19,5 80.5 

Diseasesofrespiratorysystem... . . . . . . . . . . . . . . . . . . . . 146,014 10,255 70 22,3 77.7 

Diseasesofdigestive system... . . . . . . . . . . . . . . . . . . . 49,060 2,610 53 44.2 55.8 

Diseases ofgenitourinarysystem . . . . . . . . . . . . . . . . . . . ,.,., 66,504 3,394 50 52.5 47.5 

Diseasesofskin and subcutaneous tissue, 69,421 1,303 19 39.5 60.5 

Diseases ofmusculoskeletal system . 79,206 37,208 470 18.9 81.0 

Symptoms, signs, andill-defined conditions . . 38,526 3,261 85 39.4 60.6 

Injury and poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94,723 16,561 175 38.1 61.9 

Normal pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51,307 ’205 *4 ,.. 

Problem categories 

Acute’ problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422,223 48,386 115 29.0 71,0 ( 

Chronic probiem, routine . . . . . . . . . . . . . . . . . . . . . . . 325,791 25,066 77 24.2 75,8 

Chronic problem, flareup . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106,393 16,239 153 27,9 72,1 

Postsurgery or postinjury . . . . . . . . . . . . . . . . . . . . . 101,792 7,125 70 41,6 56.2 

Nonillness care . . . . . . . . . . . . . . . . . . . . . . . . . 204,722 2,765 14 ‘20,6 79,4 

A// analgesics Opioids

llncludes only those analgesics ordered or provided for the principal diagnosia, excluding some 17,060,000 mentions where analgesics were utilized for “all 

reasons, ” 

Table4. Number ofoffice visits, number ofanalgesic mentions, andnumber ofmentions perl,WO visits, byageand sexofpatienb and percent 

distribution byopioid sndnonopioid mentions, accor@ng toageand sexof patienti United States, 1980-81 

Analgesic mentions 

Number All analgesics Opioids Nonopioids of 

visits Percent of Percent of 

in Number Rate per all all 

Age and sex thousands in 1,000 analgesic analgesic 

of patient thousands visits mentions mentions 

All visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,160,922 116,641 100 26.9 73.1 

Age 

Under 15years .,, .,..... . . . . . . . . . . . . . . 216,128 9,310 43 9.8 90.2 

15-24years ., . . . . . . . . . . . . . . . . . . . . . . . . 160,795 10,044 62 34.2 65.8 

25-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310,384 28,899 93 39.0 61.0 

25-29years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,,. 97,109 7,159 74 42.6 57.4 

30-34years . . . . . . . . . . . . . . . . . . . . . . . . . 86,896 7,421 65 37.4 62.6 

35-39years . . . . . . . . . . . . . . . . . . . . . . . . . . ..,, 69,611 7,053 101 37.6 62.2 

40-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,,, 56,768 7,266 128 38.3 61.7 

45-64years . . . . . . . . . . . . . . . . . . . . . . 265,700 36,838 139 26.3 73.7 

45-49years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56,265 6,459 115 29.6 70.4 

50-54years . . . . . . . . . . . . . . . . . . . . . . . . . 68,032 9,907 146 30.9 69.1 

55-59years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70,825 10,390 147 24.2 75.8 

60-64years . . . . . . . . . . . . . . . . . . . . . 70,578 10,081 143 21.7 78.3 

65 years Andover . . . . . . . . . . . . . . . . . . . . . . . . . . . 207,915 31,550 152 19.3 80.7 

65-69years . . . . . . . . . . . . . . . . . . . . . . . 67,884 9,549 141 22.8 77.2 

70-74years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57,577 8,925 155 19.5 80.5 

75-79 years . . . . . . . . . . . . . . . . . . . . . . . . . 43,309 6,931 160 15.2 84.8 

80yearsandover . . . . . . . . . . . . . . . . . 39,145 6,145 157 17.9 82.1 

Sex � 

Female . . . . . . . . . . . . . . . . . . . . . . . . . . . 699,718 69,656 100 26.7 73,3 

Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461,204 46,785 101 27.2 72.8 
------

admncedata 5 

Patient characteristics All analgesics 

160 . . . . . . . . Nonoplo!ds (152) From its lowest rate. for patients under 15 years of 

140 (139) 

in each successive age group throughout the age spectrum, 

130 the sharpest acceleration occurring in the age interval from 

120 the 25th through the 64th year (table 4 and figure 2). It 

110 is the utilization rates for the nonopioids that chiefly determine 

the shape of the overall curve; these rates, in their turn, 

150 Oplolds age. the overall utilization of analgesics generally increased 

100 largely reflected the strong preference for the nonopioids 

90 in the treatment of the musculoskeletal diseases. Opioid utiliza80 tion, probably due chietly to the above-average preference 

70 

80 

(62) 

for opioids in the treatment of injuries. rises steadily up 

to the 45th year (the injury-prone period). levels off in the 

50 (43) 

45-to-64 age group, and probably declines slightly in the 

later years of life. 40 

30 (39) 

(21)+-. --* 

Aithough the average overall rates ofanalgesic utilization 

were the same for both male and female patients 

20 �* # (table 4). there were marked differences between the sexes *#* 

10 in the age intervals at which the analgesic therapy was most 

I I I I intensely applied (table 5 and figure 3). The male rate, 0 

Under 15-24 25-44 45-64 65 years substantially higher in the age interval 15-44 years, results 

15 years years years years and over chiefly from the fact that the,proportion of visits for injuries 

Age of patient in this age group was almost twice as great among male 

patients as among females. The female rate. higher among 

Figure 2. Analgesic utilization rates by category of analgesic and age of patients age 45 years and over, largely reflects a growing patienk United States, 1980-61 

proneness toward musculoskeletai disease that is proportionately greater among older females than among their male 

counterparts. � Table5. Number ofoffwe visits, number ofanalgesic mentions, andnumber ofmentions perl,Wvisi@ bysektedp atientc haracteristica; andpercent 

distribution byoptid andnonoptid mentionq wcordng toseleded patient characteristi=: United States, 1980-81 

Analgesic mentions 

Number 

of All analgesics Opioids Nonopioids 

Wslts Percent of Percent of 

in Number Rate per all all 

thousands m 1,000 analgesic analgesic 

Selected patient characteristic thousands visits mentions mentions 

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,160,922 116,641 100 26.9 73.1 

Sex and age 

Female 

Under 15years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102,633 4,394 43 ‘8.0 92.0 

15-24years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107,276 5,525 52 37.4 62.6 

25-44years . . . . . . . . . . . . . . . . . . . . . 206,394 16,352 79 39.5 60.5 

45-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157,031 22,311 142 26.4 73.6 

65yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126,383 21,275 168 18.1 81.9 

Male 

Under 15years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113,495 4,916 43 ‘11.4 88.6 

15-24years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53,519 4,519 84 30.4 69.6 

25-44years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103,990 12,548 121 36.3 61.7 

45-64years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108,668 14,527 134 26.1 73.9 

65yearsandover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81,532 10,275 126 21.6 78.4 

Race’ 

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,037,590 100,634 97 25.5 74.5 

Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110,546 14,784 134 36.4 63.6 

� Ethnicity 

Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53,337 6,144 115 25.7 74.3 

Not Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,107,585 110,497 100 27.0 73.0 

‘Excludes about 12,786,000 visits by patients of races other than white or black. 

. 
�

6 aciwncedata 

The significantly higher rate among black office patients Physician characteristics 

(table 5) is chiefly related to the finding that black patients 

suffered proportionately more than white patients from the Of the most-visited, office-based specialities, five exfour conditions that command the highest rates of analgesic 

use: musculoskeletal diseases, injuries, circulatory diseases, 

ceeded 

Ranked by 

the 

magnitude 

average rate 

of rate, 

of 

these 

analgesic 

specialties 

utilization 

were: 

(table 6), �

and symptoms and ill-defined conditions Rank Specialty 

1. . Orthopedic surgery 

2. Internal medicine 

3 . . . . . . . . . Neurology ....... Male 4., . . . . . . . General and family practice 

170 - — Female (168) 5. . . Cardiovascular disease 

160


Shifting attention from rate of analgesic utilization to sheer ~ 150 .-

,$ (142) volume of use, it is worthy -of note, however, that two 

0 140 primary-care providers, the internist and the general or family 0

0, 130 practitioner, accounted for fully two-thirds of all analgesic 

120 .“ mentions and nearly the same proportion (62 percent) of 

110 .“

.“ opioid mentions. .* 

100 .“ 

.“ 

90 (84~”” Other visit characteristics 

80 .* 

.“ The most conservative utilization of analgesics occurred 

‘6 70 .“

.“ 

with new patients (table 7), a pattern common throughout “ 60 .“ all office-based drug therapy. The most intensive use occurred 

.“ 

50 .’ when a new problem was presented by a patient with whom 

.“ 

40 the doctor already had a clinical relationship. Thus, given [43) 

o	 L , ! t 1 J what may be the same problem, the physician’s decision 

Under 15-24 25-44 45-64 65 years whether or not to use an analgesic is obviously influenced 

15 years years years years and over by familiarity with the patient’s history, including possible 

Age of patient drug reactions. 

Figure 

States, 

3. Analgesic 

1980-81 

utilizationrates by sex and age of patient: United analgesic 

The findings 

therapy with 

in table 

the forms 

8 document 

of nondrug 

the associations 

treatment that 

of �

most frequently accompanied it. Perhaps most arresting is 

Table 6. Number of office visits, number of analgeaic mentions, and number of mentions per 1,000 visits, by selected physician characteristics; and 

percent distributionby opioid and nonopioidmentions, according to selected physician characteristics: United States, 1980-61 

Analgesic mentions 

Number 

of All analgesics Opioids Nonopioids 

visits Percent of Percent of 

in Number Rate per all all 

thousands in 1,000 analgesic analgesic 

Selected physician characteristic thousands visits mentions mentions 

All office-based physicians . . . . . . . . . . . . . . . . 1,160,922 116,641 100 26.9 73.1 

Selected specialties 

Gkeral and family practice . . . 381,710 51,255 134 27.9 72.1 

Internal medicine . . . . . . . . . . ,, . . . . . 144,172 26,252 162 19.8 80.2 

Pediatrics . . . . . . . . . . . . . . . . . . 126,762 5,429 42 “1 0.6 89.4 

Obstetrics and gynecology . 109,035 2,669 24 38.1 61.9 

General surgery..........,,.. . 61,013 5,823 95 38.7 61.2 

Orthopedic surgery.........,.. . 55,470 12,071 218 26.3 73,7 

Cardiovascular disease . . 14,781 1,887 128 “21 .9 78.1 

Psychiatry . . . . . . . . . . . . . . . ,, 31,810 �61 5 “19 “57.6 *42.4 

Neurology . . : . . . . . . . . . . . . . 6,379 1,117 175 ‘1 9.7 60.3 

Professional identity 

Doctor of medicine . . . . . . . . . . . . . . . . . . . . . . . 1,089,638 108,468 100 27.0 73.0 

Doctor of osteopathy.......,,, . . . . . . . . 71.284 8,173 115 25.3 74.7 

Type of practice � 

solo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635,651 63,624 100 27.4 72.6 

Multiple member . . . . . . . . . . . . . . . . . .,, ,. . . . 525,271 53,017 101 26.3 73.7 
adwllwaiata 7 

Tsbie 7. Number of office visits, number of analgesic mentions, and number of mentions per 1,000 visits, by selected visit charsctenstic~ anff percent 

distribution by opioid and nonopioid mentions, according to selected visit characterist”~ United States, 1980-61 

0 Analgesic mentions 

Number 

of All analgesics Opioids Nonopioids

visits Percent of Percent of 

in Number Rate per all all 

thousands in 1,000 analgesic analgesic 

Selected visit characteristic thousands visits mentions mentions 

Allvisits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,160,922 116,641 100 26.9 73.1 

Referral status 

Referredbyanotherphysician.. . . . . . . . . . . . . . . . . . . . . . . . . 51,392 4,513 66 28.9 71.1 

Notreferred byanotherphysician . . . . . . . . . . . . . . . . . . 1>109,530 112,128 101 26.8 73.2 

Patient visit status 

Newpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166,675 15,346 92 31.0 69.0 

Old patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 994,247 101,294 102 26.3 73.7 

New problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258,778 31,793 123 26.4 73.6 

Old problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735,469 69,501 94 26.2 73.8 

Problem status 

Newproblem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425,453 47,140 111 27.9 72.1 

Retumvisitforold problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . 735,469 69,501 94 26.2 73.8 

the broad extent to which drug therapy was the exclusive 

form of treatment employed. At about one-half of the visits 

that involved the use of an analgesic—alone or accompanied 

by agents of other drug classes—there was no concurrent 

seofanyformof nondm-gtherapy. aable 8. Number and percent distribution of analgesic visitq by 

nonmedmt”mntherap~ United States, 1960-81 

Analqesic visitsz 

Number 

in Percent 

Nonmedication therapy 7 thousands distribution 

Tots/visik . . . . . . . . . . . . . . . . . . . . 106,718 100,0 

None . . . . . . . . . . . . . . . . . . . . . 52,070 48.8 

Medicalcounsefing . . . . . . . . . . . . . . . . 31,454 29,5 

Physiotherapy, . . . . . . . . . . . . . . . . 14,891 14.0 

Officesurgery . . . . . . . . . . . . . . . . . . 4,178 3.9 

Psychotherapy or therapeutic listening . 3,557 3.3 

Other, . . . . . . . . . . . . . . . . . . . . 12.436 11.7 

‘Because it was possible to use more than one form of nonmedication therapy 

at a given visit, estimates will exceed the totals at the top of the columns. 

‘An analgasic visit is an office visit at which one or more analgesic agents was 

utilized. 

Co-occurrence 

Utilized at 62 percent of all office visits, drug therapy 

(of all types) is by far the most frequent form of treatment 

provided in office practice. Further, when they do use a 

drug, physicians tend to use more than one. The overall 

average is about two drugs per drug visit, but larger multiples 

are not uncommon, especially when the patient suffers from 

more than one disorder. With co-occurrence the rule rather 

than the exception, it is instructive to explore the patterns 

of concomitant utilization of drugs that occurred in the office 

visits at which an analgesic agent was ordered or provided. 

At the 106.7 million visits at which an analgesic agent 

was utilized, its use (expressed as a percent of these visits) 

co-occumed most frequently with the use of one or more 

members of the following ten therapeutic families: 

Co-occurring therapeutic Percent of 

familyd co-occurrence 

Antibiotics . . . . . . . . . . . . . . . . . . . 12.2 

Diuretics . . . . . . . . . . . . . . . . . . 12.2 

Antianxiety agents, sedatives, hypnotics . 8.3 

Cardiac drugs . ...,..... . 

Adrenals . . . . . . . . . . . . . . 

Anfihyparfensives . . . . 

Gastrointestinal drugs . . . . 

Skeletal muscle relaxants . . . . 

Antidepressives and antipsychotics 

Expectorants and cough preparations 

. . . . . 6.9 

. . . . 6.6 

,, . . . . 6.4 

. . . . . 5.3 

. . . . 3.9 

. . . . 3.4 

. . 3.0 

‘American ffospilat Formu[ury Ciass!jicurioil .fyslem. op cit. 
Technical notes 

Source of data and sample design 

The estimates presented in this report are based on the 

findings of the National Ambulatory Medical Care Survey 

(NAMCS), a sample survey of office-based care conducted 

annually from 1973 through 198 I by the National Center 

for Health Statistics. The target universe of NAMCS is composed of office visits made by ambulatory patients to non-Federal and noninstitutional physicians who are principally engaged in office-based, patient-care practice. Visits to physicians practicing in Alaska and Hawaii are excluded from 

the range of NAMCS, as are visits to anesthesiologists, 

pathologists, and radiologists. 

NAMCS uses a multistage probability sample design 

that involves a step sampling of primary sampling units 

(PSU’S), physicians’ practices within PSU’S, and patient visits 

within physicians’ practices. The physician sample (5,805 

physicians for 1980 and 1981 ) was selected from master 

files maintained by the American Medical Association and 

the American Osteopathic Association. Those members of 

the sample who proved to be inscope and eligible participated 

at a rate of 77.3 percent. Responding physicians completed 

visit records for a systematic random sample of office visits 

made during a randomly assigned weekly reporting period. 

Telephone contacts were excluded. During 1980 and 1981 

responding physicians completed 89,447 visit records on 

which they recorded 97,796 drug mentions. Characteristics 

of the physician’s practice, such as primary specialty and 

type of practice, were obtained during an induction interview. 

The National Opinion Research Center, under contract to 

the National Center for Health Statistics, was responsible 

for the field operations of the survey. 

Table 1. Approximate relative standard errors of estimated numbers of 

office visits and of drug mentions when drug is listed by product name 

(for example, Darvon), based on all physician specialties 

National Ambulatory Medical Care Survey, 1980-81 

Re/adve 

Estimated number of office visits standard 

or specific drug mentions error 

Number in thousands Percent 

‘200 .,,..,..,,..,...,., . . . ‘44.8 

‘400 . . . . . . . . . . . . . . . . . . . . . . . “31.7


‘450 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “30.0


600 . . . . . . . . . . . . . . . . . . . . . 26.0


800 . . . . . . . . . . . . . . . . . . . . 22.6


1,000, , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20.2


2,000 . . . . . . . . . . . . . . . . 14.5


5,000 . . . . . . . . . . . . . . . . . . 9.5


10,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.1


20,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.6


50,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4


100,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.9


200,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.6


500,000 . . . . . . . . . . . . . . . . ,, . . . . . . . . . . . . . . 3.5


1,000,000. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4


Example of use of table: An aggregate estimate of 35,000,000 office visits has 

a relative standard error of 5.0 percent or a standard error of 1,750,000 visits 

(5.0 percent of 35,000,000 visits). 

Sampling errors and rounding 

The standard error is ameasure of the sampling variabilit 

that occurs by chance because only a sample, rather th 

the entire universe, is surveyed. The relative standard errom 

of an estimate is obtained by dividing the standard error 

by the estimate itself and is expressed as a percent of the 

estimate. In this report, any estimate that exceeds a relative 

standard error of 30 percent is marked with an asterisk. 

Table I should be used to obtain the relative standard error 

for aggregates of office visits or for mentions of drugs by 

specific name (for example, Darvon). Table II should be 

used to obtain the relative standard error for drug mentions 

expressed as drug groups (for example, the analgesic drug 

family). 

In the tables of this report estimates have been rounded 

to the nearest thousand. For this reasons, detailed estimates 

do not always add to totals. 

Table Il. Approximate relative standard errora of estimated numbers of 

drug mentions when druga appear in groups (for example, the 

analgesic drug family), based on all physician specialties: National Ambulatory Medical Care Suwey, 1980-81 

Re/afive 

Estimatednumber of standard 

grouped drug mentions error 

Number in thousands 

�54.2 

“38.5 

’31.5 

“30.0� 27.3 

24.5 

17.6 

11.6 

8.7 

6.8 

5.3 

4.7 

4.4 

4,2 

4,1 

Example of use of table: An aggregate estimate of 30,000,000 drug mentions 

has a relative standard error of 7.0 percent or a standard error of 2,100,000 

mentions (7.0 percent of 30,000,000 mentions). 

Definitions 

An ofiice is a place that physicians identify as a location 

for their ambulatory practice. Responsibility for patient care 

and professional services rendered in an office resides with 

the individual physician rather than an institution. 

A L’isiris adirect personal exchange between anambulatory patient seeking health care and a physician, or staff 

member working under thephysician’s supervision, who provides the health services. 

A drug rrrerztiorr is tlie physician’s entry on the vis” 

record of a pharmaceutical agent ordered or provided 

any route of administration for prevention, diagnosis, ortrea 0 

ment. Generic as well as brand-name drugs are included, 

!i 
achmncedata 9 

as are nonprescription as well as prescription drugs. The is of a regular, maintenance nature. 

physician records all new drugs and also records all continued A chronic problem flare up is a sudden exacerbation 

- medications if the patient is specifically instructed during of a preexisting chronic condition. 

the visit to continue the medication. Nonillness care denotes health examinations and care .. An acufe problem is a morbid condition with a relatively provided for presumably healthy persons. Examples of nonillsudden or recent onset (within 3 months of the visit). ness care include prenatal and postnatal care, annual physicals, 

A chronic problem is a morbid condition that existed well-child examinations, and insurance examinations. 

for 3 months or longer before the visit. The care indicated 
10 advancedata 

Symbols 

.-. Data not available 

Category not applicable 

Quantity zero 

0.0	 Quantity more than zero but less than 

0.05 

z	 Quantity more than zero but less than 

500 where numbers are rounded to 

thousands 

* Figure does not meet standards of 

reliability or precision (more than 30-

percent relative standard error) 

#	 Figure suppressed to comply with 

confidentiality requirements 
10 ackncedata 

-. ~. 

12


Recent Issues of Advance Data From V77aland Health Statistics 

No. 95. 1982 Summary: National Hospital Discharge Survey (Issued No. 92. Americans Needing Help to Function at Home (Issued 

December 27, 1983) September 14, 1983) . 

No. 94. Discharge Status of Inpatients Discharged From Short-Stay No. 91. An Overview of the 1980 National Master Facility Inventory 

Hospitals: United States, 1965–8 I (Issued November 22, 1983) Suwey of Nursing and Related Care Homes (Issued 

August 12, 1983) 

No. 93. Utilization of Short-Stay Hospitals by Adolescents: United 

States, 1980 (Issued September 14, 1983) 

SUGGESTED CITATION


National Center for Health Statistics, H. Koch and


D. Knapp: Utilization of analgesic drugs in office-based


ambulatory care: National Ambulatory Medical Care


Survey, 1980-81. Advance Dafa From Vita/ and HeMr


Statistics, No. 96. DHHS Pub. No. (PHS) 84-1250. Copyright Information


Public Health Service, Hyattsville, Md.,


March 14, 1984.	 This report may be reprinted without further 

permission. 

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