Opioid Prescribing: What Are the Numbers? (2017)

News on the opioid crisis from the Centers for Disease Control and Prevention (CDC)1-3: Total opioid prescriptions in the United States were 214.9 million in 2016, down from 241 million in 2014. The total number of patients receiving an opioid prescription was 61.9 million in 2016, compared to 65.8 million in 2014. The majority of prescription were for the purpose of management of pain, whether acute or chronic. The reduction in overall prescription opioid exposure is presumed to be a favorable trend, probably related to factors such as development of consensus guidelines for safe prescribing and abuse prevention, mandatory educational requirements for healthcare professionals, increased regulatory monitoring and restriction of opioid prescribing, physician-patient contracts delineating expectations and obligations, and other mitigation strategies.4-10 Pharmaceutical industry developments to the same end include the availability of abuse-deterrent sustained-release opioid preparations and slow-release subcutaneous implants.11, 12 Still, the news overall is mixed. Opioid-related deaths due to overdose have increased substantially since 2012.1 The majority of overdose deaths are unintentional, and the role of illegal opioids (such as heroin) or illicitly obtained prescription synthetic opioids (tramadol, fentanyl) has shown the most dramatic increase. Regional differences in opioid misuse and overdosage have received considerable attention. Published CDC sources do not provide information on the extent of prescribing of specific opioid preparations. Private entities that were previously generous with proprietary data on medication prescribing have become increasingly tight-lipped, in part because the corporate landscape involving prescribing data acquisition and dissemination is continuously changing.13 ClinCalc.com/DrugStats is a valuable public web site that catalogues prescribing data from the annual Medical Expenditure Panel Survey (MEPS), a survey conducted by the Agency for Healthcare Research and Quality, a federal agency. All data are publicly available at no cost on the MEPS web site.13 ClinCalc ranks the top 300 prescription drugs in the United States for a 12-month period from mid-2014 to mid-2015. A limitation of this source is that the numbers are based on outpatient retail prescriptions—medication dispensing in nonretail settings (hospitals, clinics, and institutions) is unlikely to be captured. For example, methadone dispensing in liquid form at methadone maintenance clinics probably is missed. Table 1 shows the number of prescriptions for opioid medications that appear in the top 300. Several features stand out. First, more than 55% of the 116 million total prescriptions were accounted for by the hydrocodone + acetaminophen combination preparation. Misuse and overdosage of this preparation is necessarily complicated by the involvement of acetaminophen. Second, prescribing of tramadol is extensive—tramadol has been identified as a “risk” opioid increasingly involved in fatal overdosage.1, 2 Finally, prescribing of oxycodone also is extensive. ClinCalc does not identify the specific oxycodone dosage forms being prescribed, but we assume that the number (13.9 million) represents a mix of immediate-release and sustained-release preparations. IMS Health is a second source of prescribing information independent of ClinCalc. The IMS Health list of the most prescribed opioids in 2013 was published in MD Magazine on October 6, 2014 (Table 2). Combination preparations containing opioids plus a coingredient such as acetaminophen account for the majority of prescriptions. Fentanyl14 and methadone are both captured on this list, but tramadol is not. Extended-release oxycodone, either as the brand name or as generic equivalents, accounts for 22 million prescriptions. What about dollar cost? Retail prescription costs in 2017 are available from Data-Rx.com. The majority of medications from Tables 1 and 2 are obtainable as both brand-name and generic forms, with the generics being less expensive (the exception being hydrocodone + acetaminophen). Table 3 lists the cost of an “intermediate” dose unit strength dispensed in a 100-unit prescription (this is for ease of calculation and is not an endorsement of this prescription size). Note that all of the extended-release opioid preparations incorporate the abuse-deterrent feature. We have compiled this information to support and assist with debate and policy-making decisions regarding the opioid crisis. We are not expressing a position on the problem or on how best to confront it. Still, we are reminded that every deterrent, restriction, and obstacle to opioid prescribing intended to enhance safe use and prevent abuse and overdosage also has the potential to impede medication availability to those patients who are in legitimate need.15