BMJ report recommends opioid interventions focus on top 1 percent of health providers

A new report published in the medical journal BMJ last week ascribed nearly half of all opioid doses in the U.S. to merely 1 percent of health providers in 2017.

Further, that 1 percent was responsible for more than a quarter — 27 percent — of all opioid prescriptions in 2017.

The report was not restricted to 2017, however. It covered the distribution and patterns of opioid prescriptions between 2003 and 2017, finding an annual average of 669,495 providers provided 8.9 million opioid prescriptions to 3.9 million patients. The authors — which included Matthew Kiang, postdoctoral research fellow; Keith Humphreys, professor and senior research career scientist; professor Mark Cullen; and Sanjay Basu, faculty director and senior honorary research fellow — said the data revealed most U.S. providers are careful with prescribing. That fact, they note, should affect how the United States moves to counter the opioid epidemic.

“Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden,” the authors wrote. “A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.”

Strict limits should be focused on a small percentage of providers, by the authors’ estimation. After all, the top 1 percent of providers prescribed an average of nearly 1,000 times more than the middle 1 percent of providers.

“Our results clarify an important medical reality,” the authors said. “Specifically, our results suggest that interventions targeted at high prescribing opioid providers should be prioritized for three reasons. First, most of the prescriptions written by the majority of providers are below recommended thresholds, suggesting that most U.S. providers prescribe opioids carefully. Additional, potentially burdensome, constraints on this set of providers are unlikely to be beneficial. Because the majority of opioid prescriptions by this group are probably appropriate, any increase in restrictions is more likely to reduce appropriate use rather than prevent those of concern. Second, the top centile of providers is stable over time, which suggests that interventions targeted at this group will produce sustained results. Third, the top centile of providers accounts for a disproportionate number of patients receiving high amounts of opioids, and interventions targeted here will reach these high-risk patients efficiently.”

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