Who Fills Opioid Prescriptions? Trends by Age and Sex, 2008–2018

In 2017, prescription opioids were involved in 36% of opioid overdose deaths in the United States, and 66%–83% of new heroin users said their opioid use began with misusing a prescription opioid. Following prescribing guidelines can cut exposure and lower the risk of misuse, opioid use disorder and overdose. But which groups have the most exposure to prescription opioids hadn't been well defined. This CDC study looked at who filled opioid prescriptions from 2008 to 2018.

The data

Researchers used two IQVIA databases covering about 50,400 retail pharmacies — 92% of U.S. retail prescriptions — weighted to national estimates, and counted adults 20 and older who filled at least one opioid prescription each year. They excluded prescriptions from veterinarians and oncologists, cough and cold medicines containing opioids, and buprenorphine products commonly used to treat opioid use disorder; mail-order prescriptions and those dispensed at methadone clinics weren't available.

A big decline

• In 2018, 19.2% of U.S. adults — about one in five — filled an opioid prescription, averaging 3.6 prescriptions each.
• From 2008 to 2018, that share fell 31%, from 27.8% to 19.2%, an average drop of 3.5% a year — and it fell in every age group, for both sexes.

The decline may reflect new prescribing guidelines, stronger prescription drug monitoring programs and other quality improvement efforts.

Share of adults filling an opioid prescription, by age group and sex, 2008–2018. Credit: Centers for Disease Control and Prevention.

Persistent gaps

Older adults. People 65 and older had the highest fill rates and the smallest decline — only 16% over 11 years. They may have more frequent, longer-lasting or more intense chronic pain. That's worrying, because older adults are more likely to suffer adverse events, even death, from opioids: they may lose track of doses, have balance or gait problems, face interactions with other medicines, or clear opioids more slowly as liver and kidney function change.

Women. In every age group, women were more likely than men to fill an opioid prescription throughout the 11 years. Possible reasons include differences in how women experience pain, higher rates of diagnosed mental health conditions, more use of health care, more of the chronic conditions often treated with opioids (such as arthritis and fibromyalgia), and, for younger women, painful reproductive conditions such as dysmenorrhea or endometriosis. How much each factor contributes is unknown.

Odds of women filling an opioid prescription compared with men, by age group, 2008–2018. Credit: Centers for Disease Control and Prevention.

Limitations

• Only retail pharmacy fills were counted.
• Dose, duration and formulation weren't analyzed.
• The data don't show prescriptions written but not filled, whether patients took their medicine, or whether a fill was new or a refill.
• Drug diversion to illicit sources wasn't assessed.
• Whether prescriptions fit patients' conditions couldn't be judged.

What it means

The groups with the highest fill rates — women and adults 65 and older — deserve particular attention. Best practices for pain differ by condition and by how the body processes drugs, and conditions vary by age and sex. Following evidence-based guidelines, weighing each patient's benefits and risks, and using multimodal approaches to pain management could make care safer while still relieving pain.

Sources

Based on Schieber LZ, Guy GP Jr, Seth P, Losby JL, "Variation in Adult Outpatient Opioid Prescription Dispensing by Age and Sex — United States, 2008–2018," Morbidity and Mortality Weekly Report 69(11), Centers for Disease Control and Prevention; a work of the United States government in the public domain. Original report.