This page summarizes a CDC analysis of data from January 2014 to March 2017.
Drug overdose is the leading cause of death from unintentional injury in the United States. Of 70,237 fatal overdoses in 2017, prescription opioids were involved in 17,029 (24.2%). Opioid-related death rates have been higher in nonmetropolitan (rural) areas, and in 2017, 14 of the 15 counties with the highest opioid prescribing rates were rural. High prescribing rates put patients at risk of addiction and overdose.
Researchers from CDC, the Robert Wood Johnson Foundation and the electronic health record company Athenahealth used de-identified Athenahealth records to see how primary care providers' opioid prescribing varied from the most urban to the most rural counties, and how it changed after CDC released its Guideline for Prescribing Opioids for Chronic Pain in March 2016.
The data
About 100,000 providers serving some 86 million patients use Athenahealth's systems. The study used prescription records from 31,422 primary care providers (family medicine, general practice and general internal medicine, including nurse practitioners and physician assistants) serving about 17 million patients, over the 166 weeks from January 5, 2014, to March 11, 2017. Each week a patient had a record counted as one patient-week, and the researchers noted whether an opioid was prescribed that week. Opioid cough and cold medicines were not counted.
The data were split into three periods, the last beginning just after the guideline's release:
| Period | Dates |
|---|---|
| 1 | January 5, 2014, to January 3, 2015 (52 weeks) |
| 2 | the next 63 weeks, to March 19, 2016 |
| 3 | the last 51 weeks, to March 11, 2017 |
Counties were grouped into six urban-rural categories used by CDC's National Center for Health Statistics, from most to least densely populated: large central metropolitan, large fringe metropolitan, medium metropolitan, small metropolitan, micropolitan and noncore.
What they found
Across 128,194,491 patient-weeks, an opioid was prescribed in 8,810,237 (6.9%), falling from 7.4% in period 1 to 6.4% in period 3. Buprenorphine, prescribed for pain or for opioid use disorder, made up only 0.02% of opioid prescriptions.
Rural patients were far more likely to get opioids. Over the whole study, the share of patients with an opioid prescription ranged from 5.2% in large central metropolitan counties to 9.6% in noncore counties, the most rural. Patients in noncore counties were 87% more likely to receive an opioid prescription than patients in large central metropolitan counties. Large central metropolitan counties had the lowest period rates (5.0%–5.4%) and noncore counties the highest (9.0%–10.3%), except in period 3, when large central metropolitan counties matched large fringe metropolitan counties (5.0%) and noncore counties were similar to micropolitan counties (9.1%).
Rural prescribing had been rising. In period 1, the odds of an opioid prescription rose 6.4% a year in noncore counties and 9.7% a year in micropolitan counties. Those increases stopped in period 2, when rates flattened or fell. In the other county groups, trends were flat or falling in both periods.
Prescribing fell everywhere after the guideline. In period 3, after the guideline's release, the odds of receiving an opioid prescription fell significantly in all six county groups. In micropolitan and large central metropolitan counties this was a new decline after a flat trend; in the other four groups it continued declines already under way.
Why rural areas differ
The authors suggest several reasons rural patients received more opioids: earlier use and misuse of prescription drugs and more chronic pain among rural residents, larger older populations with more painful conditions, prescribing shaped by providers' personal relationships with patients (sometimes at odds with guidelines), limited access to medication-assisted treatment and alternative therapies, and differences in how prescription drug monitoring programs and state laws, such as pain clinic rules, play out in rural and urban communities.
What it means
Although opioid prescribing had been falling, opioid overdose deaths had risen, driven largely by heroin and illicitly manufactured fentanyl, and many people who report using heroin previously misused prescription opioids. Prescription drug monitoring programs and practice aligned with the CDC guideline can improve prescribing decisions and help providers and patients weigh the benefits and risks of opioids. The authors also note that electronic health record data can usefully supplement traditional surveillance, potentially with a lag of only weeks.
Rural areas showed both real progress and a continuing need to reduce prescribing, so the authors conclude that health care practices and prevention programs must be tailored to each community.
Limitations: the Athenahealth records may not represent all primary care patients; they do not show why an opioid was prescribed or whether it was filled and taken; and the analysis did not account for differences between counties in age or insurance.
Sources
- García MC, Heilig CM, Lee SH, et al. "Opioid Prescribing Rates in Nonmetropolitan and Metropolitan Counties Among Primary Care Providers Using an Electronic Health Record System — United States, 2014–2017." MMWR 68(2). https://www.cdc.gov/mmwr/volumes/68/wr/mm6802a1.htm
- Supplementary tables and figures: https://stacks.cdc.gov/view/cdc/61741, 61742, 61743, 61744; CDC opioid prescribing rate maps: https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html
- The report's chart is not reproduced here because it was prepared jointly with a foundation and a private company.
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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