Relationship between high-risk patients receiving prescription opioids and high-volume opioid prescribers

Aims: (1) To characterize the amount of prescription opioids prescribed for high-risk patients by low-volume prescribers; (2) to quantify how high- and low-volume prescribers differ systematically in their prescribing patterns. Design: Cross-sectional study using 2015 longitudinal, all-payer QuintilesIMS pharmacy claims. We conducted an aggregated analysis for the first aim and an individual-level analysis for the second aim. Setting: California, Florida, Georgia, Maryland, and Washington, USA. Participants: Among 4 046 275 patients, we identified 375 848 concomitant users (filling more than 30-days of concomitant opioids and benzodiazepines), 150 814 chronic users (using 100+ morphine milligram equivalents (MMEs) per day for more than 90 days), and 3190 patients prescribed opioids by > 3 prescribers and filling opioids at > 3 pharmacies during any 90-day period. Among 192 126 prescribers, we identified 8023 high-volume prescribers, who comprised the highest fifth percentile of opioid volume during four calendar quarters. Measurements: (1) MME dose per transaction, (2) days supplied per transaction, (3) total opioid volume per patient and (4) number of prescriptions per patient. We also examined differences in opioid dispensing between high- and low-volume prescribers among patients receiving opioids from both. Findings: Low-volume prescribers accounted for 15–29% of opioid volume and 18–56% of opioid prescriptions for high-risk patients, compared with 28–37% and 53–58% for low-risk patients. After accounting for state of residence, comorbid burden, prescriber specialty and care sequence, patients were more likely to receive higher doses (60.9 versus 53.2 MMEs per day, P < 0.01), longer supplies (22.1 versus 15.6 days, P < 0.01), more prescriptions (4.0 versus 2.6 prescriptions, P < 0.01) and greater opioid volume (5.6 versus 1.9 g, P < 0.01) from high- than low-volume prescribers. Conclusions: In the United States, high-risk patients obtain a substantial proportion of prescription opioids from low-volume prescribers. The differences in prescribing patterns between high- and low-volume prescribers suggest the importance of interventions targeting prescriber behaviors.