The significant morbidity and mortality that have resulted from the use of opioids over the past few decades have led public health authorities to declare an opioid epidemic in the United States.1 Opioid analgesics are now responsible for more deaths than both suicide and motor vehicle accidents, and more deaths than from cocaine and heroin combined.1 In New Jersey alone, drug overdose is currently the leading cause of accidental death. In addition, the rate of overdose by heroin in New Jersey is three times the U.S. average.2 Over the last two decades, the rate of death from overdose in the United States has increased dramatically, and much of that growth has been attributed to physician-prescribing patterns for opioids.3
The over-prescription of opioids can be traced back to the historic campaign, Pain as the Fifth Vital Sign, of 1995, which resulted in a nationwide effort to combat the under-treatment of pain.4 Concurrently, there was a dramatic increase in the manufacturing and marketing of opioids.5,6 These factors led to a substantial increase in the opioid prescribing rate, and eventually, contributed significantly to the current opioid crisis in the United States.3,7 In 2012, the total number of opioid prescriptions dispensed nationally peaked at 255 million with a prescribing rate of 81.3 prescriptions per 100 persons.8
“Opioids are currently the main driver of drug overdose deaths.”
Opioids are currently the main driver of drug overdose deaths. In 2017, opioids were involved in 47,600 overdose deaths in the United States.9 New Jersey is among the states with statistically significant increases in drug overdose death rates from 2016 to 2017. To help combat this epidemic, in 2012 the New Jersey Department of Human Services expanded its Partnership for a Drug-Free New Jersey (PDFNJ) to include the Do No Harm symposium series. The new PDFNJ extension aimed to educate prescribers on the opioid crisis and safe prescribing practices.10 Although opioids are historically the cornerstone of perioperative pain control, there has been a statewide movement to decrease the utilization of opioids and rely more heavily on multi-modal analgesia.11
The present analysis sought to identify whether New Jersey practitioners have responded to the opioid epidemic by reducing the rate at which they prescribe opioids.
Methods
This retrospective study obtained prescribing data from the Centers for Medicare and Medicaid Services (CMS) Part D beneficiary data from 2013 to 2017.12 Data were filtered to include only information about opioid prescriptions in the state of New Jersey. Prescribers were assigned to groups according to their medical specialty, as well as the region of New Jersey in which they practiced. The number of prescriptions provided, number of days supplied and number of beneficiaries were collected from the CMS database. In this specific database, prescription information is available for individual medications prescribed more than 10 times by an individual physician. For individual medications with fewer than or 10 prescriptions per physician, exact prescribing numbers were not available and were recorded as fewer than or 10. Opioid prescribing rates were generated by comparing the number of prescriptions for opioids to the total number of prescriptions by specialty. Opioid prescription rate per provider is a variable provided by the database which represents the percentage of the total claim count made up by the opioid claim count for each New Jersey provider. This variable was chosen for analysis because it is a more accurate representation of prescribing rates for each provider and provides multiple data points for a linear regression model. The opioid medications included in this analysis are listed in the Addendum. All statistical analysis was performed using SPSS Version 23 (IBM-SPSS, Inc., Armonk, NY). To evaluate the linear trend in opioid prescribing rates, the individual prescribing rates for more than 20,000 prescribers per year were regressed on the corresponding year number from 2013 to 2017. We set the alpha level at 0.05 and considered variables with a p value of less than 0.05 to be statistically significant. The CMS database does not contain patient-identifying information. Therefore, institutional review board (IRB) approval was not required according to the standing policies of the IRB at Rutgers New Jersey Medical School.Results
The number of prescriptions New Jersey providers wrote for Medicare beneficiaries with Part D coverage ranged from 33,890,715 in 2013 to 36,542,645 in 2017. Of these prescriptions, the average number of total opioid claims across all five years was 1,438,599.2. The opioid prescribing rate was calculated as the percentage of opioid prescriptions of the total prescription claims. In 2013, the overall opioid prescribing rate in New Jersey was 4.26%. This rate increased slightly in 2014 (4.27%) and then steadily declined over the next few years (2015: 4.16%; 2016: 3.99%; 2017: 3.71%) (see Table 1). Similarly, the long-acting opioid prescription rate in New Jersey overall declined from 2013 to 2017 (16.24%, 16.11%, 16.30%, 16.28% and 16.18%, respectively) (see Table 1). This pattern of declining rates is reflected in the average opioid prescription rate per New Jersey provider. Using linear regression, between the years 2013 and 2017, there was a statistically significant decrease in the opioid prescribing rate per provider of 0.556% (p ≤ 0.001).
Yearly opioid claims were compared for the 10 medical specialties with the highest opioid prescription rates within the state of New Jersey (see Table 3). The medical specialties with the highest number of opioid claims per provider include pain management, interventional pain management, hand surgery, surgical oncology, orthopedic surgery, physical medicine and rehabilitation, palliative care, neurosurgery, general surgery and oral surgery (dentists only). Each medical specialty demonstrated a pattern of decreasing opioid prescribing rates between the years 2013 and 2017, except for palliative care (4.03%, 43.42%, 41.44%, 36.51% and 42.67%, respectively). Orthopedic surgery had the greatest decline in opioid prescription rates within the four-year period (2014: 45.38% vs. 2017: 36.34%), while surgical oncology had the smallest decline (2014: 47.95% vs. 2017: 47.86%) (see Table 3).
Discussion
As the devastating impact of the opioid epidemic is realized, the medical community and state authorities have pushed to identify strategies for adequately treating pain without the use of opioids. Starting in 2012, New Jersey public health officials have made an effort to educate practitioners about the opioid crisis and safe prescribing practices through the PDFNJ Do No Harm symposium series. Their efforts have resulted in hundreds of physicians registering for the state prescription drug monitoring program and thousands of healthcare providers reporting they would change the way they prescribe.10 The present analysis sought to determine whether these efforts were successful and delineate whether New Jersey physicians responded appropriately to the opioid epidemic by changing their opioid prescribing patterns over the past few years.“New Jersey public health officials have made an effort to educate practitioners about the opioid crisis and safe prescribing practices through the PDFNJ Do No Harm symposium series.”In a presumed response to the devastating morbidity and mortality associated with the use of opioids, the national prescribing rate for opioids steadily decreased from 2013 to 2017 (5.80%, 5.73%, 5.50%, 5.32% and 5.05%, respectively) based on data reported by CMS.12 New Jersey has demonstrated a similar pattern of decreasing rates, however, with a lower overall prescribing rate for state physicians between the years 2013 and 2017 (4.26%, 4.27%, 4.16%, 3.99% and 3.71%, respectively) (see Table 1). In addition, the average opioid prescription rate per New Jersey provider declined from 2013 to 2017 (see Table 2). Previous studies highlighted the success of public health campaigns in altering opioid prescribing patterns.13–15 It is likely that New Jersey’s recent public health effort, spearheaded by the PDFNJ, is responsible for the decreased opioid prescribing rates found in the present analysis. To further delineate the prescribing patterns of New Jersey Medicaid and Medicare enrollees, the prescribing rates for long-acting opioids were calculated. Although the New Jersey long-acting opioid prescribing rates declined from 2013 to 2017 (16.24%, 16.11%, 16.30%, 16.28% and 16.18%, respectively), the rates remained higher than the national rate throughout this time period (12.54%, 12.56%, 12.91%, 12.68% and 12.27%, respectively12) (see Table 1). A recent study by Shah and colleagues demonstrated that patients initiated on long-acting opioids have the highest probabilities of long-term use, when compared to short-acting opioids.16 Further state reform should focus on educating New Jersey practitioners regarding the harmful effects of long-acting opioids in an effort to alter practitioners’ practice patterns.
The present analysis traced which medical specialties contribute the greatest burden of opioid prescriptions among CMS beneficiaries. Similar to national data, the rate of opioid prescribing was greatest for specialists in surgery, pain management, and physical medicine and rehabilitation.17 In line with overall prescribing patterns in New Jersey, all medical specialties showed a decline in opioid prescribing (see Table 3), except hospice and palliative care, which exhibited a sharp incline in opioid prescribing rates from 2013 to 2017 (4.03%, 43.42%, 41.44%, 36.51% and 42.67%, respectively) (see Table 3). A possible reason for this outlier may be related to an error in the database itself, such as a reporting error or another variation of database vulnerabilities.
“The present analysis emphasized the potential need for enhanced education and a more comprehensive approach to combating long-term opioid addiction.”
These outcomes provide evidence, albeit indirect, that New Jersey practitioners have responded to the opioid epidemic in terms of the overall prescribing rate; however, the state rate remains higher than the national rate in the use of long-acting opioids. The reason for this discrepancy may lie in the lack of content regarding the addictive nature of long-acting opioids in the New Jersey education initiatives. The PDFNJ has developed comprehensive public awareness campaigns to address the opioid crisis at the state level. However, as recently as 2018, it was documented that gaps of knowledge remain for community members and practitioners.2 The present analysis emphasized the potential need for enhanced education and a more comprehensive approach to combating long-term opioid addiction.
The limitations of this analysis must be mentioned. First, data were limited to the years 2013 to 2017, as this is what is available through the CMS website. In addition, we were unable to compare prescribing rates before the 2012 PDFNJ educational reforms. Although Medicare Part D is the largest single payer of prescription drugs, a large proportion of patients are older than the age of 65 and thus, may demonstrate unique patterns regarding the prescription of opioids. Importantly, the database does not provide the indications for which medications have been prescribed. However, the majority of opioid utilization can be assumed to be for pain management. As this was an observational study, we could not definitively establish causality between implementation of state education campaigns and opioid prescribing patterns. Finally, there are limitations inherent to any database, such as a reliance on accurate reporting.
Conclusion
The opioid epidemic has resulted in substantial morbidity and mortality in New Jersey, resulting in state-wide efforts to change opioid prescribing patterns. In response to this crisis, New Jersey opioid prescribing rates decreased steadily from 2013 to 2017. State prescribing rates remained lower than the national rate throughout this time period, perhaps as a result of the recent New Jersey public health education campaigns. Although New Jersey demonstrates favorable overall opioid prescribing rates, the state remains behind the national rate in the use of long-acting opioids, which are, reportedly, more likely to lead to long-term opioid use. This is a component of New Jersey prescribing patterns that deserves attention and educational reform.
Table 1.
The Prescribing Rate of Opioids in New Jersey in the Years 2013 to 2017
| 2013 | 2014 | 2015 | 2016 | 2017 | |
|---|---|---|---|---|---|
| Total Providers Assessed | 29,842 | 30,024 | 30,654 | 31,116 | 31,587 |
| Total NJ Claim Count | 33,890,715 | 34,486,697 | 35,369,970 | 36,378,002 | 36,542,645 |
| Total Opioid Claims | 1,442,925 | 1,473,349 | 1,471,865 | 1,450,449 | 1,354,408 |
| Opioid Prescribing Rate | 4.26% | 4.27% | 4.16% | 3.99% | 3.71% |
| Long-Acting Opioid Claims | 234,339 | 237,390 | 239,892 | 236,081 | 219,080 |
| Long-Acting Prescribing Rate | 16.24% | 16.11% | 16.30% | 16.28% | 16.18% |
Table 2.
The Average Opioid Prescription Rate Per New Jersey Provider in the Years 2013 To 2017
| Year | Average Opioid Prescription Rate Per Provider | Number of Prescribers Analyzed |
|---|---|---|
| 2013 | 10.326% | 20,492 |
| 2014 | 10.204% | 20,762 |
| 2015 | 9.868% | 21,477 |
| 2016 | 9.201% | 21,797 |
| 2017 | 8.069% | 22,085 |
R2= 0.002
Coefficient of change: –0.556%
p= <0.001
Table 3.
The Top 10 Medical Specialties With the Highest Opioid Prescribing Rate Between the Years 2013 and 2017
| Specialty | 2013 | 2014 | 2015 | 2016 | 2017 |
|---|---|---|---|---|---|
| Pain Management | 58.95% | 56.04% | 56.44% | 56.26% | 52.09% |
| Interventional Pain Management | 53.74% | 53.26% | 50.76% | 48.53% | 50.16% |
| Hand Surgery | 53.54% | 52.46% | 57.06% | 54.05% | 52.62% |
| Surgical Oncology | 47.95% | 48.55% | 46.28% | 45.48% | 47.86% |
| Orthopaedic Surgery | 45.38% | 44.31% | 42.94% | 41.59% | 37.34% |
| Physical Medicine and Rehabilitation | 36.37% | 36.01% | 36.31% | 36.06% | 35.73% |
| Hospice and Palliative Care | 4.03% | 43.42% | 41.44% | 36.51% | 42.67% |
| Neurosurgery | 35.49% | 35.72% | 38.04% | 35.10% | 30.54% |
| General Surgery | 36.00% | 34.52% | 34.86% | 35.19% | 34.31% |
| Oral Surgery (dentists only) | 34.95% | 33.46% | 32.65% | 30.71% | 28.27% |
Addendum. List of Opioids Utilized in the Present Analysis
acetaminophen with codeine, butalbit/acetaminophen/caffeine/codeine, codeine sulfate, codeine/butalbital/aspirin/caffeine, fentanyl, hydrocodone bitartrate/homatropine ME-BR, hydrocodone/acetaminophen, hydrocodone/chlorphen polis, hydrocodone/ibuprofen, hydromorphone HCL, morphine sulfate, oxymorphone HCL, oxycodone HCL/acetaminophen, oxycodone HCL, tapentadol HCL, tramadol HCL, tramadol HCL/acetaminophen, butorphanol tartrate, promethazine HCL/codeine
