Prescription opioids are often used to treat chronic and acute pain and, when used appropriately, can be an important component of treatment. However, serious risks are associated with their use, and it is essential to carefully consider the risks of using prescription opioids alongside their benefits. These risks include misuse, opioid use disorder (addiction), and even overdoses and death.
Millions of Americans suffer from pain, and these patients are often prescribed opioids to treat their conditions. However, the dangers of prescription misuse, opioid use disorder, and overdose have been a growing problem throughout the United States.
Since the 1990s, when the amount of opioids prescribed to patients began to grow, the number of overdoses and deaths from prescription opioids has also increased. Even as the amount of opioids prescribed and sold for pain has increased, the amount of pain that Americans report has not similarly changed.
From 1999 to 2016, more than 200,000 people died in the United States from overdoses related to prescription opioids. Overdose deaths involving prescription opioids were five times higher in 2016 than in 1999.1
Taking prescription opioids for longer periods of time or in higher dosages can increase the risk of opioid use disorder (addiction), overdose, and death. It is also important for patients and providers to discuss the risks of opioids, consider alternative therapies, and, if prescribing opioids is appropriate, the provider should offer fewer prescriptions for fewer days and at lower dosages.
The overall opioid prescribing rate in the United States peaked in 2010 and has been declining since 2012, but the amount of opioids in morphine milligram equivalents (MME) prescribed per person is still around three times higher than it was in 1999.2 MME is a way to calculate the total amount of opioids, accounting for differences in opioid drug type and strength.
The leveling off and declines in opioid prescribing rates since 2012 and high-dose prescribing rates (≥90 MME) since 2009 suggest that healthcare providers have become more cautious in their opioid prescribing practices.
In 2016, however, there were still almost 67 opioid prescriptions written for every 100 Americans.
- More than 19% of Americans had at least one opioid prescription filled, with an average of 3.5 opioid prescriptions dispensed per patient.
- Per prescription, the average daily amount was more than 47 MME.
- The average number of days per prescription continues to increase, with an average of 18 days in 2016.3
There is wide variability at the county level in the amount of opioids received per resident. Counties with higher prescribing have been shown to have these characteristics:
- Generally smaller cities or larger towns
- Higher percentage of white residents
- Higher number of dentists and primary care physicians
- More people who are uninsured or unemployed
- More residents who have diabetes, arthritis, or a disability2
Healthcare providers report concerns about opioid-related risks of addiction and overdose for their patients, as well as insufficient training in pain management. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain offers recommendations that may help to improve prescribing practices and ensure all patients receive safer, more effective pain treatment. Healthcare providers can also earn continuing education through this interactive training series called Applying the CDC Guideline for Prescribing Opioids.
When looking at overdose deaths from prescription opioids, CDC analyzes the following:
- Natural opioids: Pain medications like morphine and codeine
- Semi-synthetic opioids: Pain medications like oxycodone, hydrocodone, hydromorphone, and oxymorphone
- Methadone: A synthetic opioid used to treat pain, but it can also be provided through opioid treatment programs to treat opioid use disorders
Current information reported about overdose deaths does not distinguish pharmaceutical fentanyl from illegally-made fentanyl. In order to account for increases in illicitly manufactured fentanyl, CDC Injury Center separates synthetic opioids (other than methadone) from prescription opioid death calculations.
Overdose Deaths Involving Prescription Opioids
Prescription opioids continue to contribute to the opioid overdose epidemic in the United States. More than 40% of all U.S. opioid overdose deaths in 2016 involved a prescription opioid, with more than 46 people dying every day from overdoses involving prescription opioids.4
The most common drugs involved in prescription opioid overdose deaths include:
- Oxycodone (such as OxyContin®)
- Hydrocodone (such as Vicodin®)5
For people who died from prescription opioid overdose in 2016:
- Overdose rates from prescription opioids were highest among people aged 25 to 54 years.
- Overdose rates from prescription opioids were higher among non-Hispanic whites and American Indian or Alaskan Natives, compared to non-Hispanic blacks and Hispanics.
- The rate of overdose deaths from prescription opioids among men was 6.2 per 100,000 people and the rate among women was 4.3 in 2016.
The highest overdose death rates from prescription opioids were in West Virginia, Maryland, Maine, and Utah.4
Health systems can create Electronic Health Record (EHR) alerts (e.g., for high daily dosage, multiple opioid prescriptions), which allows providers to make informed prescribing decisions within clinical workflow.
In March 2016, CDC released the CDC Guideline for Prescribing Opioids for Chronic Pain to ensure that patients have access to safer, more effective chronic pain treatment, while reducing the number of people who misuse opioids, develop opioid use disorder, or overdose. The Guideline focused on the prescribing of opioid pain medication to patients 18 years and older in primary care settings outside of active cancer treatment, palliative care and end of life care.
CDC is evaluating implementation of the Guideline by providers, health systems, and insurers with the goal of identifying how the recommendations are being applied, and potential barriers to implementation.
As of April 2018:
- 46 states are now implementing activities to improve local prescribing practices so that they are in alignment with the Guideline
- 1,300 continuing education (CE) credits have been earned from the interactive training series, Applying CDC’s Guideline for Prescribing Opioids.
- 3,600 CE credits have been earned from the COCA Call Webinar Series
- 35 state Medicaid programs have elected to or plan to implement the Guideline’s recommendations.5
- Providers have downloaded
Large central metro—Counties in metropolitan statistical areas of 1 million or more population that:
- Contain the entire population of the largest principal city
- Have their entire population contained in the largest principal city
- Contain at least 250,000 inhabitants of any principal city
- Large fringe metro—Counties of 1 million or more population that did not qualify as large central metro counties.
- Medium metro—Counties of populations of 250,000 to 999,999.
- Small metro—Counties of populations less than 250,000.
- Micropolitan—Counties in micropolitan statistical areas that have a population of at least 10,000 but less than 50,000.
- Noncore—Nonmetropolitan counties that did not qualify as micropolitan.
Categories of 2013 NCHS Urban-Rural Classification Scheme for Counties (https://www.cdc.gov/nchs/data_access/urban_rural.htm)
Age-adjusted death rates for prescription opioids are plotted above by urbanization classification of residence for 2015 to 2016. Rates increased significantly for large central metro (14.6%), large fringe metro (23.8%), and medium metro (7.1%) areas. The prescription opioid overdose death rate also increased in the United States overall—a statistically significant 10.6% increase from 2015 to 2016, with a total of 17,087 deaths in 2016. Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug overdose deaths are identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14. Drug overdose deaths, as defined, that have prescription (natural and semi-synthetic) opioids (T40.2) or methadone (T40.3) as a contributing cause. Age-adjusted death rates were calculated using the direct method and the 2000 standard population.1
- Seth P, Rudd R, Noonan, R, Haegerich, T. Quantifying the Epidemic of Prescription Opioid Overdose Deathsexternal icon. American Journal of Public Health, March 2018;108(4),e1-e3.
- Centers for Disease Control and Prevention. Vital Signs: Changes in Opioid Prescribing in the United States, 2006–2015. MMWR 2017; 66(26):697-704.
- Centers for Disease Control and Prevention. Annual Surveillance Report of Drug-Related Risks and Outcomes — United States, 2017pdf icon. Surveillance Special Report. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2017
- Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants – United States, 2015-2016. MMWR Morb Mortal Wkly Rep. March 2018. 67(12);349–358.
- Warner M, Trinidad JP, Bastian BA, Minino AM, Hedegaard H. Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2010-2014pdf icon. National Vital Statistics Reports, vol 65, no 10. National Center for Health Statistics. 2016.
- Kaiser Family Foundation, Medicaid Moving Ahead in Uncertain Times: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2017 and 2018, (Washington, DC: Kaiser Family Foundation, October 2017).