ANASTASIA A. MITAYANINA, BS
SUMMARY POINTS
Less than 10% of Dermatologists prescribe opioids.
There has been an overall decrease in opioid prescribing by Dermatologists from 2011 to 2020.
The number of Hydrocodone prescriptions peaked in 2011 and has been declining since, while the number of Tramadol prescriptions has been inversely increasing over the same time.
Dermatologists in southern states prescribe more opioids than Dermatologists from other states in the U.S.
ANALYSIS
Background
Opioid sales increased by 400% between 1999 and 2011 and prescription opioid related deaths subsequently surpassed those related to the use of heroin and cocaine [1]. In 2016 the opioid epidemic was declared a public health emergency and since then there has been an increase in efforts to decrease the prescription of opioids by healthcare providers of different specialties.
Opioid prescribing in Dermatology hasn’t been widely studied. Most opioids prescribed by dermatologists are following Mohs micrographic surgeries and conventional excisions [1]. Despite updates in opioid prescribing guidelines among many medical and surgical specialties, there has been a lack of opioid prescription guidelines and opioid-related research in the field of dermatology [1,2]. Although Dermatology presents a very small percentage of the total opioid prescribers, studies have shown that even short-term use of opioids postoperatively can lead to long-term use [3]. While only 10% or less of patients actually require postoperative opioid treatment following dermatologic procedures, approximately 7000 patients annually will continue to use opioids for at least one year following dermatological surgeries [2]. Generally, acute postoperative dermatologic treatment can be managed with a combination of NSAIDs and acetaminophen, however, finding the right and safe pain management treatment can still be a challenge for Dermatologists [4]. The goal of this analysis is to present recent data on opioid-prescribing trends in Dermatology.
Data were obtained from the Part D Prescriber Public Use File using the Center of Medicare and Medicaid Services (CMS) database [8]. Part D is a prescription drug plan that is provided for people 65 years and older, as well as people with disabilities. In 2021 48 million Americans were enrolled in Medicare Part D [6]. The CMS database provides information on the amount and types of providers, as well as the number of beneficiaries and claims. There is currently data available for 2013-2019. For the purpose of this study, the data from 2014-2019 was analyzed and only Dermatologists were included for analysis. The percentage of the providers prescribing opioids was obtained by dividing the number of providers that prescribe opioids by the total number of providers. The total number of claims was calculated to analyze the yearly trend. This data will be presented along with related published data on opioid prescribing in Dermatology.
Findings
Overall Opioid Prescription Rates in Dermatology
Figure 1 and Figure 2 were created. from the statistical analysis of the Part D Medicare database of the CMS. The percentage of Dermatologists prescribing opioids declined from 14.6% in 2014 to 9.5% in 2019 (Figure 1). The total number of prescriptions declined from 112,732 prescriptions in 2015 to 81,328 in 2019 (Figure 2). It is important to note that this data only shows the trends within the group of patients enrolled in Medicare Part D.
Figure 1: Percentage of Providers Prescribing opioids in Dermatology. The figure shows an overall decline in opioid prescriptions by Dermatologists in 2014-2019 within the population of patients enrolled in Medicare Part D.
Figure 2: The number of opioid prescriptions in Dermatology by year. The figure shows an overall decline in the total number of prescriptions to the patients enrolled in Medicare Part D.
Most patients who do receive opioids do so following dermatologic surgery [4]. Figure 3 shows the percentage of patients who received opioids following Mohs micrographic surgery. The same trend can be seen in this data. The rate of prescriptions decreased from 39.6% in 2011 to 11.7% in 2020 [1].
Figure 3: Percentage of patients who underwent Mohs micrographic surgery and were prescribed opioids postoperatively by year. SEE ARTICLE from Veerabagu SA, Cheng B, Wang S, et al. Rates of Opioid Prescriptions Obtained After Mohs Surgery: A Claims Database Analysis From 2009 to 2020. JAMA Dermatol. 2021;157(11):1299-1305. doi:10.1001/jamadermatol.2021.3468
Prescription by Medication Type
Hydrocodone was the most prescribed opioid medication between 2009 and 2020 (Figure 4) [1]. The peak of prescriptions was seen in 2011 and constituted 67.1% of all the opioids prescribed by dermatologists after surgery. In 2014 the US Food and Drug Administration declared Hydrocodone a Schedule II drug which led to a decline in the number of prescriptions by 21.7% between 2012 and 2020 [1].
In contrast, the number of Tramadol prescriptions increased 10-fold from 2009 to 2020 (Figure 4). Tramadol is a Schedule IV drug and was advertised as a safer opioid prescription medication. However, more recent studies found that respiratory depression and addiction occur more frequently than previously expected [1]. Moreover, studies have shown that Tramadol is not any more effective than ibuprofen in postoperative patients (1). The number of Oxycodone and Codeine prescriptions appeared to be steady during this time (Figure 4).
Figure 4: Types of medications prescribed to dermatologic patients postoperatively by year. SEE ARTICLE from Veerabagu SA, Cheng B, Wang S, et al. Rates of Opioid Prescriptions Obtained After Mohs Surgery: A Claims Database Analysis From 2009 to 2020. JAMA Dermatol. 2021;157(11):1299-1305. Doi:10.1001/jamadermatol.2021.3468
Prescription Rates by State
Dermatologists in the Southern states prescribe more opioids than dermatologists in the rest of the country. The highest prescription rates are seen in Alabama, Georgia, and West Virginia (Figure 5). This is consistent with the overall opioid prescription trends in the US and attributed to the attitude towards opioids in the Southern states (4).
Figure 5: Opioid prescription rate by state. SEE ARTICLE from Cao S, Karmouta R, Li DG, Din RS, Mostaghimi A. Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2017.5835
Discussion
Despite Dermatology being a small medical specialty with an even smaller percentage of Dermatologists even prescribing opioids, according to the study done by Veerabagu and et. [1], the specialty still contributes to over 700,000 opioid pills that may remain unused every year [1]. Limiting opioid prescriptions is important to combat the opioid crisis in the US [7]. This analysis demonstrates a decline in opioid prescriptions in Dermatology. Dermatologic surgery can expose opioid-naive patients to these medications and it has been shown that even short-term opioid use can increase the risk of addiction [4].
This analysis demonstrated an overall decrease in opioid prescription by Dermatologists with Southern Dermatologists prescribing opioids at the highest rate which is most likely due to the attitudes towards opioids in those states [4]. The data obtained from both the CMS database [8] and the study by Veerabagu and et. [1] demonstrate a decrease in opioid prescriptions in the U.S. In 2016 the opioid epidemic was declared a nationwide public health emergency [9)] and more research studies were conducted regarding opioid safety and the risks of opioid abuse [10]. This may have discouraged Dermatologists from prescribing opioids leading to a decrease in prescription rates.
Hydrocodone prescription rate, once the most prescribed drug, has been steadily declining over the past years with Tramadol used as a replacement. In 2014 Hydrocodone was declared a schedule II controlled substance which led to a decrease in its prescription rate [11]. Tramadol is a schedule IV controlled substance that was initially proven to be a safer medication with lower abuse potential [12]. Yet, Tramadol was shown to be no more effective than ibuprofen for short-term use [1]) and there have been Tramadol dependence cases reported in opioid naïve individuals [13]. In fact, Raji and et. (5) demonstrated that substituting opioid pain management with a combination of ibuprofen and acetaminophen has led to a decrease in pain complaints from patients following dermatologic surgery [5].
The next steps for this study would be to find the data from insurance companies other than Medicare to analyze the prescription rates for the non-Medicare population. This would include the population of people who live below the poverty level as well as patients younger than 65 that rely on private insurance companies for medical services. Also, more recent data should be obtained on the prescription rate, however, it is not yet available on CMS. Keeping this positive trend in Dermatology is important to ending the opioid crisis and bettering people's lives.
REFERENCES
Veerabagu SA, Cheng B, Wang S, et al. Rates of Opioid Prescriptions Obtained After Mohs Surgery: A Claims Database Analysis From 2009 to 2020. JAMA Dermatol. 2021;157(11):1299-1305. doi:10.1001/jamadermatol.2021.3468
McLawhorn JM, Stephany MP, Bruhn WE, et al. An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures. J Am Acad Dermatol. 2020;82(3):700-708. doi:10.1016/j.jaad.2019.09.080
Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults [published correction appears in JAMA Surg. 2019 Mar 1;154(3):272]. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504
Cao S, Karmouta R, Li DG, Din RS, Mostaghimi A. Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2017.5835
Raji K, Yeung H, Bein AA, Lequeux-Nalovic KG. Dermatologic Surgeons Can Positively Impact the Opioid Epidemic: A Quality Improvement Study of Pain Management in Dermatology Surgery. Dermatol Surg. 2020;46(5):635-638. doi:10.1097/DSS.0000000000002198
An Overview of the Medicare Part D Prescription Drug Benefit. https://www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/ Published 2021. Accessed June 15, 2022.
Harder VS, Plante TB, Koh I, et al. Influence of Opioid Prescription Policy on Overdoses and Related Adverse Effects in a Primary Care Population. J Gen Intern Med. 2021;36(7):2013-2020. doi:10.1007/s11606-021-06831-4
Part D Prescriber Public Use File. https://data.cms.gov/provider-summary-by-type-of-service/medicare-part-d-prescribers/medicare-part-d-prescribers-by-provider
The Lancet. The opioid crisis in the USA: a public health emergency. Lancet. 2017;390(10107):2016. doi:10.1016/S0140-6736(17)32808-8
Webster LR. Risk Factors for Opioid-Use Disorder and Overdose. Anesth Analg. 2017;125(5):1741-1748. doi:10.1213/ANE.0000000000002496
Kuschel LM, Mort JM. Impact of the Hydrocodone Schedule Change on Opioid Prescription Patterns in South Dakota. S D Med. 2017;70(10):449-455.
Preston KL, Jasinski DR, Testa M. Abuse potential and pharmacological comparison of tramadol and morphine. Drug Alcohol Depend. 1991;27(1):7-17. doi:10.1016/0376-8716(91)90081-9
Ojha R, Bhatia SC. Tramadol dependence in a patient with no previous substance history. Prim Care Companion J Clin Psychiatry. 2010;12(1):PCC.09100779. doi:10.4088/PCC.09100779ecr
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