Geographic Variation in Opioid Prescribing in the U.S.


      Estimates of geographic variation among states and counties in the prevalence of opioid prescribing are developed using data from a large (135 million) representative national sample of opioid prescriptions dispensed during 2008 by 37,000 retail pharmacies. Statistical analyses are used to estimate the extent to which county variation is explained by characteristics of resident populations, their healthcare utilization, proxy measures of morbidity, availability of healthcare resources, and prescription monitoring laws. Geographic variation in prevalence of prescribed opioids is large, greater than the variation observed for other healthcare services. Counties having the highest prescribing rates for opioids were disproportionately located in Appalachia and in southern and western states. The number of available physicians was by far the strongest predictor of amounts prescribed, but only one-third of county variation is explained by the combination of all measured factors. Wide variation in prescribing opioids reflects weak consensus regarding the appropriate use of opioids for treating pain, especially chronic noncancer pain. Patients’ demands for treatment have increased, more potent opioids have become available, an epidemic of abuse has emerged, and calls for increased government regulation are growing. Greater guidance, education, and training in opioid prescribing are needed for clinicians to support appropriate prescribing practices.


      Wide geographic variation that does not reflect differences in the prevalence of injuries, surgeries, or conditions requiring analgesics raises questions about opioid prescribing practices. Low prescription rates may indicate undertreatment, while high rates may indicate overprescribing and insufficient attention to risks of misuse.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ballantyne J.C.
        Opioid controls: Regulate to educate.
        Pain Med. 2010; 11: 480-481
        • Caudill-Slosberg M.A.
        • Schwartz L.M.
        • Woloshin S.
        Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000.
        Pain. 2004; 109: 514-519
      1. Centers for Disease Control and Prevention: Unintentional Drug Poisoning in the United States, 2010

      2. Centers for Disease Control and Prevention: CDC health disparities and inequalities report – United States, 2011

        • Chou R.
        • Ballantyne J.C.
        • Fanciullo G.J.
        • Fine P.G.
        • Miaskowski C.
        Research gaps on use of opioids for chronic noncancer pain: Findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline.
        J Pain. 2009; 10: 147-159
        • Chou R.
        • Fanciullo G.J.
        • Fine P.G.
        • Adler J.A.
        • Ballantyne J.C.
        • Davies P.
        • Donovan M.I.
        • Fishbain D.A.
        • Foley K.M.
        • Fudin J.
        • Gilson A.M.
        • Kelter A.
        • Mauskop A.
        • O’Connor P.G.
        • Passik S.D.
        • Pasternak G.W.
        • Portenoy R.K.
        • Rich B.A.
        • Roberts R.G.
        • Todd K.H.
        • Miaskowski C.
        Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
        J Pain. 2009; 10: 113-130
        • Cicero T.J.
        • Surratt H.
        • Inciardi J.A.
        • Munoz A.
        Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States.
        Pharmacoepidemiol Drug Saf. 2007; 16: 827-840
        • Coalition Against Insurance Fraud
        Prescription for Peril: How Insurance Fraud Finances Theft and Abuse of Addictive Prescription Drugs.
        Coalition Against Insurance Fraud, Washington, D.C.2007
      3. Congressional Budget Office: Geographic Variation in Health Care Spending, 2008

        • Curtis L.H.
        • Stoddard J.
        • Radeva J.I.
        • Hutchison S.
        • Dans P.E.
        • Wright A.
        • Woosley R.L.
        • Schulman K.A.
        Geographic variation in the prescription of schedule II opioid analgesics among outpatients in the United States.
        Health Serv Res. 2006; 41: 837-855
        • Curtis L.H.
        • Stoddard J.
        • Radeva J.I.
        • Hutchison S.
        • Dans P.E.
        • Wright A.
        • Woosley R.L.
        • Schulman K.A.
        Correction to ‘‘Geographic Variation in the Prescription of Schedule II Opioid Analgesics among Outpatients in the United States’’.
        Health Serv Res. 2006; 41: 856-859
        • Denisco R.A.
        • Chandler R.K.
        • Compton W.M.
        Addressing the intersecting problems of opioid misuse and chronic pain treatment.
        Exp Clin Psychopharmacol. 2008; 16: 417-428
        • Diehr P.
        • Cain K.
        • Connel F.
        • Volinn E.
        What is too much variation? The null hypothesis in small-area analysis.
        Health Serv Res. 1990; 24: 741-771
      4. Federation of State Medical Boards of the United States I: Model guidelines for the use of controlled substances for the treatment of pain. Euless, Texas, 1998

      5. Federation of State Medical Boards of the United States I: Model policy for the use of controlled substances for the treatment of pain. Euless, Texas, 2004

        • Fisher E.S.
        • Wennberg D.E.
        • Stukel T.A.
        • Gottlieb D.J.
        • Lucas F.L.
        • Pinder E.L.
        The implications of regional variations in Medicare spending. Part 1: The content, quality, and accessibility of care.
        Ann Intern Med. 2003; 138: 273-287
        • Fisher E.S.
        • Wennberg D.E.
        • Stukel T.A.
        • Gottlieb D.J.
        • Lucas F.L.
        • Pinder E.L.
        The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care.
        Ann Intern Med. 2003; 138: 288-298
        • Fishman S.M.
        • Papazian J.S.
        • Gonzalez S.
        • Riches P.S.
        • Gilson A.
        Regulating opioid prescribing through prescription monitoring programs: Balancing drug diversion and treatment of pain.
        Pain Med. 2004; 5: 309-324
        • Institute of Medicine
        Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
        The National Academies Press, Washington, DC,2011
        • Joranson D.E.
        • Ryan K.M.
        • Gilson A.M.
        • Dahl J.L.
        Trends in medical use and abuse of opioid analgesics.
        JAMA. 2000; 283: 1710-1714
        • Joranson D.E.
        • Gilson A.M.
        • Dahl J.L.
        • Haddox J.D.
        Pain management, controlled substances, and state medical board policy: A decade of change.
        J Pain Symptom Manage. 2002; 23: 138-147
        • Lebovits A.H.
        • Florence I.
        • Bathina R.
        • Hunko V.
        • Fox M.T.
        • Bramble C.Y.
        Pain knowledge and attitudes of healthcare providers: Practice characteristic differences.
        Clin J Pain. 1997; 13: 237-243
        • Luo X.
        • Pietrobon R.
        • Hey L.
        Patterns and trends in opioid use among individuals with back pain in the United States.
        Spine (Phila Pa 1976). 2004; 29 (discussion 91): 884-890
        • Meghani S.H.
        • Byun E.
        • Gallagher R.M.
        Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States.
        Pain Med. 2012; 13: 150-174
      6. Office of National Drug Control Policy: Epidemic: Responding to America’s Prescription Drug Abuse Crisis. Office of National Drug Control Policy, Washington, DC, 2011

        • Olsen Y.
        • Daumit G.L.
        • Ford D.E.
        Opioid prescriptions by U.S. primary care physicians from 1992 to 2001.
        J Pain. 2006; 7: 225-235
        • Paulozzi L.J.
        • Ryan G.W.
        Opioid analgesics and rates of fatal drug poisoning in the United States.
        Am J Prev Med. 2006; 31: 506-511
        • Paulozzi L.J.
        • Budnitz D.S.
        • Xi Y.
        Increasing deaths from opioid analgesics in the United States.
        Pharmacoepidemiol Drug Saf. 2006; 15: 618-627
        • Paulozzi L.J.
        • Jones C.M.
        • Mack K.A.
        • Rudd R.A.
        Vital Signs: Overdoses of prescription opioid pain relievers–United States, 1999-2008.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 1-6
        • Pergolizzi J.
        • Böger R.H.
        • Budd K.
        • Dahan A.
        • Erdine S.
        • Hans G.
        • Kress H.G.
        • Langford R.
        • Likar R.
        • Raffa R.B.
        • Sacerdote P.
        Opioids and the management of chronic severe pain in the elderly: Consensus statement of an international expert panel with focus on the six clinically most often used World Health Organization step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone).
        Pain Pract. 2008; 8: 287-313
        • Schneider M.F.
        • Bailey J.E.
        • Cicero T.J.
        • Dart R.C.
        • Inciardi J.A.
        • Parrino M.
        • Munoz A.
        Integrating nine prescription opioid analgesics and/or four signal detection systems to summarize statewide prescription drug abuse in the United States in 2007.
        Pharmacoepidemiol Drug Saf. 2009; 18: 778-790
        • Smith M.Y.
        • Irish W.
        • Wang J.
        • Haddox J.D.
        • Dart R.C.
        Detecting signals of opioid analgesic abuse: Application of a spatial mixed effect poisson regression model using data from a network of poison control centers.
        Pharmacoepidemiol Drug Saf. 2008; 17: 1050-1059
      7. Strakowski SM, Weiss RD, Roy-Byrne PP, Compton WM: Tackling prescription drug abuse with formulary restriction? In Medscape Psychiatry 2012

      8. Substance Abuse and Mental Health Services Administration: The NSDUH Report: Trends in Nonmedical Use of Prescription Pain Relievers: 2002 to 2007. Rockville, MD, 2009

      9. Substance Abuse and Mental Health Services Administration: Treatment Episode Data Set (TEDS) Highlights - - 2007 National Admissions to Substance Abuse Treatment Services. OAS Series #S-45, HHS Publication No. (SMA) 09–4360 ed. Office of Applied Studies, Rockville, MD, 2009

        • Substance Abuse and Mental Health Services Administration
        Drug Abuse Warning Network, 2009: National Estimates of Drug-Related Emergency Department Visits.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2011
        • Trescot A.M.
        • Helm S.
        • Hansen H.
        • Benyamin R.
        • Glaser S.E.
        • Adlaka R.
        • Patel S.
        • Manchikanti L.
        Opioids in the management of chronic non-cancer pain: An update of American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines.
        Pain Physician. 2008; 11: S5-S62
        • Turk D.C.
        • Brody M.C.
        • Okifuji E.A.
        Physicians’ attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain.
        Pain. 1994; 59: 201-208
      10. U.S. Dept. of Health and Human Services: Area Resource File (ARF) Access System 2008. (Health Resources and Services Administration Bureau of Health Professions, Ed.). Rockville, MD, 2008

      11. U.S. Dept. of Justice: Automation of Reports and Consolidated Orders System (ARCOS), Retail Drug Summary. Available at: Accessed December 2011

        • Van Zee A.
        The promotion and marketing of oxycontin: Commercial triumph, public health tragedy.
        Am J Public Health. 2009; 99: 221-227
        • Von Korff M.
        • Dunn K.M.
        Chronic pain reconsidered.
        Pain. 2008; 138: 267-276
        • Webster B.S.
        • Diluents M.
        • Verma S.
        • Pransky G.
        Geographic variation in opioid prescribing for acute, work-related, low back pain and associated factors: A multilevel analysis.
        Am J Ind Med. 2009; 52: 162-171
        • Weinstein J.N.
        • Lurie J.D.
        • Olson P.R.
        • Bronner K.K.
        • Fisher E.S.
        United States’ trends and regional variations in lumbar spine surgery: 1992-2003.
        Spine (Phila Pa 1976). 2006; 31: 2707-2714
        • Weissman D.B.
        Do drug regulations affect medical practice?.
        J Pain Symptom Manage. 1992; 7: 257-258
        • Wennberg J.E.
        Time to tackle unwarranted variations in practice.
        BMJ. 2011; 342
        • Wennberg J.E.
        • Fisher E.S.
        • Skinner J.S.
        Geography and the debate over Medicare reform.
        Health Aff (Millwood). 2002; : W96-114
        • Wolfert M.Z.
        • Gilson A.M.
        • Dahl J.L.
        • Cleary J.F.
        Opioid analgesics for pain control: Wisconsin physicians’ knowledge, beliefs, attitudes, and prescribing practices.
        Pain Med. 2010; 11: 425-434
        • Zacny J.
        • Bigelow G.
        • Compton P.
        • Foley K.
        • Iguchi M.
        • Sannerud C.
        College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: Position statement.
        Drug Alcohol Depend. 2003; 69: 215-232
        • Zerzan J.T.
        • Morden N.E.
        • Soumerai S.
        • Ross-Degnan D.
        • Roughead E.
        • Zhang F.
        • Simoni-Wastila L.
        • Sullivan S.D.
        Trends and geographic variation of opiate medication use in state Medicaid fee-for-service programs, 1996 to 2002.
        Med Care. 2006; 44: 1005-1010
        • Zhang Y.
        • Baicker K.
        • Newhouse J.P.
        Geographic variation in Medicare drug spending.
        N Engl J Med. 2010; 363: 405-409
        • Zhang Y.
        • Baicker K.
        • Newhouse J.P.
        Geographic variation in the quality of prescribing.
        N Engl J Med. 2010; 363: 1985-1988