Last month, the CDC released information comparing rates of opioid and benzodiazepine prescriptions by state and by region. It did not surprise me to learn the South had the highest rates of benzodiazepine and opioid prescribing of the entire nation.
U.S. citizens already receive twice the number of pain pills per capita than our Canadian neighbors. But in addition to that difference, there’s a 2.7-fold difference between the state with the lowest opioid prescribing rate per capita (Hawaii) and the states with the highest rate per capita (Tennessee and Alabama tied for first place). 
The same held true for benzodiazepines, with even more difference in prescribing rates. In Hawaii, doctors prescribed benzodiazepines for 19.3 people out of every 100. But in Tennessee, 61.4 people out of 100 received benzodiazepine prescriptions. That’s over a three-fold difference between these states.
Alabama, Tennessee, and West Virginia were the top three prescribers for both opioid and benzodiazepines. We already know that higher prescribing rates are associated with higher overdose deaths rates from these medications. Incredibly, these three states were more than two standard deviations away from mean prescribing rates for the entire country.
Even more disturbing, Tennessee doctors prescribed oxymorphone (Opana) at an amount 22 times that of doctors in Minnesota.
That’s just bizarre. It could also explain why so many of the patients I admit to OTPs in the mountains of North Carolina mention Opana as their drug of choice.
The CDC authors of this report admit it’s unlikely there’s much difference in rates of disorders needing treatment with opioids or benzodiazepines. My interpretation of this statement is that it’s an indirect way of saying doctors in the South are overprescribing opioids and benzodiazepines. The authors allude to the problem of overprescribing in the South, mentioning that the South also has higher rates of prescribing for antibiotics, stimulants in children, and medications known to be high risk for the elderly.
How did my state of North Carolina compare to the rest of the nation? Our data isn’t as embarrassing as that for Tennessee, but there’s certainly room for improvement. In NC, doctors prescribed around 97 opioid prescriptions per 100 people, and 45 benzo prescriptions per 100 people.
Benzodiazepine co-addiction complicates induction onto methadone and buprenorphine done by opioid treatment programs for the treatment of opioid addiction, and this co-addiction also predicts poorer treatment outcomes. [2, 3]
This supports what I’ve long suspected: the treatment of opioid addicts with MAT is different in the South than in the West. My colleagues in California, inferring from the CDC’s report, don’t have to deal with benzodiazepine co-addiction as often as I do in the mountains of North Carolina. That co-occurring addiction changes the clinical picture, and makes induction onto methadone particularly more risky.
This is not the South’s finest hour. We must do more to educate doctors about appropriate prescribing, starting in medical school and continuing throughout the physicians’ professional careers. If doctors don’t start this change, someone else will surely do it for us.
2. Brands et al, 2008, Journal of Addictive Disease
3. Eiroa-orosa et al, 2010, Drug and Alcohol Dependence