Opioids and Benzodiazepines Prescribed More Frequently in the South


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). [1]

The same held true for benzodiazepines, with even more difference in prescribing rates. In Hawaii, doctors prescribed benzodiazepines 19.3 times for every 100 people. But in Tennessee, doctors prescribed benzodiazepines 61.4 times for every 100 people. 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.

1. http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html
2. Brands et al, 2008, Journal of Addictive Disease
3. Eiroa-orosa et al, 2010, Drug and Alcohol Dependence

12 responses to this post.

  1. Posted by Kristi Whitaker on August 25, 2014 at 3:51 am

    Hi. I’ve been sober for 4.5 years. During my active addiction I lived in Florida and South Carolina. When I first started abusing prescription meds I was being treated for a bad car accident. At the time I had been clean off heroin for 2 years. I did not tell the doctor. He started me on Lortab 7.5mg. It was for 120 a month!! I was really surprised at first. I did have serious back problems though. But after a few months my pain subsided. But by then I was already addicted again. I was also in physical therapy at the same office. To make a long story short… I continued to see this doctor for almost a year. Every few months he would give me more pills per month. He also gave me a prescription for Xanax. One day I went in for my appointment and my doctor was gone. He’d left that practice. The doctor I did see said I shouldn’t be on any of that medicine and refused to fill the medicine. I was very sick. I found out about a local methadone clinic And the rest is my road to sobriety. Now I’m glad that happened. But at the time I was damn near suicidal. I was in so much pain from wd’s.

    The problem I have is that my original doctor should never have given me that much medicine. I actually never asked for it. But once I was hooked I wanted more and more. And he gave it to me. The other problem is the 2nd doctor. How could he do that to a patient. Why not wean them down or try to get them some help.

    Is there a way to stop the doctors from over priscribing? Now that I’m sober I wish it would have been harder to get drugs. I might have gone into treatment sooner. During the addiction I thought it was great that this doctor was writing all the scripts. It was like Christmas once a month.

    Last year I looked that doctor up. He now is a suboxone subscribing doctor. And on the website in bold letters it says insurance AND SELF PAY patients welcomed. Makes me think it’s more about the cash flow and not helping people.

    Sorry this is so long 😉


  2. Posted by Charlie on August 25, 2014 at 2:26 pm

    As a resident of the biggest ‘offender’ here, Tennessee, a few very relevant facts in our defense should be noted. Tennessee, Arkansas, and Mississippi are the three poorest states in the Union- 48th, 49th, and 50th- respectively. (lowest per-capita household incomes) The poor face higher rates of mental and physical problems, and less resources with which to deal with them. Here’s a random, yet highly relevant example of inequality: did anyone know that there is no dental school in the State of Arkansas? That’s right! A US state with millions of people has to send those it can across the river to our dental school. (The University of Tennessee School of Dentistry) Here in Tennessee we have excellent hospitals and teaching institutions- Le Bonheur Children’s Hospital, St. Jude Children’s Research Hospital, The “MED” (The Regional Medical Center, Memphis- a publicly-funded, level-1 trauma center treating many patients of two other states- Arkansas and Mississippi- who offer Tennessee little if any financial help for it’s uninsured citizens), the Semmes-Murphy Clinic, (neurology) Vanderbilt Medical Center, etc. The list goes on. Our doctors are not ignorant hayseeds, writing prescriptions with reckless abandon. Rather, they are treating a much less healthy population with less to work with. I hope the esteemed author of this excellent blog will publish this inconvenient entry.


    • That’s the heart of the issue: are opioids and benzos being prescribed appropriately in the states with highest prescribing rates? The CDC report gently suggested there is not a great deal of difference in the severity of mental and physical health issues, but perhaps that’s not the case. Poverty probably does play some role…i suspect it’s more expensive to get one-hour CBT counseling for four weeks than to fill a clonazepam prescription…


  3. Posted by subfilmtaker on August 26, 2014 at 12:26 am

    Jana, I agree with Charlie above. I was going to say, my initial thought concluded that it was related to US Military bases. North Carolina has (5) Army bases, (3) Marine bases and (2) Air Force bases. Just in the Army and Marines alone, esp. in that state, I just about can guarantee (unfortunately) that many of those prescriptions for opioids most likely are for veterans and active-duty military (but I could be wrong). I just wanted to make a note of that and hope you include this comment on your post. Also, thank you Charlie for mentioning the hospitals and such in Tennessee – that makes a lot of sense too! Love this blog! – Tommy 🙂


  4. Dr burson’ I know my comment has nothing to do with your post but I am excited to tell you:

    I FINALLY got to talk to dr Levitch in Memphis this last Monday!

    He had fired the two office staff workers bc he was informed by other patients that had been discharged! The mother and son duo were fired in march.

    I told him I had to know for closure for myself on what happened – did he or did he not discharge/ abandon me
    May 30th 2013,

    And I was right 🙂 HE had NO CLUE’

    I explained to him that his staff wouldn’t take my calls, my drs calls, wouldnt let me talk to him in any form or fashion, wouldnt release my records, waited 30 days to give me a forged discharge letter….they left me to die!

    Again- he had no clue! I told him 23 patients were discharged with me and he didn’t know it. Some were on methadone and Xanax and me on subutex- and that people could be dead now from his staffs behavior and he will never know it!

    He said, my God, there is no telling what all they did. This is terrible. But we both agreed karma would get them, and I know God will.

    He apologized, I was crying tears of joy’
    I felt and said all along he didn’t do it- but there was still that nagging 20% doubt!

    He said, honey that is not my signature on this discharge letter! I said I thought it was stamped and he said no a stamp would look like my signature! Janice (his office manager at time) FORGED it! He was shocked!

    I told him it was no need for an apology- it wasn’t his fault. But I thought it would be a great idea to keep a closer eye on his staff, and to also be more available to his patients in case this ever happens again. He agreed.

    I told him I didn’t want to come back to him for treatment, and he asked my dr now, and when I said dr farmer- he said honey you are with the best! I replied I know 🙂

    He thanked me for not suing him, after i i explained to him several drs were willing to go to court on my behalf due to clear negligence/abandonment, and lawyers were calling it a dream case!
    and I am so glad that what I believed all along was the truth- and that I did not sue a 70 year old dr who is in bad health himself! So glad!

    I told him I lost 30 lbs quickly in withdrawal when this occurred and that a dr in North Carolina via blog is the only one who gave me hope in my most desperate hour’ I turned him
    Onto your blog, and I just wanted to thank you again!

    I hugged him and told him I’d never see him again, but this goodbye was much better than a unexpected letter! We laughed, he thanked me for my courage in meeting and telling him about this, and I left.

    You didn’t have to respond to my cry for help last may- but you did’ and you made a difference – thank you’

    I am so glad to finally have closure on this situation! And just wanted you to know the true outcome 🙂

    It’s a SCARY one for sure! But a true one!

    God bless!


  5. Posted by steve minnick on October 16, 2014 at 11:17 pm

    First of all, I’m about a month behind you here; I just ran across your blog. I can’t say enough praise about you Doc so I’ll just say THANKS A BUNCH for your keen insite & selfless dedication.
    I was recently kicked off a mmt program after 30yrs. I had a perfect record; no dirties ever, & no other discrepencies of any kind. I had even made a habit of being most congenial and pleasant with staff, which is’nt too far off base for me, but mainly because of some staff member’s hair trigger reactions to some situations. Well one day I inadvertanly hurt my consulars feelings. In consuling, we were going over my treatment plan and I mentioned I was having a hard time not eating a particular food item. He perceded to treat me like I was some kind of idiot; ” like did;nt I know I had to resist that type of food”?, & really going all out at being nasty about it. { I should mention his attitude the past couple of years has been very disrespectful.} I asked him why he was giving me such a hard time about it. He then asks me if I was satisfied with him as my consular.[DUH] I sayed ”frankly no”. He says,”no problem, I’ve had 3 other people leave me this month 1 more’s no biggey, and he sincerely acted like that did’nt bother him. It was 2 or 3 days later I get called to bring back in my take homes to be checked. So I go in and instead of calling me back to the dosing window, the director takes my doses[actually 1 dose] from me in the lobby & then precedes wherever with it. Then comes back to me over an hour later saying it was short. I was floored, I could’nt believe she would stupe so low. So Doc if you have any ideas or anyone knows of a lawyer for this situation, I’ll be here. Also if I can be of any help,Dr, just hollar. [ p.s.can’t wait to get your book.


    • The behavior you describe is appalling. I’d recommend starting with writing a grievance for both of these events.
      Your counselor (ex-counselor by now?) could benefit from going to trainings on Motivational Enhancement and Cognitive Behavioral counseling techniques. Sounds like he may be poorly trained.
      The program director usually doesn’t handle a take home recall, unless he/she is also has medical training. I find that odd. At all the programs I’ve worked at, the dosing nurses inspect the take home bottles that are recalled.


      • Posted by stephen minnick on October 20, 2014 at 6:52 pm

        Thanks for your reply. I suppose my biggest obstacle is it’s taken me several month’s trying to gather as much info with this situation. It’s been a delight running across your blog; very informing. My contact in the state [ky] office has listened, but has never called back, even after me calling him back. He referred to my clinic director by her first name, so I suspect that says a lot. I ran across an older client’s rights book [4yrs] last nite, that states all clients can expect due process if administratively detoxed. This was not so with me So it seems like my best bet is to sue, especially seeing as they will probably be punitive at any juncture along the way if I was allowed back. Thanks Steve.

  6. Posted by Crystal Powell on June 7, 2016 at 2:01 am

    I have 2 herniated discs and a cyst growing bigger on my spine. I live in va. And I was getting Vicodin 5/325 which wasn’t helping my pain at all. I asked for something stronger and my doctor cut me off saying I need a pain clinic. I also have fibromyalgia and sacatica. And severe pain in my neck and back. I stay in constant pain 24/7 no dr. Seems to want to help me. They say because I’m only 35 what does that have to do with anything. I need help with my pain can someone please tell me something that can help me.


    • I’m sorry to hear of your situation. If you don’t have addiction, probably not much I can say to help.
      However, I always say it doesn’t hurt to get a second opinion, particularly if it’s something out of the ordinary, like a cyst on the spine. Maybe see a neurosurgeon?


  7. Posted by Brent on June 13, 2017 at 12:15 pm

    Jana I have no one else to turn to for help and I really need your advice even if you don’t repl right away please email me or comment back here


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