Long-Term Opioid Prescribing Drops 24% Over Eight Years, But Gabapentinoid Co-Prescribing Surges

The number of Americans receiving long-term opioid therapy for chronic pain has fallen by nearly a quarter over the past eight years, according to research published this month in the Journal of the American Medical Association. The findings, based on analysis of over 16 million prescription episodes, document a 24.3 percent reduction in patients on extended opioid regimens between 2015 and 2023, even as the population receiving these medications has grown significantly older and more reliant on Medicare coverage.

Researchers from the University of Michigan School of Public Health examined national prescription data from the IQVIA Longitudinal Prescription Database, which captures the majority of retail pharmacy dispensing in the United States. Their analysis reveals that long-term opioid therapy episodes, defined as continuous opioid use for 90 days or more, declined from 5.6 million in 2015 to 4.2 million in 2023. Despite this substantial reduction, the study raises new concerns about emerging patterns of polypharmacy, particularly the sharp increase in co-prescribing opioids with gabapentinoids.

Shifting Demographics of Chronic Pain Treatment

The patient population receiving long-term opioids has undergone a marked demographic transformation during the study period. The mean age of these patients increased from 52.5 years to 60.5 years, reflecting both an aging cohort of existing patients and potentially more restrictive prescribing to younger individuals. By 2023, Medicare had replaced commercial insurance as the primary payer for long-term opioid therapy, a shift with significant implications for healthcare policy and medication safety monitoring.

Women constituted the majority of patients on extended opioid regimens throughout the study period, a pattern consistent with higher prevalence of chronic pain conditions among female populations. By 2023, patients receiving long-term opioid therapy represented 11.5 percent of all individuals receiving any opioid prescriptions, down from previous years but still comprising a substantial population with complex medical needs.

The Rise of Gabapentinoid Co-Prescribing

While the overall volume of long-term opioid prescribing has declined, the study documents a concerning trend in combination therapy. Co-prescribing of opioids with gabapentinoids, a class of medications including gabapentin and pregabalin commonly used for neuropathic pain and increasingly for various off-label indications, rose from 47 percent to 58.7 percent over the same period. This represents a significant increase in the proportion of chronic pain patients receiving both medication classes simultaneously.

The safety implications of this trend warrant careful attention. Both opioids and gabapentinoids carry risks of respiratory depression, and concurrent use may potentiate these effects. The U.S. Food and Drug Administration issued warnings in recent years about the dangers of combining these medication classes, particularly for patients with underlying respiratory conditions or those also taking benzodiazepines. The study authors emphasize that rising polypharmacy in an aging population, which is more susceptible to adverse drug events and drug interactions, requires enhanced monitoring and clinical vigilance.

Declining Benzodiazepine Co-Use, Rising Stimulant Combinations

The research reveals divergent trends in other categories of concurrent prescribing. Co-prescribing with benzodiazepines, long recognized as a particularly dangerous combination due to enhanced overdose risk, declined during the study period. This reduction likely reflects increased awareness among prescribers and the implementation of prescription drug monitoring programs that flag dangerous combinations.

Conversely, the study documents a slight increase in stimulant use alongside opioids, a pattern that may reflect growing recognition of attention deficit disorders in adults, efforts to counter opioid-induced sedation, or potentially concerning trends in stimulant prescribing more broadly. The overall proportion of long-term opioid patients receiving concurrent medications of any type increased from 68.5 percent in 2015 to 72.3 percent in 2023, highlighting the complexity of modern chronic pain management.

Declining Dosages Amid Continued Concerns

The average daily dose of opioids, measured in morphine milligram equivalents, decreased over the study period. This reduction aligns with clinical guideline recommendations that emphasize using the lowest effective dose and reflects broader shifts in prescribing culture following the Centers for Disease Control and Prevention's 2016 opioid prescribing guidelines.

However, the study authors note that millions of Americans continue to receive long-term opioid therapy despite well-documented risks including misuse, dependence, and overdose. The 4.2 million patients on extended regimens in 2023 represent a substantial population requiring ongoing clinical oversight, particularly given the aging demographic and increased prevalence of polypharmacy.

Context of Opioid Stewardship Efforts

The documented decline in long-term opioid prescribing occurs against the backdrop of intensive regulatory and educational efforts to curb inappropriate use. The CDC's 2016 prescribing guidelines, updated in 2022, recommended more conservative approaches to chronic pain treatment. State-level prescription drug monitoring programs have expanded dramatically, providing prescribers with real-time data on patient medication histories. Medical education initiatives have emphasized non-opioid alternatives and risk assessment strategies.

These efforts have contributed to a broader reduction in opioid prescribing across all categories, not merely long-term therapy. However, the study raises questions about whether reduced opioid prescribing has been accompanied by adequate investment in alternative pain management strategies, or whether some patients may have experienced reduced access to effective treatment without corresponding gains in functional outcomes.

Limitations and Data Gaps

The study has several important limitations that temper interpretation of its findings. The analysis relies on retail pharmacy dispensing data and does not capture prescriptions from Veterans Affairs pharmacies, which serve a substantial population of veterans with chronic pain and service-related disabilities. The absence of detailed clinical data, including prescribing indications, comorbidities, and prescriber characteristics, limits the ability to assess the appropriateness of specific prescribing patterns.

The study cannot determine whether reduced long-term opioid prescribing represents appropriate de-escalation of previously excessive regimens, transitions to alternative treatments, or potentially undertreatment of chronic pain in some patient populations. Similarly, the rise in gabapentinoid co-prescribing may reflect appropriate adjunctive therapy for neuropathic pain or potentially problematic substitution of one medication class for another without addressing underlying pain conditions.

Implications for Clinical Practice and Policy

The findings carry significant implications for healthcare providers, policymakers, and patients navigating chronic pain treatment. For clinicians, the data underscore the importance of careful medication review and monitoring for patients on long-term opioid therapy, particularly those also receiving gabapentinoids or other central nervous system depressants. The aging demographic of the long-term opioid population highlights the need for enhanced attention to geriatric prescribing considerations, including fall risk, cognitive effects, and drug interactions.

For policymakers, the study raises questions about the adequacy of safety monitoring systems for the growing population receiving combination therapies. While prescription drug monitoring programs have expanded, their effectiveness in identifying dangerous polypharmacy patterns varies across states. The shift toward Medicare as the primary payer suggests that federal programs will bear increasing responsibility for ensuring safe prescribing practices among older adults.

The research also contributes to ongoing debates about the balance between reducing opioid-related harms and ensuring access to effective pain management. While the decline in long-term prescribing likely reflects appropriate response to previous overprescribing, advocates for chronic pain patients have raised concerns that pendulum swings may leave some individuals without adequate relief. The rise in gabapentinoid prescribing may represent one response to this tension, though the long-term safety and efficacy of these medications for chronic pain remains incompletely understood.

Looking Forward

As the nation continues grappling with the aftermath of the prescription opioid crisis and the ongoing challenge of illicit synthetic opioids, the JAMA findings offer both encouragement and caution. The substantial reduction in long-term opioid prescribing demonstrates that intensive public health interventions can shift clinical practice patterns. However, the concurrent rise in polypharmacy, particularly with medications carrying their own risks, reminds that medication-focused approaches to chronic pain remain imperfect solutions to complex biopsychosocial conditions.

The study authors call for continued vigilance in monitoring prescribing trends and their clinical consequences. With millions of Americans still receiving long-term opioid therapy and an aging population facing increasing chronic pain burden, the need for balanced, evidence-based approaches to pain management remains as urgent as ever. The research provides a foundation for understanding how prescribing has changed; the challenge now lies in ensuring those changes produce genuine improvements in patient outcomes while minimizing harm.