Prescribing Associated with High-Risk Opioid Exposures Among Non-cancer Chronic Users of Opioid Analgesics: a Social Network Analysis

  • Keiki HinamiEmail author
  • Michael J. Ray
  • Kruti Doshi
  • Maria Torres
  • Steven Aks
  • John J. Shannon
  • William E. Trick



The continued rise in fatalities from opioid analgesics despite a steady decline in the number of individual prescriptions directing ≥ 90 morphine milligram equivalents (MME)/day may be explained by patient exposures to redundant prescriptions from multiple prescribers.


We evaluated prescribers’ specialty and social network characteristics associated with high-risk opioid exposures resulting from single-prescriber high-daily dose prescriptions or multi-prescriber discoordination.


Retrospective cohort study.


A cohort of prescribers with opioid analgesic prescription claims for non-cancer chronic opioid users in an Illinois Medicaid managed care program in 2015–2016.

Main Measures

Per prescriber rates of single-prescriber high-daily-dose prescriptions or multi-prescriber discoordination.

Key Results

For 2280 beneficiaries, 36,798 opioid prescription claims were submitted by 3532 prescribers. Compared to 3% of prescriptions (involving 6% of prescribers and 7% of beneficiaries) that directed ≥ 90 MME/day, discoordination accounted for a greater share of high-risk exposures—13% of prescriptions (involving 23% of prescribers and 24% of beneficiaries). The following specialties were at highest risk of discoordinated prescribing compared to internal medicine: dental (incident rate ratio (95% confidence interval) 5.9 (4.6, 7.5)), emergency medicine (4.7 (3.8, 5.8)), and surgical subspecialties (4.2 (3.0, 5.8)). Social network analysis identified 2 small interconnected prescriber communities of high-volume pain management specialists, and 3 sparsely connected groups of predominantly low-volume primary care or emergency medicine clinicians. Using multivariate models, we found that the sparsely connected sociometric positions were a risk factor for high-risk exposures.


Low-volume prescribers in the social network’s periphery were at greater risk of intended or discoordinated prescribing than interconnected high-volume prescribers. Interventions addressing discoordination among low-volume opioid prescribers in non-integrated practices should be a priority. Demands for enhanced functionality and integration of Prescription Drug Monitoring Programs or referrals to specialized multidisciplinary pain management centers are potential policy implications.


opioid analgesic prescribing social network analysis care discoordination epidemiology harm reduction Medicaid 


Additional Contributions

Momin M. Malik, PhD, provided advice on data visualization.


The Illinois Department of Healthcare and Family Services approved the research use of CountyCare data. Cook County Health supported this project.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5114_MOESM1_ESM.docx (767 kb)
ESM 1 (DOCX 767 kb)


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Keiki Hinami
    • 1
    • 2
    • 3
    Email author
  • Michael J. Ray
    • 1
    • 2
  • Kruti Doshi
    • 1
    • 2
  • Maria Torres
    • 4
  • Steven Aks
    • 5
  • John J. Shannon
    • 1
  • William E. Trick
    • 1
    • 2
  1. 1.Department of Medicine Cook County HealthChicagoUSA
  2. 2.Collaborative Research UnitCook County Health ChicagoUSA
  3. 3.Section of Preventive MedicineCook County HealthChicagoUSA
  4. 4.Department of Anesthesiology, Division of Pain ManagementCook County Health ChicagoUSA
  5. 5.Department of Emergency Medicine, Division of Medical ToxicologyCook County Health ChicagoUSA

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