The opioid epidemic is still shaking America, with 115 Americans dying every day from an opioid overdose. Many receive opioids legally through a prescription from their physician. In the last two decades, opioid prescribing has grown dramatically, but the prevalence of pain has not grown at the same rate. This raises concerns that physicians have not been appropriately prescribing opioid pain killers.

A study by associate professor of health care policy Nicole Maestas, PhD, Tisamarie Sherry, MD, PhD, an associate physician policy researcher at the RAND Corporation, and Adrienne Sabety, a doctoral candidate in health policy at Harvard University, published in Annals of Internal Medicine investigates the medical diagnoses that are associated with opioid prescriptions in ambulatory care. They found that opioids were prescribed in almost 809 million outpatient visits between 2006 and 2015. Of these appointments, the leading diagnosis associated with opioid prescriptions was musculoskeletal conditions. But, surprisingly, 28.5% of visits that resulted in an opioid prescription had no record of pain or conditions that commonly cause pain, and instead cited conditions such as high blood pressure or high cholesterol. Opioid dependence cannot explain the discrepancy, since it accounted for only 2.2% of the visits without pain documentation. Lack of pain documentation was even more common in visits where an existing opioid prescription was being continued (30.5%) than when being newly prescribed (22.7%).

The medical community agrees that opioids need to be prescribed more responsibly, but this study uncovers a major challenge in doing this—the clinical rationale for prescribing opioids is often weak and not clearly documented. This makes it impossible to assess which opioid prescriptions might be appropriate and which are not, so that feedback can be given to providers about common errors. “Our findings point to a need for more robust requirements to document clinical rationale,” says Maestas, “but we also must enable physicians to comply with them without creating undue administrative burden.”

Opioids aren’t the only area of prescribing that has been called into questions- concerns of excess prescribing of antibiotics, benzodiazepines and other medications have risen as well. However given the devastating public health consequences of the opioid epidemic, opioid prescribing behavior in particular has attracted heightened scrutiny.

This study has been highlighted by NIH director Franics S. Collins on twitter.