To Limit Antibiotic Overprescribing, Take a Page From the Opioid Epidemic

In 2012, approximately 255 million opioid prescriptions were written in the U.S. At the time, prescribers may have thought these drugs were safe and effective, but in reality, opioids were sending many patients down a spiral of abuse and addiction from which they would not recover.

While opioids can be beneficial, it seems obvious in retrospect that many of these prescriptions were unnecessary and harmful. Those of us in healthcare should have done better.

In 2024, nearly 256 million oral antibiotic prescriptions were written in the U.S. Beyond the similar prescription numbers, there are several parallels between antibiotic and opioid overuse.

What Do Antibiotic and Opioid Prescriptions Have in Common?

Most notably, like opioids, many prescriptions for antibiotics are unnecessary. By some estimates, at least 30% of antibiotic prescriptions in the U.S. are not indicated, due to being prescribed for viral infections, seasonal allergies, and other conditions for which they provide no benefit.

While antibiotics can be life-saving when used appropriately, they can be deadly when misused, particularly given their impact on antimicrobial resistance. According to one analysis, drug-resistant infections are projected to cause more deaths than cancer by 2050. Antibiotics can also cause other serious harms, including C. difficile infection, adverse drug reactions, and disruption of the microbiome.

If they can be so harmful, then why are antibiotics overprescribed? The reasons mirror those that drove inappropriate opioid prescribing years ago. In fact, physicians and dentists who are high opioid prescribers also may be more likely to overprescribe antibiotics.

What Drives Antibiotic Overprescription?

Doctors prescribe antibiotics inappropriately for a host of reasons.

One reason is a genuine desire to help sick patients. Antibiotics are often prescribed for patients with likely respiratory viral infections, despite offering no benefit. While misguided, this practice may stem from a sincere desire to help sick patients, similar to prescribing opioids for pain even when less potent treatments are preferred.

Other times, doctors are avoiding difficult conversations. Patients may request antibiotics or opioids when they are not indicated, and providers, perhaps overwhelmed with busy schedules and crowded waiting rooms, may prescribe them to avoid prolonged discussions about why these medicines are unnecessary. With opioids and antibiotics, the demands of clinical practice may steer some providers towards overprescribing to avoid conflict and save time.

In the same vein, doctors may want to avoid conflict to maintain favorable patient reviews, and prevent low satisfaction scores. As online ratings become increasingly influential, there may be significant financial and professional pressures to avoid disagreement with patients. Financial incentives related to patient satisfaction have previously been implicated in increasing opioid prescribing.

Finally, some clinicians may underestimate the harms of inappropriate prescriptions. Long-acting opioids were once marketed as safer and less addictive than alternatives, and poor understanding of the harms of these drugs led physicians to prescribe them widely. Inadequate awareness of the dangers of antibiotics may similarly underlie antibiotic overprescribing.

Since antibiotic overprescription is so common and its causes are so varied, reducing unnecessary use can seem impossible. But a recent push to reverse the opioid epidemic suggests that progress is attainable: by 2023 the number of opioid prescriptions in the U.S. had fallen to about 125 million, roughly half the rate of a decade earlier. To combat antibiotic overuse, we can use some of the same strategies.

Strategies to Reduce Overprescribing

The following strategies may help reduce inappropriate prescribing:

• Prescription drug monitoring programs. Statewide programs to monitor opioid prescriptions are credited with curbing prescribing rates. While these programs are intended to provide clinicians with patients’ medication histories, they can also be used to identify outlier over-prescribers, and artificial intelligence can be used to quickly analyze large prescribing datasets and recognize patterns of overuse.
• Prescriber education and feedback. Institutional programs focused on individual prescriber education and feedback can reduce both opioid and antibiotic prescribing. Since 2019, the Centers for Medicare & Medicaid Services has required hospitals to implement inpatient antimicrobial stewardship programs, which monitor antibiotic prescription and promote appropriate use. Similar requirements do not yet exist for outpatient settings, where most antibiotic prescribing occurs, and expanding outpatient stewardship efforts could substantially reduce overuse.
• Published treatment guidelines. In 2016, the CDC released evidence-based guidelines for the use of opioids for chronic pain, which helped reduce opioid use by encouraging lower doses, shorter durations, and non-opioid alternatives. While guidelines for antibiotic prescribing do exist, more definitive recommendations for avoiding antibiotics in patients with a low likelihood of bacterial infection could help promote more judicious prescribing.
• Public education campaigns. Campaigns to educate the public on the harms of antibiotic misuse would reduce the demand for these medicines, just as growing awareness of the dangers of opioids has prompted some patients to ask for alternative options for pain relief.

What Should We Do Next?

These strategies aim to promote education among patients and providers and convey that antibiotics are powerful medicines that can be effective when used correctly, but dangerous when misused. If this message resonates, then it will become clear that the current state of antibiotic overuse in the U.S. is no longer acceptable.

Looking back at opioid prescribing 15 years ago, it now seems obvious that regulators, institutions, and clinicians could have done more to limit excessive opioid prescriptions. Fifteen years from now, when people look back at antibiotic prescribing today, what will they say about us?

Timothy Sullivan, MD, is an associate professor in the Division of Infectious Diseases at the Icahn School of Medicine at Mount Sinai in New York City.

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