Alabamians received more prescribed opioids per person than residents of any other state in 2018, according to data recently released by the U.S. Centers for Disease Control and Prevention.

Patients in Alabama received 97.5 prescriptions per 100 people. The national average was 51.4 prescriptions per 100 people, according to the most recent surveillance data.

Overall, prescription rates have fallen since 2012. That year, residents of Alabama received 143 prescriptions per 100 people, enough to supply every person in the state with one and a half bottles of painkillers.

“The Medical Association is keenly aware of the high number of opioid prescriptions written in Alabama and has undertaken several initiatives to address the problem,” said Mark Jackson, executive director of the Medical Association of the State of Alabama. “Beginning in 2009 the Medical Association has put on education courses for physicians, nurse practitioners, and physician assistants to make them aware of the dangers and addictive nature of opioids. This past year, we had over 550 providers attend those courses and we have had 5,000 attend since 2009.”

Other states with high rates of opioid prescriptions included Arkansas (93.5), Tennessee (81.8) and Kentucky (79.5). The District of Columbia had the lowest rate at 25 prescriptions per 100 people, roughly one quarter of Alabama’s rate, according to the CDC.

Opioids are commonly prescribed to control pain, but can also be abused, which can lead to addiction and death. Drug overdose deaths in the United States have more than tripled since 1999, and the majority include opioids, a class of drugs that includes everything from prescription OxyContin and fentanyl to illicit heroin sold on the street.

Drug overdose deaths began to increase as painkiller prescriptions became more widespread, according to CDC data. In the past decade, state authorities began implementing policies to decrease the rate of prescriptions. In Alabama, new rules require doctors to check the prescription drug monitoring database before writing prescriptions for controlled substances.

Several states have enacted even stricter regulations on prescription opioids. Fifteen states imposed seven-day limits on prescriptions for acute pain, including Oklahoma, Louisiana, South Carolina and Missouri. Some states have imposed five-day limits. These limits are not intended for patients already taking opioids long-term for chronic pain.

Jackson said the medical association has pushed for several changes to decrease prescriptions, including upgrading the prescription monitoring program and educating physicians about how to reduce risks when prescribing.

“The Medical Association believes that these initiatives have proven to be effective in lowering the amount of opioid prescriptions in the state but recognizes there is still work to be done. We also believe that there are patients that are suffering from real pain related issues that need access to opioids and it is essential to find a proper balance between further restriction and continued access to medications,” Jackson said.