The August online issue of the British Medical Journal reports that the use of prescription opioids remains high in the U.S., despite public health efforts and growing awareness of risks for abuse and overdose.

Over a decade, the proportion of adults being prescribed opioid medications has changed little, but dosages have continued to rise and are especially high among patients with permanent disability, researchers report in The BMJ.

Reuters Health reports that it was surprising to study leader Molly Moore Jeffery of the Mayo Clinic in Rochester, Minnesota. “You expect to see them using more, but it was bigger than I expected,” she said.

Also concerning were the number of patients with prescriptions for both opioids and benzodiazepines, because the combination can raise the risk of death, Jeffery said.

The U.S. has the highest per capita rate of opioid use in the world – nearly double that of second-ranked Germany and seven times higher than the UK, the researchers note. On average, 40 people die in the U.S. daily from prescription opioid overdoses, a four-fold increase since 1999, they add.

Jeffery’s team analyzed a national database of medical and pharmacy claims to examine trends in opioid use among 48 million people with health insurance between 2007 and 2016. They included working-age adults with commercial insurance, as well as Medicare beneficiaries eligible for coverage either because they were over age 65 or younger but disabled.

Overall, 14 percent of commercially insured patients and 26 percent of older Medicare beneficiaries used opioids during the study period. The rate was 52 percent among disabled Medicare beneficiaries.

To allow comparisons between different opioid medications, the researchers converted all prescription doses into so-called milligram morphine equivalents (MME).

Like other recent studies, this one showed that opioid use and average dose leveled off after peaking in 2012-2013. But the MME dose in all groups of patients was still higher in 2016 than it was in 2007.

“All reports are showing that opioid prescribing still occurs too frequently and (is) far higher than in the 1990s in the U.S.,” said Dr. John Mafi of the David Geffen School of Medicine at the University of California, Los Angeles, who wasn’t involved in the study.

“This is a cause for alarm and we need rapid and effective policy changes to decrease overprescribing and reduce opioid-related deaths. Specifically, we need to improve access and coverage of evidence-based non-opioid pain alternatives, such as topical non-steroidal anti-inflammatory medications for acute musculoskeletal pain or physical therapy for chronic low back pain.”