Using data from a large, national private insurance provider including 134 million opioid prescription claims, this study characterized prescribing patterns from 2003-2017. In 2017, the top 1% of opioid providers prescribed 27% of all opioid prescriptions and accounted for nearly half (49%) of all opioid doses. A large proportion of prescriptions written by high prescribing opioid providers exceeded guidelines for recommended dosing levels and length. In contrast, the majority of prescriptions for the bottom 99% of prescribers met prescribing guidelines. The authors conclude that broad interventions focused on enforcing prescribing thresholds are likely be ineffective since most providers are prescribing within guidelines. Instead, interventions to reduce inappropriate prescribing should be tailored towards the top 1% of opioid prescribers and their patients, and should focus on improving the supportive management of patients with complex pain and addressing associated comorbidities.