Over the past two decades, research has shown that rates of abuse and diversion of opioid prescription medications are increasing in the United States. “In response to the epidemic, many groups have implemented interventions to reduce opioid abuse and diversion at the local, regional, state, and federal level,” explains Richard C. Dart, MD, PhD. Such efforts include prescription-drug monitoring programs as well as the development of databases documenting histories of prescription drug use, misuse, and toxicity.
To gain a better understanding of the effect of programs on opioid abuse and diversion, Dr. Dart and colleagues had a study published in the New England Journal of Medicine that used the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS®) System and analyzed data from 2002 to 2013. Because drug abuse is illegal and often concealed by patients, the RADARS System uses an approach that measures abuse and diversion from multiple perspectives so that it can describe this hidden phenomenon as comprehensively as possible.
An In-Depth Look at Trends in Diversion
For the study, investigators used five programs from the RADARS® System to describe trends in the diversion and abuse of all products and formulations of several prescription opioid analgesics over an 11-year period. Each of the programs gathered data from drug-diversion investigators, poison centers, substance-abuse treatment centers, and college students. The six opioids included oxycodone, hydrocodone, hydromorphone, fentanyl, morphine, and tramadol.
According to the study, the number of prescriptions for opioid analgesics in the U.S. increased substantially from 2002 through 2010 but then decreased slightly from 2011 through 2013 (Figure 1). The number of opioid prescriptions trended slightly downward from 2011 through 2013, ending at 60 million prescriptions per quarter. “Importantly, data from four of the five programs from the RADARS® System showed lower opioid abuse rates since 2010,” Dr. Dart says. “This is remarkable considering that each of these groups operates independently.”
Mortality: Heroin Use vs Rx Opioids
The study also compared the mortality rates associated with heroin use with that of prescription opioid drugs. Using data from the National Poison Data System, the rate of opioid-related deaths increased from 2002 to 2006, but then plateaued from 2006 through 2008 and decreased slightly from 2009 through 2013. Conversely, the rate of heroin-related deaths remained flat from 2002 to 2010, but then increased each subsequent year through 2013 (Figure 2).
Factors in Opioid Abuse
The observed trends in opioid abuse could be related to several factors, according to Dr. Dart. For example, he says, “the flattening rate of prescription volume since 2011 may have limited the availability of prescription opioids for abuse. This may be due to a decreased supply from prescribers that results in fewer prescriptions being written for these drugs. Demand may also be dropping because of fewer patients requesting these opioids.”
It is also possible that the programs implemented to improve opioid prescribing, reduce doctor-shopping, and limit questionable practices by pain clinics may be leading to more appropriate use of opioids. Several guidelines and educational initiatives advocate for responsible prescribing of opioids, which may decrease opportunities for patients to experiment with these drugs. Other possible factors include the following:
♦ More states are now using prescription-monitoring programs.
♦ New opioid formulations are being developed that resist tampering.
♦ Law enforcement is more actively intervening in drug abuse and diversion.
♦ Physicians are reducing the number of prescriptions for opioid analgesics.
“The link between abusing prescription opioids and using high-purity, low-cost heroin is important to consider,” Dr. Dart says. “As efforts have been made to reduce the potential abuse of opioids, patients may be more likely to experiment with alternative drugs like heroin. A better understanding of the relation between prescription opioid abuse and heroin use is crucial for developing public health policy and to help guide prevention and treatment initiatives.”
Continuing Fight Against Opioid Abuse
Few national data are available on trends in prescription opioid abuse and diversion since 2010, but it appears that the problem may have lessened in some environments. The availability of opioids increased greatly in the 1990s and continued through 2010, but then plateaued from 2011 through 2013. “Our results suggest that we’re making some progress in combating prescription opioid abuse, but we still have a long way to go,” Dr. Dart says. “We need to be vigilant about opioid abuse and keep a watchful eye on potential alternative drugs that are being abused. We also need to find out if public perceptions on opioids are changing. As this information becomes available, changes in public health policies and strategies may become necessary to further reduce the burden of opioid abuse and diversion.”
Readings & Resources (click to view)
Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015; 372:241-248. Available at: http://www.nejm.org/doi/full/10.1056/NEJMsa1406143#t=article.
Franklin GM, Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D. Bending the prescription opioid dosing and mortality curves: impact of the Washington State opioid dosing guideline. Am J Ind Med. 2012;55:325-331.
Surratt HL, O’Grady C, Kurtz SP, et al. Reductions in prescription opioid diversion following recent legislative interventions in Florida. Pharmacoepidemiol Drug Saf. 2014;23:314-320.
Dart RC. Monitoring risk: post marketing surveillance and signal detection. Drug Alcohol Depend. 2009;105:Suppl 1:S26-S32.
Dart RC, Bartelson BB, Adams EH. Nonmedical use of tapentadol immediate release by college students. Clin J Pain. 2014;30:685-692.