Trends in Prescription Opioid Drug Abuse, 2002-2013

Tuesday, October 27, 2015
Author: 

Richard L. Wynn, PhD

After a steady rise, trends show a decline starting in 2011. There has been an epidemic of prescription opioid abuse over the last two decades. A 2015 New England Journal of Medicine study authored by drug abuse experts from multiple substance abuse centers revealed a substantial increase in the rates of opioid diversion and abuse from 2002 to 2011. But then the rates flattened or decreased from 2011 through 2013. The rate of opioid-related deaths rose and fell in a similar pattern.

Could these findings suggest that the United States may be making progress in controlling the abuse of prescription opioid analgesics?

Opioid abuse study

Dart, R.C., et al. “Trends in opioid analgesic abuse and mortality in the United States.” New Eng J Med 2015; 372 (3): 241-248.

The past two decades have seen a prescription opioid abuse epidemic, leading to the implementation of hundreds of local, regional, state and federal interventions to address the problem. Chief among them are the creation of prescription drug monitoring programs (PDMPs) in the individual states. As of the date of this published study in the New England Journal of Medicine, there have been 49 states which have enacted such drug monitoring programs.

The object of the study was to describe the trends in the diversion and abuse of prescription opioid analgesics. The authors used the Research Abuse, Diversion, and Addiction-Related Surveillance System (RADARS) to describe the abuse of prescription opioid analgesics using data from January 2002 through the end of 2013.

Under the RADARS system, the authors examined five different programs useful for data collection on prescription opioid abuse:

  1. Drug Diversion Program – This records the drugs involved in cases opened by law enforcement agencies investigating prescription drug diversion
  2. Opioid Treatment Program – This queries new patients entering substance abuse treatment about medications they have abused in the previous 30 days
  3. Survey of Key Informants’ Patients Program – Similar to the Opioid Treatment Program, this also queries patients entering substance abuse treatment programs about medications they have abused in the past 30 days
  4. Poison Center Program – This records the substances involved in poison center cases classified as intentional abuse
  5. College Survey Program – This is a Web-based survey in which self-identified college students report their nonmedical use of prescription drug during the past 30 days

The opioid analgesics that were included from the data collected were all marketed products and formulations, including brands and generics of six prescription pain relievers:

  • Hydrocodone
  • Hydromorphone
  • Oxycodone
  • Fentanyl
  • Morphine
  • Tramadol

In addition, the authors collected data on reported heroin use in the previous 30 days in three of the surveillance programs (numbers 2, 3 and 5 above). From each RADARS surveillance program, the term “event” was used to quantitate the rate of prescription drug abuse. An “event” was defined as a case which involved opioid analgesic mentions. For analyses, the authors plotted the quarterly event rate by dividing the total number of events for the prescription opioid group for each of the five surveillance programs by the population of the jurisdiction or coverage area of the program.

Results

At the beginning of 2006, there were 47 million prescriptions dispensed per quarter in the United States for opioid pain relievers included in this study. That volume of pain relievers peaked in the fourth quarter of 2012 at 62 million prescriptions dispensed. Then, except for one quarter, the number of prescriptions trended downward from 2011 through 2013, ending at 60 million prescriptions per calendar quarter for study medications.

The results according to each of the five programs within RADARS were as follows:

  1. Drug Diversion Program – The calculated quarterly event rate for prescription opioids increased from 1.5 per 100,000 population in 2002 to 2.9 in 2012. It then decreased to 2.5 by the end of 2013
  2. Opioid Treatment Program – The rate of prescription opioid abuse increased from 1.6 per 100,000 population in 2005 to 7.3 in 2012. It then decreased to 3.5 by the end of 2013
  3. Survey of Key Informants’ Patients Program – The rate of prescription opioid abuse increased from 1.5 per 100,000 population in 2008 to 3.8 in 2011. It then decreased to 2.8 by the end of 2013
  4. Poison Center Program – The quarterly abuse rate for opioid analgesics increased from 0.20 per 100,000 population in 2003 to 0.56 in 2010. It then decreased to 0.35 by the end of 2013
  5. The College Survey Program – The rate of nonmedical use increased from 0.14 per 100,000 population in 2008 to 0.35 by the end of 2013. According to this program, there was a steady increase in the nonmedical use of the opioids

Heroin use

Data from the National Poison Data System reported that the rate of heroin-related cases started increasing in 2006 and appeared to accelerate in late 2010. While heroin use increased, cases involving the extended-release formulation of oxycodone decreased substantially after the approval of an abuse-deterrent formulation.

According to the Opioid Treatment Program, the rate of heroin use was flat for the period of 2005 through 2013, and the rate of abuse of reformulated extended-release oxycodone decreased after 2010.

The Survey of Key Informants’ Patients Program reported that the rate of heroin use increased in 2011 and remained at that higher level, while the rate of abuse of reformulated extended-release oxycodone decreased.

The College Survey Program says the rate of heroin use was volatile but generally flat during the period of the study, while the rate of abuse of the reformulated extended-release oxycodone edged upward.   

Opioid-related deaths

From 2002 to 2006, the rate of opioid-related deaths increased, and then plateaued through 2008. After that, deaths decreased from 2009 through 2013. The rate of heroin-related deaths was flat from 2002 to 2010, but then increased each subsequent year through 2013.

Points of discussion by the authors

The results showed a parallel relationship between the prescribing of opioid analgesics and the diversion and abuse of these drugs. The increases in drug availability and abuse was reflected in the numbers of deaths caused by prescription opioids, which increased for 11 consecutive years reaching a peak in 2010 with over 16,000 deaths nationally. The authors indicated that few data regarding national trends in prescription drug abuse and diversion since 2010 have been published.

However, some emerging data show a trend in a reduction in prescription opioid abuse. Some factors cited are:

  • Local and state efforts, such as Florida’s legislative interventions, have resulted in a reduction in the numbers of prescription opioid abuse events
  • A flattening of the numbers of opioid prescriptions written and filled since 2011
  • Introduction of new opioid analgesic formulations that resist tampering
  • Programs implemented by local, state and federal governments to improve opioid prescribing resulting in reduced doctor-shopping, limiting questionable practices by pain clinics, and improving and optimizing the use of opioid analgesics in the United States
  • Implementation of PDMPs in most states

The tragic switching by individuals from the abuse of prescription opioids to the use of high-purity, low-cost heroin was also addressed. Unfortunately, heroin use by patients in substance abuse programs nearly doubled after the market launch of the abuse-deterrent OxyContin. However, in terms of prescription drug abuse, the study results suggest that the U.S. is making progress in combating the abuse of prescription opioid analgesics.

The centers participating in the study were Rocky Mountain Poison and Drug Center, Denver; Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, Florida; Department of Psychiatry, Washington University, School of Medicine, St Louis; American Association for the Treatment of Opioid Dependence, New York. 

Richard L. Wynn, PhD, is Professor of Pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.

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