Prescription Opioid Abuse Waning

A study examining opioid abuse trends between 2002 and 2013 showed that prescriptions for opioid analgesics, rates of opioid diversion and abuse, and opioid-related deaths increased significantly from 2002 through 2010.

However, all three measures flattened or decreased from 2011 through 2013.

“There’s been so many efforts in the United States to curb prescription opioid abuse that eventually something’s going to work,” lead author Richard Dart, MD, PhD, director of the Rocky Mountain Poison and Drug Center, of the Denver Health and Hospital Authority, Colorado said.

“We don’t know why this happened exactly, but it seems to correlate well with other sources,” said Dr Dart, adding that “it’s not really going down, but at least the slope of that line is changing dramatically so that it’s no longer going up.”

The study was published in the January 15 issue of the New England Journal of Medicine.

Too Many Deaths
A total of 16,651 deaths in the United States were attributed to prescription opioids in 2010, report the investigators.

“In response, hundreds of federal, state, and local interventions have been implemented. For example, 49 states have enacted legislation to create prescription-drug monitoring programs,” they write.

However, “in about 2011, we noticed that the slope in prescription drug abuse in all of our programs that had been increasing for at least a decade started to flatten. We watched and thought there might be some explanation, but then the rate started to go down,” said Dr Dart.

“We wanted to give it a couple of years to be sure that the observation was right and that it wasn’t just one or two quarters,” he added.

The investigators examined 2002-2013 data from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System. To determine trends, they assessed five RADARS programs. These included the following:
· The Poison Center Program
· The Drug Diversion Program
· The Opioid Treatment Program
· The Survey of Key Informants’ Patients (SKIP) Program
· The College Survey Program

“Because drug abuse is an illegal activity that is often concealed from authorities, the RADARS System uses a ‘mosaic’ approach, measuring abuse and diversion from multiple perspectives,” the researchers write.

The following six prescription opioid analgesics were included in this search: hydrocodone, hydromorphone, fentanyl, morphine, oxycodone, and tramadol. In addition, data on heroin use in the past 30 days were included from the RADARS programs that asked about the substance.

Downward Trend
Results showed that 47 million opioid analgesics were prescribed per quarter starting in 2006; this number peaked at 62 million in the fourth quarter of 2012.

“Except for this one quarter, the number of prescriptions trended slightly downward from 2011 through 2013, ending at 60 million prescriptions per calendar quarter for study medications,” report the investigators.

The rate of diversion or abuse increased before mid-2010 and then trended downward in all of the RADARS programs except one.

The intentional abuse rate for opioid analgesics was 0.20 per 100,000 population in 2003 vs 0.56 in 2010 vs 0.35 at the end of 2013 in the Poison Center Program. For the Opioid Treatment Program, the rates of abuse were 1.6 in 2005, 7.3 in 2010, and 3.5 in 2013.

The rates were 1.5 in 2008, 3.8 in 2011, and 2.8 in 2013 for the SKIP Program and 1.5 in 2002, 2.9 in 2012, and 2.5 in 2013 for the Drug Diversion Program.

The College Survey Program was the only one to show an increase in nonmedical use of opioids, with 0.14 per 100,000 population in 2008 and 0.35 per 100,000 by the end of 2013.

Heroin use was a problem across most of the programs.

The Poison Center Program showed an increase in heroin-related cases in 2006, with accelerating increases in late 2010. At the same time, extended-released (ER) oxycodone-related cases “decreased substantially after the introduction of an abuse-deterrent formulation.”

The SKIP Program also showed an increased rate of heroin use, starting in 2011 and remaining high, and a decrease in reformulated ER oxycodone.

On the other hand, the College Survey Program showed that heroin use was “volatile but generally flat” and that there was an increase in abuse of reformulated ER oxycodone.

Although the Opioid Treatment Program also showed a flat rate for heroin use from 2005 through 2013, it showed a decrease in ER oxycodone after 2010.

Data from the National Poison Data System showed that from 2002 to 2006, the rate of opioid-related deaths increased before plateauing from 2006 through 2008 and then decreased from 2009 through 2013.

More troubling, the rate of heroin-related deaths was flat from 2002 to 2010, but that rate has increased every year since then.

Policy Changes Needed
“Few data regarding national trends in prescription-drug abuse and diversion since 2010 have been published. However, emerging data suggest that abuse of prescription opioids may have lessened in some environments,” write the investigators.

“If our observation…is confirmed, changes in public health policy strategy will be needed,” they add.

Dr Dart noted that “there are literally hundreds of interventions” that have been performed in the United States during the last 15 years to fight prescription drug abuse.

These include abuse deterrent formulations, increased law enforcement, rescheduling of some drugs by the US Food and Drug Administration to more tightly control them, treatment guidelines for prescribers, and the establishment of prescription monitoring plans in most states, he said.

“The question now for public policy is, which one worked? Because if you could figure that out, then you could apply that nationwide and have a much bigger effect.”

He added that there is currently a delicate balance for clinicians.

“You want to treat the patients who have real pain with a drug that really works, like an opioid. But you need to somehow screen out those who are not real patients at all and are just there to get drugs from you,” said Dr Dart.

“There are tools published out there on how to do that. I would just encourage people to use those because, ultimately, most of these drugs come from a doctor’s prescription. And we bear responsibility for that.”

Turning a Corner
Reached for comment, Petros Levounis, MD, vice-chair of the American Psychiatric Association’s Council on Addiction Psychiatry, said he was “delighted” by the results.

“It took a lot of work from physician groups, governmental agencies, and other organizations. Everybody chipped in to try and reverse the real disaster that was the prescription opioid epidemic. So it’s wonderful to see that we have turned the corner,” he said.

However, Dr Levounis, who is also chair of the Department of Psychiatry at Rutgers New Jersey Medical School and chief of service at University Hospital, in Newark, noted that clinicians “should not get too happy” just yet.

“The reduction in prescription opioids has gone hand in hand with the dramatic increase in heroin use,” he said.

“These people were made to be addicted to opioids. Then when the medical profession decided this was a bad idea, we reformulated oxycontin and put all these regulations in place. But the patients were already addicted, so they had to get their opioids somehow, and ended up switching to something that is pure, cheap, and easily available.”

In other words, clinicians should not let their guard down.

“It’s a moving target. I don’t want to underappreciate the hopeful results that this study communicates in terms of the plateauing and decreasing of prescription opioid abuse. But as the article very correctly points out, we closed one door and perhaps opened another,” said Dr Levounis.

“So we now need to look into the heroin profile as well.”