Joshua D. Madera, MD Department of Medical Education Geisinger Commonwealth School of Medicine Scranton PA

Declines, but pronounced and persistent state level disparities, in prescription opioids in the US Interview with:

Joshua D. Madera, MDDepartment of Medical Education
Geisinger Commonwealth School of Medicine
Scranton PA

Dr. Madera

Joshua D. Madera, MD
Department of Medical Education
Geisinger Commonwealth School of Medicine
Scranton PA

What is the background for this study?

Response: The US population continues to be drastically impacted by the opioid epidemic, with opioid-related deaths significantly increased compared to European countries. While prescription opioid distribution has gradually declined since its peak in 2011 [1], the rate of opioid prescriptions remains increased compared to 2000.

Furthermore, there is considerable interstate variability in opioid distribution across the US. Identifying patterns in this variability may guide public health efforts to reduce opioid-related harms. Therefore, the primary objective of this study [2] from Geisinger Commonwealth School of Medicine was to explore variations in production quotas and state-level distribution of ten prescription opioids between 2010 and 2019.

What are the main findings?

Response: Opioid production quotas and distribution data were obtained from the US Drug Enforcement Administration’s Production Quota System and Automation of Reports and Consolidated Orders System, respectively. A 41.5% decrease in production quotas was identified between 2013 (87.6 MME metric tons) and 2019 (51.3). Distribution for all ten opioids peaked between 2010 and 2013, except for codeine in 2015. From 2011 to 2019, opioid distribution per capita decreased by 52.0%, with the observed largest decrease in Florida (-61.6%) and the smallest decrease in Texas (-18.6%).

Relative to the other nine opioids, oxycodone distribution was the most pronounced and also demonstrated the largest decline in opioid distribution relative to its peak year. Oxymorphone had the highest ratio of per capita MME distribution from the maximum and minimum states in both 2011 (27.4) and 2019 (38.9), and fentanyl had the lowest ratio in both 2011 (2.5) and 2019 (3.1). Furthermore, the mean 95th/5th ratio of prescription opioids per state per capita remained consistent in 2011 (4.78 + 0.70) relative to 2019 (5.64 + 0.98).

What should readers take away from your report?

Response: Overall, aggregate production quotas implemented by the Drug Enforcement Administration may only partially explain the decline in opioid production observed in 2017 [3]. Opioid distribution continued to steadily decline. However, the exact mechanism responsible for this observed decrease may be multifactorial. Furthermore, despite the overall observed decline in opioid distribution, variability remains among different opioids. Moreover, state-level differences may be explained by differences in legislative policies, provider and patient behaviors, and should be investigated further.

What recommendations do you have for future research as a result of this study?

Response: Additional investigative efforts should be dedicated to further analyzing the observed interstate variability in opioid distribution to identify contributory factors. This insight may assist with developing strategies to reduce the rate of opioid-related harms in the US.

Is there anything else you would like to add?

Response: The Drug Enforcement Administration’s ARCOS database is comprehensive for Schedule II substances, timely, and publicly available [3]. More public health researchers or data journalists should  make use of this resource to inform opioid stewardship


  1. Piper BJ, et al. Trends in medical use of opioids in the U.S., 2006–2016. Am. J. Prev. Med. 2018, 54, 652–660.
  2. Madera JD, et al. Declining but pronounced state-level disparities in prescription opioid distribution in the United States. Pharmacy 2024;12:14.
  3. Department of Justice. Review of the Drug Enforcement Administration’s Regulatory and Enforcement Efforts to Control the Diversion of Opioids. Available online:


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Last Updated on February 3, 2024 by Marie Benz MD FAAD