Prescription Opioids Peaked in 2011 and Have Declined Rapidly Since Interview with:

Brian J. Piper, PhD, MS Assistant Professor of Neuroscience Department of Basic Sciences, Geisinger Commonwealth School of Medicine, Scranton PA 18509

Dr. Brian Piper

Brian J. Piper, PhD, MS
Assistant Professor of Neuroscience
Department of Basic Sciences,
Geisinger Commonwealth School of Medicine,
Scranton PA 18509 What is the background for this study? What are the main findings? 

Response: The US is experiencing an opioid crisis. There were 63,800 drug overdose deaths in 2016 which is three-fold higher than in 1999. Drug overdose deaths involving synthetic opioids like fentanyl increased 27-fold. Overdoses may even have contributed to decreases in the US lifespan. Emergency Room visits involving opioids have also shown recent increases, particularly in the Southwest and Western US. The US accounts for less than 5% of the world’s population but consumed over two-thirds (69.1%) of the world’s supply of six opioids (fentanyl: 30.1%, methadone: 48.1%, morphine: 51.2%, hydromorphone: 53.0%, oxycodone: 73.1% and hydrocodone: 99.7%) in 2014.

The goal of this study was to examine changes in medical use of ten opioids within the United States, and US Territories, from 2006 to 2016 as reported to the Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS). Prior estimates of the Morphine Mg Equivalent (MME), per person in the US (640), although much higher than most other developed countries, may be an underestimate because of a federal regulation (42 CFR Part 2) that prevents reporting methadone from narcotic treatment programs.

We discovered that prescription opioid use peaked in 2011 (389.5 metric ton MMEs) and has been rapidly declining (346.5 in 2016). Relative to 2011, there were decreases in hydrocodone (–28.4%); oxymorphone (–28.0%); fentanyl (–21.4%); morphine (–18.9%); oxycodone (–13.8%); and meperidine (–58.0%). However, there was a pronounced increase in buprenorphine (75.2%). Similar changes were observed from 2015 to 2016 with a statistically significant reduction in all opioids except buprenorphine which was increased. There were substantial geographical variations in rates with a seven fold difference between the highest Morphine Milligram Equivalents in 2016 (Rhode Island = 2,624 mg/person) relative to Puerto Rico (351 mg/person).

Two drugs used in treating an opioid use disorder (methadone and buprenorphine) accounted for over-half (52%) of the total MME in 2016. What should readers take away from your report? 

Response: The US opioid crisis is frequently described as iatrogenic or caused by a medical treatment. The culture surrounding opioid prescribing, particularly for chronic non-cancer pain, continues to change. However, there is continued room for progress within the US. The total Morphine Mg Equivalent identified in this study (1,124 metric tons) in 2016 is enough to supply every person in the US with a 5-mg tablet of hydrocodone, every day, for over 7 months.

An international perspective may be beneficial as other areas, including those with longer lifespans (Japan, US Territories) use opioids much more judiciously. What recommendations do you have for future research as a result of this work?

Response: Because of a federal regulation, 42 CFR Part 2, most prior pharmacoepidemiological research has vastly underestimated medical use of opioids in the US. The segmented health care delivery system has also resulted in other important groups (veterans, Native Americans) being excluded. The DEA makes ARCOS, a much more comprehensive source of opioid information, publically available each year. Is there anything else you would like to add?

Response: Pain is a biopsychosocial condition. However, there is no reason to believe that the citizens of Rhode Island are biologically different than those from North Dakota. There is much left to learn about the social, cultural and economic factors that are responsible for the five-fold opioid prescribing differences across states.

Given the significant reductions in opioid prescribing, the high visibility of labels like “opioid epidemic” continues to be surprising. This phrase continues to be used too widely. The 64,000 drug overdoses, including about 20,100 involving fentanyl and 17,680 involving prescription opioids, are extremely unfortunate as many could have been prevented. The escalation from prescription opioids to heroin, and from oral to non-oral routes of administration, continues to be too frequent. However, heroin and illicitly manufactured fentanyl, not prescription drugs, are accounting for an increasing portion of those overdoses. Public education efforts should devote resources according to the magnitude of the problem. The “opioid epidemic” should be viewed in the context of the number of deaths caused each year by alcohol (88,000) or cigarette smoking (480,000).

The federal regulation (42 CFR Part 2) that prevents reporting methadone from narcotic treatment programs to Prescription Drug Monitoring Programs was well intentioned but should be modified. Doctors and pharmacists should be aware of the medications their patients are receiving.

Addiction is also a biopsychosocial condition. Methadone and buprenorphine are important evidence based treatments for an opioid use disorder which save lives. These are as effective as medications for other chronic diseases like diabetes. There continue to be too many barriers to prevent access to these treatments, both economic and social (stigma). These treatments work best when combined with psychological interventions like contingency management which are too often unavailable.

Given the history of opioid misuse, we have some public policy suggestions. First, all potential policy makers that make decisions regarding opioids at a state or national level should be thoroughly screened for their conflicts of interest. Second, some states have developed strategies like the Diversion Alert Program to improve communication about opioids between law-enforcement and health care providers. Third, direct to consumer marketing, for example, promotion of the OxyContin fishing hat, was a large contributor to relaxed attitudes about opioids for chronic non-cancer pain. Most other countries do not have direct to consumer marketing. These laws need to be modified to prevent a future crisis

Disclosures: This study was completed using software provided by the National Institute of Environmental Health Sciences and was supported by the Health Resources and Services Administration and internal grants from the Husson University School of Pharmacy and the Geisinger Commonwealth School of Medicine. I have also received travel and research supplies from the National Institute of Drug Abuse and research support from the Center for Wellness Leadership (a non-profit organization) for studies about the benefits and risks of medical marijuana and am a Fahs-Beck fellow (a non-profit organization). I have no disclosures relevant to opioids.


Trends in Medical Use of Opioids in the U.S., 2006–2016

Brian J. Piper, PhD, MSCorrespondence information about the author PhD, MS , MS Brian J. PiperEmail the author PhD, MS Brian J. Piper, Dipam T. Shah, BS Olapeju M. Simoyan, MD, MPH Kenneth L. McCall>, PharmD, BCGP Stephanie D. Nichols, PharmD, BCPS, BCPP

AJPM March 15, 2018

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Last Updated on March 19, 2018 by Marie Benz MD FAAD