Article

Supply-Side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids

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Abstract

Overdose deaths from prescription opioid pain relievers nearly quadrupled between 1999 and 2010, making this the worst drug overdose epidemic in U.S. history. In response, numerous supply-side interventions have aimed to limit access to opioids. However, these supply disruptions may have the unintended consequence of increasing the use of substitute drugs, including heroin. We study the consequences of one of the largest supply disruptions to date to abusable opioids – the introduction of an abuse-deterrent version of OxyContin in 2010. Our analysis exploits across state variation in exposure to the OxyContin reformulation. Using data from the National Survey on Drug Use and Health (NSDUH), we show that states with higher pre-2010 rates of OxyContin misuse experienced larger reductions in OxyContin misuse, permitting us to isolate consumer substitution responses. We estimate large differential increases in heroin deaths immediately after reformulation in states with the highest initial rates of OxyContin misuse. We find less evidence of differential reductions in overall opioid-related deaths, potentially due to substitution towards other opioids, including more harmful synthetic opioids such as fentanyl. Our results imply that a substantial share of the dramatic increase in heroin deaths since 2010 can be attributed to the reformulation of OxyContin.

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... This replacement represented a substantial shock to the availability of abusable prescription opioids as OxyContin was often the "drug of choice" for non-medical users (Cicero et al., 2005). Prior research has shown that states with higher rates of non-medical use of OxyContin experienced disproportionate growth in heroin overdose rates after reformulation (Alpert et al., 2018). In recent years, widespread substitution to illicit opioids has only increased in importance (Pardo et al., 2019), leading to disproportionately fast overdose rate growth in states more exposed to reformulation (Powell and Pacula, forthcoming). 1 There have been Congressional hearings on the economic effects specifically: see https://www.govinfo.gov/content/pkg/CHRG-115shrg26119/html/CHRG-115shrg26119.htm, last accessed July 8, 2019. ...
... Recent research has shown that replacing the original formulation with the abuse-deterrent version increased heroin overdose rates (Alpert et al., 2018;Evans et al., 2019), heroin-specific substance abuse treatment admissions (Alpert et al., 2018), and rates of infectious diseases Beheshti, 2020). 14 Recent work suggests that the longer-term effects of OxyContin reformulation were especially important. ...
... Recent research has shown that replacing the original formulation with the abuse-deterrent version increased heroin overdose rates (Alpert et al., 2018;Evans et al., 2019), heroin-specific substance abuse treatment admissions (Alpert et al., 2018), and rates of infectious diseases Beheshti, 2020). 14 Recent work suggests that the longer-term effects of OxyContin reformulation were especially important. ...
... From 2017 to 2018, the CDC reported a decrease in fatal overdoses due to prescription opioids (13.5%) and heroin (4.1%), but a 10% increase in fatal overdoses involving synthetic opioids, including fentanyl and its derivatives [5]. This shift could be due to targeted efforts at changing opioid prescribing practices, leading some individuals to seek illicit drugs, and the proliferation of fentanyl and its derivatives in the heroin supply [11][12][13][14]. ...
... Given its potency, fentanyl use, whether intentional or not, significantly increases the chance for overdose [16][17][18]. Current data shows that fentanyl use is steadily rising [13,19]. For example, in New Jersey, reports showed a staggering 949% increase in fentanyl submissions to New Jersey State Police Office of Forensic Science labs from 2015 to 2019 [20]. ...
... This resulted in increased production and distribution of fentanyl as a response, especially in places where prescription opioids are widely available [23]. While supply-side interventions for pharmaceutical opioids, such as "abuse-deterrent" opioid formulations and provider education to reduce opioid prescribing, were successful at reducing overdoses from prescription pills, there is some evidence that this led to an increase in use of other opioids, like heroin and fentanyl [13,14]. While prescription opioid overdose has been on the decline, the amount of fentanyl available to purchase on the street has rapidly increased. ...
Article
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Purpose of Review The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis. Recent Findings Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose. Summary The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.
... Examining a set of outcomes may also help identify unintended or iatrogenic policy effects. A classic example is the abuse-deterrent reformulation of oxycodone, which led to a decline in oxycodone misuse yet an increase in heroin use and opioid-related fatalities (Alpert et al. 2018;Cicero and Ellis 2015;Evans et al. 2018). Fundamentally, it is very important that researchers understand how specific measures are assessed and collected; this is essential to understanding their appropriate interpretations as well as their limitations. ...
... To address limitations of individual measures, replicating analyses using several different, albeit error-prone, measurements of the same or closelyrelated constructs can strengthen inference if results are generally consistent. For example, Alpert et al. (2018) validate their primary outcome, self-reported OxyContin misuse from the NSDUH with two related measures-oxycodone distribution volume and Oxy-Contin prescription claims from the Medical Expenditure Panel Survey. As discussed in a recent paper by Kline et al. (2019), examining several correlated outcomes may require a joint model. ...
Article
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Opioid-related mortality increased by nearly 400% between 2000 and 2018. In response, federal, state, and local governments have enacted a heterogeneous collection of opioid-related policies in an effort to reverse the opioid crisis, producing a policy landscape that is both complex and dynamic. Correspondingly, there has been a rise in opioid-policy related evaluation studies, as policymakers and other stakeholders seek to understand which policies are most effective. In this paper, we provide an overview of methodological challenges facing opioid policy researchers when conducting opioid policy evaluation studies using observational data, as well as some potential solutions to those challenges. In particular, we discuss the following key challenges: (1) Obtaining high-quality opioid policy data; (2) Appropriately operationalizing and specifying opioid policies; (3) Obtaining high-quality opioid outcome data; (4) Addressing confounding due to systematic differences between policy and non-policy states; (5) Identifying heterogeneous policy effects across states, population subgroups, and time; (6) Disentangling effects of concurrent policies; and (7) Overcoming limited statistical power to detect policy effects afforded by commonly-used methods. We discuss each of these challenges and propose some ways forward to address them. Increasing the methodological rigor of opioid evaluation studies is imperative to identifying and implementing opioid policies that are most effective at reducing opioid-related harms.
... There is some emerging evidence that supply-side interventions that limit access to opioids may increase the use of some other illicit substances. Notably, the reformulation of OxyContin into a misuse-deterrent formulation, and its market entry in 2010, has been found to be associated with a sharp increase in mortality from heroin overdose (Alpert et al., 2018;Evans et al., 2019). Interactions with supply and distribution networks in illicit drug markets have been especially prone to violence, gang activity, and crimes involving guns. ...
... 54 Data from the 2014 NSDUH indicate that among young adults ages 18-24, who had ever misused opioid pain relievers, 31.1% had reported being arrested. implemented a PDMP, and while the early literature on the effects of PDMPs did not find these programs to be effective, numerous recent studies have found a significant effect of mandatoryaccess PDMPs on opioid use disorders and opioid related deaths (Alpert et al., 2018;Buchmueller and Carey, 2018;Grecu et al., 2019). However, there are costs associated with PDMPs, particularly mandatory-access PDMPs, and there is still some debate regarding the appropriateness of PDMP legislation. ...
Article
We study the effects of prescription drug monitoring programs (PDMPs) on crime, and inform how policies that restrict access to Rx opioids per se within the healthcare system would impact broader non‐health domains. In response to the substantial increase in opioid use and misuse in the United States, PDMPs have been implemented in virtually all states to collect, monitor, and analyze prescription opioid data with the goal of preventing its misuse and diversion. Using a differences‐in‐differences approach and data on offenses known to law enforcement from the Uniform Crime Reports (UCR), we find that mandatory access PDMPs reduced overall crime by 5%, particularly driven by assault, burglary and motor vehicle theft. Overall, these results provide evidence that appropriately designed PDMPs are an effective social policy tool to mitigate some of the negative consequences of opioid misuse, and more broadly indicate that opioid policies can have important spillover effects into crime.
... How bounded rationality of pain patients affects addiction to prescription drugs and illicit drug use is in detail explored in Strulik (2021) . 3 Alpert et al. (2018) show that the introduction of abuse-deterrent OxyContin in 2010, which makes is difficult to crush or dissolve the pills and thus avoids fast release of the active ingredient known as particularly promoting addiction, is largely responsible for the subsequent heroin epidemic in the U.S. This suggests that OxyContin and heroin are highly substitutable. ...
... As discussed in the introduction, opioid pain relievers are not prescribed to treat mental distress. Heroin is a close substitute to OPR and their street price exceeds the street price of heroin by about factor 10 ( Gupta, 2016;Alpert et al., 2018 ). Our income-constrained individuals will thus prefer heroin over non-medical OPR use as form of self-treatment of mental distress. ...
Article
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Empirical evidence for the U.S. suggests that illicit consumption of opioids increases in association with socio-economic deprivation of the middle-class. To explore the underlying mechanisms, we set up a task-based labor market model with endogenous mental health status and a health care system. The decline of tasks that were historically performed by the middle class and the associated decline in socio-economic status increases the share of mentally distressed middle class workers. Mentally distressed workers can mitigate their hardships by the intake of illicit drugs or by consuming health goods. We argue that explaining the rise in illicit drug use among the U.S. middle class requires an interaction of socio-economic decline and falling opioid prices, i.e. one factor in isolation is insufficient. Our analysis also points to a central role of the health care system. Extending mental health care could motivate the mentally distressed to abstain from illicit drug consumption.
... 34 Despite the declining prescription numbers, overdose deaths have not declined, due to the increased use of heroin and illicit fentanyl. 35,36 There are inescapable public and practitioner awareness of the opioid crisis, extensively documented inappropriate SPECIAL ARTICLE outpatient oral opioid use and overprescribing, innumerable federal, state, local, and institutional regulatory, legislative, and guidance restrictions on opioid prescribing, and billions of dollars invested to combat the opioid crisis over the past 5 yr. Nonetheless, these approaches are failing to retard or reverse the epidemic of opioid-related fatalities. ...
... 25,190,191 Prescription opioid-dependent patients, faced with unavailability due to decreased provider prescribing and other supply-side reductions, abuse-deterrent reformulations, tamper-resistant pill dispensers, street market shortages, and high street costs, simply turned to cheaper and more accessible heroin as the unintended policy consequence. 18,35,105 Heroin became substitution therapy for prescription opioids. Fentanyl was subsequently introduced as an efficient supply-side market response to opioid demand, prescription opioid shortages, declining heroin purity, shortages, and "supply shocks," as well as lower production cost, easier distribution, and greater profitability of fentanyl versus heroin. ...
Article
While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.
... Sixth, morbidity changes may be equally important but were not included in our primary analysis. Seventh, the time period of the study predated the coronavirus disease 2019 (COVID- 19) pandemic. Accordingly, COVID-19 was not analyzed as a unique cause of death. ...
... Evidence suggests that many people transitioned into these substances after prescription opioids were made more difficult to obtain. 19,20 Thus, we attributed these deaths to pharmaceuticals as well, even if some of the "technology" was related to the ability to supply illegal drugs. ...
Article
Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and -7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.
... 24,25 However, these substitution results are somewhat at odds with research on US policy concluding that the introduction of tamper-resistant opioids increased the use of illicit drugs such as heroin. 26,27 Our main results add important complexity to these previous studies: We don't know whether patients reacted to the introduc-tion of OxyNeo or the end of grandfathering by using illicit drugs, but it seems that chronic users of opioids were able to maintain treatment by switching among prescription opioids under the direction of a prescriber. On the other hand, formulary restrictions more clearly appear to prevent the use of prescription opioids for new users, a population less likely than chronic users to be dependent on opioids and, therefore, less likely to seek illicit drugs when they are unable to obtain prescription drugs. ...
... On the other hand, the OxyNeo results are consistent with the conclusion that chronic users tend to receive an opioid despite regulation of any particular drug. 26 ▪ ...
Article
Responding to an opioid crisis in Canada, policy makers have implemented supply-side interventions seldom used in the US, regulating insurance reimbursement to discourage the prescribing of specified opioids. Using national databases of all opioids dispensed through provincial pharmaceutical programs and of opioid hospitalizations from January 2006 through March 2017, we found that requiring physicians to obtain prior authorization for patients to receive reimbursement for OxyContin prescriptions substantially reduced OxyContin fills, particularly among opioid-naive patients; it also reduced overall opioid prescriptions, suggesting limited substitution. "Grandfathering" OxyNeo (an abuse-resistant OxyContin variant), allowing previous OxyContin patients to obtain OxyNeo, increased OxyNeo fills but had no detectable effect on total opioid prescriptions, which points to substantial opioid substitution among chronic users of prescription opioids. We found no effects of regulatory changes on opioid-related hospitalizations. These results suggest that restrictions on pharmaceutical formularies can reduce fills of targeted opioids with the additional benefit of altering treatment of opioid-naive and other patients differently. Canadian policy makers may wish to extend such regulations to more provincial formularies and private insurers, and policy makers in the US and elsewhere could fruitfully follow suit.
... 9 1 There is also a substantial literature that focuses on the causes of opioid use abuse and overdoses and the effect of policy changes on outcomes. For example, a number of papers have examined how policy has affected use, including prescription drug monitoring programs (Ali et al., 2017;Buchmueller and Carey, 2018;Grecu et al., 2019), Naloxone (Coffin and Sullivan, 2013;Rees et al., 2019), abuse-deterrent opioids (Alpert et al., 2018), physician interventions (Schnell and Currie, 2018), treatment (Borgschulte et al., 2018), and legalized marijuana (Bachhuber et al., 2014;Bradford and Bradford, 2016;Powell et al., 2018). 2 There are several studies that examine how opioids in the home affect family life (e.g. Garbutt et al., 2019;Wilens et al., 2002). ...
Article
One of the more salient aspects of the opioid crisis in America has been the disparate impact it has had on communities. This paper considers the possibility that opioid abuse might have negative spillovers onto student performance in schools within the communities most affected. We use administrative data on individual children's test scores (grades 3 through 8) in South Carolina from the 2005–06 to 2016-17 academic years. These data are then linked to county-level changes in opioid prescriptions rates. Findings show that an increase in the opioid prescription rate in a county is associated with a statistically significant reduction in white student test scores, but no such decline was found among non-white students. This relationship is robust to controls for changing county-level economic conditions, time-varying controls for student-level poverty, county characteristics, and county time trends. Among white students, the association is strongest among rural students in households that are not receiving SNAP or TANF benefits. Given the importance of educational attainment, this reduction in test scores associated with high rates of opioid prescriptions may indicate that there will be long-lasting spillover effects of the opioid crisis.
... The pendulum began to swing back with new guidelines for prescribers (Dowell et al. 2016); laws aimed at curbing unscrupulous pain management clinics, prescribers, and dispensers (Kuehn 2014); and federal promotion of abuse deterrents such as the reformulation of oxycodone. Some of these measures coincided with a rise in heroin deaths (Alpert et al. 2018, Cicero et al. 2012, Evans et al. 2019, with some individuals potentially trading down to cheaper and more accessible heroin as a result of those regulations, whereas others might have transitioned simply because of tolerance developed from prescription pain relievers (Mars et al. 2014). ...
Article
The traditional US heroin market has transformed into a broader illegal opioid market, dominated first by prescription opioids (PO) and now also by fentanyl and other synthetic opioids (FOSO). Understanding of opioid-use disorder (OUD) has also transformed from being seen as a driver of crime to a medical condition whose sufferers deserve treatment. This creates new challenges and opportunities for the criminal justice system (CJS). Addressing inmates’ OUD is a core responsibility, including preventing overdose after release. Treatment can be supported by diversion programs (e.g., drug courts, among others) and by providing medication-assisted treatment in prison, not only as a crime-control strategy but also because of ethical and legal responsibilities to provide appropriate healthcare. The CJS also has opportunities to alter supply that were not relevant in the past, including deterring pill-mill doctors and disrupting web sites used to distribute FOSO. Expected final online publication date for the Annual Review of Criminology, Volume 4 is January 13, 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
... However, an unintentional consequence of these interventions was a substantial resurgence of PWUD initiating with heroin, which became more easily available at a lower cost, triggering a second "wave" of the epidemic. 36,39,40 The emergence of synthetic opioids like illegally manufactured fentanyl and its many related analogues, which was partly due to economic pressures generated by law enforcement "crackdowns" of heroin suppliers, 4,16 critically shifted the drug supply and initiation environment for a third time. 41 Fentanyl is estimated to be 50 times more potent than heroin and accounts for 40% of overdose deaths. ...
Article
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Policy Points • This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. • In order to successfully reduce drug‐related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. Context Drug overdose is the leading cause of injury‐related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. Methods In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The “continuum of overdose risk” framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. Findings De‐escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. Conclusions Without recognizing the full drug‐use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.
... The combination of Naloxone access law and increasing availability of high potency drugs could be partially responsible for not finding a significant result within the states that pass such a law (Doleac and Mukherjee, 2018). We are not able to control for an accurate measurement of opioid potency, but studies suggest opioid users shift toward consuming stronger, more illicit drugs like heroin and synthetic opioids like fentanyl when policies are enacted limiting opioid misuse Alpert et al., 2018;Evans et al., 2018;Jones et al., 2018). 41 There are two channels to explain this shift: less availability of prescription painkillers and drug users seeking out a stronger high. ...
Article
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Opioid overdoses are the leading cause of unintentional death in the U.S. This research investigates the effects of state-level Naloxone access laws on opioid overdose death rates. Spatial difference-in-differences models reveal that no matter how the access law is measured (either as a binary variable, number of days after the law, or differentiated between access law provisions), the only consistent result is positive indirect effects on overdose death rates. These results indicate that Naloxone access provisions have regional impacts via spillover effects in neighboring states. Looking across multiple provisions, our findings show that, except for third party authorization, there are significant positive effects on overdose death rates. When access laws are evaluated in isolation of any other state-level policy response to opioids, increasing access to Naloxone does not reduce overdose death rates, but leads to an overall increase. Thus, the moral hazard problem stemming from this public health policy may be an accurate assessment of the outcome.
... Federal regulations relating to the approval, formulation, or scheduling of prescription opioids were evaluated in 20 (14 %) studies. Specific policies examined included: up-scheduling hydrocodone combination products to Schedule II (e.g., Murimi et al., 2019;Raji et al., 2018), introduction of the abuse-deterrent reformulation of OxyContin (e.g., (Alpert et al., 2018;Cicero and Ellis, 2015;Larochelle et al., 2015), FDA approval of generic OxyContin (Bailey et al., 2006), and FDA-requested withdrawal of propoxyphene from the U.S. market (Delcher et al., 2017;Larochelle et al., 2015). ...
Article
Objective Characterize the state of the science in opioid policy research based on a literature review of opioid policy studies. Methods We conducted a scoping review of studies evaluating the impact of U.S. state-level and federal-level policies on opioid-related outcomes published in 2005-2018. We characterized: 1) state and federal policies evaluated, 2) opioid-related outcomes examined, and 3) study design and analytic methods (summarized overall and by policy category). Results In total, 145 studies were reviewed (79% state-level policies, 21% federal-level policies) and classified with respect to 8 distinct policy categories and 7 outcome categories. The majority of studies evaluated policies related to prescription opioids (prescription drug monitoring programs (PDMPs), opioid prescribing policies, federal regulation of prescription opioids, pain clinic laws) and considered policy impacts with respect to proximal outcomes (e.g., opioid prescribing behaviors). In total, only 29 (20% of studies) met each of three key criteria for rigorous design: analysis of longitudinal data with a comparison group design, adjustment for difference between policy-enacting and comparison states, and adjustment for potentially confounding co-occurring policies. These more rigorous studies were predominately published in 2017-2018 and primarily evaluated PDMPs, marijuana laws, treatment-related policies, and overdose prevention policies. Conclusions Our results indicated that study design rigor varied notably across policy categories, highlighting the need for broader adoption of rigorous methods in the opioid policy field. More evaluation studies are needed regarding overdose prevention policies and policies related to treatment access. Greater examination of distal outcomes and potential unintended consequences are also warranted.
... For instance, parallel social programmes aimed at managing the demand side of the market might attenuate the emergence of criminal responses that could be connected with the compulsive need of heavy drug users to fund their addiction. This suggestion is in line with the recently signed 21st Century Cures Act, which will provide $1 billion in funding for demand-side interventions, such as prevention and substance abuse treatment, which aim to reduce the prevalence of addiction (Alpert et al. 2018). ...
Article
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This paper evaluates the effects on crime of supply‐side interventions that restricted access to pseudoephedrine‐based medications in the USA , drastically reducing the domestic production of methamphetamine. I find that these government interventions increased property and violent crime by around 3–4%, with criminogenic effects lasting for up to 7 months. Stronger evidence is detected in counties where laboratories producing methamphetamine were previously in operation. My findings suggest that policy interventions that have a limited effect on supply and no impact on the demand for drugs could open up the way to unwarranted crime responses. Timely policy implications are discussed.
... Oxycodone: 2016 evaluation of the susceptibility to tampering of biphasic immediate-release oxycodone/acetaminophen tablets compared with IR OC/APAP tablets [350]; evaluation of trends of diversion, abuse and street price of OxyContin to assess the durability of the initial reduction in abuse of abuse deterrent formulations [351]; 2017 Long-term efficacy and safety of oxycodonenaloxone prolonged-release formulation (up to 180/90 mg daily) [352]; design and evaluation of an extended-release matrix tablet formulation (oxycodone); the combination of hypromellose acetate succinate and hydroxypropylcellulose [353]; abuse potential of Oxycodone DETERx (R) (Xtampza (R) ER) [354]; development and characterization of a mucoadhesive sublingual formulation (oxycodone film) [355]; evaluation of a newly-developed oxycodone prolonged-release tablet [356]; 2018 Roxybond -abuse-deterrent formulation of immediate-release Oxycodone [357]; study of the introduction of an abuse-deterrent version of OxyContin in 2010 [358]; trends and uptake of new formulations of controlled-release oxycodone in Canada [359]; abuse-deterrent formulations of Oxycodone hydrochloride immediate-release analgesic for managing severe pain [360]; evaluation of the impact of OxyContin reformulation [361]; effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm [362]; evaluation of the safety, tolerability, and analgesic efficacy of Oxycodone DETERx extendedrelease (ER) and abuse-deterrent capsules (Xtampza (R) ER) [363]; total synthesis of the pharmacologically significant morphinan alkaloid, oxycodone [364]; abuse potential of the new opioid analgesic Molecule NKTR-181 compared with Oxycodone [365]; 2019 synthesis of (À)-Oxycodone via anodic aryl-aryl coupling [366]. ...
Article
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This review paper covers the forensic-relevant literature in controlled substances from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20Papers%202019.pdf.
... However, many believe that the most useful types of programs focus on reducing opioid supply and changing prescriber patterns (Bonnie, Ford, and Phillip 2017). Such programs include state-run Prescription Drug Monitoring Programs, increased prescriber education and training, abuse-deterrent drug reformulations, and additional black box drug warnings to avoid possibility of overprescribing, reduce diversion, and discouraging drug misuse (Alpert, Powell, and Pacula 2017;Clark and Schumacher 2017). ...
Article
Importance: A number of strategies and policies have been implemented to mitigate the opioid crisis, including state Prescription Drug Monitoring Programs (PDMPs) that are used to track and compile patient prescription data. Because PDMPs are run independently by states, different characteristics of PDMPs can impact success rates of the programs in controlling opioid prescriptions and overdose deaths. Objective: To assess the association between PDMP operating agency type and opioid prescriptions and opioid overdose death rates. Research Design: The study utilized time-series data provided by the CDC and KFF, which included information for 49 states and Washington D.C. with effective PDMPs. The impact of state operating type was analyzed using regressions that controlled for the presence of a mandate. A qualitative portion was conducted through an online opt-in survey that was sent out to emergency medicine, pain management, and primary care physicians. Main Outcome and Measures: The unit of observation was state-years, and the study period was 2006 to 2016 for opioid prescription rate and 2000 to 2017 for opioid overdose death rates. Results: Using opioid prescription rates, PDMPs with health-facing agencies combined with a mandate decreased prescriptions by approximately 26 prescriptions per 100 individuals, which was statistically significant at the 0.1% level. While most of the specific six agency types also decreased prescription rate, most coefficients were not statistically significant. Looking at opioid overdose death, PDMPs with health-facing agencies showed approximately 6 fewer deaths per 100,000 population, reaching statistically significance at the 0.1% level. Similarly, broken down by specific agency type, most of these coefficients did not reach similar statistically significant. The qualitative survey revealed that the majority of physicians are aware of Pennsylvania’s PDMP operating agency. In addition, these physicians routinely check the PDMP for patient prescription information, and 75.5% of participants have changed their patients’ prescription plan after viewing the PDMP. Conclusions and Relevance: These findings suggest that operating agency type impacts effectiveness of PDMPs in controlling for prescription rates and opioid overdose deaths. To maximize impact, health-facing agencies should implement and operate PDMPs.
... Overdose and Fatality 5 studies suggested a decline in overdose rate (−34%, −20%, −85%, −87%), 2-year overdose fatality rate (−56%, −65%), and 3-year overdose fatality rate (−85%, −87%) after OxyContin reformulation. However, heroin overdose rate and overdose fatality increased (23% and 310% respectively), while other opioids (morphine ER, oxymorphone ER, oxycodone IR, hydromorphone IR, ilicit drugs) showed no statistically significant changes in overdose and overdose fatality rate.[167,[177][178][179][180]] Doctor shopping 2 studies reported a 50% reduction in doctor-shopping after OxyContin reformulation, but an increase in doctor-shopping for oxycodone IR (5%), hydromorphone IR(25), and oxymorphone ER (66%).[181,182,] ...
Article
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Introduction: Opioids continue to be used widely for pain management. Widespread availability of prescription opioids has led to opioid abuse and addiction. Besides steps to reduce inappropriate prescribing, exploiting opioid pharmacology to make their use safer is important. Areas covered: This article discusses the pathology and factors underlying opioid abuse. Pharmacokinetic and pharmacodynamic properties affecting abuse liability of commonly abused opioids have been highlighted. These properties inform development of ideal abuse deterrent products. Mechanisms and cost-effectiveness of available abuse deterrent products have been reviewed in addition to the pharmacology of medications used to treat addiction. Expert opinion: The opioid crisis presents unique challenges to managing pain effectively given the limited repertoire of strong analgesics. The 5-point strategy to combat the opioid crisis calls for better preventive, treatment and recovery services, better data, better pain management, better availability of overdose-reversing drugs and better research. There is an urgent need to decrease the cost of abuse deterrent opioids which deters their cost-effectiveness. In addition, discovery of novel analgesics, further insight into central and peripheral pain mechanisms, understanding genomic risk profiles for efficient targeted efforts, and education will be key to winning this fight against the opioid crisis.
... Potential explanations are that the insurance expansion occurred at the same time as the oxycontin reformulation in 2012 which led to a transition from prescription opioid misuse to heroin use. 24 We suspect a small portion of those exposed to prescription opioid pain medications may have developed an addiction, but then transitioned quickly to heroin during this period. [25][26][27][28][29] On the other hand, we did not find any association between the young adult insurance expansion with fatal prescription, non-prescription, heroin, or methadone overdoses, nor ED encounters for overdose from prescription opioids and methadone. ...
Article
Background Several policymakers have suggested that the Affordable Care Act (ACA) has fueled the opioid epidemic by subsidizing opioid pain medications. These claims have supported numerous efforts to repeal the ACA.Objective To determine the effect of the ACA’s young adult dependent coverage insurance expansion on emergency department (ED) encounters and out-of-hospital deaths from opioid overdose.DesignDifference-in-differences analyses comparing ED encounters and out-of-hospital deaths before (2009) and after (2011–2013) the ACA young adult dependent coverage expansion. We further stratified by prescription opioid, non-prescription opioid, and methadone overdoses.ParticipantsAdults aged 23–25 years old and 27–29 years old who presented to the ED or died prior to reaching the hospital from opioid overdose.Main MeasuresRate of ED encounters and deaths for opioid overdose per 100,000 U.S. adults.Key ResultsThere were 108,253 ED encounters from opioid overdose in total. The expansion was not associated with a significant change in the ED encounter rates for opioid overdoses of all types (2.04 per 100,000 adults [95% CI − 0.75 to 4.82]), prescription opioids (0.60 per 100,000 adults [95% CI − 1.98 to 0.77]), or methadone (0.29 per 100,000 adults [95% CI − 0.78 to 0.21]). There was a slight increase in the rate of non-prescription opioid overdoses (1.91 per 100,000 adults [95% CI 0.13–3.71]). The expansion was not associated with a significant change in the out-of-hospital mortality rates for opioid overdoses of all types (0.49 per 100,000 adults [95% CI − 0.80 to 1.78]).Conclusions Our findings do not support claims that the ACA has fueled the prescription opioid epidemic. However, the expansion was associated with an increase in the rate of ED encounters for non-prescription opioid overdoses such as heroin, although almost all were non-fatal. Future research is warranted to understand the role of private insurance in providing access to treatment in this population.
... 20,21,35 There is substantial concern about individuals progressing from opioid analgesic use and misuse to heroin, 5-7 particularly when there is a disruption of the opioid analgesic supply. 38,39 Of individuals reporting past-year prescription opioid misuse, a minority met criteria for OUD or reported heroin use. Targeted prevention and intervention efforts are warranted to ensure that individuals comprising this sizeable, at-risk population of those with prescription opioid misuse do not develop more serious opioid-related problems. ...
Article
Background: Prescription opioid misuse among older adults has received little attention to date. Potential age variation in characteristics of and motivations for prescription opioid misuse has not been fully characterized yet has important implications for preventing diversion and misuse. Objective: To examine (1) age-specific patterns of source of misused prescription pain relievers and motives for misuse and (2) age-specific and source-specific associations with opioid use disorder (OUD), heroin use, benzodiazepine misuse, and OUD treatment utilization. Design: Cross-sectional study using 3 waves (2015–2017) of the National Survey on Drug Use and Health (68% average response rate) Participants: Respondents aged 12 and older with past-year prescription pain reliever misuse (n = 8228) Main Measures: Source for the most-recently misused prescription pain reliever (categorized as medical, social, or illicit/other), motive for last episode of misuse, OUD, heroin use, benzodiazepine misuse, and OUD treatment. Key Results: Adults 50 and older comprised approximately 25% of all individuals reporting past-year prescription opioid misuse. A social source was most common for individuals under age 50 while a medical source was most common for individuals 50 and older. The most commonly reported motive for misuse was to “relieve physical pain”; the frequency of this response increased across age groups (47% aged 12–17 to 87% aged 65+). Among adults age 50 and older with prescription opioid misuse, 17% met criteria for OUD, 15% reported past-year benzodiazepine misuse, and 3% reported past-year heroin use. Conclusions: Physicians continue to be a direct source of prescription opioids for misuse, particularly for older adults. Ongoing clinical initiatives regarding optimal opioid prescribing practices are needed in addition to effective non-opioid strategies for pain management. Clinical initiatives should also include screening adult and adolescent patients for non-medical use of prescription opioids as well as improving access to OUD treatment for individuals of all ages.
... Growth of oxycodone and OxyContin sales5 Link to the ARCOS Data published by the Washington Post.As we can see fromFigure 1, total oxycodone sales increased substantially from 2000 to 2010, with per-person sales nearly quadrupling in the ten years period. From 2010 to 2015, sales of oxycodone declined as a result of aggressive measures taken by the states and the federal government to counter opioid addiction (Kennedy-Hendricks et al., 2016).The newly available ARCOS data suggests that the commonly held belief about OxyContin's dominance in the prescription opioid market at the time of reformulation is incorrect. ...
Preprint
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The opioid epidemic began with prescription pain relievers. In 2010 Purdue Pharma reformulated OxyContin to make it more difficult to abuse. OxyContin misuse fell dramatically, and concurrently heroin deaths began to rise. Previous research overlooked generic oxycodone and argued that the reformulation induced OxyContin users to switch directly to heroin. Using a novel and fine-grained source of all oxycodone sales from 2006-2014, we show that the reformulation led users to substitute from OxyContin to generic oxycodone, and the reformulation had no overall impact on opioid or heroin mortality. In fact, generic oxycodone, instead of OxyContin, was the driving factor in the transition to heroin. Finally, we show that by omitting generic oxycodone we recover the results of the literature. These findings highlight the important role generic oxycodone played in the opioid epidemic and the limited effectiveness of a partial supply-side intervention.
... 9 1 There is also a substantial literature that focuses on the causes of opioid use abuse and overdoses and the effect of policy changes on outcomes. For example, a number of papers have examined how policy has affected use, including prescription drug monitoring programs (Ali et al., 2017;Buchmueller and Carey, 2018;Grecu et al., 2019), Naloxone (Coffin and Sullivan, 2013;Rees et al., 2019), abuse-deterrent opioids (Alpert et al., 2018), physician interventions (Schnell and Currie, 2018), treatment (Borgschulte et al., 2018), and legalized marijuana (Bachhuber et al., 2014;Bradford and Bradford, 2016;Powell et al., 2018). 2 There are several studies that examine how opioids in the home affect family life (e.g. Garbutt et al., 2019;Wilens et al., 2002). ...
... 26 Furthermore, preliminary evidence suggests that a more restrictive control of prescribing and dispensing of opioid medications is associated with increased nonmedical use of opioid analgesic prescriptions as well as increased use of illicit opioids like heroin and illicitly manufactured fentanyl across the population overall. 27, 28 We did not study the implications of the FL HB21 policy on these patient outcomes and we propose to Pharmacists often have limited access to information regarding the indication for a prescription, but they are charged with ensuring both the safety of the patient as well as compliance with legislative restrictions on supply, which could place additional burden on both pharmacists and prescribers by necessitating prescription verifications and could delay or prevent access to care for patients. 29,30 Specific guidance for managing the care of patients with acute and chronic pain conditions will require tailoring and adapting health technology to ensure that pharmacists and prescribers can seamlessly communicate with each other and their patients to promote continuity of care. ...
Article
Full-text available
Objective To assess the impact of Florida’s 3-day opioid prescription supply law, effective July 2018, on opioids dispensed for acute pain patients. Methods Pharmacy claims from a health plan serving a large Florida employer from January 2015 through March 2019 were analyzed. We used an interrupted time series study design accounting for autocorrelation of trends before and after policy change. Acute pain patients met inclusion criteria if they had not received any opioid containing medications in the past 180 days. Patients could contribute to additional new use time if subsequent opioid claims occurred ≥180 days since the previous claim. Outcomes included mean number of units dispensed of the initial opioid prescription, mean morphine milligram equivalents (MMEs) per day of initial prescription by month, and mean total MMEs per initial prescription by month. Results A total of 8,375 enrollees had 10,583 unique opioid starts in the given timeframe. Following the policy, there was an immediate significant decrease in the units dispensed per prescription of 4.9 (95% CI -8.95, -0.82 units). Additionally, there was a significant immediate reduction in total MMEs dispensed per prescription of 25.6 (95% CI -44.76, -6.44 MMEs). Conclusions Among a group of privately-insured plan enrollees in Florida, and as a result of the law, there were significant decreases in the number of units dispensed, and total MMEs of opioid prescriptions. The immediate reduction in new opioid utilization following policy implementation suggests effective policy; however, impacts on chronic pain patients were not assessed.
... The disproportionate increase in heroin use among White individuals may be an unintended consequence of policies aimed at reducing opioid prescribing and misuse (Cicero et al., 2014). Prior studies have linked state and federal policies targeting prescription opioids to a rise in heroin use (Alpert et al., 2018;Cicero and Ellis, 2015;Cicero et al., 2012;, and qualitative work found that individuals switched to or supplemented with heroin when prescription opioids became too difficult/expensive to obtain (Cicero et al., 2014). Indeed, as the supply of prescription opioids contracted, the availability of heroin sharply increased, accompanied by a decline in price and an increase in purity (Office of National Drug Control Policy, 2014). ...
Article
Objective To characterize racial/ethnic differences in past-year prescription opioid misuse and heroin use Methods Data on 1,117,086 individuals age 12 and older were from the 1999-2018 National Survey on Drug Use and Health. We compared relative prevalences across 6 racial/ethnic groups for prescription opioid misuse analyses and 4 racial/ethnic groups for heroin analyses. Unadjusted and gender- and age-adjusted prevalences are reported for 5 time periods (1999-2002, 2003-2006, 2007-2010, 2011-2014, 2015-2018). Survey-weighted Poisson regression models with robust variance were used to estimate risk ratios by race/ethnicity and to test for time trends. Results Prescription opioid misuse was significantly higher among non-Hispanic White individuals than among Black, Hispanic, and Asian individuals across all time periods, yet was highest among Native American individuals in every time period. The relative difference between White and both Hispanic and Asian individuals significantly widened over time, whereas the gap between Black and White individuals significantly decreased. Early in the study period, heroin use was highest among Black and Hispanic individuals. Heroin use among White individuals first surpassed all other groups in 2007-2010 and continued to steadily increase, more than doubling from 1999-2002 to 2015-2018. Conclusions While heroin use has risen among all racial/ethnic groups, the demographics of heroin use have changed significantly in the past two decades such that prevalence is now highest among White individuals. Opioid prevention and treatment initiatives should both be informed by the changing demographics of heroin use and seek to reduce opioid-related harms and expand treatment access equitably for all racial/ethnic groups.
... Overall opioid prescribing has fortunately receded, 25 yet overdose deaths have negligibly changed because of this more lethal wave of heroin and illicit fentanyl abuse. 26,27 The point is this: Notably absent from this entire historical narrative is any mention of, association with, or causal attribution of the opioid crisis to intraoperative and immediate postoperative use of opioids to treat moderate-to-severe surgical pain. Similarly, it is a great and unfounded leap to say that there is an opioid crisis and therefore we must stop using opioids for surgery. ...
... To further test for illicit opioids as a confounder, we include the non-medical OxyContin misuse rate used in Alpert et al. (2018) interacted with time indicators as controls. This variable, which was constructed using the 2004À2009 National Survey on Drug Use and Health, was found to strongly predict the rise in heroin and synthetic opioid overdoses after the reformulation of OxyContin in 2010. ...
Article
As the opioid crisis has escalated, states have enacted numerous policies targeting opioid access and monitoring possible misuse. Recently, the majority of states have passed electronic prescribing mandates for controlled substances. These mandates require that controlled substances be prescribed electronically directly to the pharmacy. The electronic system maintains a rich patient history that prescribers will observe when issuing a prescription while also reducing opportunities for fraud. The first enforced mandate was implemented in New York in March 2016; thus empirical evidence about the effects of such mandates is limited. We study how adoption of the New York e-prescribing mandate affected opioid supply and opioid-related overdoses. We estimate that the mandate reduced the rate of overdoses involving natural and semi-synthetic opioids by 22%. We find little evidence of any corresponding changes in overdose rates involving illicit opioids.
... Previous studies suggest that policy change to restrict prescription of opioid therapy could potentially cause worsening outcomes for patients receiving COT for pain management (27); namely, reduced access to prescription therapies for patients with stable pain management increases risks of nonmedical use of opioid prescriptions, or alternatives with unfavorable risk, as well as risk for worsening quality of life and suicide (28,29). We found that although HB21 likely reduced the number of patients receiving COT, those patients who continued to receive COT retained similar quantities and dosage strengths of opioid therapy. ...
Article
Full-text available
Background: Florida House Bill 21 (HB21) was implemented in July 2018 to limit Schedule II opioids prescriptions for patients with acute pain to a 3-day supply. Little is known about the potential unintended effects that such opioid restriction policies may have on chronic pain patients, who are exempt from the law. Objective: We aimed to evaluate the effect of HB21 on opioid utilization measures among a cohort of chronic opioid therapy (COT) patients. Study design: A quasi-experimental design with interrupted time series analyses. Setting: Pharmacy claims from January 1, 2015 to June 31, 2019 from a large employer-based health plan in Florida. Methods: COT patients were those who received a ≥ 70 days' supply of opioids in the prior 90 days, representing 15,310 patients. Interrupted time series analyses were conducted to compare the following monthly measures among COT patients before and after HB21 implementation: 1) number of COT patients, 2) daily Morphine Milligram Equivalents [MMEs], 3) days' supply of prescriptions. Results: There was a significant 25% reduction in the trend (pre-HB21 RR: 0.95, 95% CI: 0.93, 0.96 versus post-HB21 RR: 0.70, 95% CI: 0.65, 0.76) and an 8% immediate decrease (RR: 0.92, 95% CI: 0.88, 0.97) in the monthly prevalence of COT patients after HB21 implementation. However, no significant change was observed in trends for monthly number of days supplied per prescription, monthly MMEs per COT patient-day, or total MMEs per prescription. Limitations: Our study used data from employer-based private health insurance and did not include a longer post-policy period to adjust for implementation lag. Conclusion: Fewer patients received COT after HB21; however, patients who continued to receive COT experienced no significant changes in their regimen. The study did not assess whether COT patients were appropriately tapered or if therapeutic alternatives were initiated for new chronic pain patients.
... Although this change had a large effect on the demand for oxycodone products and their substitutes, there is little reason to expect a large positive effect on shipments to Kentucky relative to Indiana. Alpert et al. (2016) show that Kentucky and Indiana had the same rates of Oxycontin misuse before the reformulation and thus were similarly exposed to it. ...
Thesis
The US healthcare system faces numerous challenges. In this dissertation I study issues of access to care, healthcare costs, and responses to the opioid epidemic. I take an applied economic approach, using causal inference methods to examine the effects of recent policies and changes to landscape of healthcare providers. In the first chapter, I study urgent care centers (UCCs), which provide timely care for nonchronic, low-severity health conditions. Over the past decade, UCCs have disrupted the market for outpatient healthcare. The entry of these new providers may reduce healthcare spending by diverting care from higher cost emergency departments. Alternatively, if UCC entry increases healthcare utilization, total spending may increase. I use administrative insurance claims data from Massachusetts to estimate the effect of UCC entry on healthcare utilization and spending. The data span 2012 to 2015, during which the number of UCCs increased by 88 percent. In the months immediately following UCC entry, patients substitute away from other outpatient providers. Patients substantially reduce visits to physician offices and outpatient clinics, and slightly reduce visits to emergency departments. Overall, UCC entry increases the efficiency of the healthcare system. Aggregate spending appears to modestly decline, while in areas with few primary care providers, UCC entry increases the total number of healthcare visits. The second chapter examines the effect of insurance coverage on utilization of prescription drugs that treat ADHD. It uses a regression discontinuity design that exploits the change in eligibility for dependent insurance coverage at age 26. From 2014-2017, the probability of insurance coverage decreased by 5 percentage points at this threshold. I examine the effect on central nervous system stimulant expenditures using an administrative database that captures all prescriptions filled at Kentucky pharmacies. At the eligibility threshold, the probability of purchasing a prescription drops by 5-7 percentage points and expenditures fall by 18-27 percent. Only 30 percent of the decrease in prescriptions purchased with insurance is offset by an increase in prescriptions purchased out-of-pocket. People also decrease expenditures by switching from branded medications to a category of similar generics that costs $104 (43 percent) less per prescription. The probability of filling a prescription recovers as people regain insurance, but decreases in expenditures persist longer-term. The third chapter studies opioid control policies that target the prescribing behavior of health care providers. In this chapter, (co-authored by Thomas Buchmueller and Colleen Carey), we study the first comprehensive state-level policy requiring providers to access patients' opioid history before making prescribing decisions. We compare prescribers in Kentucky, which implemented this policy in 2012, to those in a control state, Indiana. Our main difference-in-differences analysis uses the universe of prescriptions filled in the two states to assess how the information provided affected prescribing behavior. We find that a significant share of low-volume providers stopped prescribing opioids altogether after the policy was implemented, though this change accounted for a small share of the reduction in total volume. The most important margin of response was to prescribe opioids to fewer patients. While providers disproportionately discontinued treating patients whose opioid histories showed the use of multiple providers, there were also economically-meaningful reductions for patients without multiple providers and single-use acute patients.
Article
Context: Opioid prescribing to cancer patients is declining, but it is unknown whether reductions have been tailored to those at highest risk of opioid-related harms. Objectives: Examine whether declines in opioid dispensing to patients receiving active cancer treatment are sharper in patients with substance use disorder (SUD) or mental health diagnoses. Methods: We used 2008-2018 national, commercial healthcare claims data to examine adjusted and unadjusted trends in opioid dispensing (receipt of ≥1 fill; average daily dosage; receipt of high-dose opioids; receipt of concurrent opioids and benzodiazepines) to patients ages ≥18 receiving treatment for one of four cancer types (breast; colorectal; head and neck; sarcoma; N=324,789 patients). To compare declines across subgroups with varying risk of opioid-related harms, we stratified by SUD and mental health diagnosis. To address potential confounding, we estimated subgroup-specific trends using generalized estimating equations, adjusting for covariates. Results: Across groups, rate of ≥1 opioid fill per quarter fell 32.5% (95% CI: 31.8%-33.2%) from 2008 to 2018; daily dose among those receiving opioids fell 37.6% (95% CI: 36.7%-38.6%). In most cases, these declines were not sharper in subgroups at greater risk of opioid-related harms. For example, patients with opioid use disorder experienced the smallest declines in dispensing frequency, and there was no evidence that declines were sharper in patients with mental health diagnoses. Conclusion: Sharp declines in opioid prescribing during the drug overdose crisis have affected a wide range of patients undergoing cancer treatment and may not have been sufficiently tailored to patient characteristics. Research on implications for opioid-related harms and pain management is needed.
Article
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The United States is currently in the midst of the worst drug epidemic in its history, with nearly 64,000 overdose deaths in 2016. In response, pharmaceutical companies have begun introducing abuse‐deterrent painkillers, pills with properties that make the drug more difficult to misuse. The first such painkiller, a reformulated version of OxyContin, was released in 2010. Previous research has found no net effect on opioid mortality, with users substituting from OxyContin toward heroin. This paper explores health effects of the reformulation beyond mortality. In particular, I show that heroin is substantially more likely to be injected than OxyContin, increasing exposure to blood‐borne diseases. Exploiting variation across states in OxyContin misuse prior to the reformulation, I find relative increases in the spread of hepatitis B and C in states most likely to be affected by the reformulation. In aggregate, the estimates suggest that absent the reformulation, we would have observed approximately 76% fewer cases of hepatitis C and 53% fewer cases of hepatitis B from 2011 to 2015. I find some suggestive evidence that the reformulation also lead to increases in HIV and hepatitis A, although these findings are less robust. These findings have important implications for future policies addressing the opioid crisis.
Article
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Mandatory access Prescription Drug Monitoring Programs (MA‐PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA‐PDMP's effect on specialty‐specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA‐PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA‐PDMPs may help close provider‐patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.
Article
The introduction of abuse-deterrent OxyContin in 2010 was intended to reduce its misuse by making it more tamper resistant. However, some studies have suggested that this reformulation might have had unintended consequences, such as increases in heroin-related deaths. We used the 2005-2014 cross-sectional U.S. National Survey on Drug Use and Health to explore the impact of this reformulation on intermediate outcomes that precede heroin-related deaths for individuals with a history of OxyContin misuse. Our study sample consisted of adults who misused any prescription pain reliever prior to the reformulation of OxyContin (n = 81,400). Those who misused OxyContin prior to the reformulation were considered the exposed group and those who misused other prescription pain relievers prior to the reformulation were considered the unexposed group. We employed multivariate logistic regression under a difference-in-differences framework to examine the effect of the reformulation on five dichotomous outcomes: prescription pain reliever misuse; prescription pain reliever use disorder; heroin use; heroin use disorder; and heroin initiation. We found a net reduction in the odds of prescription pain reliever misuse (OR:0.791, p < 0.001) and heroin initiation (OR:0.422, p = 0.011) after the reformulation for the exposed group relative to the unexposed group. We found no statistically significant effects of the reformulation on prescription pain reliever use disorder (OR: 0.934, p = 0.524), heroin use (OR: 1.014p = 0.941), and heroin use disorder (OR: 1.063, p = 0.804). Thus, the reformulation of OxyContin appears to have reduced prescription pain reliever misuse without contributing to relatively greater new heroin use among those who misused OxyContin prior to the reformulation.
Article
Background Parental substance misuse impacts millions of children globally and is a major determinant of repeat maltreatment and out-of-home placement. There is little published research on family-based, comprehensive treatment models that simultaneously address parental substance misuse and child maltreatment. Objective This study reports outcomes from a randomized clinical trial examining the effectiveness of the Multisystemic Therapy – Building Stronger Families (MST-BSF) treatment model with families involved with Child Protective Services due to physical abuse and/or neglect plus parental substance misuse. Participants and setting Ninety-eight families who had an open case with Child Protective Services in two areas of the state of Connecticut participated. Method Families referred by the Connecticut Department of Children and Families were randomly assigned to MST-BSF or Comprehensive Community Treatment (CCT). Both interventions were delivered by community-based therapists. Outcomes were measured across 5 assessments extending 18 months post-baseline. Results Intent-to-treat analyses showed that MST-BSF was significantly more effective than CCT in reducing parent self-reported alcohol and opiate use and in improving child-reported neglectful parenting. Although means were in predicted directions, new incidents of abuse across 18 months did not differ between groups. The study features high recruitment and engagement rates for a population experiencing multiple involvements with child protection. Conclusion The outcomes of this study support the effectiveness of MST-BSF, an intensive family- and ecologically- based treatment, for significantly reducing parental alcohol and opiate misuse and child neglect. These findings help in our understanding of how best to address the understudied issue of interventions for child neglect.
Article
Background: Since 2016, an increasing number of states have passed laws restricting the days' supply for opioid prescriptions, yet little is known about how these laws affect patients. This study evaluates the effect of the Tennessee Prescription Regulatory Act, which was implemented on Oct. 1st, 2013 and restricted the maximum days' supply that could be dispensed for any opioid prescription by any prescriber to 30 days, on patients receiving long-term opioid treatment. Methods: A quasi experimental model, an interrupted time series (ITS), was used with observational data to estimate the effect of the policy on monthly patient opioid prescription outcomes. Data for this study came from the Tennessee Controlled Substance Monitoring Database between October 1st, 2012 and October 31st, 2014. The study population included patients receiving long-term opioid treatment who filled an opioid prescription in at least 4 months in the 12-month pre-policy period and received at least one prescription in the pre-policy period with a days' supply exceeding 30 days. Three outcomes were measured each month for every patient based on their opioid prescriptions: per-prescription days' supply per-prescription, daily morphine milligram equivalent (DMME), and total opioid prescriptions. All models controlled for individual fixed effects, age, and benzodiazepine prescriptions and utilized cluster robust standard errors to address serial correlation. Results: The change in law was associated with a decline in the average days' supply by -5.30 days (95% CI: -5.64, -4.96), and number of prescriptions by -1.3% (95% CI: -3%, -0.07%), but an increase in the average DMME by 1.41 (95% CI: 0.37, 2.45). Conclusions: Prescribers responded to the Addison Sharp Prescription Regulatory Act by significantly decreasing the days' supply in opioid prescriptions among current patients receiving long-term opioid treatment who had at least one prescription exceeding the maximum days' supply set by the law in the pre-policy period.
Article
Introduction Rising rates of methamphetamine use among populations using opioids is an escalating public health concern. The purpose of this manuscript is to identify socioecologic factors driving increases in methamphetamine use among Appalachian Kentucky adults with a history of opioid use. Methods Semi-structured qualitative interviews were conducted among 20 Appalachian Kentuckians in the Social Network of Appalachian Peoples (SNAP) cohort who reported lifetime opioid use and past 30-day methamphetamine use. Interviews focused on initiation of methamphetamine use, factors that influence methamphetamine use at the individual, interpersonal, community and society levels. Results Participants reported using methamphetamine to self-treat underlying issues, including withdrawal from opioids, chronic pain, and emotional distress. Initiation of use was most often facilitated through their drug networks. Participants reported that methamphetamine was widely available and affordable in their community. Several participants with extensive histories of non-medical prescription opioid (NMPO) use described transitioning to methamphetamine as their drug of choice as opioids became less available in their community. Participants also reported economic distress and lack of recreational opportunities as drivers of increased methamphetamine use. Discussion Recent increases in methamphetamine use among those with a history of opioid use is facilitated by methamphetamine’s relative availability and affordability. Methamphetamine use was also highly influenced by societal factors such as economic deprivation and policies that decreased availability of NMPOs. Surging methamphetamine use exacerbates inequities in addiction care brought to light by the opioid epidemic. Interventions aimed at addressing the socioecological drivers of methamphetamine use among people who use opioids are warranted.
Article
Drug overdoses involving opioid analgesics have increased dramatically since 1999, representing one of the United States’ top public health crises. Opioids have legitimate medical functions, but they are often diverted, suggesting a tradeoff between improving medical access and nonmedical abuse. We provide causal estimates of the relationship between the medical opioid supply and drug overdoses using Medicare Part D as a differential shock to the geographic distribution of opioids. Our estimates imply that a 10% increase in opioid medical supply leads to a 7.1% increase in opioid-related deaths among the Medicare-ineligible population, suggesting substantial diversion from medical markets.
Article
s This article explores the question of what we can consider to be real in drug policy. It examines two increasingly common aspects of drug policy analysis; radical constructionist critique and successionist data science. It shows how researchers using these assumptions have produced interesting findings, but also demonstrates their theoretical incoherence, based on their shared ‘flat ontology’. The radical constructionist claim that reality is produced within research methods – as seen in some qualitative studies - is shown to be unsustainably self-defeating. It is analytically ‘paralyzing’. This leads to two inconsistencies in radical constructionist studies; empirical ambivalence and ersatz epistemic egalitarianism. The Humean successionist approach of econometric data science is also shown to be unsustainable, and unable to provide explanations of identified patterns in data. Four consequent, limiting characteristics of this type of drug policy research are discussed: causal inference at a distance, monofinality, limited causal imagination, and overly confident causal claims. The article goes on to describe the critical realist approach towards ‘depth ontology’ and ‘generative causation’. It provides examples of how this approach is deployed in critical realist reviews and discourse analysis of drug policy. It concludes by arguing that critical realism enables more deeply explanatory, methodologically eclectic and democratically inclusive analysis of drug policy development and effects.
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The evolution of risk identification and ultimately the public and private responses that have become known collectively as the “opioid crisis” is an important case study in risk management due to the reach and magnitude of its impacts. This article examines a number of “signals” related to opioid risks using the social amplification of risk framework (SARF) to investigate a limited set of public‐sector activities and policy responses. We evaluate whether the SARF presents an effective lens to examine the serious shortcomings of risk management of opioid use, which has a history of risk attenuation and, more recently, evidence of risk amplification. Our goal in this article is limited to addressing “goodness of fit” of the SARF as a descriptive tool. We consider whether the SARF effectively reveals important gaps in public risk management responses for the opioid example and other similarly situated societal risk problems. Applying SARF supports that its suggested relationship between risk signals and inappropriate attenuated public response does generate useful insights into regulatory efficacy for examples of public risk management. Similar such conclusions about inappropriate public responses stemming from the amplification factors are less supported because, in this case, the risk is, and continues to be, large. Overall, we find that the SARF's particular focus on the signaling function of risk information performs best as an organizational aid to study historical information rather than as a predictive tool for determining inappropriate risk management responses.
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Many opioid control policies target the prescribing behavior of health care providers. In this paper, we study the first comprehensive state‐level policy requiring providers to access patients' opioid history before making prescribing decisions. We compare prescribers in Kentucky, which implemented this policy in 2012, to those in a control state, Indiana. Our main difference‐in‐differences analysis uses the universe of prescriptions filled in the two states to assess how the information provided affected prescribing behavior. We find that a significant share of low‐volume providers stopped prescribing opioids altogether after the policy was implemented, though this change accounted for a small share of the reduction in total volume. The most important margin of response was to prescribe opioids to fewer patients. Although providers disproportionately discontinued treating patients whose opioid histories showed the use of multiple providers, there were also economically meaningful reductions for patients without multiple providers and single‐use acute patients.
Article
Umbrella branding is a marketing practice whereby multi-product firms leverage their reputation across different product categories. The paper investigates how advertising in the market for non-prescription drugs affects the decision to buy prescription drugs from the same firm. To estimate the effects of umbrella branding, I exploit the fact that consumer directed advertising of prescription drugs is prohibited in Germany and identify advertising spillovers with an instrumental variable that builds on exogenous seasonality in the non-prescription drug industry. Umbrella branding results in market expansion, particularly for generic firms, and can have a positive effect on consumer welfare in under-treated therapeutic areas.
Article
Objective To determine the association between the abuse-deterrent reformulation of OxyContin and adolescent lifetime heroin use in the United States. Methods The quasi-experimental study uses individual survey data from the 1999-2019 Youth Risk Behavior Surveillance System to examine whether the reformulation of OxyContin in August 2010 affected adolescent lifetime heroin use, exploiting heterogeneity in state-level rates of OxyContin misuse before the reformulation. Multiple regression analysis adjusted for state and year fixed effects, adolescent demographics, and time-varying state characteristics and policies. Results The release of the abuse-deterrent reformulation of OxyContin was associated with a reduction in adolescents reporting ever using heroin. An adolescent in a state with a one percentage point higher state-level rate of pre-reformulation OxyContin misuse was 1.7 percentage points less likely to report ever using heroin after the reformulation (95 percent confidence interval, [(CI) = -0.007, -0.027]). These effects are strongest for adolescent males (estimate: -0.028, [(CI) = -0.016, 0.040]) and non-whites (estimate: -0.021, [(CI) = -0.005, -0.037]). Conclusions These results suggest the release of abuse-deterrent OxyContin is associated with a decrease in the likelihood of adolescent lifetime heroin use in states with higher pre-reformulation rates of OxyContin misuse. Pharmaceutical innovations and policies that reduce the likelihood of prescription opioid misuse may be effective in reducing adolescent lifetime heroin use.
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Drug control policy can have unintended consequences by pushing existing users to alternative, possibly more dangerous substances. Policies that target only new users may therefore be especially promising. Using commercial insurance claims data, we provide the first evidence on a set of new policies intended to reduce opioid initiation in the form of limits on initial prescription length. We also provide the first evidence on the impact of must-access prescription drug monitoring programs (MA-PDMPs), laws that do not target new users, on initial opioid use. Although initial limit policies reduce the average length of initial prescriptions, they do so primarily by raising the frequency of short prescriptions, resulting in increases in opioids dispensed to new users. In contrast, we find that MA-PDMPs reduce opioids dispensed to new users, even though they do not explicitly set out to do so. Neither policy significantly affects extreme use such as doctor shopping among new patients, because such behavior is very rare.
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States have responded to the opioid epidemic by implementing statewide prescription drug monitoring programs (PDMPs). By helping identify patients at “high risk” for suspected misuse, diversion, and doctor shopping, mandatory PDMPs aim to reduce prescription‐opioid misuse and related overdose mortality. So far, however, there is little research on whether prescribing declines following mandatory PDMP laws were targeted toward patient‐age groups with a higher incidence of prescription‐opioid misuse. To examine the heterogeneous impacts of state laws on different patient‐age groups, this study exploits the implementation of PDMP reforms in Kentucky starting July 20, 2012. The analysis uses novel data from PDMPs, including the universe of opioid prescriptions dispensed between January 2012 and November 2013. Individual prescriber‐level difference‐in‐differences, with Indiana as the control state, show that practitioners responded to Kentucky's new laws as expected, by prescribing opioids to fewer patients and authorizing fewer prescriptions and days of supply per prescription. Opioid prescribing declined most sharply to patient sub‐populations with the highest past incidence of prescription‐opioid‐involved overdose mortality—ages 25–54 years. Considering the implication for overdose mortality, we find that Kentucky's PDMP reform was associated with significant declines in prescription‐opioid overdose deaths, particularly among adolescents and younger adults (ages 15–34 years). However, the decline in prescription‐opioid‐involved mortality was offset by an increase in illicit‐drug mortality, resulting in no net change in total drug‐overdose mortality in Kentucky following its mandatory PDMP.
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Background United States (US) policies to mitigate the opioid epidemic focus on reducing access to prescription opioids to prevent overdoses. We examined the impact of state policies in Vermont (July 2017) and Maine (July 2016) on opioid overdoses and opioid-related adverse effects. Methods Study population included patients 15 years and older in all-payer claims of Vermont (N = 597,683; Jan.2016-Dec.2018) and Maine (N = 1,370,960; Oct.2015-Dec.2017). We used interrupted time series analyses to assess the impact of opioid prescribing policies on monthly opioid overdose rate and opioid-related adverse effects rate. We used the International Classification of Disease-10-CM to identify overdoses (T40.0 × 1-T40.4 × 4, T40.601-T40.604, T40.691-T40.694) and adverse effects (T40.0 × 5, T40.2 × 5-T40.4 × 5, T40.605, T40.695). Results Immediately after the policy, the level of Vermont's opioid overdose rate increased by 34% (95% confidence interval, CI: 1.09, 1.65) while the level of opioid-related adverse effects rate decreased by 29% (95% CI: 0.58, 0.87). In Maine, there was no level change in opioid overdose rate, but the slope of the adverse effects rate after the policy decreased by 3.5% (95% CI: 0.94, 0.99). These results varied within age and rurality subgroups in both states. Conclusion While the decrease in rate of adverse effects following the policy changes is promising, the increase in Vermont's opioid overdose rate may suggest there is an association between policy implementation and short-term risk to public health.
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In response to the opioid crisis, each US state has implemented a prescription drug monitoring program (PDMP) to collect data on controlled substances prescribed and dispensed in the state. I study whether health information technology (HIT) complements patient prescription data in PDMPs to reduce opioid‐related mortality and morbidity. A novel dataset is constructed that records state policies that integrate PDMP with HIT and facilitate interstate data sharing. Using difference‐in‐differences models, I find that PDMP‐HIT integration policies reduce opioid‐related inpatient morbidity. The reductions are substantial in states that established integration without ever mandating the use of a PDMP. A mechanism test suggests that PDMP integration works mainly through the hospital system while a mandate affects legal opioids prescription. The impacts from integration are strongest for the vulnerable groups—middle‐aged, low‐to middle‐income patients, and those with public insurance. There is suggestive evidence that interstate data sharing further complements integration despite not having a significant impact independently. The results are robust to a set of tests using alternative specifications and measures. The total benefits from integration far exceed the associated costs.
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: Rates and patterns of transition from opioid analgesic to illicit opioid (ie, heroin) use is of great clinical significance. Exposure to opioid analgesics, and whether use is therapeutic or outside a doctor's orders, may have overlapping yet different patterns of transition to heroin use. Yet, this topic is rarely examined in longitudinal studies. With data from the landmark Monitoring the Future (MTF) study, McCabe and colleagues have now studied the transition from adolescent use of opioid analgesics (both medical and nonmedical) to heroin over a seventeen year follow up for adolescents first recruited from 1975 to 2000. Key findings include an overall association of both nonmedical and medical use of opioid analgesics with transition to heroin use, with particular concerns about early nonmedical use. Of note, more recent cohorts apparently have an increased risk of transition to heroin, suggesting a need for minimizing opioid prescribing and for screening of youth and young adults for prior nonmedical opioid analgesic use before prescribing opioids. New research is also suggested to address such questions as: What is the time course of exposure to the start of heroin use? How does the frequency and dosage of exposure matter? Continued analyses of MTF data, as well as exploration of other data are needed to address these and related compelling issues.
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We study the relationship between opioid use and child well‐being. We combine data on legal opioid prescriptions, opioid‐related emergency department visits, and opioid‐involved mortality with foster care entrance records and child maltreatment reports. We find that increases in opioid‐related mortality and emergency department visits are associated with increased foster care entry, particularly among young children. We find no significant relationship between legal opioid distribution quantities and home removals. Finally, we examine the relationship between opioid‐related public policies and child welfare outcomes, finding mixed relationships between various policies and removal from the home.
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The Medicaid expansions made addiction treatment more accessible but they also made it less costly to obtain the prescription opioids that can trigger an addiction. We investigated the association between the Medicaid expansions and drug-related deaths. We add to the literature by explicitly accounting for the properties of illicit drug markets and by conducting a simulation-based power analysis to assess whether a plausible change in drug-related mortality could be detected with our data. We identify three main challenges in isolating the effect of the Medicaid expansions on drug-related mortality that cannot be sufficiently addressed with current data: (a) nonparallel preexpansion trends in drug-related mortality, (b) the contemporaneous surge in the supply of illicitly manufactured fentanyl, and (c) lack of statistical power. We argue that more comprehensive data are needed to answer this question.
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Wicked problems are open-ended, highly interdependent issues that cross agency, stakeholder, jurisdictional, and geopolitical boundaries. In response, there has been advocacy for interagency working. However, this confounds conventional approaches to government because policies and budgets tend to be aligned within organizational boundaries and not across them, making it difficult to bring the appropriate talent, knowledge and assets into an interagency approach to tackle the interdependencies of whatever wicked problem is at hand. In addition, the purposes, perspectives and values of the various government agencies and other stakeholders can often be in conflict. This is one of a pair of papers reporting on research to develop and evaluate a systemic intervention approach involving the use of multiple methods underpinned by boundary critique to address a wicked problem. In this first paper, the major focus is how to create a common understanding of a wicked problem among multiple agencies using a participatory problem structuring method called ‘systemic perspective mapping’. The wicked problem we tackled was international organized drug crime and its intersection with local urban gang activity (using Chicago, USA, as a representative city). Perspectives on the problem were structured with participation from various local, regional and federal agencies involved in countering illegal drug trafficking. Our research found that the combined use of boundary critique and systemic perspective mapping was able to generate enough of a common understanding to provide a foundation for the design of an interagency organization using the viable system model (the latter is reported in the second paper).
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Although supply-side drug policies that limit access to legal opioids have reduced prescription opioid abuse, growing evidence shows that these policies have had the unintended consequence of increasing use of illegal opioids, including heroin. I add to this literature by studying the consequences of must-access prescription drug monitoring programs (PDMPs), which legally require providers to access a state-level database with a patient's prescription history before prescribing controlled substances under certain circumstances. Using a difference-in-differences specification, I find strong evidence that must-access PDMPs have increased heroin death rates. My estimates indicate that two years after implementation, must-access PDMPs were associated with 0.9 more heroin deaths per 100,000 in a half-year period, relative to control states. My results suggest that even if must-access PDMPs reduce prescription opioid deaths, the decrease is offset by a large increase in illegal opioid deaths.
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This paper documents how substance abuse treatment (SAT) providers and services respond to increases in population‐level opioid addiction. I do this by exploiting the implementation of Medicare Part D as an exogenous increase in the availability of prescription opioids. Starting in 2006, states with higher shares of the population eligible for Medicare Part D experienced increases in residential and hospital inpatient SAT facilities, beds dedicated to SAT, and SAT facilities offering medication‐assisted treatment, relative to states with lower shares. These results suggest that the supply of SAT in the United States is capable of responding significantly to changes in demand.
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Importance: It is important to understand the magnitude and distribution of the economic burden of prescription opioid overdose, abuse, and dependence to inform clinical practice, research, and other decision makers. Decision makers choosing approaches to address this epidemic need cost information to evaluate the cost effectiveness of their choices. Objective: To estimate the economic burden of prescription opioid overdose, abuse, and dependence from a societal perspective. Design, setting, and participants: Incidence of fatal prescription opioid overdose from the National Vital Statistics System, prevalence of abuse and dependence from the National Survey of Drug Use and Health. Fatal data are for the US population, nonfatal data are a nationally representative sample of the US civilian noninstitutionalized population ages 12 and older. Cost data are from various sources including health care claims data from the Truven Health MarketScan Research Databases, and cost of fatal cases from the WISQARS (Web-based Injury Statistics Query and Reporting System) cost module. Criminal justice costs were derived from the Justice Expenditure and Employment Extracts published by the Department of Justice. Estimates of lost productivity were based on a previously published study. Exposure: Calendar year 2013. Main outcomes and measures: Monetized burden of fatal overdose and abuse and dependence of prescription opioids. Results: The total economic burden is estimated to be $78.5 billion. Over one third of this amount is due to increased health care and substance abuse treatment costs ($28.9 billion). Approximately one quarter of the cost is borne by the public sector in health care, substance abuse treatment, and criminal justice costs. Conclusions and relevance: These estimates can assist decision makers in understanding the magnitude of adverse health outcomes associated with prescription opioid use such as overdose, abuse, and dependence.
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In an effort to reduce wide-scale abuse of the proprietary oxycodone hydrochloride formulation OxyContin, an abuse-deterrent formulation (ADF) was introduced in 2010. Although the reformulation produced an immediate drop in abuse rates, a definite ceiling effect appeared over time, beyond which no further decrease was seen. To examine the factors that led to the initial steep decline in OxyContin abuse and the substantial levels of residual abuse that have remained relatively stable since 2012. We used data from the ongoing Survey of Key Informants' Patients program, part of the Researched Abuse, Diversion and Addiction-Related Surveillance system that collects and analyzes postmarketing data on misuse and diversion of prescription opioid analgesics and heroin. For our survey study, patients with a DSM-V diagnosis of opioid use disorder and primary drug of abuse consisting of a prescription opioid or heroin (N = 10 784) at entry to 1 of 150 drug treatment programs in 48 states completed an anonymous structured survey of opioid abuse patterns (surveys completed from January 1, 2009, through June 30, 2014). A subset of these patients (n = 244) was interviewed to add context and expand on the structured survey. In addition to key demographic measures, past-month abuse of opioids was the primary measure in the structured surveys. In the interviews, the effect of the introduction of the ADF on drug-seeking behavior was examined. Reformulated OxyContin was associated with a significant reduction of past-month abuse after its introduction (45.1% [95% CI, 41.2%-49.1%] in January to June 2009 to 26.0% [95% CI, 23.6%-28.4%] in July to December 2012; P < .001; χ2 = 230.83), apparently owing to a migration to other opioids, particularly heroin. However, this reduction leveled off, such that 25% to 30% of the sample persisted in endorsing past-month abuse from 2012 to 2014 (at study end [January to June 2014], 26.7% [95% CI, 23.7%-29.6%]). Among the 88 participants who indicated experience using pre-ADF and ADF OxyContin, this residual level of abuse reflects the following 3 phenomena: (1) a transition from nonoral routes of administration to oral use (38 participants [43%]); (2) successful efforts to defeat the ADF mechanism leading to a continuation of inhaled or injected use (30 participants [34%]); and (3) exclusive use of the oral route independent of formulation type (20 participants [23%]). Abuse-deterrent formulations can have the intended purpose of curtailing abuse, but the extent of their effectiveness has clear limits, resulting in a significant level of residual abuse. Consequently, although drug abuse policy should focus on limiting supplies of prescription analgesics for abuse, including ADF technology, efforts to reduce supply alone will not mitigate the opioid abuse problem in this country.
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Public health authorities have described, with growing alarm, an unprecedented increase in morbidity and mortality associated with use of opioid pain relievers (OPRs). Efforts to address the opioid crisis have focused mainly on reducing nonmedical OPR use. Too often overlooked, however, is the need for preventing and treating opioid addiction, which occurs in both medical and nonmedical OPR users. Overprescribing of OPRs has led to a sharp increase in the prevalence of opioid addiction, which in turn has been associated with a rise in overdose deaths and heroin use. A multifaceted public health approach that utilizes primary, secondary, and tertiary opioid addiction prevention strategies is required to effectively reduce opioid-related morbidity and mortality. We describe the scope of this public health crisis, its historical context, contributing factors, and lines of evidence indicating the role of addiction in exacerbating morbidity and mortality, and we provide a framework for interventions to address the epidemic of opioid addiction. Expected final online publication date for the Annual Review of Public Health Volume 36 is March 18, 2015. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.
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Key findings: Data from the National Vital Statistics System, Mortality File. The age-adjusted rate for opioid-analgesic poisoning deaths nearly quadrupled from 1.4 per 100,000 in 1999 to 5.4 per 100,000 in 2011. Although the opioid-analgesic poisoning death rates increased each year from 1999 through 2011, the rate of increase has slowed since 2006. Natural and semisynthetic opioid analgesics, such as hydrocodone, morphine, and oxycodone, were involved in 11,693 drug-poisoning deaths in 2011, up from 2,749 deaths in 1999. Benzodiazepines were involved in 31% of the opioid-analgesic poisoning deaths in 2011, up from 13% of the opioid-analgesic poisoning deaths in 1999. During the past decade, adults aged 55-64 and non-Hispanic white persons experienced the greatest increase in the rates of opioid-analgesic poisoning deaths. Poisoning is the leading cause of injury death in the United States (1). Drugs-both illicit and pharmaceutical-are the major cause of poisoning deaths, accounting for 90% of poisoning deaths in 2011. Misuse or abuse of prescription drugs, including opioid-analgesic pain relievers, is responsible for much of the recent increase in drug-poisoning deaths (2). This report highlights trends in drug-poisoning deaths involving opioid analgesics (referred to as opioid-analgesic poisoning deaths) and updates previous Data Briefs on this topic.
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Background: Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation. Methods: CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines. Results: In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone. Conclusions: Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety. Implications for public health: State policy makers might reduce the harms associated with abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.
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During 2003-2009, the number of deaths caused by drug overdose in Florida increased 61.0%, from 1,804 to 2,905, with especially large increases in deaths caused by the opioid pain reliever oxycodone and the benzodiazepine alprazolam. In response, Florida implemented various laws and enforcement actions as part of a comprehensive effort to reverse the trend. This report describes changes in overdose deaths for prescription and illicit drugs and changes in the prescribing of drugs frequently associated with these deaths in Florida after these policy changes. During 2010-2012, the number of drug overdose deaths decreased 16.7%, from 3,201 to 2,666, and the deaths per 100,000 persons decreased 17.7%, from 17.0 to 14.0. Death rates for prescription drugs overall decreased 23.2%, from 14.5 to 11.1 per 100,000 persons. The decline in the overdose deaths from oxycodone (52.1%) exceeded the decline for other opioid pain relievers, and the decline in deaths for alprazolam (35.6%) exceeded the decline for other benzodiazepines. Similar declines occurred in prescribing rates for these drugs during this period. The temporal association between the legislative and enforcement actions and the substantial declines in prescribing and overdose deaths, especially for drugs favored by pain clinics, suggests that the initiatives in Florida reduced prescription drug overdose fatalities.
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Purpose Abuse of opioid analgesics for their psychoactive effects is associated with a large number of fatalities. The effect of making opioid tablets harder to crush/dissolve on opioid-related fatalities has not been assessed. The objective of this study was to assess the impact of introducing extended-release oxycodone (ERO [OxyContin®]) tablets containing physicochemical barriers to crushing/dissolving (reformulated ERO) on deaths reported to the manufacturer. Methods All spontaneous adverse event reports of death in the US reported to the manufacturer between 3Q2009 and 3Q2013 involving ERO were used. The mean numbers of deaths/quarter in the 3 years after reformulated ERO introduction were compared with the year before. Changes in the slope of trends in deaths were assessed using spline regression. Comparison groups consisted of non-fatal reports involving ERO and fatality reports involving ER morphine. Results Reports of death decreased 82% (95% CI: −89, −73) from the year before to the third year after (131 to 23 deaths per year) reformulation; overdose death reports decreased 87% (95% CI: −93, −78) and overdose deaths with mention of abuse-related behavior decreased 86% (95% CI:−92, −75). In contrast, non-fatal ERO reports did not decrease post-reformulation, and reported ER morphine fatalities remained unchanged. The ratio of ERO fatalities to all oxycodone fatalities decreased from 21% to 8% in the year pre-reformulation to the second year post-reformulation. Conclusions These findings, when considered in the context of previously published studies using other surveillance systems, suggest that the abuse-deterrent characteristics of reformulated ERO have decreased the fatalities associated with its misuse/abuse. © 2014 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd.
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Abuse and misuse of prescription opioids are serious public health problems. Abuse-deterrent formulations are an intervention to balance risk mitigation with appropriate patient access. This study evaluated the effects of physicochemical barriers to crushing and dissolving on safety outcomes associated with extended-release oxycodone (ERO) tablets (OxyContin) using a national surveillance system of poison centers. Other single-entity (SE) oxycodone tablets and heroin were used as comparators and to assess substitution effects. The National Poison Data System covering all US poison centers was used to measure changes in exposures in the year before versus the 2 years after introduction of reformulated ERO (7/2009-6/2010 vs 9/2010-9/2012). Outcomes included abuse, therapeutic errors affecting patients, and accidental exposures. After ERO reformulation, abuse exposures decreased 36% for ERO, increased 20% for other SE oxycodone, and increased 42% for heroin. Therapeutic errors affecting patients decreased 20% for ERO and increased 19% for other SE oxycodone. Accidental exposures decreased 39% for ERO, increased 21% for heroin, and remained unchanged for other SE oxycodone. During the study period, other interventions to reduce opioid abuse occurred, for example, educational and prescription monitoring programs. However, these have shown small effects and do not explain a drop for ERO exposures but not for other opioids. After ERO reformulation, calls to poison centers involving abuse, therapeutic errors affecting patients, and accidental exposures decreased for ERO, but not for comparator opioids. Abuse-deterrent formulations of opioid analgesics can reduce abuse, but switching to other accessible non abuse-deterrent opioids might occur. © 2013 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd.
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This study evaluated changes in abuse exposures, therapeutic error exposures, and diversion into illegal markets associated with brand extended-release oxycodone (ERO) following introduction of reformulated ERO. Original ERO and reformulated ERO street prices also were compared. Data from the Poison Center and Drug Diversion programs of the Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System were used. Quarterly rates 2 years prior to introduction of reformulated ERO (October 2008 through September 2010) were compared to quarterly rates after introduction (October 2010 through March 2012) using negative binomial regression. Street prices were compared using a mixed effects linear regression model. Following reformulated ERO introduction, poison center ERO abuse exposures declined 38% (95% confidence interval [CI]: 31-45) per population and 32% (95% CI: 24-39) per unique recipients of dispensed drug. Therapeutic error exposures declined 24% (95% CI: 15-31) per population and 15% (95% CI: 6-24) per unique recipients of dispensed drug. Diversion reports declined 53% (95% CI: 41-63) per population and 50% (95% CI: 39-59) per unique recipients of dispensed drug. Declines exceeded those observed for other prescription opioids in aggregate. After its introduction, the street price of reformulated ERO was significantly lower than original ERO. This article indicates that the abuse, therapeutic errors, and diversion of ERO declined following the introduction of a tamper-resistant reformulation of the product. Reformulating abused prescription opioids to include tamper-resistant properties may be an effective approach to reduce abuse of such products.
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In 2010, an abuse-deterrent formulation of the widely abused prescription opioid OxyContin replaced the original formulation. After the new formulation was introduced, patients reported that they used OxyContin less often and other drugs (including heroin) more often.
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Although economists have long been aware of Jensen's inequality, many econometric applications have neglected an important implication of it: under heteroskedasticity, the parameters of log-linearized models estimated by OLS lead to biased estimates of the true elasticities. We explain why this problem arises and propose an appropriate estimator. Our criticism of conventional practices and the proposed solution extend to a broad range of applications where log-linearized equations are estimated. We develop the argument using one particular illustration, the gravity equation for trade. We find significant differences between estimates obtained with the proposed estimator and those obtained with the traditional method. Copyright by the President and Fellows of Harvard College and the Massachusetts Institute of Technology.
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Chicago —Excuses for inadequate pain control appear to have run their course and will no longer be accepted because poor pain control is unethical, clinically unsound, and economically wasteful. This was the prevailing notion underlying the spring Leadership Summit on Pain Management sponsored by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the American Pain Society (APS). The second such meeting will be held this week in Los Angeles.
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Aim: To investigate 25-year trends in community use of prescribed opioid analgesics in Australia, and to map these trends against major changes to opioid registration and subsidy. Methods: We obtained dispensing data from 1990 to 2014 from two sources: dispensing claims processed under Australia's national drug subsidy program, the Pharmaceutical Benefits Scheme, including under co-payment records from 2012; and estimates of non-subsidised medicine use from a survey of Australian pharmacies (until 2011). Utilisation was expressed in defined daily doses (DDD)/1000 population/day. Results: Opioid dispensing increased almost 4-fold between 1990 and 2014, from 4.6 to 17.4 DDD/1000 pop/day. In 1990, weak, short-acting or orally administered opioids accounted for over 90% of utilisation. Use of long-acting opioids increased over 17-fold between 1990 and 2000, due primarily to the subsidy of long-acting morphine and increased use of methadone for pain management. Between 2000 and 2011, oxycodone, fentanyl, buprenorphine, tramadol and hydromorphone use increased markedly. Use of strong opioids, long-acting and transdermal preparations also increased, largely following the subsidy of various opioids for non-cancer pain. In 2011, the most dispensed opioids were codeine (41.1% of total opioid use), oxycodone (19.7%) and tramadol (16.1%); long-acting formulations comprised approximately half, and strong opioids 40%, of opioid dispensing. Conclusions: Opioid utilisation in Australia is increasing, although these figures remain below levels reported in the US and Canada. The increased use of opioids was largely driven by the subsidy of long-acting formulations and opioids for the treatment of non-cancer pain.
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What is already known on this topic? The rate for drug overdose deaths has increased approximately 140% since 2000, driven largely by opioid overdose deaths. After increasing since the 1990s, deaths involving the most commonly prescribed opioid pain relievers (i.e., natural and semisynthetic opioids) declined slightly in 2012 and remained steady in 2013, showing some signs of progress. Heroin overdose deaths have been sharply increasing since 2010. What is added by this report? Drug overdose deaths increased significantly from 2013 to 2014. Increases in opioid overdose deaths were the main factor in the increase in drug overdose deaths. The death rate from the most commonly prescribed opioid pain relievers (natural and semisynthetic opioids) increased 9%, the death rate from heroin increased 26%, and the death rate from synthetic opioids, a category that includes illicitly manufactured fentanyl and synthetic opioid pain relievers other than methadone, increased 80%. Nearly every aspect of the opioid overdose death epidemic worsened in 2014. What are the implications for public health practice? Efforts to encourage safer prescribing of opioid pain relievers should be strengthened. Other key prevention strategies include expanding availability and access to naloxone (an antidote for all opioid-related overdoses), increasing access to medication-assisted treatment in combination with behavioral therapies, and increasing access to syringe service programs to prevent the spread of hepatitis C virus infection and human immunodeficiency virus infections. Public health agencies, medical examiners and coroners, and law enforcement agencies can work collaboratively to improve detection of and response to outbreaks associated with drug overdoses related to illicit opioids. © 2016, Department of Health and Human Services. All rights reserved.
Article
Successful supply-side interdictions into illegal drug markets are predicated on the responsiveness of drug prices to enforcement and the price elasticity of demand for addictive drugs. We present causal estimates that targeted interventions aimed at methamphetamine input markets ('precursor control') can temporarily increase retail street prices, but methamphetamine consumption is weakly responsive to higher drug prices. After the supply interventions, purity-adjusted prices increased then quickly returned to pre-treatment levels within 6-12 months, demonstrating the short-term effects of precursor control. The price elasticity of methamphetamine demand is -0.13 to -0.21 for self-admitted drug treatment admissions and between -0.24 and -0.28 for hospital inpatient admissions. We find some evidence of a positive cross-price effect for cocaine, but we do not find robust evidence that increases in methamphetamine prices increased heroin, alcohol, or marijuana drug use. This study can inform policy discussions regarding other synthesized drugs, including illicit use of pharmaceuticals. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.
Article
Enforcement against drug selling remains the principal tool of drug control in the United States and many other countries. Though the risk of incarceration for a drug dealer has risen fivefold or more over the last 25 years in the United States, the prices of cocaine and heroin have fallen substantially. Different models of how enforcement affects drug supply may help explain the paradox. There are substantial periods in which drug markets are not in the stable equilibrium that has informed much of the empirical research. Enforcement is likely to be more effective in preventing the formation of a mass market than in suppressing such a market once it has formed. Once a mass market is established, there may be little return to intense enforcement. A modest level of enforcement may generate most of the benefits from prohibition.
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In the the past two decades the medical use of prescription opioids (POs), in particular oxycodone, increased up to 14-fold in the U.S. and Canada. The high consumption of these pain relievers also led to non-medical use and abuse of these substances which in turn resulted in a dramatic increase in the number of PO related fatalities and opioid dependent subjects. In the U.S. POs became the second most prevalent type of abused drug (4.5 million abusers; 1.7% of the population) after marijuana (8 million abusers) with currently 1.9 million (0.7% of the population) people dependent on opioid pain relievers. Pain relief was the leading motive for non-medical use in about 40% of the cases, but about half of non-medical PO users reported non-pain relief motives only, like to get high or to relax. Since 2011, there is a decline in the use and misuse of POs and reduction in painkiller overdose deaths in the U.S. probably due to the introduction of a variety of restrictive regulations. In Europe, the medical use of POs is increasing as well, but at a much slower rate than in the U.S. Moreover, in Europe non-medical use of POs and fatal PO incidents are (still) rare. The paper highlights and discusses the differences between Europe versus U.S. and Canada in an attempt to assess the risk of a PO abuse and overdose epidemic in Europe. It is concluded that the risk in Europe seems to be rather limited but vigilance is needed.
Article
In the second half of 2010, abuse-deterrent extended-release oxycodone hydrochloride (OxyContin; Purdue Pharma) was introduced and propoxyphene was withdrawn from the US market. The effect of these pharmaceutical market changes on opioid dispensing and overdose rates is unknown. To evaluate the association between 2 temporally proximate changes in the opioid market and opioid dispensing and overdose rates. Claims from a large national US health insurer were analyzed, using an interrupted time series study design. Participants included an open cohort of 31.3 million commercially insured members aged 18 to 64 years between January 1, 2003, and December 31, 2012, with median follow-up of 20 months (last follow-up, December 31, 2012). Introduction of abuse-deterrent OxyContin (resistant to crushing or dissolving) on August 9, 2010, and market withdrawal of propoxyphene on November 19, 2010. Standardized opioid dispensing rates and prescription opioid and heroin overdose rates were the primary outcomes. We used segmented regression to analyze changes in outcomes from 30 quarters before to 8 quarters after the 2 interventions. Two years after the opioid market changes, total opioid dispensing decreased by 19% from the expected rate (absolute change, -32.2 mg morphine-equivalent dose per member per quarter [95% CI, -38.1 to -26.3]). By opioid subtype, the absolute change in dispensing by milligrams of morphine-equivalent dose per member per quarter at 2 years was -11.3 (95% CI, -12.4 to -10.1) for extended-release oxycodone, 3.26 (95% CI, 1.40 to 5.12) for other long-acting opioids, -8.19 (95% CI, -9.30 to -7.08) for propoxyphene, and -16.2 (95% CI, -18.8 to -13.5) for other immediate-release opioids. Two years after the market changes, the estimated overdose rate attributed to prescription opioids decreased by 20% (absolute change, -1.10 per 100 000 members per quarter [95% CI, -1.47 to -0.74]), but heroin overdose increased by 23% (absolute change, 0.26 per 100 000 members per quarter [95% CI, -0.01 to 0.53]). Opioid dispensing and prescription opioid overdoses decreased substantially after 2 major changes in the pharmaceutical market in late 2010. Pharmaceutical market interventions may have value in combatting the prescription opioid overdose epidemic, but heroin overdose rates continue to increase. Complementary strategies to identify and treat opioid abuse and addiction are urgently needed.
Article
The use of prescription opioid medications has increased greatly in the United States during the past two decades; in 2010, there were 16,651 opioid-related deaths. In response, hundreds of federal, state, and local interventions have been implemented. We describe trends in the diversion and abuse of prescription opioid analgesics using data through 2013. We used five programs from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System to describe trends between 2002 and 2013 in the diversion and abuse of all products and formulations of six prescription opioid analgesics: oxycodone, hydrocodone, hydromorphone, fentanyl, morphine, and tramadol. The programs gather data from drug-diversion investigators, poison centers, substance-abuse treatment centers, and college students. Prescriptions for opioid analgesics increased substantially from 2002 through 2010 in the United States but then decreased slightly from 2011 through 2013. In general, RADARS System programs reported large increases in the rates of opioid diversion and abuse from 2002 to 2010, but then the rates flattened or decreased from 2011 through 2013. The rate of opioid-related deaths rose and fell in a similar pattern. Reported nonmedical use did not change significantly among college students. Postmarketing surveillance indicates that the diversion and abuse of prescription opioid medications increased between 2002 and 2010 and plateaued or decreased between 2011 and 2013. These findings suggest that the United States may be making progress in controlling the abuse of opioid analgesics. (Funded by the Denver Health and Hospital Authority.).
Article
AimsTo review empirical research that seeks to relate marginal increases in enforcement against the supply of illicit drugs to changes in drug prices at the level of the drug supply system being targeted. Method Review of empirical studies. FindingsAlthough the fact of prohibition itself raises prices far above those likely to pertain in legal markets, there is little evidence that raising the risk of arrest, incarceration or seizure at different levels of the distribution system will raise prices at the targeted level, let alone retail prices. The number of studies available is small; they use a great variety of outcome and input measures and they all face substantial conceptual and empirical problems. Conclusion Given the high human and economic costs of stringent enforcement measures, particularly incarceration, the lack of evidence that tougher enforcement raises prices call into question the value, at the margin, of stringent supply-side enforcement policies in high-enforcement nations.
Article
PurposeFlorida has been at the center of the nation's ongoing prescription opioid epidemic, with largely unregulated pain clinics and lax prescribing oversight cited as significant contributors to the opioid problem in the state. Methods In an effort to mitigate prescription opioid abuse and diversion in Florida, legislative interventions were implemented during 2010 and 2011, which included two primary elements: (i) comprehensive legislation to better regulate the operation of pain clinics; and (ii) a statewide prescription drug monitoring program to promote safer prescribing practices. Using systematic longitudinal data collected on a quarterly basis from law enforcement agencies across Florida, this report examined changes in prescription opioid diversion rates following implementation of these regulatory initiatives. Quarterly diversion rates for buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone, and tramadol were calculated, and subsequently, hierarchical linear models were fit to test for differences in diversion rates over the 15 quarter period of interest. ResultsSignificant declines in diversion rates were observed for oxycodone, methadone, and morphine; hydrocodone displayed a marginally significant decline. Conclusions This study documented reductions in statewide opioid diversion rates following implementation of Florida's pain clinic and prescription drug monitoring program legislative interventions. Although these initial findings appear promising, continued surveillance of diversion is clearly warranted. Copyright © 2013 John Wiley & Sons, Ltd.
Article
The reformulation of oxycodone hydrochloride controlled-release (CR) tablets in August 2010 created a natural experiment at a national scale, providing an opportunity to evaluate patterns of abuse of prescription opioids and other drugs before and after introduction of this abuse-deterrent formulation (ADF). Observational, cross-sectional study SETTING: Sentinel sample of adults assessed for substance abuse treatment within the NAVIPPRO(®) surveillance system SUBJECTS: Two hundred thirty-two thousand and eight hundred seventy-four adults at 437 facilities during January 1, 2008 through December 31, 2011. Time-series analysis using logistic regression to estimate quarterly prevalence of past 30-day abuse (adjusted for covariates and prescription volume) and changes in abuse pre-and post-ADF introduction. Increases in abuse prevalence occurred for all prescription opioids as a class and for extended-release (ER) opioids. Significantly greater abuse of ER oxymorphone and buprenorphine occurred in the post-ADF period (relative risk [RR] = 2.91, 95% confidence interval [CI] = 2.59-3.27 and RR = 1.85, 95% CI = 1.74-1.96). Increases in abuse for these two compounds were significant among groups who reported abuse via preferential routes of administration (oral only, snorting only, injection only) post-ADF introduction. Replacement of a widely prescribed opioid formulation known for its abuse potential alone may have had little impact on overall rates of prescription opioids as a class. However, changes in abuse levels of certain opioids coinciding with ADF introduction suggest possible switching of abuse among this study sample to specific long-acting opioid analgesics. Additional follow-up studies will be important to monitor changing abuse patterns and their public health impact as new opioid formulations are developed and introduced to market.
Article
The purpose of the present study was to identify the factors that influence the selection of hydrocodone and oxycodone as primary drugs of abuse in opioid-dependent subjects (n=3520) entering one of 160 drug treatment programs around the country. Anonymous, self-administered surveys and direct qualitative interviews were used to examine the influence of demographic characteristics, drug use patterns, and decision-related factors on primary opioid selection. Our results showed that oxycodone and hydrocodone were the drugs of choice in 75% of all patients. Oxycodone was the choice of significantly more users (44.7%) than hydrocodone (29.4%) because the quality of the high was viewed to be much better by 54% of the sample, compared to just 20% in hydrocodone users, who cited acetaminophen as a deterrent to dose escalation to get high and hence, its low euphoric rating. Hydrocodone users were generally risk-averse women, elderly people, noninjectors, and those who prefer safer modes of acquisition than dealers (ie, doctors, friends, or family members). In contrast, oxycodone was a much more attractive euphorigenic agent to risk-tolerant young, male users who prefer to inject or snort their drugs to get high and are willing to use more aggressive forms of diversion. Prevention and treatment approaches, and pain physicians, should benefit from these results because it is clear that not all drug abusers share the same characteristics, and the decision to use one drug over another is a complex one, which is largely attributable to individual differences (eg, personality, gender, age, and other factors).
Article
The purpose of this paper is to help empirical economists think through when and how to weight the data used in estimation. We start by distinguishing two purposes of estimation: to estimate population descriptive statistics and to estimate causal effects. In the former type of research, weighting is called for when it is needed to make the analysis sample representative of the target population. In the latter type, the weighting issue is more nuanced. We discuss three distinct potential motives for weighting when estimating causal effects: (1) to achieve precise estimates by correcting for heteroskedasticity, (2) to achieve consistent estimates by correcting for endogenous sampling, and (3) to identify average partial effects in the presence of unmodeled heterogeneity of effects. In each case, we find that the motive sometimes does not apply in situations where practitioners often assume it does. We recommend diagnostics for assessing the advisability of weighting, and we suggest methods for appropriate inference.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.
Article
Between 1973 and 1978, 12 states with collectively over one-third of the total U.S. population enacted laws that decriminalized the possession of marijuana. This article uses standard metropolitan statistical area (SMSA) level data on hospital emergency room drug episodes collected by the Drug Abuse Warning Network to measure the effect of changes in drug penalties on substance abuse crises. The regression models demonstrate that marijuana decriminalization was accompanied by a significant reduction in episodes involving drugs other than marijuana and an increase in marijuana episodes. Although possible biases in the data preclude firm conclusions, the results suggest that some substitution occurs towards the less severely penalized drug when punishments are differentiated.
Article
Supply-side enforcement remains the primary U.S. strategy to control illicit drugs and reduce their consequences. Yet, efforts to evaluate its effectiveness have produced mixed results, in part, because the nature of the interventions, the correlation between supply and enforcement success, and the quality of the data complicate identification. This paper leverages a unique supply-side intervention targeting OTC consumer products containing methamphetamine precursors, which became effective in all states over a three-year period from 2004 to 2006. The state and federal regulations placed restrictions on retailers and limited consumer purchases of common OTC sinus and cold medications such as Sudafed and Tylenol Cold. The paper’s identification strategy relies on a state fixed effects design that links changes in each state’s regulatory environment to changes in its outcomes. This design is an improvement over the time-series identification common in this literature. Graphical and econometric analyses show an overall decline of approximately 48% in the number of methamphetamine labs though the reduction is smaller among larger labs. Purity, which had been increasing over a number of years, declined by 36% after the regulations were implemented. The reduced availability and purity of methamphetamine interrupted an increasing trajectory of positive drug tests among employees and among individuals admitted to hospitals, but the reductions were smaller (12%) and less precisely measured than the disruptions to methamphetamine markets. Despite these successes, there is no evidence of substantive reductions in our health outcome measured by drug treatment admissions for methamphetamine. Nor do the regressions provide consistent evidence of substantial changes in property or violent crimes attributable to methamphetamine.
Article
Marijuana and cocaine, two mass-market drugs, have been the object of a major campaign by the federal government over the past five years. That campaign apparently has not led to a significant tightening in the availability of the two drugs, though the relatively high prices of these drugs historically are a consequence of enforcement. The reason for this lack of response to recent law enforcement pressures may lie in structural characteristics of these markets rather than in a failure of tactics or of coordination of law enforcement efforts. The federal effort aims at importation and high-level distribution, which account for a modest share of the retail prices of these drugs. Increasing the risks to importers or high-level distributors is thus likely to have modest effects on the retail price and is unlikely to have any other effect on the conditions of use. Street-level enforcement is hindered by the sheer scale of the two markets and because so few of the final purchases occur in public settings. Many of the risks associated with drug trafficking come from the actions of other participants in the trades themselves, and this also limits the ability of law enforcement agencies to act in ways that will cause prices to increase or alter market conditions. Law enforcement efforts directed at heroin have been much more effective at restricting drug use.
Article
Overdoses involving prescription drugs in the United States have reached epidemic proportions over the past 20years. This review categorizes and summarizes literature on the topic dating from the first published reports through 2011 using a traditional epidemiologic model of host, agent, and environment. Host factors include male sex, middle age, non-Hispanic white race, low income, and mental health problems. Agent risk factors include use of opioid analgesics and benzodiazepines, high prescribed dosage for opioid analgesics, multiple prescriptions, and multiple prescribers. Environmental factors include rural residence and high community prescribing rates. The epidemiology of prescription drug overdoses differs from the epidemiology of illicit drug overdoses. Incomplete understanding of prescription overdoses impedes prevention efforts. This epidemic demands additional attention from injury professionals.
Article
Unlabelled: Oxycodone hydrochloride controlled-release, also known as extended-release oxycodone (ER oxycodone), was reformulated with physicochemical barriers to crushing and dissolving intended to reduce abuse through nonoral routes of administration (ROAs) that require tampering (eg, injecting and snorting). Manufacturer shipments of original ER oxycodone (OC) stopped on August 5, 2010, and reformulated ER oxycodone (ORF) shipments started August 9, 2010. A sentinel surveillance sample of 140,496 individuals assessed for substance abuse treatment at 357 U.S. centers between June 1, 2009, and March 31, 2012, was examined for prevalence and prescription-adjusted prevalence rates of past-30-day abuse via any route, as well as abuse through oral, nonoral, and specific ROAs for ER oxycodone and comparators (ER morphine and ER oxymorphone) before and after ORF introduction. Significant reductions occurred for 8 outcome measures of ORF versus OC historically. Abuse of ORF was 41% lower (95% CI: -44 to -37) than historical abuse for OC, with oral abuse 17% lower (95% CI: -23 to -10) and nonoral abuse 66% lower (95% CI: -69 to -63). Significant reductions were not observed for comparators. Observations were consistent with the goals of a tamper resistant formulation for an opioid. Further research is needed to determine the persistence and generalizability of these findings. Perspective: This article presents preliminary findings indicating that 8 outcome measures of abuse of a reformulated ER oxycodone were lower than that for original ER oxycodone historically, particularly through nonoral ROAs that require tampering (ie, injection, snorting, smoking), in a sentinel sample of individuals assessed for substance use problems for treatment planning.
Article
This paper estimates the effects of alcohol prices, marijuana decriminalization, cocaine prices, and heroin prices on the demand for these four substances. Both own price effects and cross price effects are estimated. The estimated price elasticities for alcohol, cocaine, and heroin are, respectively, –.30, –.28 and –.94. Marijuana decriminalization was found to increase the probability of marijuana participation by about 8%. The results for the cross price effects provide general evidence of complementarity. It is estimated that decriminalization of cocaine and heroin might lead to about 260,000 new regular cocaine users and about 47,000 new regular heroin users. (JEL 110)
Article
This paper exploits the discontinuity created by the minimum legal drinking age of 21 years to estimate the causal effect of increased alcohol availability on marijuana use. We find that consumption of marijuana decreases sharply at age 21, while consumption of alcohol increases, suggesting that marijuana and alcohol are substitutes. We further find that the substitution effect between alcohol and marijuana is stronger for women than for men. Our results suggest that policies designed to limit alcohol use have the unintended consequence of increasing marijuana use.
Article
In mid-1995, a government effort to reduce the supply of methamphetamine precursors successfully disrupted the methamphetamine market and interrupted a trajectory of increasing usage. The price of methamphetamine tripled and purity declined from 90 percent to 20 percent. Simultaneously, amphetaminerelated hospital and treatment admissions dropped 50 percent and 35 percent, respectively. Methamphetamine use among arrestees declined 55 percent. Although felony methamphetamine arrests fell 50 percent, there is no evidence of substantial reductions in property or violent crime. The impact was largely temporary. The price returned to its original level within four months; purity, hospital admissions, treatment admissions, and arrests approached preintervention levels within eighteen months. (JEL I12, K42).
Article
Previous studies suggest that alcohol and marijuana are economic substitutes, so recent policies restricting the availability of alcohol have led to an increase in the amount of marijuana consumed. Using micro-level data from the National Longitudinal Survey of Youth (NLSY) to estimate individual demand equations for alcohol and marijuana, this research finds that alcohol and marijuana are economic complements, not substitutes. Further, this research finds that increases in the federal tax on beer will generate a larger reduction in the unconditional demand for marijuana than for alcohol in percentage terms.
Article
Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing. Just over 100 years ago, opium poppies were still grown on the Cambridgeshire fens in the UK to provide oblivion for the working man and his family, but the brewing lobby argued on thin evidence that their potions were less dangerous. The restriction of opioid availability to protect society and the individual continues in many countries. In this review I focus on chronic and cancer pain, but many of the principles apply in acute pain. The justification for this focus is that patients with chronic pain may suffer longer and unnecessarily if we prescribe and legislate badly.
Article
This paper analyzes the impact of increases in the minimum drinking age on the prevalence of alcohol and marijuana use among high school seniors. The empirical analysis is based on a large sample of students from 43 states over the years 1980-1989. We find that increases in the legal minimum drinking age did slightly reduce the prevalence of alcohol consumption. We also find, however, that increased legal minimum drinking ages had the unintended consequence of slightly increasing the prevalence of marijuana consumption. Estimates from a structural model suggest that this unintended consequence is attributable to standard substitution effects.
Article
Previous research has shown that the recent tightening of college alcohol policies has been effective at reducing college students' drinking. Over the period in which these stricter alcohol policies have been put in place, marijuana use among college students has increased. This raises the question of whether current policies aimed at reducing alcohol consumption are inadvertently encouraging marijuana use. This paper begins to address this question by investigating the relationship between the demands for alcohol and marijuana for college students using data from the 1993, 1997 and 1999 waves of the Harvard School of Public Health's College Alcohol Study (CAS). We find that alcohol and marijuana are economic complements and that policies that increase the full price of alcohol decrease participation in marijuana use.