Abstract
Risk of opioid use disorder, overdose, and death from prescription opioids increases as dosage, duration, and use of extended-release and long-acting formulations increase. States are well suited to respond to the opioid crisis through legislation, regulations, enforcement, surveillance, and other interventions. To estimate temporal trends and geographic variations in 6 key opioid prescribing measures in 50 US states and the District of Columbia. Population-based cross-sectional analysis of opioid prescriptions filled nationwide at US retail pharmacies between January 1, 2006, and December 31, 2017. Data were obtained from the IQVIA Xponent database. All US residents who had an opioid prescription filled at a US retail pharmacy were included. Primary outcomes were annual amount of opioids prescribed in morphine milligram equivalents (MME) per person; mean duration per prescription in days; and 4 separate prescribing rates-for prescriptions 3 or fewer days, those 30 days or longer, those with a high daily dosage (≥90 MME), and those with extended-release and long-acting formulations. Between 2006 and 2017, an estimated 233.7 million opioid prescriptions were filled in retail pharmacies in the United States each year. For all states combined, 4 measures decreased: (1) mean (SD) amount of opioids prescribed (mean [SD] decrease, 12.8% [12.6%]) from 628.4 (178.0) to 543.4 (158.6) MME per person, a statistically significant decrease in 23 states; (2) high daily dosage (mean [SD] decrease, 53.1% [13.6%]) from 12.3 (3.4) to 5.6 (1.7) per 100 persons, a statistically significant decrease in 49 states; (3) short-term (≤3 days) duration (mean [SD] decrease, 43.1% [9.4%]) from 18.0 (5.4) to 10.0 (2.5) per 100 persons, a statistically significant decrease in 48 states; and (4) extended-release and long-acting formulations (mean [SD] decrease, 14.7% [13.7%]) from 7.2 (1.9) to 6.0 (1.7) per 100 persons, a statistically significant decrease in 27 states. Two measures increased, each associated with the duration of prescription dispensed: (1) mean (SD) prescription duration (mean [SD] increase, 37.6% [6.9%]) from 13.0 (1.2) to 17.9 (1.4) days, a statistically significant increase in every state; and (2) prescriptions for a term of 30 days or longer (mean [SD] increase, 37.7% [28.9%]) from 18.3 (7.7) to 24.9 (10.7) per 100 persons, a statistically significant increase in 39 states. Two- to 3-fold geographic differences were observed across states, measured by comparing the ratio of each state's 90th to 10th percentile for each measure. In this study, across 12 years, the mean duration and prescribing rate for long-term prescriptions of opioids increased, whereas the amount of opioids prescribed per person and prescribing rate for high-dosage prescriptions, short-term prescriptions, and extended-release and long-acting formulations decreased. Some decreases were significant, but results were still high. Two- to 3-fold state variation in 5 measures occurred in most states. This information may help when state-specific intervention programs are being designed.
Highlights
Prescription opioids were involved in approximately 36% of all deaths in the United States associated with opioid overdose in 2017.2 The risk of opioid use disorder, overdose, and death increases as prescription opioids are taken in higher dosages,3-5 for longer periods of time,6-8 or as extended-release and long-acting formulations
Overdose risk is dosage dependent, doubling from 50 to morphine milligram equivalents (MME) per day and increasing up to 9-fold at dosages of MME or greater per day compared with overdose risk at dosages less than or equal to 20 MME/d
The epidemic is shifting from prescription opioids toward street drugs, 66% to 83% of new users of heroin report that their addiction began with the misuse of a prescription opioid
Summary
The recent decline in US life expectancy is attributed, in part, to premature deaths from opioid overdose. Prescription opioids were involved in approximately 36% of all deaths in the United States associated with opioid overdose in 2017.2 The risk of opioid use disorder (commonly called addiction), overdose, and death increases as prescription opioids are taken in higher dosages, for longer periods of time, or as extended-release and long-acting formulations. Duration of use is the strongest predictor of opioid use disorder and overdose. Prescription opioids were involved in approximately 36% of all deaths in the United States associated with opioid overdose in 2017.2 The risk of opioid use disorder (commonly called addiction), overdose, and death increases as prescription opioids are taken in higher dosages, for longer periods of time, or as extended-release and long-acting formulations.. Each additional week of use has been associated with a 20% increased risk for the development of an opioid use disorder or occurrence of an overdose.. Use of extended-release and long-acting agents increases risk; unintentional overdoses are twice as likely to occur in those initiating therapy with extended-release and long-acting formulations compared with those starting with immediate-release opioids, especially in the first 2 weeks of use.. Misuse refers to drugs taken for a purpose other than that directed by the prescribing physician, in greater amounts, more often, or for a longer duration than prescribed. The epidemic is shifting from prescription opioids toward street drugs (heroin, fentanyl, and fentanyl analogues), 66% to 83% of new users of heroin report that their addiction began with the misuse of a prescription opioid.
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