Prescription Opioid Diversion Research Articles

Prescription Opioid Diversion Sources Among African Americans: Implications for Overdose Prevention

Recent data show that African Americans (AAs) experienced a greater increase in overdose deaths involving prescription opioids relative to other racial/ethnic groups. One possible mechanism through which elevated risk for overdose is conferred to AAs could be due to greater exposure to contaminated counterfeit pills. Unfortunately, prescription opioid diversion is understudied among AAs and less is known regarding which sources AAs use to access pharmaceutical opioids. The objective of this study, therefore, was to identify and describe the most commonly used diversion sources for prescription opioids among AAs. Qualitative interview data are also presented to contextualize the most prevalent sources. This study used data from the Florida Minority Health Study, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of AAs. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida. Analyses revealed that the most widely used sources for prescription opioids were dealers (33.0%) and friends/relatives (34.7%). Additionally, interview data indicated that dealers are the access point where larger volume acquisitions are made and high potency formulations are accessed. These findings suggest that AAs may utilize nonhealthcare related sources at higher rates than healthcare related sources to acquire prescription opioids. This is concerning because opioid pills acquired through nonhealthcare related sources are especially susceptible to fentanyl adulteration. These findings invite further study using nationally representative data to determine if AAs disproportionately use nonhealthcare related sources compared to persons from other racial/ethnic groups.

The Opioid Industry Documents Archive: Advancing Public Health Through Industry Document Disclosure.

More than twenty-five years after the first signs of potential harm, the US remains locked in the grip of an opioid epidemic, with more Americans dying from overdoses than ever before.1 Diversion of prescription opioids plays an important role in opioid-related harms. Much of the scientific and public health focus on diversion has been on end-users, given how commonly non-medical prescription opioid use occurs, as well as the proportion of individuals who report that their source of non-medical opioids was friends or family. However, diversion of opioids, as well as their rampant oversupply, can be discerned higher up the supply chain, including among wholesalers, pharmacies and rogue prescribers whose behavior may trigger well-described "flags" warranting further evaluation and action.

Elucidating determinants of medication disposal programs at retail pharmacies in North Carolina

BackgroundPharmacy-based medication disposal programs is one approach to prevent diversion of unused prescription opioids. Objective(s)The objective of this study was to assess the extent to which disposal programs have been implemented by retail pharmacies and identify determinants of implementation using the Consolidated Framework for Implementation Research. MethodsA sequential mixed-method design was used to examine implementation of medication disposal programs at pharmacies in Pitt County, NC. We conducted environmental scans of all retail pharmacies that served community members (N = 31) to assess the extent to which disposal programs had been implemented. Then, we conducted interviews with pharmacists (n = 15; 48.4%) to identify determinants of implementation. The following pharmacy types were represented in the completed interviews: corporate chain (n = 10), small chain (n = 1), independently owned and operated (n = 1), medical (n = 2), and government (n = 1). ResultsWe found that 32.3% of pharmacies (n = 10) had a medication disposal box and 12.9% (n = 4) had posted a flyer on medication disposal. Pharmacists perceived that patients benefit from disposal boxes and medication disposal is in their purview. Determinants of implementation included the cost of sustaining the intervention, polices of corporate and regional management, variable local control in the decision-making process to implement a disposal box, and experience with having a medication disposal box. ConclusionOur findings highlight one way in which pharmacists can have a vital role in preventing diversion of opioid analgesics and associated consequences. There is a need to expand disposal boxes at pharmacies to increase community member accessibility and use. Future research is needed to determine the cost-effectiveness of expanding the scale of disposal box implementation in community pharmacies.

Extended-release and long-acting opioids for chronic pain management.

Chronic pain from both cancer and noncancer sources affects approximately one quarter of the adult population in the United States. In addition to the considerable health burden, there is the burden of the patient suffering, loss of work productivity, and loss of social effectiveness for many patients. Untreated chronic pain has been documented to interfere with sleep patterns, increase anxiety and depression, decrease quality of life, and interfere with social relationships and the ability of a patient to cope with life. Long-term opioid therapy for the management of chronic-nonmalignant pain (CNMP) has been used with a subset of patients and found to be efficacious. Although the treatment of patients suffering from CNMP is viewed as humanitarian, their use has been complicated by side effects such as constipation, dose escalation, sedation, endocrine suppression, inadequate analgesic effect, prescription opioid diversion, and unwanted prescription-opioid- related death. Thus, a healthcare professional taking care of patients using long-term opioid therapy must be extremely well versed in the appropriate assessment, management, and specific pharmacology of opioid analgesic products.

The Effect of a Large Prescription Opioid Diversion Event on Opioid Mortality in The U.S.

The Effect of a Large Prescription Opioid Diversion Event on Opioid Mortality in The U.S.

Optimizing return and secure disposal of prescription opioids to reduce the diversion to secondary users and black market

Opioid Use Disorder (OUD) has reached an epidemic level in the US. Diversion of unused prescription opioids to secondary users and black market significantly contributes to the abuse and misuse of these highly addictive drugs, leading to the increased risk of OUD and accidental opioid overdose within communities. Hence, it is critical to design effective strategies to reduce the non-medical use of opioids that can occur via diversion at the patient level. In this paper, we aim to address this critical public health problem by designing strategies for the return and safe disposal of unused prescription opioids. We propose a data-driven optimization framework to determine the optimal incentive disbursement plans and locations of easily accessible opioid disposal kiosks to motivate prescription opioid users of diverse profiles in returning their unused opioids. We develop a Mixed-Integer Non-Linear Programming (MINLP) model to solve the decision problem, followed by a reformulation scheme using Benders Decomposition that results in a computationally efficient solution. We present a case study to show the benefits and usability of the model using a dataset created from Massachusetts All Payer Claims Data (MA APCD). Our proposed model allows the policymakers to estimate and include a penalty cost considering the economic and healthcare burden associated with prescription opioid diversion. Our numerical experiments demonstrate the model's ability and usefulness in determining optimal locations of opioid disposal kiosks and incentive disbursement plans for maximizing the disposal of unused opioids. The proposed optimization framework offers various trade-off strategies that can help government agencies design pragmatic policies for reducing the diversion of unused prescription opioids.

How Patients Dispose of Unused Prescription Opioids: A Survey of over 300 Postoperative Patients

IntroductionDiversion of unused prescription opioids is a common source of opioid sensitization in the community. Educating patients about safe opioid use has been shown to be effective in decreasing opioid use. However, decreasing diversion will also require educating patients on proper opioid disposal. A survey was administered to better understand patients’ habits with opioid disposal for opioids prescribed after orthopedic surgery.MethodsA cross-sectional survey study of 469 patients who had undergone orthopedic surgery was conducted to learn their preferences and habits regarding the disposal of unused prescription opioids received after orthopedic surgery.ResultsThe survey respondents consisted of 48.8% female and 51.2% male patients. Ninety-four point two percent (94.2%) of those receiving opioid prescriptions reported having leftover unused opioids. In terms of voluntary disposal, 68.8% claimed to dispose of their prescription opioids while 31.2% did not. Gender, but not age, had a significant effect on plans for opioid disposal and how seriously respondents viewed issues of opioid misuse. When asked their preferred location for prescription opioid disposal, the most common preference was a local pharmacy.DiscussionThis survey identified that most patients do not store their prescription opioids in a locked location, claim to dispose of their unused prescription opioids, and would prefer to dispose of them at a pharmacy if possible. This information points to the need for close prescriber-to-pharmacy collaboration to promote the safe disposal of prescription opioids and mitigate drug diversion.

Prevalence of andRisk Factors for Prescription Opioid Misuse, Abuse, Diversion and Doctor Shopping in Japan: A Survey Study.

IntroductionOpioid use disorder is a global problem. Although opioid analgesics are prescribed less frequently in Japan than in many other countries, the rate of aberrant prescription opioid-taking behaviors in Japan is unknown.MethodsAn internet survey was conducted to estimate the prevalence of and risk factors for prescription opioid misuse, abuse, diversion and doctor shopping in Japanese subjects with chronic pain who had been prescribed opioid analgesics. ResultsThe proportion of respondents (n = 387) who reported opioid misuse was 45.5% (95% confidence interval [CI]: 40.4–50.6); rates were: 24.6% (95% CI: 20.3–29.2) for abuse; 15.0% (95% CI: 11.6–19.0) for diversion; and 10.6% (95% CI: 7.7–14.1) for doctor shopping. Aberrant prescription opioid-taking behaviors were higher in participants with chronic post-cancer treatment pain (misuse, 64.2%; abuse, 52.2%) or chronic cancer pain (misuse, 57.4%; abuse, 26.2%) than in those with chronic noncancer pain (misuse, 37.8%; abuse, 17.0%). Younger age, male sex, smoking, habitual drinking, diagnosis of psychiatric disease, use of opioids other than tramadol, and use of opioids for chronic post-cancer treatment pain and chronic cancer pain were identified as risk factors for aberrant prescription opioid-taking behaviors.ConclusionEven in Japan, which has not experienced the surge in opioid consumption documented in other countries, aberrant prescription opioid-taking behaviors were observed. When prescribing opioid analgesics, universal precautions should always be taken for both cancer and non-cancer patients.Trial RegistrationUMIN000041788.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-022-00409-6.

Surgery Prescription Opioid Misuse and Diversion in US Adults and Associated Risk Factors.

To justify a practice change, it is critical to determine if opioids prescribed after surgery, surgery prescription (Rx) opioids, are in fact associated with opioid misuse and diversion. Currently, there is only limited data to support this assumption. We administered a 40-question survey to US adults (18+) who had received a surgery Rx opioid within the last 5y on Amazon Mechanical Turk, an online crowdsourcing worksite. Incidence and risk factors for surgery Rx opioid misuse, self-reported taking of surgery Rx opioids in a way other than instructed by a provider, and diversion, self-reported having one's surgery Rx opioids shared, sold, or stolen, were analyzed. The government validated Opioid Risk Tool (ORT) was used. A total of 966 participants from all 50 states met inclusion: 52% were male, 43% were aged 30-39y, and 79% self-identified as white. Overall, 34% (n=333) of respondents reported misusing their surgery Rx opioids and risk factors included working in healthcare, scoring high on the ORT, experiencing an elevated mood with opioids, refilling a Rx, and keeping leftover pills. A total of 22% (n=212) reported diverting their surgery Rx opioids, and risk factors included working in healthcare, scoring high on the ORT, undergoing plastic surgery, refilling a Rx, and keeping leftover pills. Rates of surgery Rx opioid misuse and diversion in the US may be as high as one in three and one in five adults, respectively. Efforts to improve leftover pill disposal and risk stratification for prescribing patterns may help to mitigate risk.

What lessons from Europe's experience could be applied in the United States in response to the opioid addiction and overdose crisis?

What lessons from Europe's experience could be applied in the United States in response to the opioid addiction and overdose crisis?

Rates and correlates of medicine disposal program implementation at pharmacies in North Carolina: A longitudinal study, 2016-2021

BackgroundUnused prescription opioids from family and friends continue to be the primary access point to prescription opioids for nonmedical use among youth. Implementation of medicine disposal boxes at pharmacies is one approach to facilitate removal of unused prescription opioids from the home to prevent diversion. ObjectivesWe sought to examine the implementation rates of disposal boxes at pharmacies in North Carolina from 2016 to 2021 and place-based health disparities in availability. MethodsWe identified pharmacies with a disposal box in 2016, 2018, and 2021 among licensed pharmacies in North Carolina in 2018 (N = 2587). We computed descriptive statistics to describe disposal box implementation rates over time and used geographic information systems to identify spatial trends. We used separate logistic regression models in 2018 and 2021 to assess the relationship between neighborhood characteristics and the likelihood of a pharmacy implementing a disposal box. ResultsWe found an increase in disposal boxes over time with 43 pharmacies (1.7%) in 2016, 144 (5.6%) in 2018, and 350 (13.5%) in 2021 implementing a disposal box. In 2018, independent pharmacies were more likely than chains to have a disposal box. In 2021, medical-affiliated and pharmacies defined as “other” were less likely than chains to have a disposal box. In both 2018 and 2021, pharmacies in census tracts with a higher percentage of the population below the federal poverty line were more likely to have a disposal box. In 2021, pharmacies in tracts with a higher percentage of the population unemployed were less likely to have a disposal box. In 2018, pharmacies located in counties with a greater number of opioid overdose deaths were more likely to have a disposal box. ConclusionOur findings highlight the growth of disposal boxes in North Carolina over time and the potential for continued expansion to provide opportunities to prevent prescription opioid diversion.

Opioid Prescribing Risk Factors in Nonoperative Ankle Fractures: The Impact of a Prospective Clinical Decision Support Intervention

Opioids are frequently used for acute pain management of musculoskeletal injuries, which can lead to misuse and abuse. This study aimed to identify the opioid prescribing rate for ankle fractures treated nonoperatively in the ambulatory and emergency department setting across a single healthcare system and to identify patients considered at high risk for abuse, misuse, or diversion of prescription opioids that received an opioid. A retrospective cohort study was performed at a large healthcare system. The case list included nonoperatively treated emergency department, urgent care and outpatient clinic visits for ankle fracture and was merged with the Prescription Reporting With Immediate Medication Mapping (PRIMUM) database to identify encounters with prescription for opioids. Descriptive statistics characterize patient demographics, treatment location and prescriber type. Rates of prescribing among subgroups were calculated. There were 1,324 patient encounters identified, of which, 630 (47.6%) received a prescription opioid. The majority of patients were 18-64 years old (60.3%). Patients within this age range were more likely to receive an opioid prescription compared to other age groups (p < .0001). Patients treated in the emergency department were significantly more likely to receive an opioid medication (68.3%) compared to patients treated at urgent care (33.7%) or in the ambulatory setting (16.4%) (p < .0001). Utilizing the PRIMUM tool, 14.2% of prescriptions were provided to patients with at least one risk factor. Despite the recent emphasis on opioid stewardship, 14.2% of patients with risk factors for misuse, abuse, or diversion received opioid analgesics in this study, identifying an area of improvement for prescribers.

A Dental School Survey Assessing Dental Student Knowledge, Attitudes and Prescribing Behavior Regarding Opioid Use and Abuse

Purpose/Objectives: While improvements have been made in the amount of opioid prescriptions written by dentists, studies continue to show wide variability in opioid prescribing practices among dentists, suggesting additional education in this area is needed. The purpose of this study was to evaluate opioid knowledge, attitudes and prescribing behaviors among dental school students. Methods: The authors conducted a web-based survey of dental students at the University of Minnesota School of Dentistry from 2016 through 2018. The survey was comprised of demographic information, student knowledge of clinical and regulatory interventions to reduce prescription opioid abuse, student attitudes and knowledge regarding the magnitude and causes of opioid misuse and abuse, and student opioid prescribing patterns. Statistical analysis was conducted to determine whether calendar time or progression in the dental program were associated with differences in survey responses. Results: The response rate was 43.67% for a total of 586 dental student participants over the course of this study. The knowledge, attitudes, and behaviors regarding opioid use and abuse among dental students was influenced by both the dental school program curriculum as well as the passage of time during which the evolution of students views and awareness about opioids impacted their responses. Conclusions: Misperceptions and a lack of knowledge influence dental student attitudes and behaviors related to prescription opioids. Understanding the influence of the dental school curriculum and the passage of time on dental students’ knowledge, attitudes, and prescribing behavior may assist in guiding the development of dental curriculum to improve best practices in pain management and prevent the misuse, abuse, and diversion of prescription opioids. Academic dentistry plays a significant role in targeting gaps in student knowledge and understanding that will lead to the development and consistent implementation of best practices for pain management and safe opioid prescribing in dentistry

“People need them or else they're going to take fentanyl and die”: A qualitative study examining the ‘problem’ of prescription opioid diversion during an overdose epidemic

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the “problem” of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the “problem” of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment.

Opioid-free Anesthesia: Time to Regain Our Balance.

Opioid-free Anesthesia: Time to Regain Our Balance.

Analysis of unused prescription opioids and benzodiazepines remaining after death among Medicare decedents

BackgroundMillions of opioid and benzodiazepine prescriptions are dispensed near end-of-life. After death, patients’ unused prescription pills belong to family members, who often save rather than dispose of them. We sought to quantify this exposure in Medicare beneficiaries. MethodsWe estimated the share of decedent Medicare beneficiaries who potentially left behind opioid or benzodiazepine pills at the time of death using Part D claims of a 20 % national sample of Medicare beneficiaries between 2006−2015 linked to the National Death Index. ResultsWe estimated that 1 in 6 Medicare beneficiaries who died between 2006−2015 potentially left behind opioid pills, and 1 in 10 who died between 2013−2015 potentially left benzodiazepines as well. Leftover pills were more common among younger, dually enrolled, and lower-income beneficiaries, as well as beneficiaries living in non-urban areas and those with a history of mental illness, drug use disorders, and chronic pain. North American Natives and Non-Hispanic Whites had higher proportions than Black, Hispanic, and Asian decedents. ConclusionsOpioids and benzodiazepines are commonly left behind at death. Policies and interventions that encourage comprehensive and safe medication disposal after death may reduce risk for intra-household diversion and misuse of prescription opioids and benzodiazepines.

Estimating the prevalence of and characteristics associated with prescription opioid diversion among a clinic population living with HIV: Indirect and direct questioning techniques

BackgroundEvidence suggests that over 50 % of individuals who used prescription opioids non-medically obtained their prescription from friends or family. Despite its high consequence, reliable opioid diversion prevalence estimates are lacking due to social desirability bias. We used indirect questioning, a technique designed to measure sensitive behaviors, to assess the prevalence of prescription opioid diversion among a cohort of individuals with HIV. MethodsWe randomized 581 participants from a large urban HIV clinical cohort to answer either a direct or indirect question about opioid diversion between October 2016-July 2018. We estimated the prevalence of diversion under each method. We also estimated diversion prevalence in subsets of the sample by age, sex, race, HIV risk group, substance use, and mental health co-morbidities. ResultsOf 1,285 patients screened, 581 (45.2 %) reported ever having received an opioid prescription. Of these, 252 (43.4 %) directly answered whether they had ever diverted opioids and 313 (53.9 %) answered the indirect question. The prevalence of opioid diversion under direct and indirect questioning was 6.3 % (95 % CI 3.7 %–10.1 %) and 15.3 % (95 % CI 10.4 %–20.3 %), respectively. In unadjusted analyses, males, non-African Americans, and patients with a history of illicit drug use had a higher diversion prevalence. In adjusted analyses, ever having used cocaine was most associated with diversion (OR 15.67, 95 % CI 0.93−263.17). ConclusionsOpioid diversion was common among this population, with the estimated prevalence more than doubling under the indirect questioning method designed to elicit less biased responses.

Genetic variation regulates opioid-induced respiratory depression in mice

In the U.S., opioid prescription for treatment of pain nearly quadrupled from 1999 to 2014. The diversion and misuse of prescription opioids along with increased use of drugs like heroin and fentanyl, has led to an epidemic in addiction and overdose deaths. The most common cause of opioid overdose and death is opioid-induced respiratory depression (OIRD), a life-threatening depression in respiratory rate thought to be caused by stimulation of opioid receptors in the inspiratory-generating regions of the brain. Studies in mice have revealed that variation in opiate lethality is associated with strain differences, suggesting that sensitivity to OIRD is genetically determined. We first tested the hypothesis that genetic variation in inbred strains of mice influences the innate variability in opioid-induced responses in respiratory depression, recovery time and survival time. Using the founders of the advanced, high-diversity mouse population, the Diversity Outbred (DO), we found substantial sex and genetic effects on respiratory sensitivity and opiate lethality. We used DO mice treated with morphine to map quantitative trait loci for respiratory depression, recovery time and survival time. Trait mapping and integrative functional genomic analysis in GeneWeaver has allowed us to implicate Galnt11, an N-acetylgalactosaminyltransferase, as a gene that regulates OIRD.

Gender differences in diversion among non-medical users of prescription opioids and sedatives

ABSTRACT Background Non-medical use of prescription drugs is a major public health concern in the United States. Prescription opioids and sedatives are among the most widely abused drugs and their combined use can be lethal. Increasingly rigid prescribing guidelines may contribute to the changing context of opioid use and increase drug diversion. Objective To examine gender differences in diversion of prescription opioids and sedatives among non-medical prescription opioid and sedative polysubstance users. We hypothesize that men will be more likely than women to engage in incoming diversion. Methods Data from the Prescription Drug Abuse, Misuse, and Dependence Study, a cross-sectional study focused on prescription drug users, were analyzed. Non-medical use was defined as use of a drug that was not prescribed or use in a way other than prescribed. Individuals who reported past 12-month non-medical opioid and sedative use were included; diversion was defined as incoming (obtaining drugs from a source other than a health professional) and outgoing (giving away/selling/trading prescription drugs). Results Among the 198 polysubstance users, 41.4% were female. Men were 2.85 times as likely as women to report incoming diversion (95% CI: 1.21–6.72). Women were more likely to obtain opioids from a healthcare professional; men were more likely to obtain sedatives from a roommate, coworker, or friend. Over half of men and women reported outgoing diversion opioids or sedatives. Conclusion Drug diversion highlights an important point of intervention. Current prevention efforts that target prescribers should be expanded to include users and diversion activities; these interventions should be gender-specific.

Dynamic changes in prescription opioids from 2006 to 2017 in Texas.

BackgroundThe US is experiencing an epidemic of opioid overdoses which may be at least partially due to an over-reliance on opioid analgesics in the treatment of chronic non-cancer pain and subsequent escalation to heroin or illicit fentanyl. As Texas was reported to be among the lowest in the US for opioid use and misuse, further examination of this state is warranted.Materials and MethodsThis study was conducted to quantify prescription opioid use in Texas. Data was obtained from the publicly available US Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) which monitors controlled substances transactions from manufacture to commercial distribution. Data for 2006–2017 from Texas for ten prescription opioids including eight primarily used to relieve pain (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, oxymorphone) and two (buprenorphine and methadone) for the treatment of an Opioid Use Disorder (OUD) were examined.ResultsThe change in morphine mg equivalent (MME) of all opioids (+23.3%) was only slightly greater than the state’s population gains (21.1%). Opioids used to treat an OUD showed pronounced gains (+90.8%) which were four-fold faster than population growth. Analysis of individual agents revealed pronounced elevations in codeine (+387.5%), hydromorphone (+106.7%), and oxycodone (+43.6%) and a reduction in meperidine (−80.3%) in 2017 relative to 2006. Methadone in 2017 accounted for a greater portion (39.5%) of the total MME than hydrocodone, oxycodone, morphine, hydromorphone, oxymorphone, and meperidine, combined. There were differences between urban and rural areas in the changes in hydrocodone and buprenorphine.ConclusionsCollectively, these findings indicate that continued vigilance is needed in Texas to appropriately treat pain and an OUD while minimizing the potential for prescription opioid diversion and misuse. Texas may lead the US in a return to pre-opioid epidemic prescription levels.