Long-acting Opioids Research Articles

Pharmacologic Management of Paroxysmal Sympathetic Hyperactivity After Brain Injury.

Paroxysmal sympathetic hyperactivity (PSH) is a result of acute brain injury that has been well known for many decades. However, the evidence for management of PSH is almost entirely anecdotal in nature. We reviewed case reports or series of pharmacotherapy management of PSH. These studies mentioned treatment options, but few studies exist to guide treatment strategies. For many years, the syndrome was not clearly understood; therefore, the therapy has focused on control of symptoms. In 2014, a Steering Committee came together to develop a conceptual definition and produced a consensus set of diagnostic criteria. Although understanding the diagnostic criteria is very well needed in management of patients with PSH, pharmacologic management is also crucial. Data describing the drug choices, dosing, and duration of therapy are also sparse. Recognition of appropriate medications is important because PSH is associated with morbidity, longer hospitalization, delaying transfer to rehabilitation units, and increasing cost. In this review article, we discussed the common medications used in the treatment of PSH. Treatment should target symptom abortion, prevention of symptoms, and refractory treatment. Symptom-abortive medications are indicated to control discrete breakthrough episodes, using medications such as morphine and short-acting benzodiazepines. Other medications used for prevention of symptoms and refractory treatment include long-acting benzodiazepines, nonselective β-blockers, α2 agonists, opioids, and GABA agonists. The mechanisms by which these agents improve symptoms of PSH remain speculative. However, a combination of medications from different classes seems the most effective approach in managing PSH symptoms. There is wide variability in clinical practice with regard to drug choices, dosing, and duration of therapy. Future research needs to be conducted using the new PSH assessment measure to appropriately apply drug management.

(237) Patterns in the use of prescription opioids among children: persistence and total daily dosage of short- and long-acting opioids

(237) Patterns in the use of prescription opioids among children: persistence and total daily dosage of short- and long-acting opioids

Trends in long-term opioid prescribing in primary care patients with musculoskeletal conditions: an observational database study.

Long-term opioids may benefit patients with chronic pain but have also been linked to harmful outcomes. In the United Kingdom, the predominant source of opioids is primary care prescription. The objective was to examine changes in the incidence, length, and opioid potency of long-term prescribing episodes for musculoskeletal conditions in UK primary care (2002-2013). This was an observational database study (Clinical Practice Research Datalink, 190 practices). Participants (≥18 years) were prescribed an opioid for a musculoskeletal condition (no opioid prescribed in previous 6 months), and issued ≥2 opioid prescriptions within 90 days (long-term episode). Opioids were divided into short- and long-acting noncontrolled and controlled drugs. Annual incidence of long-term opioid episodes was determined, and for those still in a long-term episode, the percentage of patients prescribed each type 1 to 2 years, and >2 years after initiation. Annual denominator population varied from 1.25 to 1.38 m. A total of 76,416 patients started 1 long-term episode. Annual long-term episode incidence increased (2002-2009) by 38% (42.4-58.3 per 10,000 person-years), remaining stable to 2011, then decreasing slightly to 55.8/10,000 (2013). Patients prescribed long-acting controlled opioids within the first 90 days of long-term use increased from 2002 to 2013 (2.3%-9.9%). In those still in a long-term opioid episode (>2 years), long-acting controlled opioid prescribing increased from 3.5% to 22.6%. This study has uniquely shown an increase in prescribing long-term opioids to 2009, gradually decreasing from 2011 in the United Kingdom. The trend was towards increased prescribing of controlled long-acting opioids and earlier use. Further research into the risks and benefits of opioids is required.

“They Got How Much Methadone?” What We Learned About How to Best Respond to Opioid Dosage Errors (SA535)

•Describe the risks associated with dosage errors for both long-acting opioids such as methadone and short-acting opioids such as morphine. Participants will be able to describe appropriate assessment components and frequency of assessment after an opioid dosage error and develop an appropriate plan of care based on the type and amount of opioid involved in the error.•Describe the components of a protocol outlining the safe and appropriate use of narcan in opioid tolerant patients with pain along with the risks of using narcan for full reversal of opioids in opioid tolerant patients with pain. Despite robust teaching, opioid dosage errors occur in the hospice and palliative care setting. This presentation will explore the components of a robust opioid teaching plan, including patient teaching tools. We will review the risks associated with opioid dosage errors based on the type of opioid (short or long acting) and the patient’s history of opioid use and discuss appropriate follow up for each type of dosage error. Narcan is not always the answer. We will share the protocol we developed in response to a methadone dosage error.

Opioid Analgesics and the Risk of Serious Infections Among Patients With Rheumatoid Arthritis: A Self-Controlled Case Series Study.

Animal studies and in vitro human studies suggest that certain opioid analgesics impair crucial immune functions. This study was undertaken to determine whether opioid use is associated with increased risk of serious infection in patients with rheumatoid arthritis (RA). We conducted a self-controlled case series analysis on a retrospective cohort of 13,796 patients with RA enrolled in Tennessee Medicaid in 1995-2009. Within-person comparisons of the risk of hospitalization for serious infection during periods of opioid use versus non-use were performed using conditional Poisson regression. Fixed confounders were accounted for by design; time-varying confounders included age and use of disease-modifying antirheumatic drugs, glucocorticoids, and proton-pump inhibitors. In additional analyses, risks associated with new opioid use, use of opioids known to have immunosuppressive properties, use of long-acting opioids, and different opioid dosages were assessed. Sensitivity analyses were performed to account for potential protopathic bias and confounding by indication. Among 1,790 patients with RA who had at least 1 hospitalization for serious infection, the adjusted incidence rate of serious infection was higher during periods of current opioid use compared to non-use, with an incidence rate ratio (IRR) of 1.39 (95% confidence interval [95% CI] 1.19-1.62). The incidence rate was also higher during periods of long-acting opioid use, immunosuppressive opioid use, and new opioid use compared to non-use (IRR 2.01 [95% CI 1.52-2.66], IRR 1.72 [95% CI 1.33-2.23], and IRR 2.38 [95% CI 1.65-3.42], respectively). Results of sensitivity analyses were consistent with the main findings. In within-person comparisons of patients with RA, opioid use was associated with an increased risk of hospitalization for serious infection.

Aggregation of Marginal Gains in Cardiac Surgery: Feasibility of a Perioperative Care Bundle for Enhanced Recovery in Cardiac Surgical Patients.

The aim of this pilot study was to assess the feasibility of a perioperative care bundle for enhanced recovery after cardiac surgery (ERACS). A prospective, observational study. A major urban teaching and university hospital and tertiary referral center. The study included 53 patients undergoing cardiac surgery before implementation of an ERACS protocol (pre-ERACS group) and 52 patients undergoing cardiac surgery after implementation of an ERACS protocol (ERACS group). Based on recommendations from a consensus review in colorectal surgery, the following enhanced recovery perioperative care bundle was applied: detailed preoperative information, avoidance of prolonged fasting periods preoperatively, preoperative carbohydrate beverages, optimization of analgesia with avoidance of long-acting opioids, prevention of postoperative nausea and vomiting, early enteral nutrition postoperatively, and early mobilization. The authors hypothesized that length of hospital stay would be reduced with ERACS. Secondary outcome variables included a composite of postoperative complications and pain scores. Whereas the length of stay in the group of patients receiving the bundle of enhanced recovery interventions remained unchanged compared with the non-ERACS group, there was a statistically significant reduction in the number of patients in the ERACS group presenting with one or more postoperative complications (including hospital-acquired infections, acute kidney injury, atrial fibrillation, respiratory failure, postoperative myocardial infarction, and death). In addition, postoperative pain scores were improved significantly in the ERACS group. This pilot study demonstrated that ERACS is feasible and has the potential for improved postoperative morbidity after cardiac surgery. A larger multicenter quality improvement study implementing perioperative care bundles would be the next step to further assess outcomes in ERACS patients.

The Opioid Challenge.

The Opioid Challenge.

Critical appraisal of “Prescription of long-acting opioids and mortality in patients with chronic nonmalignant pain”☆

Critical appraisal of “Prescription of long-acting opioids and mortality in patients with chronic nonmalignant pain”☆

Long-acting opioids increase risk of death by 64%

Long-acting opioids increase risk of death by 64%

Dramatic Reduction in Hydrocodone Prescriptions in an Urban Safety Net Health Care System: Has It Improved Patient Safety or Led to Increased Patient Suffering?

Pain management, chronic use of opioids for non-cancer pain, and opioid overdose have become nationwide public health challenges. According to a recent Institute of Medicine report, up to one-third of U.S. adults report chronic pain [1]. Following nationwide policy changes, updated practice guidelines, and the loosening of opioid prescribing restrictions in the 1990s, a dramatic increase was seen in the prescriptions of opioids for non-cancer chronic pain [2]. In addition, over the last 20 years there has been a dramatic increase in opioid-related accidental overdoses and deaths, with 16,651 deaths attributed to prescription opioids in 2010 [3,4]. The majority of these deaths are attributable to long-acting opioids and methadone [5]. The increased mortality rate is due not simply to the overall increase in prescriptions but also to prescriber knowledge deficits, patient behaviors and co-morbidities, and payor and system policies [5,6]. In addition to the risk of accidental overdose and death, chronic use of opioids creates other risks to patient safety including abuse, addiction, transition to heroin use, diversion, and accidents [7]. Lastly, opioids can be associated with numerous adverse effects, such as constipation, sedation, hormonal imbalance, and hyperalgesia [8–10]. At the same time, opioids are necessary to meet a critical need for adequate control of both acute and chronic pain in certain patient populations. Withholding and restricting necessary medical treatment may cause undue patient suffering [11]. In addition, prescriber bias and societal stigmas may result in unintended and problematic barriers to improved quality of life for certain groups [12]. In response to increases in opioid-related morbidity and mortality, various recommendations have been made for safe opioid prescribing, including urine drug monitoring, state prescription monitoring databases, and treatment agreements …

Is Early Prescribing of Opioid and Psychotropic Medications Associated With Delayed Return to Work and Increased Final Workers' Compensation Cost?

To explore the association between the initial 60 days of prescriptions for psychotropic medications and final workers' compensation claim outcomes. A cohort of 11,394 claimants involved in lost time injuries between 1999 and 2002 were followed through December 31, 2009. Logistic regressions and Cox Proportional Hazard Models were used in the analysis. The initial 60 days of prescriptions for psychotropic medications were significantly associated with a final claim cost at least $100,000. Odds ratios were 1.88 for short-acting opioids, 2.14 for hypnotics, antianxiety agents, or antidepressants, and 3.91 for long-acting opioids, respectively. Significant associations were also found between decreased time lost from work and decreased claim closures during the study period. Early prescription of opioids and other psychotropic drugs may be useful predictors of high claim costs and time lost from work.

Successful interventions in decreasing oxycodone CR prescriptions within an underserved population

To use fundamental population health and Patient Centered Medical Home guidelines to create an effective intervention that would decrease the quantity of inappropriate oxycodone controlled release (CR) prescriptions within an uninsured population. This was a prospective interventional study. Patients seen in the newly formed University of Florida Community Health and Family Medicine Department Total Care Clinic, for chronic nonmalignant pain. This clinic was designed to serve the uninsured patients of Jacksonville, FL. A structured, step-wise pain management protocol was introduced and implemented, and an improved Controlled Substance User Agreement was created and implemented. Pharmacists and primary care providers collaborated on care. The primary study outcome measures were the number of oxycodone CR prescriptions over an 8-month period. At the initiation of the program, the authors averaged over 40 oxycodone CR prescriptions per month. After 3 months, the number of prescriptions dropped to an average of 10 per month, a 75 percent decrease. More importantly, the number of oxycodone CR tablets saw a corresponding 75 percent drop from over 2,500 tablets per month to approximately 600 per month. Of course, the authors were concerned that the reduction of oxycodone CR may lead to increases in the use of other opioids. However, trends for hydrocodone/acetaminophen also showed a reduction in total usage as well as all other long-acting opioids. In addition, patient satisfaction did not change significantly, and no significant complaints from patients regarding this specific change were received. By implementing criteria for oxycodone CR prescribing in an innovative, comprehensive, and unified patient-centered practice model, the authors saw a significant decrease in the number of oxycodone CR tablets prescribed per month and also a decrease in total prescriptions per month.

State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states

BackgroundMany people lack access to primary care services in the United States. One possible solution is to increase utilization of advanced practice registered nurses (APRNs). A common patient safety concern about independent prescribing by APRNs is that prescribers will increase prescriptions for medications with abuse/dependence potential, such as opioids or benzodiazepines. PurposeThe purpose was to investigate the relationship in opioid- and benzodiazepine-prescribing rates between independent vs. nonindependent APRN prescribing states. MethodsTertiary analysis of a Centers for Disease Control and Prevention study reporting state variation in prescribing rates of opioids and benzodiazepines using 2012 Intercontinental Marketing Services Health retail prescription data representing 259,000,000 prescriptions. Analyses were performed using different definitions for independent states: (a) states allowing at least one APRN type independent prescribing and (b) states allowing all APRN types independent prescribing. ANOVA tests were used to test for differences in mean number of opioid- and benzodiazepine-prescribing rates per 100 residents. Analysis of Covariance tests were employed controlling for state characteristics previously determined to affect controlled substance–prescribing rates (e.g., Medicare rates, race, socioeconomic status, number of physicians/capita). Results/DiscussionThere were significantly higher opioid and benzodiazepine prescriptions in states with nonindependent APRN prescribing laws than those in states with independent APRN prescribing laws and no significant differences in long-acting opioids or high-dose opioids. This study found no evidence to support the argument that independent prescribing increases prescriptions with abuse potential. ConclusionIndependent prescriptive authority, only one piece of APRN practice, has been one of the most controversial issues but one with great potential to help ease access to U.S. health care problems. Empirical evidence demonstrating the safety of this practice can help promote this potential.

Controlled Substance Prescribing Patterns--Prescription Behavior Surveillance System, Eight States, 2013.

Drug overdose is the leading cause of injury death in the United States. The death rate from drug overdose in the United States more than doubled during 1999-2013, from 6.0 per 100,000 population in 1999 to 13.8 in 2013. The increase in drug overdoses is attributable primarily to the misuse and abuse of prescription drugs, especially opioid analgesics, sedatives/tranquilizers, and stimulants. Such drugs are prescribed widely in the United States, with substantial variation by state. Certain patients obtain drugs for nonmedical use or resale by obtaining overlapping prescriptions from multiple prescribers. The risk for overdose is directly associated with the use of multiple prescribers and daily dosages of >100 morphine milligram equivalents (MMEs) per day. 2013. The Prescription Behavior Surveillance System (PBSS) is a public health surveillance system that allows public health authorities to characterize and quantify the use and misuse of prescribed controlled substances. PBSS began collecting data in 2012 and is funded by CDC and the Food and Drug Administration. PBSS uses standard metrics to measure prescribing rates per 1,000 state residents by demographic variables, drug type, daily dose, and source of payment. Data from the system can be used to calculate rates of misuse by certain behavioral measures such as use of multiple prescribers and pharmacies within specified time periods. This report is based on 2013 de-identified data (most recent available) that represent approximately one fourth of the U.S. Data were submitted quarterly by prescription drug monitoring programs (PDMPs) in eight states (California, Delaware, Florida, Idaho, Louisiana, Maine, Ohio, and West Virginia) that routinely collect data on every prescription for a controlled substance to help law enforcement and health care providers identify misuse or abuse of such drugs. In all eight states, opioid analgesics were prescribed approximately twice as often as stimulants or benzodiazepines. Prescribing rates by drug class varied widely by state: twofold for opioids, fourfold for stimulants, almost twofold for benzodiazepines, and eightfold for carisoprodol, a muscle relaxant. Rates for opioids and benzodiazepines were substantially higher for females than for males in all states. In most states, opioid prescribing rates peaked in either the 45-54 years or the 55-64 years age group. Benzodiazepine prescribing rates increased with age. Louisiana ranked first in opioid prescribing, and Delaware and Maine had relatively high rates of use of long-acting (LA) or extended-release (ER) opioids. Delaware and Maine ranked highest in both mean daily opioid dosage and in the percentage of opioid prescriptions written for >100 MMEs per day. The top 1% of prescribers wrote one in four opioid prescriptions in Delaware, compared with one in eight in Maine. For the five states whose PDMPs collected the method of payment, the percentage of controlled substance prescriptions paid for in cash varied almost threefold, and the percentage paid by Medicaid varied sixfold. In West Virginia, for 1 of every 5 days of treatment with an opioid, the patient also was taking a benzodiazepine. Multiple-provider episode rates were highest in Ohio and lowest in Louisiana. This report presents rates of population-based prescribing and behavioral measures of drug misuse in the general population that have not been available previously for comparison among demographic groups and states. The higher prescribing rates for opioids among women compared with men are consistent with a higher self-reported prevalence of certain common types of pain, such as lower back pain among women. The trend in opioid prescribing rates with age is consistent with an increase in the prevalence of chronic pain with age, but the increasing prescribing rates of benzodiazepines with age is not consistent with the fact that anxiety is most common among persons aged 30-44 years. The variation among states in the type of opioid or benzodiazepine of choice is unexplained. Most opioid prescribing occurs among a small minority of prescribers. Most of the prescriptions by top-decile prescribers probably are written by general, family medicine, internal medicine, and midlevel practitioners. The source of payment varied by state, for reasons that are unclear. Persons who are prescribed opioids also are commonly prescribed benzodiazepine sedatives despite the risk for additive depressant effects. States can use their prescription drug monitoring programs to generate population-based measures for the prescribing of controlled substances and for behaviors that suggest their misuse. Comparing data with other states and tracking changes in these measures over time can be useful in measuring the effect of policies designed to reduce prescription drug misuse.

Laryngeal clefts

Laryngeal clefts

The 5 P’s: The Postoperative Pain Patient, a Preoperative Priority

Patients receiving long-acting opioids preoperatively need special consideration postoperatively. The PeriAnesthesia Practice Council identified this population of surgical patients as a group that did not always receive timely pain control postoperatively as standard postoperative analgesic orders were often inadequate. Proper equianalgesic dosing regimens needed to be calculated preoperatively and available on admission to the Post Anesthesia Care Unit (PACU) to better achieve optimal pain relief.

Adherence to Analgesics for Cancer Pain: A Comparative Study of African Americans and Whites Using an Electronic Monitoring Device

Despite well-documented disparities in cancer pain outcomes among African Americans, surprisingly little research exists on adherence to analgesia for cancer pain in this group. We compared analgesic adherence for cancer-related pain over a 3-month period between African Americans and whites using the Medication Event Monitoring System (MEMS). Patients (N = 207) were recruited from outpatient medical oncology clinics of an academic medical center in Philadelphia (≥18 years of age, diagnosed with solid tumors or multiple myeloma, with cancer-related pain, and at least 1 prescription of oral around-the-clock analgesic). African Americans reported significantly greater cancer pain (P < .001), were less likely than whites to have a prescription of long-acting opioids (P < .001), and were more likely to have a negative Pain Management Index (P < .001). There were considerable differences between African Americans and whites in the overall MEMS dose adherence, ie, percentage of the total number of prescribed doses that were taken (53% vs 74%, P < .001). On subanalysis, analgesic adherence rates for African Americans ranged from 34% (for weak opioids) to 63% (for long-acting opioids). Unique predictors of analgesic adherence varied by race; income levels, analgesic side effects, and fear of distracting providers predicted analgesic adherence for African Americans but not for whites. PerspectiveDespite evidence of disparities in cancer pain outcomes among African Americans, surprisingly little research exists on African Americans' adherence to analgesia for cancer pain. This prospective study uses objective measures to compare adherence to prescribed pain medications between African American and white patients with cancer pain.

Successful Discontinuation of Systemic Opioids After Implantation of an Intrathecal Drug Delivery System.

An implantable drug delivery system (IDDS) provides an alternate route of opioid administration for patients with chronic pain. We collected data on systemic opioid use before and after IDDS implantation; patients who successfully discontinued systemic opioids; and physician support of discontinuation. This was a single-center, retrospective chart review of 99 consecutive patients who used IDDSs for at least six months. Data collection included pre/postimplant systemic opioid use and pain scores, and patient demographic and clinical characteristics. The study population averaged 67 years of age, was 68% women, and 77% were Medicare beneficiaries. Ninety-five percent of patients had low back pain, and 86% had limb pain. The majority (81%) had pain for >5 years. Failed treatments included epidural injections (74%), lumbar spine surgery (46%), spinal cord stimulation (14%), and facet joint injections (11%), with 84% also reporting significant systemic opioid side-effects. All patients taking long-acting opioids discontinued these within one month of implant. Total systemic opioid elimination was accomplished by 68% of patients at one month postimplant, 84% at one year, and 92% at five years. At one month postimplant, 60% of patients reported decreased pain (mean change: -4.07), and at one year, 64% did (mean change: -3.42). IDDS can provide significant and lasting pain relief and an alternate route of delivery compared with systemic opioids with their associated side-effects. We demonstrated that systemic opioid elimination could be accomplished after IDDS implantation in the majority of cases through appropriate patient selection, monitoring, and participation.

Rates of opioid dispensing and overdose after introduction of abuse-deterrent extended-release oxycodone and withdrawal of propoxyphene.

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.

Abuse-deterrent opioid formulations: part of a public health strategy to reverse the opioid epidemic.

Rapid increases in the supplyofopioid analgesicshave largely driven the nearly unremitting increase in overdose deaths in the United States, which have grown bymore than 150%over thepast decade, from16 849 in 1999 to41 502 in 2012.1,2 Since the 1990s, opioid analgesic sales have increased more than 4-fold,with risingandwidely variable regional prescribing patterns. Increased market supply makes opioids more available for misuse and diversion to people engaging in recreational use and topeoplewith addiction. In both cases,misuseanddiversion increase, elevatingpopulationoverdose risk. In fact, geographic areas with higher opioid prescribing rates experience higher overdose rates.2 In addition, patient-level data demonstrate that the intensity of opioid exposure, includinghigherprescribeddosesand longerdurationof therapy, elevates overdose risk.3,4 Given this opioid-overdose epidemic, the clinical literature isunderstandably repletewithefforts that target individuals most at risk, including strategies such as routine screening for risk of addiction, patient agreements, andurine toxicologymonitoring.Unfortunately, these approaches havenot yet demonstratedwidespread effectiveness in reversing the epidemic.5 Public health approaches to reduce opioid-related overdosesarealsoneeded,sincemostoverdosesdonotoccuramong patients who are receiving daily prescribed opioids or among those receiving thehighestdosesdespite the fact thatdoseand daily use confer elevated risk at an individual level.2 In this issueofJAMAInternalMedicine,Larochelleandcolleagues6highlight the critical importance of one public health lever: market supply of opioids. The authors studied 2 nearly simultaneously implementedpharmaceuticalmarket changes among commercial health plan beneficiaries: substitution of abuse-deterrent long-actingoxycodonehydrochloride (which reducespotential tamperingof its time-releasemechanism) for the non–abuse-deterrent formulation and the removal of the weak opioid propoxyphene. Following thesemarket changes, the rate of nonfatal emergency department visits and inpatient visits for opioid analgesic overdoses decreased. The pharmaceutical market changes were also associated with a decrease in overall milligrams of morphineequivalent doses (MEDs) dispensed, resulting in adecrease of dispensed opioid dose per covered beneficiary from a high of 163 mg MED in late 2010 to 139 mg MED in early 2012. These market changes in the opioid supply may have reduced the numbers of overdoses for several reasons. With fewer opioids prescribed, beneficiaries with prescriptions consumed less, lowering individual risk, particularly from long-acting oxycodone,which is amore commonlyprescribedopioid than propoxypheneandassociatedwithhigheroverdose risk.3 Less opioidprescribing also likely led to fewer opioids available for diversion (to both beneficiaries andnonbeneficiaries), lowering population risk. Finally, making long-acting oxycodone availableonly inanabuse-deterrent formulationmayhaveprevented divertedmedications from being used parenterally or intranasally—both riskier than oral use. Regardless, making long-actingopioidsexclusivelyavailable inabuse-deterrent formulations, particularly for new medications as they are released to the market, is a structural lever that may minimize adverse public health consequences of long-acting opioids. Abuse-deterrent formulations composeonlypart of apublic health strategy to reduce overdose andmisuse. These formulationswill not prevent people receivinghighdoses of opioids fromoverdosing. It remainspossible tooverdoseby taking oralmedications, evenwhenusing themas directed, particularlywhen incombinationwithotherprescribedor illicitdrugs. Abuse-deterrentmedicationsalsodonotprevent the initial exposure to opioids. Most opioid use carries some risk, and intensity of the exposure via dose and length of treatment increases subsequent risk of misuse and overdose. Related article page 978 Effect of Abuse-Deterrent Oxycodone Introduction and PropoxypheneWithdrawal Original Investigation Research