Reformulation of oxycodone 80 mg to prevent misuse: A cohort study assessing the impact of a supply-side intervention

The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis

BACKGROUND

Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use.

METHODS

We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use.

RESULTS

The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection.

CONCLUSIONS

A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.

Association Between Statewide Opioid Prescribing Interventions and Opioid Prescribing Patterns in North Carolina, 2006-2018

OBJECTIVE

To examine the impact of three sequential statewide policy and legislative interventions on opioid prescribing practices among privately insured individuals in North Carolina.

METHODS

An interrupted time series approach was used to examine level and trajectory changes of new and prevalent opioid prescription rates, days' supply, and daily morphine milligram equivalents before and after implementation of a 1) prescription drug monitoring program, 2) state medical board initiative, and 3) legislative action. Analyses were conducted using individual-level claims data from a large private health insurance provider serving North Carolina residents, ages 18-64 years, from January 2006 to August 2018.

RESULTS

Rates of new and prevalent prescription opioid patients were relatively unaffected by the prescription monitoring program but sharply declined in the months immediately following both medical board (-3.7 new and -19.3 prevalent patients per 10,000 person months) and legislative (-14.1 new and -26.7 prevalent patients) actions. Among all opioid prescriptions, days' supply steadily increased on average over the study period but declined after legislative action (-1.5 days' supply per year).

CONCLUSIONS

The voluntary prescription drug monitoring program launched in 2010 only marginally affected opioid prescribing patterns on its own, but its redeployment as an investigative and clinical tool in multifaceted public policy approaches by the state medical board and legislature later in the decade plausibly contributed to notable declines in prescription rates and days' supply. This study lends new emphasis to the importance of enforcement mechanisms for state and national policies seeking to reverse this critical public health crisis.

Abuse-Deterrent Opioids: A Survey of Physician Beliefs, Behaviors, and Psychology

Objective

Evaluate beliefs and behaviors pertaining to abuse-deterrent opioids (ADFs).

Design

Survey in 2019 by invitation to all licensed physicians.

Setting

Commonwealth of Kentucky.

Participants

374 physicians.

Methods

Descriptive statistics, and hypothesis test that early adopter prescribers would have greater endorsement of opioid risk management.

Results

Of all prescribers, 55% believed all opioid analgesics should have ADF requirements (15% were unsure); 74% supported mandating insurance coverage. Only one-third considered whether an opioid was ADF when prescribing, motivated by patient family diversion (94%) and societal supply reduction (88%). About half believed ADFs were equally effective in preventing abuse by intact swallowing, injection, chewing, snorting, smoking routes. Only 4% of OxyContin prescribers chose it primarily because of ADF properties. Instead, the most common reason (33%) was being started by another prescriber. A quarter of physicians chose not to prescribe ADFs because of heroin switching potential. Early adopters strongly believed ADFs were effective in reducing abuse (PR 3.2; 95% CI 1.5, 6.6) compared to mainstream physicians. Early-adopter risk-management practices more often included tools increasing agency and measurement: urine drug screens (PR 2.0; 1.3, 3.1), risk screening (PR 1.3; 0.94, 1.9). While nearly all respondents (96%) felt that opioid abuse was a problem in the community, only 57% believed it was a problem among patients in their practice. Attribution theory revealed an externalization of opioid abuse problems that deflected blame from patients on to family members.

Conclusions

The primary motivator for prescribing ADFs was preventing diversion by family members, not patient-level abuse concerns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-021-00343-z.

The release of abuse-deterrent OxyContin and adolescent heroin use

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% points less likely to report ever using heroin after the reformulation (95% 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.