Opioid Prescribing Laws Are Not Associated with Short-term Declines in Prescription Opioid Distribution

Declining but Pronounced State-Level Disparities in Prescription Opioid Distribution in the United States

The United States (US) opioid epidemic is a persistent and pervasive public health emergency that claims the lives of over 80,000 Americans per year as of 2021. There have been sustained efforts to reverse this crisis over the past decade, including a number of measures designed to decrease the use of prescription opioids for the treatment of pain. This study analyzed the changes in federal production quotas for prescription opioids and the distribution of prescription opioids for pain and identified state-level differences between 2010 and 2019. Data (in grams) on opioid production quotas and distribution (from manufacturer to hospitals, retail pharmacies, practitioners, and teaching institutions) of 10 prescription opioids (codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, and tapentadol) for 2010 to 2019 were obtained from the US Drug Enforcement Administration. Amounts of each opioid were converted from grams to morphine milligram equivalent (MME), and the per capita distribution by state was calculated using population estimates. Total opioid production quotas increased substantially from 2010 to 2013 before decreasing by 41.5% from 2013 (87.6 MME metric tons) to 2019 (51.3). The peak year for distribution of all 10 prescription opioids was between 2010 and 2013, except for codeine (2015). The largest quantities of opioid distribution were observed in Tennessee (520.70 MME per person) and Delaware (251.45) in 2011 and 2019. There was a 52.0% overall decrease in opioid distribution per capita from 2010 to 2019, with the largest decrease in Florida (-61.6%) and the smallest in Texas (-18.6%). Southern states had the highest per capita distribution for eight of the ten opioids in 2019. The highest to lowest state ratio of total opioid distribution, corrected for population, decreased from 5.25 in 2011 to 2.78 in 2019. The mean 95th/5th ratio was relatively consistent in 2011 (4.78 ± 0.70) relative to 2019 (5.64 ± 0.98). This study found a sustained decline in the distribution of ten prescription opioids during the last five years. Distribution was non-homogeneous at the state level. Analysis of state-level differences revealed a fivefold difference in the 95th:5th percentile ratio between states, which has remained unchanged over the past decade. Production quotas did not correspond with the distribution, particularly in the 2010-2016 period. Future research, focused on identifying factors contributing to the observed regional variability in opioid distribution, could prove valuable to understanding and potentially remediating the pronounced disparities in prescription opioid-related harms in the US.

Opioid Prescribing Patterns After Imposition of Setting-Specific Limits on Prescription Duration

Importance

Despite their widespread adoption across the US, policies imposing one-size-fits-all limits on the duration of prescriptions for opioids have shown modest and mixed implications for prescribing.

Objective

To assess whether a prescription duration limit policy tailored to different clinical settings was associated with shorter opioid prescription lengths.

Design, Setting, and Participants

This cross-sectional study examined changes in opioid prescribing patterns for opioid-naive Medicaid enrollees aged 12 to 64 years before and after implementation of a statewide prescription duration limit policy in West Virginia in June 2018. Patients with cancer or Medicare coverage were excluded. The policy assigned a 7-day duration limit to opioid prescriptions for adults treated in outpatient hospital- or office-based practices, a 4-day limit for adults treated in emergency departments, and a 3-day limit for pediatric patients younger than 18 years regardless of clinical setting. Data were examined from January 1, 2017, through September 30, 2019, and data were analyzed from June 12 to October 30, 2023.

Main Outcomes and Measures

Whether a patient's initial opioid prescription was longer in days than the June 2018 policy limit for a given care setting before and after policy implementation. Interrupted time series models were used to calculate the association between the policy's implementation and outcomes.

Results

The analytic sample included 44 703 Medicaid enrollees (27 957 patients [62.5%] before policy implementation and 16 746 patients [37.5%] after policy implementation; mean [SD] age, 33.9 [13.4] years; 27 461 females [61.4%]). Among adults treated in outpatient hospital- or office-based settings, the duration limit policy was associated with a decrease of 8.83 (95% CI, -10.43 to -7.23) percentage points (P < .001), or a 56.8% relative reduction, in the proportion of prescriptions exceeding the 7-day limit. In the emergency department setting, the policy was associated with a decrease of 7.03 (95% CI, -10.38 to -3.68) percentage points (P < .001), a 37.5% relative reduction, in the proportion of prescriptions exceeding the 4-day limit. The proportion of pediatric opioid prescriptions longer than the 3-day limit decreased by 12.80 (95% CI, -17.31 to -8.37) percentage points (P < .001), a 26.5% relative reduction, after the policy's implementation.

Conclusions and Relevance

Results of this cross-sectional study suggest that opioid prescription duration limits tailored to different clinical settings are associated with reduced length of prescriptions for opioid-naive patients. Additional research is needed to evaluate whether these limits are associated with reductions in the incidence of opioid use disorder or with unintended consequences, such as shifts to illicit opioids.

Adherence to Opioid Prescribing Guidelines in a Statewide Surgical Quality Improvement Collaborative

INTRODUCTION

The opioid crisis is an ongoing crisis in the United States. Postoperative patients who receive opioid prescriptions have a 3%-7% risk of developing a chronic opioid abuse problem. This study aims to describe on-target opioid prescribing and use of multimodal pain management strategies 2 y after the implementation of a multicomponent quality improvement initiative across our statewide collaborative.

METHODS

From July 2020 to September 2021, we prospectively collected data on opioid-prescribing and multimodal strategies for 10 targeted procedures in general, gynecologic, and orthopedic surgery at three hospitals. Prescribing was on-target if a patient was prescribed ≤50 daily morphine milligram equivalents. Multimodal strategies were defined as two or more nonopioid adjuncts used within 48 h of surgery.

RESULTS

One thousand and eleven targeted procedures were performed with prescription data available for 993 cases. The on-target prescribing rate was 79.6% (n = 790), with general surgery 92.5% (n = 285), gynecology 84.9% (n = 331), and orthopedic surgery 59.0% (n = 174). Patients who received multimodal pain approaches were associated with interventions such as patient education, transversus abdominus plane block, and prescriptions for nonopioid analgesics at discharge. There was no evidence to support a difference in the use of multimodal pain control approaches between patients whose opioid prescribing was on-target or not (73.8% versus 77.3%, P = 0.30). At the first postoperative visit, data on continued opioid use were missing in 57.3% of patients, number of pills used was missing in 93.8%, and adequate pain control was missing in 52.8%.

CONCLUSIONS

On-target prescribing and multimodal strategies are common but vary by specialty. Additionally, postoperative pain control and opioid use are often not documented. To better match prescribing to patient needs, understanding patient-level and specialty-level opioid use is important.

Medical Cannabis Legalization: No Contribution to Rising Stimulant Rates in the USA

INTRODUCTION

There has been a pronounced increase in the use of Schedule II stimulants to treat attention-deficit hyperactivity disorder (ADHD) in the United States over the last two decades. Interestingly, chronic medical cannabis (MC) use can present with cognitive impairments that resemble ADHD symptoms. This study aimed to determine if MC legalization increased prescription stimulant distribution.

METHODS

Information on the distribution of methylphenidate, amphetamine, and lisdexamfetamine for 2006 to 2021 was extracted from the Drug Enforcement Administration's comprehensive database and the three-year population-corrected slopes of stimulant distribution before and after MC program implementation were compared.

RESULTS

We found a significant main effect of time (p<0.001); however, contrary to the hypothesis, the sales status of states' MC, did not influence slopes of distribution (p=0.391). There was a significantly large interaction effect of time and MC sales status on slopes of distribution (p<0.001). Slopes of distribution rates of stimulants were significantly lower in states that proceeded to legalize MC prior to MC program implementation than those states that did not (p=0.022). After MC program implementation, however, the distribution rates of the Schedule II stimulants were not significantly different when comparing states with MC sales to those without (p=0.355).

DISCUSSION

These findings suggest that MC program legalization did not contribute to certain states having rapid increases in Schedule II stimulant distribution rates over time. Other factors, including the liberalization of the adult ADHD diagnostic criteria in the DSM-5 and the introduction of Binge Eating Disorder, also likely contributed to elevations in stimulant distribution.

Association of a State Prescribing Limits Policy with Opioid Prescribing and Long-term Use: an Interrupted Time Series Analysis

BACKGROUND

Prescription opioids were a major initial driver of the opioid crisis. States have attempted to reduce overprescribing by enacting policies that limit opioid prescriptions, but the impacts of such policies on new prescribing and subsequent transitions to long-term use are not fully understood.

OBJECTIVE

To examine the association of implementation of a state prescribing limits policy with opioid prescribing and transitions to long-term opioid use.

DESIGN

Interrupted time series analyses assessing trends in new opioid prescriptions and long-term use before and after policy implementation.

PATIENTS

A total of 130,591 New Jersey Medicaid enrollees ages 18-64 who received an initial opioid prescription from January 2014 to December 2019.

INTERVENTIONS

New Jersey's opioid prescribing limit policy implemented in March 2017.

MAIN MEASURES

Total new opioid prescriptions, percentage of new prescriptions with >5 days' supply, and transition to long-term opioid use, defined as having opioid supply on day 90 after the initial prescription.

KEY RESULTS

Policy implementation was associated with a significant monthly increase in new opioid prescriptions of 0.86 per 10,000 enrollees, halving the pre-policy decline in the prescribing rate. Among new opioid prescriptions, the percentage with >5 days' supply decreased by about 1 percentage point (-0.76 percentage points, 95% CI -0.89, -0.62) following policy implementation. However, policy implementation was associated with a significant monthly increase in the rate of initial prescriptions with supply on day 90 (9.95 per 10,000 new prescriptions, 95% CI 4.80, 15.11) that reversed the downward pre-implementation trend.

CONCLUSIONS

The New Jersey policy was associated with a reduction in initial prescriptions with >5 days' supply, but not with an overall decline in new opioid prescriptions or in the rate at which initial prescriptions led to long-term use. Given their only modest benefits, policymakers and clinicians should carefully weigh potential unintended consequences of strict prescribing limits.

An Analysis of Oxycodone and Hydrocodone Distribution Trends in Delaware, Maryland, and Virginia Between 2006 and 2014

Objective Opioid medications are widely recognized for their use in analgesia and their addictive properties that have led to the opioid epidemic. Areas with historically high prescribing patterns have been shown to suffer more from the crisis. There is also regional variability in these trends. This study is a county level analysis of oxycodone and hydrocodone use in Delaware, Maryland, and Virginia between 2006 and 2014. Materials and methods A retrospective analysis of oxycodone and hydrocodone distributed as collected by the Drug Enforcement Administration's (DEA) Washington Post Automation of Reports and Consolidated Orders System (ARCOS) in Delaware, Maryland, and Virginia. Raw drug weights in each county were adjusted to "daily average dose" (grams/county population/365) using publicly available population estimates for all state counties. Purchasing data collected from ARCOS was used to compare distribution trends during this period. This study was limited in that ARCOS report quantity of drug distribution rather than average dose of script written.  Results There was a 57.59% increase in the weight of oxycodone and hydrocodone prescribed between 2006 and 2014. Oxycodone prescriptions increased by 75.50% and hydrocodone by 11.05%. Oxycodone increased across all three states between 2006 and 2010 and declined until 2014. Hydrocodone also increased but to a lesser extent than oxycodone. There was substantial variability in daily average dose of both opioids at the county level in all states. Pharmacies accounted for largest portion of oxycodone (69.17%) and hydrocodone (75.27%) purchased in the region. Hospitals accounted for 26.67% of oxycodone and 22.76% of hydrocodone purchased. Practitioners and mid-level providers, including Nurse Practitioners and Physician Assistants, did not significantly contribute to this increase. Conclusion In the states of Maryland, Delaware, and Virginia, the distribution of the prescription opioids oxycodone and hydrocodone increased by 57.59%. Daily average dose increased between 2006 and 2010 in all three states, followed by a decline until 2014. Variability in daily average dose by county highlights the relationship between geography and likelihood of receiving high-dose opioids. Increased monitoring at regional health centers and improving substance abuse treatment infrastructure at the county level may be a more efficient strategy in combating the opioid epidemic. Future research is needed to understand the socioeconomic trends that may influence prescribing trends of opioid medications.

Reductions and pronounced regional differences in morphine distribution in the United States

OBJECTIVES

The purpose of this longitudinal study was to describe the temporal pattern of morphine distribution nationally and between states.

METHODS

Drug weight was obtained from Report 5 of the US Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) to characterize patterns in the distribution of morphine from 2012 to 2021. Morphine distribution amounts were separated by state and business type and corrected for population. States outside a 95% confidence interval relative to the national average were considered statistically significant.

KEY FINDINGS

In 2012, there was a 4.6-fold difference in morphine distribution between the highest-prescribing state, Tennessee (180.2 mg/person), and the lowest-prescribing state, Texas (39.4 mg/person). By the end of 2021, national distribution of morphine had decreased by 59.9% when compared to the peak year 2012. In 2021, Tennessee (51.1 mg/person) remained the highest-prescribing state with a 3.0-fold difference relative to Texas (17.2 mg/person). The average hospital decrease (-73.9%) from 2012 to 2021 was larger than that of pharmacies (-58.2%).

CONCLUSIONS

The national 59.9% decline in morphine in the last decade may be attributable to prioritization of the US opioid crisis as a public concern. Further research is necessary to understand the persistent regional difference between states.

U.S. state policies on opioid prescribing during the peak of the prescription opioid crisis: Associations with opioid overdose mortality

BACKGROUND

In response to the opioid overdose crisis in the United States, many states implemented policies to guide opioid prescribing, but their impact on overdose mortality (prescription and non-prescription) remains poorly understood. We examined the impact of U.S. state opioid-prescribing policies on opioid overdose mortality following implementation.

METHODS

We calculated opioid overdose mortality rates from 1999-2016 by U.S. state using the CDC WONDER database, overall and separately for overdose deaths from prescription and non-prescription opioids. For each state, policies active on 1/1/2014 were reviewed for the presence and strength of six provisions recommending judicious opioid prescribing practices; "strong" provisions used the words "should," "shall," or "must". Interrupted time series (ITS) tested the association of each strong provision with overdose mortality, overall and separately for prescription and non-prescription opioids, in the two years following implementation. Sensitivity analyses compared between states, used time-lagged analyses, and excluded synthetic opioids from non-prescription opioid deaths.

RESULTS

All six provisions had consistent direction of effect in ITS and sensitivity analyses. Strong provisions for prescriber training and limits on opioid dose reduced the slope of overall and prescription opioid overdose mortality in both ITS and sensitivity analyses. Reduced non-prescription opioid overdose mortality was only associated with strong provision for prescriber training. Some provisions had a negative impact. In ITS, strong provision for prescriber response to misuse increased the slope of non-prescription opioid overdose mortality. Strong provision for mandatory prescription drug monitoring program use had no relationship with overdose mortality in ITS and was associated with increased overall, prescription and non-prescription opioid overdose mortality in between-state sensitivity analysis.

CONCLUSION

Opioid prescribing policies in U.S. states at the peak of the prescription opioid epidemic had modest mortality benefit, and did not reduce non-prescription opioid overdose mortality. A strong provision for prescriber training was the only provision associated with reduced prescription and non-prescription opioid overdose mortality. These findings can inform future efforts addressing prescription drug epidemics.

Trends in Opioid Prescribing by General Dentists and Dental Specialists in the U.S., 2012-2019

INTRODUCTION

Evidence suggests that U.S. dentists prescribe opioids excessively. There are limited national data on recent trends in opioid prescriptions by U.S. dentists. In this study, we examined trends in opioid prescribing by general dentists and dental specialists in the U.S. from 2012 to 2019.

METHODS

Dispensed prescriptions for oral opioid analgesics written by dentists were identified from IQVIA Longitudinal Prescription Data from January 2012 through December 2019. Autoregressive integrated moving average and joinpoint regression models described monthly population-based prescribing rates (prescriptions/100,000 individuals), dentist-based prescribing rates (prescriptions/1,000 dentists), and opioid dosages (mean daily morphine milligram equivalents/day). All analyses were performed in 2020.

RESULTS

Over the 8 years, dentists prescribed >87.2 million opioid prescriptions. Population- and dentist-based prescribing rates declined monthly by -1.97 prescriptions/100,000 individuals (95% CI= -9.98, -0.97) and -39.12 prescriptions/1,000 dentists (95% CI= -58.63, -17.65), respectively. Opioid dosages declined monthly by -0.08 morphine milligram equivalents/day (95% CI= -0.13, -0.04). Joinpoint regression identified 4 timepoints (February 2016, May 2017, December 2018, and March 2019) at which monthly prescribing rate trends were often decreasing in greater magnitude than those in the previous time segment.

CONCLUSIONS

Following national trends, dentists became more conservative in prescribing opioids. A greater magnitude of decline occurred post 2016 following the implementation of strategies aimed to further regulate opioid prescribing. Understanding the factors that influence prescribing trends can aid in development of tailored resources to encourage and support a conservative approach by dentists, to prescribing opioids.

Opioid prescribing restrictions and opioid use among the Louisiana Medicaid population

BACKGROUND

Most states in the U.S. have enacted prescription opioid quantity limits to curb long-term opioid dependency. While several studies of these policies find reductions in subsequent prescriptions, others find mixed results in reducing overall opioid prescriptions and prescription length. Our objective was to examine three opioid restriction policies implemented in Louisiana Medicaid: (1) a 15-day quantity limit for opioid-naïve acute pain patients, (2) a subsequent further reduction to a 7-day quantity limit and a Morphine Milligram Equivalent Dosing (MME) limit of 120mg per day, and (3) a final reduction in daily MMEs to 90mg per day.

METHODS

Using interrupted time series (ITS) models with Medicaid pharmacy claims data, we estimated changes in trends of opioid prescription fills associated with opioid restriction policies in Louisiana Medicaid. Outcomes of interest included average opioid prescription length, average MMEs per day, and the likelihood that an opioid-naïve beneficiary who received their first opioid prescription filled a second prescription within 30 or 60 days of their initial fill.

RESULTS

15-day and 7-day opioid prescription quantity limits were associated with a 0.720 and a 0.401 day reduction in average opioid prescription lengths. 7-day limits were associated with a 2.7 and a 3.0 percentage point reduction in the likelihood of a second opioid prescription fill within 30 or 60 days of the initial fill. The 120mg per day MME limit was associated with a 0.80 MMEs per day reduction in average daily MMEs. Further restricting daily MMEs to 90mg per day had no statistically significant association with average daily MMEs.

CONCLUSION

These findings suggest that efforts to limit opioid exposure through the implementation of prescription quantity limits and MME restrictions in Louisiana's Medicaid program were successful and are likely to be associated with a reduction in future opioid dependency among the state's Medicaid population.

Declines and regional variation in opioid distribution by U.S. hospitals

ABSTRACT

The United States is enduring a preventable opioid crisis, particularly involving a population being treated in a hospital setting, a subset of whom may escalate to illicit opioids. This project analyzed trends in distribution of opioids by hospitals in the United States. Opioids monitored included buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone, powdered opium, remifentanil, and tapentadol. The Automation of Reports and Consolidated Orders System (ARCOS) reports on substances controlled by the Drug Enforcement Administration. National data from ARCOS reports 5 and 7 from 2000 to 2019 were used for an observational study on hospital opioid distribution. Morphine milligram equivalents (MMEs) were calculated using oral conversion factors. The MME per person per state was calculated to compare data from the peak year, 2012, with data from 2019. Opioid use peaked in 2012, with a -46.6% decline from 2012 to 2019. Half (25) of the states have seen a decrease of -50% or greater. Of the opioid compounds observed, buprenorphine has seen increased (+122.5%) hospital use from 2012 to 2019. All other opioids have been experiencing a decline (≥50%), particularly hydromorphone (-49.9%), oxymorphone (-57.7%), methadone (-58.7%), morphine (-66.9%), codeine (-67.5%), and meperidine (-77.6%). There was a 6-fold difference in population-corrected use of opioids in 2019 between the lowest (6.8 MME/person in New Jersey) and highest (Alaska = 39.6) states. This study demonstrates the considerable progress made thus far by hospitals in curbing the U.S. opioid crisis.

Effects of State Opioid Prescribing Laws on Use of Opioid and Other Pain Treatments Among Commercially Insured U.S. Adults

BACKGROUND

There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time.

OBJECTIVE

To study the association between state opioid prescribing cap laws, pill mill laws, and mandatory prescription drug monitoring program query or enrollment laws and trends in opioid and guideline-concordant nonopioid pain treatment among commercially insured adults, including a subgroup with chronic noncancer pain conditions.

DESIGN

Thirteen treatment states that implemented a single law of interest in a 4-year period and unique groups of control states for each treatment state were identified. Augmented synthetic control analyses were used to estimate the association between each state law and outcomes.

SETTING

United States, 2008 to 2019.

PATIENTS

7 694 514 commercially insured adults aged 18 years or older, including 1 976 355 diagnosed with arthritis, low back pain, headache, fibromyalgia, and/or neuropathic pain.

MEASUREMENTS

Proportion of patients receiving any opioid prescription or guideline-concordant nonopioid pain treatment per month, and mean days' supply and morphine milligram equivalents (MME) of prescribed opioids per day, per patient, per month.

RESULTS

Laws were associated with small-in-magnitude and non-statistically significant changes in outcomes, although CIs around some estimates were wide. For adults overall and those with chronic noncancer pain, the 13 state laws were each associated with a change of less than 1 percentage point in the proportion of patients receiving any opioid prescription and a change of less than 2 percentage points in the proportion receiving any guideline-concordant nonopioid treatment, per month. The laws were associated with a change of less than 1 in days' supply of opioid prescriptions and a change of less than 4 in average monthly MME per day per patient prescribed opioids.

LIMITATIONS

Results may not be generalizable to non-commercially insured populations and were imprecise for some estimates. Use of claims data precluded assessment of the clinical appropriateness of pain treatments.

CONCLUSION

This study did not identify changes in opioid prescribing or nonopioid pain treatment attributable to state laws.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

Strategies aimed at preventing long-term opioid use in trauma and orthopaedic surgery: a scoping review

Background

Long-term opioid use, which may have significant individual and societal impacts, has been documented in up to 20% of patients after trauma or orthopaedic surgery. The objectives of this scoping review were to systematically map the research on strategies aiming to prevent chronic opioid use in these populations and to identify knowledge gaps in this area.

Methods

This scoping review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. We searched seven databases and websites of relevant organizations. Selected studies and guidelines were published between January 2008 and September 2021. Preventive strategies were categorized as: system-based, pharmacological, educational, multimodal, and others. We summarized findings using measures of central tendency and frequency along with p-values. We also reported the level of evidence and the strength of recommendations presented in clinical guidelines.

Results

A total of 391 studies met the inclusion criteria after initial screening from which 66 studies and 20 guidelines were selected. Studies mainly focused on orthopaedic surgery (62,1%), trauma (30.3%) and spine surgery (7.6%). Among system-based strategies, hospital-based individualized opioid tapering protocols, and regulation initiatives limiting the prescription of opioids were associated with statistically significant decreases in morphine equivalent doses (MEDs) at 1 to 3 months following trauma and orthopaedic surgery. Among pharmacological strategies, only the use of non-steroidal anti-inflammatory drugs and beta blockers led to a significant reduction in MEDs up to 12 months after orthopaedic surgery. Most studies on educational strategies, multimodal strategies and psychological strategies were associated with significant reductions in MEDs beyond 1 month. The majority of recommendations from clinical practice guidelines were of low level of evidence.

Conclusions

This scoping review advances knowledge on existing strategies to prevent long-term opioid use in trauma and orthopaedic surgery patients. We observed that system-based, educational, multimodal and psychological strategies are the most promising. Future research should focus on determining which strategies should be implemented particularly in trauma patients at high risk for long-term use, testing those that can promote a judicious prescription of opioids while preventing an illicit use, and evaluating their effects on relevant patient-reported and social outcomes.

Opioid overdose survivors: Medications for opioid use disorder and risk of repeat overdose in Medicaid patients

BACKGROUND

Patients with medically-treated opioid overdose are at high risk for subsequent adverse outcomes, including repeat overdose. Understanding factors associated with repeat overdose can aid in optimizing post-overdose interventions.

METHODS

We conducted a longitudinal, retrospective cohort study using NJ Medicaid data from 2014 to 2019. Medicaid beneficiaries aged 12-64 with an index opioid overdose from 2015 to 2018 were followed for one year for subsequent overdose. Exposures included patient demographics; co-occurring medical, mental health, and substance use disorders; service and medication use in the 180 days preceding the index overdose; and MOUD following index overdose.

RESULTS

Of 4898 individuals meeting inclusion criteria, 19.6% had repeat opioid overdoses within one year. Index overdoses involving heroin/synthetic opioids were associated with higher repeat overdose risk than those involving prescription/other opioids only (HR = 1.44, 95% CI = 1.22-1.71). Risk was higher for males and those with baseline opioid use disorder diagnosis or ED visits. Only 21.7% received MOUD at any point in the year following overdose. MOUD was associated with a large decrease in repeat overdose risk among those with index overdose involving heroin/synthetic opioids (HR = 0.30, 95% CI = 0.20-0.46). Among those receiving MOUD at any point in follow-up, 10.5% (112/1065) experienced repeat overdose versus 22.1% (848/3833) for those without MOUD.

CONCLUSIONS

Repeat overdose was common among individuals with medically-treated opioid overdose. Risk factors for repeat overdose varied by type of opioid involved in index overdose, with differential implications for intervention. MOUD following index opioid overdose involving heroin/synthetic opioids was associated with reduced repeat overdose risk.

The effect of state policies on rates of high-risk prescribing of an initial opioid analgesic

BACKGROUND

Multiple state policies, such as prescription drug monitoring programs (PDMPs) and duration limits, have been implemented to decrease high-risk opioid prescribing. Studies demonstrate that many policies decrease certain opioid prescribing behaviors, but few examine their intended effects on the targeted high-risk prescribing practices, nor disentangle the effects of concurrent state or federal policies likely to influence those practices.

METHODS

Forty-one million initial prescriptions for new opioid episodes from 2007 to 2018 were identified using national pharmacy claims. We identified high-risk initial prescriptions, defined as >7 days' supply, average daily MME >90, or concurrent with benzodiazepines and estimated three multivariable logistic regression models to assess the association between policies and outcomes controlling for patient, prescriber, and county characteristics.

RESULTS

Initial prescriptions for >7 days declined from 23.8% in 2007 to 14.9% in 2018, associated with mandatory and interoperable PDMPs and prescription duration limits but not other policies examined. Initial prescriptions with daily MME > 90 declined from 13.2% to 1.9%, associated with pain management clinic laws but not consistently with other policies. Initial prescriptions concurrent with benzodiazepines declined only modestly from 6.9% to 6.5%, associated with pain management clinic laws but not other policies examined.

CONCLUSIONS

The opioid policy environment has changed rapidly with a range of different policies being implemented addressing high-risk prescribing. PDMP laws mandating prescriber use and pain clinic laws both appear efficacious but decrease different types of high-risk opioid prescribing. New policies should be considered in light of the prevalence of the problem being addressed.

Rise, and pronounced regional variation, in methylphenidate, amphetamine, and lisdexamfetamine distribution in the United States

Background

The prescription stimulants methylphenidate, amphetamine, and lisdexamfetamine are sympathomimetic drugs with therapeutic use. They are designated in the United States as Schedule II substances, defined by the 1970 Controlled Substances Act as having a “high potential for abuse”. Changing criteria for the diagnosis of Attention Deficit Hyperactivity Disorder in 2013 and the approval of lisdexamfetamine for binge eating disorder in 2015 may have impacted usage patterns. This report compared the pharmacoepidemiology of these stimulants in the United States from 2010–2017.

Methods

Distribution of amphetamine, methylphenidate, lisdexamfetamine were examined via weights extracted from the Drug Enforcement Administration’s (DEA) Automated Reports and Consolidated Ordering System (ARCOS). Median stimulant Daily Dosage per patient was determined for a regional analysis. The percent of cost and prescriptions attributable to each stimulant and atomoxetine in Medicaid from the “Drug Utilization 2018 - National Total” from the Centers for Medicare and Medicaid was determined.

Results

There was a rise in amphetamine (+67.5%) and lisdexamfetamine (+76.7%) from 2010–2017. The change in methylphenidate (−3.0%) was modest. Persons/day stimulant usage was lower in the West than in other US regions from 2014-2017. There was a negative correlation (r(48) = −0.43 to −0.65, p < .05) between the percent Hispanic population per state and the Daily Dosage/population per stimulant. Methylphenidate formulations accounted for over half (51.7%) of the $3.8 billion reimbursed by Medicaid and the plurality (45.4%) of the 22.0 million prescriptions. Amphetamine was responsible for less than one-fifth (18.4%) of cost but one-third of prescriptions (33.6%). Lisdexamfetamine’s cost (26.0%) exceeded prescriptions (16.3%).

Conclusion

The rising amphetamine and lisdexamfetamine distribution may correspond with a rise in adult ADHD diagnoses. Regional analysis indicates that stimulant distribution in the West may be distinct from that in other regions. The lower stimulant distribution in areas with greater Hispanic populations may warrant further study.

Transforming Prescription Opioid Practices in Primary Care With Change Theory

The opioid epidemic continues to be an ongoing public health crisis. Many primary health care providers aptly serve as the gatekeeper to opioid prescriptions. The opioid epidemic has challenged the primary care profession whilst many of these providers have opted out of opioid prescribing altogether. This unintended consequence affirms erosion to primary care that is vital to the ecosystem of opioid management. The purpose of this study was to understand strategies to deliver opioids safely and effectively. Results indicate primary care providers are uniquely positioned to make a positive opioid impact through focused change initiatives. Five common themes arose from the inductive analysis: (1) provide leadership support; (2) define standard of work; (3) conduct pre-visit reviews; (4) conduct post-visit reviews; and (5) measure progress. Then, each common theme was deductively analyzed through a view of Kotter’s change theory to support an effective proxy for implementing and sustaining chronic opioid therapy in a primary care context. These finding have potential to provide actionable implications for health care management professionals and primary care organizations such as hospitals and group practices.

Geographic variation in the use of triptans and opioids for the acute treatment of migraine attacks

OBJECTIVE

To assess the geographic variations in triptan and opioid prescribing patterns for patients with migraine.

BACKGROUND

Numerous guidelines recommend triptans as the standard of care for migraine attacks, yet opioids are still widely used for migraine treatment. Variation in the use of opioids and triptans for the treatment of migraine by geographic location is not well known.

METHODS

Using a US claims database, we conducted a retrospective cohort study of adults diagnosed with migraine between 2016 and 2018. We used a 12-month follow-up period to assess triptan and opioid utilization, stratified by the nine Census Bureau-designated divisions. To examine the geographic factors that affect triptan and opioid use among patients, we conducted two sets of multivariable analyses. First, we analyzed the odds of a patient being a triptan or opioid user in the follow-up period, defined as ≥1 triptan or opioid claim. We then analyzed the medication use rate among triptan or opioid users.

RESULTS

Overall, we had a final study population of 113,921 patients. In the follow-up period, 52.9% (60,247/113,921) [range: 48.0%-56.3%] of patients were triptan users and 41.0% (46,708/113,921) [range: 28.9%-48.4%] of patients were opioid users with significant differences across census divisions (p < 0.001). Triptan users had a mean (SD) of 4.8 (4.7) triptan claims annually with no significant differences across divisions (p = 0.188). Opioid users had a mean (SD) of 5.4 (6.8) opioid claims annually with significant differences across divisions (p < 0.001). The observed variation in opioid use stemmed from the proportion of patients using opioids in each region and not from the number of opioid prescriptions per user.

CONCLUSIONS

There was a significant geographic variation in the use of opioids and to a lesser degree the use of triptans. The widespread use of opioids and the large variation in use other than triptans as the standard of care suggest that improvements could be made in the acute treatment of migraine attacks.

Implementation of mandatory opioid prescribing limits in North Carolina: healthcare administrator and prescriber perspectives

BACKGROUND

Recent increases in state laws to reduce opioid prescribing have demonstrated a need to understand how they are interpreted and implemented in healthcare systems. The purpose of this study was to explore the systems, strategies, and resources that hospital administrators and prescribers used to implement the 2017 North Carolina Strengthen Opioid Prevention (STOP) Act opioid prescribing limits, which limited initial prescriptions to a five (for acute) or seven (for post-surgical) days' supply.

METHODS

We interviewed 14 hospital administrators and 38 prescribers with degrees in medicine, nursing, pharmacy, business administration and public health working across North Carolina. Interview guides, informed by the Consolidated Framework for Implementation Research, explored barriers and facilitators to implementation. Interview topics included communication, resources, and hospital system support. Interviews were recorded and transcribed, then analyzed using flexible coding, integrating inductive and deductive coding, to inform analytic code development and identify themes.

RESULTS

We identified three main themes around implementation of STOP act mandated prescribing limits: organizational communication, prescriber education, and changes in the electronic medical record (EMR) systems. Administrators reflected on implementation in the context of raising awareness and providing reminders to facilitate changes in prescriber behavior, operationalized through email and in-person communications as well as dedicated resources to EMR changes. Prescribers noted administrative communications about prescribing limits often focused on legality, suggesting a directive of the organization's policy rather than a passive reminder. Prescribers expressed a desire for more spaces to have their questions answered and resources for patient communications. While hospital administrators viewed compliance with the law as a priority, prescribers reflected on concerns for adequately managing their patients' pain and limited time for clinical care.

CONCLUSIONS

Hospital administrators and prescribers approached implementation of the STOP act prescribing limits with different mindsets. While administrators were focused on policy compliance, prescribers were focused on their patients' needs. Strategies to implement the mandate then had to balance patient needs with policy compliance. As states continue to legislate to prevent opioid overdose deaths, understanding how laws are implemented by healthcare systems and prescribers will improve their effectiveness through tailoring and maximizing available resources.

Davis C, Rudolph KE, Keyes KM, Hasin DS, Cerdá M. Prescription Opioid Laws and Opioid Dispensing in US Counties: Identifying Salient Law Provisions With Machine Learning

BACKGROUND

Hundreds of laws aimed at reducing inappropriate prescription opioid dispensing have been implemented in the United States, yet heterogeneity in provisions and their simultaneous implementation have complicated evaluation of impacts. We apply a hypothesis-generating, multistage, machine-learning approach to identify salient law provisions and combinations associated with dispensing rates to test in future research.

METHODS

Using 162 prescription opioid law provisions capturing prescription drug monitoring program (PDMP) access, reporting and administration features, pain management clinic provisions, and prescription opioid limits, we used regularization approaches and random forest models to identify laws most predictive of county-level and high-dose dispensing. We stratified analyses by overdose epidemic phases-the prescription opioid phase (2006-2009), heroin phase (2010-2012), and fentanyl phase (2013-2016)-to further explore pattern shifts over time.

RESULTS

PDMP patient data access provisions most consistently predicted high-dispensing and high-dose dispensing counties. Pain management clinic-related provisions did not generally predict dispensing measures in the prescription opioid phase but became more discriminant of high dispensing and high-dose dispensing counties over time, especially in the fentanyl period. Predictive performance across models was poor, suggesting prescription opioid laws alone do not strongly predict dispensing.

CONCLUSIONS

Our systematic analysis of 162 law provisions identified patient data access and several pain management clinic provisions as predictive of county prescription opioid dispensing patterns. Future research employing other types of study designs is needed to test these provisions' causal relationships with inappropriate dispensing and to examine potential interactions between PDMP access and pain management clinic provisions. See video abstract at, http://links.lww.com/EDE/B861.

Fewer Opioids but More Benzodiazepines? Prescription Trends by Specialty in Response to the Implementation of Michigan's Opioid Laws

OBJECTIVES

To characterize the effects of Michigan's controlled substance legislation on acute care prescriber behavior by specialty, in a single hospital system.

DESIGN

A retrospective study of opioid and benzodiazepine prescription records from a hospital electronic medical record system between August 1, 2016 and March 31, 2019 in Detroit, MI.

SETTING

Discharges from inpatient and emergency department visits.

INTERVENTION

Evaluating the impact of implementation of state controlled substance legislation, comparing prescriptions by physicians before, upon, and after June 1, 2018 using regression discontinuity analysis.

METHODS

Total daily prescriptions of opioids and total daily prescriptions of benzodiazepine by physicians in the hospital system. Prescriptions were converted to morphine and lorazepam equivalents for comparability.

RESULTS

We find 38.5% (CI: 74.1% - 2.9%) decrease of prescription in milligrams of opioid equivalents attributable to implementation of legislation. The main catalyst of the decrease was emergency medicine which experienced 63.9% (CI: 109.7% - 18.0%) decrease in milligrams of opioid equivalent prescriptions, while surgery increased prescriptions. Though we do not find any statistically significant changes in prescriptions of milligram equivalent of benzodiazepines, we estimate 43.1% (CI: 82.6 - 3.7%) decrease in count of these prescriptions, implying a significant increase in average dosage of prescriptions.

CONCLUSIONS

The introduction of new regulatory requirements for the prescription of controlled substances led to a general decrease in morphine equivalent milligrams prescribed in most specialties, though it may have increased the dosage of benzodiazepine prescriptions. The change in prescription behavior could be motivated by regulatory hassle or by change in attitude towards opioid prescriptions and increased recognition of opioid use disorder.

Can electronic prescribing mandates reduce opioid-related overdoses?

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.

Laws limiting prescribing and dispensing of opioids in the United States, 1989-2019

BACKGROUND AND AIMS

Opioid overdose is a public health emergency in the United States. In an attempt to reduce potentially inappropriate opioid prescribing, many US states have adopted legal restrictions on the ability of medical professionals to prescribe or dispense opioids for pain. This review describes the major elements of relevant US state laws and the ways in which they have changed over time.

METHODS

Systematic legal review in which two trained legal researchers collected and reviewed all US state laws that limit the amount or duration of opioids that medical professionals may prescribe or dispense for pain. These laws were then coded on a set of pre-selected measures, including when the law was enacted, dosage and duration limits imposed, circumstances in which the restrictions do not apply and whether additional requirements or restrictions apply to prescriptions issued to minors.

RESULTS

The number of US states with opioid limitation laws increased from 10 in 2016 to 39 by the end of 2019. The provisions of these laws vary between states and have shifted within states over time. At the end of 2019 the modal duration limit was 7 days, with a range of 3 to 31. Fourteen states imposed limits on the dosage of opioids that can be prescribed, ranging from 30 morphine milligram equivalents (MME) to a 120 MME daily maximum. In 16 states, different limits apply to prescriptions issued to minors.

CONCLUSIONS

The number of US states with opioid limitation laws nearly quadrupled between 2016 and 2019, with a great amount of heterogeneity between state restrictions and changes over time.

A Critical Review of the Social and Behavioral Contributions to the Overdose Epidemic

More than 750,000 people in the United States died from an overdose between 1999 and 2018; two-thirds of those deaths involved an opioid. In this review, we present trends in opioid overdose rates during this period and discuss how the proliferation of opioid prescribing to treat chronic pain, changes in the heroin and illegally manufactured opioid synthetics markets, and social factors, including deindustrialization and concentrated poverty, contributed to the rise of the overdose epidemic. We also examine how current policies implemented to address the overdose epidemic may have contributed to reducing prescription opioid overdoses but increased overdoses involving illegal opioids. Finally, we identify new directions for research to understand the causes and solutions to this critical public health problem, including research on heterogeneous policy effects across social groups, effective approaches to reduce overdoses of illegal opioids, and the role of social contexts in shaping policy implementation and impact.

Can policy affect initiation of addictive substance use? Evidence from opioid prescribing

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.

Physician Perspective and Challenges Ordering/Interpreting Laboratory Tests Related to the Opioid Crisis in America

ABSTRACT

The opioid crisis is a profound public health crisis in the United States. It has significantly increased morbidity and mortality in our nation. There are many contributing factors to the opioid crisis, including a strong national and international interest to treat pain as effectively as possible. To combat this crisis, numerous strategies have been implemented over the past few years at the legislative, health system, and patient levels. As a result of these efforts, for the first time since 1999, drug overdose deaths in the United States decreased from 2017 to 2018, when deaths involving all opioids, prescription opioids, and heroin decreased by 2%, 13.5%, and 4.1%, respectively. To continue to curb the opioid crisis, it is imperative to optimize pain control through multidisciplinary and multimodal approaches and to adhere to opioid prescribing guidelines from regulatory and professional organizations to minimize risks for opioid misuse and abuse. Urine drug testing is an important means to assist with opioid monitoring and safe opioid prescribing. There are challenges when ordering urine drug tests, collecting specimens, and interpreting test results. Inaccurate interpretations of laboratory results can have significantly negative impacts on patients care and life. There is a critical need for prescriber education by laboratory experts in the use of drug testing and interpretation of results. To interpret test results correctly and make safe prescribing decisions, it is very important for prescribers/providers to consult clinical toxicologists, laboratory directors, and reporting staff. This interaction is vital and provides excellence of care for patients. This review aims to provide information concerning the opioid crisis in the United States and summarizes the challenges ordering and interpreting opioid-related laboratory testing as well as pertinent guidelines and recommendations.

State Opioid Limits and Volume of Opioid Prescriptions Received by Medicaid Patients

BACKGROUND

Since early 2016, an increasing number of states passed legislations that limit the duration and/or dosage of initial opioid prescriptions or opioids for acute pain.

OBJECTIVE

The objective of this study was to assess changes in the number of opioid prescriptions covered by Medicaid and received by Medicaid patients associated with state implementation of legislative limits on initial opioid prescriptions.

RESEARCH DESIGN

We explored the natural experiment resulting from the staggered implementation of state legislative limits. The analysis adopted a Difference-in-Differences framework and controlled for other major state policies bearing implications for prescription opioid use. The main analysis included 26 states that implemented limits from early 2016 to late 2018. A secondary analysis included all 50 states and the District of Columbia.

MEASURES

Population-adjusted state-quarter level counts of Schedule II and III opioid prescriptions received by Medicaid patients, based on data from the Medicaid State Drug Utilization Data and state Medicaid enrollment reports for 2013-2018.

RESULTS

Implementation of legislative limits on initial opioid prescriptions was associated with a 7% reduction in the number of opioid prescriptions per 100 Medicaid enrollees. Such reduction was largely attributable to a reduction in Schedule II opioid prescriptions. Secondary analysis by including all jurisdictions and sensitivity checks supported the robustness of results.

CONCLUSION

The recent implementation of state legislative limits on initial opioid prescriptions was associated with meaningful reductions in the volume of Schedule II opioid prescriptions received by Medicaid patients.

Tackling the overdose crisis: The role of safe supply

North America is experiencing an unprecedented overdose crisis driven by the proliferation of fentanyl and its analogues in the illicit drug supply. In 2018 there were 67,367 drug overdose deaths in the United States, and since 2016, there have been more than 14,700 overdose deaths in Canada, with most related to fentanyl. Despite concerted efforts and some positive progress, current public health, substance use treatment, and harm reduction interventions (such as widespread naloxone distribution and implementation of supervised consumption sites) have not been able to rapidly decrease overdose fatalities. In view of the persistent gaps in services and the limitations of available options, immediate scale-up of low-barrier opioid distribution programs are urgently needed. This includes "off-label" prescription of pharmaceutical grade opioids (e.g., hydromorphone) to disrupt the toxic drug supply and make safer opioids widely available to people at high risk of fatal overdose.

Prescription Opioid Distribution after the Legalization of Recreational Marijuana in Colorado

There have been dynamic changes in prescription opioid use in the US but the state level policy factors contributing to these are incompletely understood. We examined the association between the legalization of recreational marijuana and prescription opioid distribution in Colorado. Utah and Maryland, two states that had not legalized recreational marijuana, were selected for comparison. Prescription data reported to the Drug Enforcement Administration for nine opioids used for pain (e.g., fentanyl, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone) and two primarily for opioid use disorder (OUD, methadone and buprenorphine) from 2007 to 2017 were evaluated. Analysis of the interval pre (2007-2012) versus post (2013-2017) marijuana legalization revealed statistically significant decreases for Colorado (P < 0.05) and Maryland (P < 0.01), but not Utah, for pain medications. There was a larger reduction from 2012 to 2017 in Colorado (-31.5%) than the other states (-14.2% to -23.5%). Colorado had a significantly greater decrease in codeine and oxymorphone than the comparison states. The most prevalent opioids by morphine equivalents were oxycodone and methadone. Due to rapid and pronounced changes in prescription opioid distribution over the past decade, additional study with more states is needed to determine whether cannabis policy was associated with reductions in opioids used for chronic pain.

Dynamic changes in prescription opioids from 2006 to 2017 in Texas

BACKGROUND

The 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 METHODS

This 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.

RESULTS

The 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.

CONCLUSIONS

Collectively, 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.

Increasing heroin, cocaine, and buprenorphine arrests reported to the Maine Diversion Alert Program

BACKGROUND

The opioid overdose crisis is especially pronounced in Maine. The Diversion Alert Program (DAP) was developed to combat illicit drug use and prescription drug diversion by facilitating communication between law enforcement and health care providers with the goal of limiting drug-related harms and criminal behaviors. Our objectives in this report were to analyze 2014-2017 DAP for: (1) trends in drug arrests and, (2) differences in arrests by offense, demographics (sex and age) and by region.

METHODS

Drug arrests (N=8193, 31.3% female, age=33.1±9.9) reported to the DAP were examined by year, demographics, and location.

RESULTS

The most common substances of the 10,064 unique charges reported were heroin (N=2203, 21.9%), crack/cocaine (N=945, 16.8%), buprenorphine (N=812, 8.1%), and oxycodone (N=747, 7.4%). While the overall number of arrests reported to the DAP declined in 2017, the proportion of arrests involving opioids (heroin, buprenorphine, or fentanyl) and stimulants (cocaine/crack cocaine, or methamphetamine), increased (p<.05). Women had significantly increased involvement in arrests involving sedatives and miscellaneous pharmaceuticals (e.g. gabapentin) while men had an elevation in stimulant arrests. Heroin accounted for a lower percentage of arrests among individuals age >60 (6.6%) relative to young-adults (18-29, 22.3%, p<.0001). Older-adults had significantly more arrests than younger-adults for oxycodone, hydrocodone, and marijuana.

CONCLUSION

Heroin had the most arrests from 2014 to 2017. Buprenorphine, fentanyl and crack/cocaine arrests increased appreciably suggesting that improved treatment is needed to prevent further nonmedical use and overdoses. The Diversion Alert Program provided a unique data source for research, a harm-reduction tool for health care providers, and an informational resource for law enforcement.