Sources of Prescription Opioids for Non-Medical Use

To the Editor

Sales of opioid medications have drastically increased in the past decade.(Dart et al., 2015) In a disturbingly parallel development, deaths from prescription opioids have emerged as a primary cause of death in the general population, taking the lives of more than 16,000 people in 2010 alone.(Jones et al., 2013) In light of these findings, limiting unnecessarily prescribed medications while improving pain management has been proposed as a key strategy for improving current opioid prescription practices.(Volkow and McLellan, 2011) In the recent issue of the Journal, (Bouland et al., 2015) report their findings on patterns and sources for obtaining controlled substances by patients with known substance use disorders. Their survey focused on patients who obtained their controlled substances from physicians. They found that primary care physicians were perceived as the easiest person from whom to obtain controlled substances in 61.1% of cases, followed by 22% for pain management specialists. As the authors point out, the majority of patients screened for their study obtained their controlled substances “from the street” and were therefore ineligible to take the survey. “From the street” referred to sources such as a dealer, friend, or family member (given consensually or stolen). Indeed, this is consistent with data from the National Survey on Drug Use and Health indicating that opioid pain relievers for non-medical use are obtained from a friend or a relative in the vast majority (70.6%) of cases.(Jones et al., 2014) Interestingly, they change hands consensually and for free in 54.4% of cases, although this occurs less frequently among people who take high doses, where buying opioid pain relievers is more common.

Assigning medical provider sources for “from the street” controlled substances is not straight-forward. General practitioners compose the largest aggregate (30.4%) of opioid prescribers for those older than 40 years of age,(Volkow et al., 2011) which given they are the most common specialty may not come as a surprise. However, other specialties, such as emergency medicine, orthopedic surgery, dentistry, and obstetrics/gynecology are also significant opioid prescribers and in aggregate greatly outweigh general practitioners in 10–29-year-old patients.(Volkow et al., 2011) Especially in acute care settings, such as after ambulatory surgery, opioids are often prescribed in a “one-size-fits-all” pattern, leading to overprescription of opioids to the majority of patients.(Rodgers et al., 2012, Harris et al., 2013) Such leftover opioids are rarely stored securely or returned appropriately.(Tanabe et al., 2012) Vulnerable patient population, such as adolescents are especially at risk for the development of substance use disorders.(Grant and Dawson, 1998) Safe and effective prescribing practices for controlled substances should therefore be a priority for all medical specialties across clinical contexts that include patients of all ages. Bouland et al. made an important contribution towards our understanding of patterns to inappropriately obtain controlled substance directly from physicians. Taking broader responsibility for controlled substances, including those that may end up “the street” for a variety of reasons, should involve providers from every medical specialty.