Prescription Opioids: A Continuing Contributor to the Epidemic

The opioid crisis is frequently conceptualized as occurring in three waves, beginning with prescription opioids in 1999, followed by heroin in 2010, and then by illicitly manufactured synthetic opioids, primarily fentanyl, in 2013.¹ However, the term “wave” is somewhat misleading, as it implies that the threats from prescription opioids and heroin have crested and then receded. In reality, overdoses from these sources have remained stubbornly high despite a variety of policy efforts. Perhaps a more apt metaphor would be that of three successive dams breaking, with each increasingly contributing to the rising water level. Notably, prescription opioid mortality hit a record high in 2017 with 17 029 deaths.² The annual number of deaths from prescription opioids has remained fairly consistent since 2010 despite overall decreases in prescribing and average dose prescribed over the same period.³ Considering the continued role of prescription opioids in the opioid epidemic, it is worth examining more closely who is using and misusing opioids and why.

USE AND MISUSE OF PRESCRIPTION OPIOIDS

The current issue of AJPH includes an article by Griesler et al. (p. 1258) that characterizes prescription opioid medical users and misusers in the US adult population. The authors analyzed cross-sectional National Survey on Drug Use and Health (NSDUH) data from 2016 through 2017 and found that 12% of prescription opioid users reported misusing prescription opioids. In this group of misusers, 27% exclusively misused their own prescription, 38% exclusively misused prescription opioids without a prescription, and 31% misused prescription opioids both ways (the remaining 4% could not be classified).

The finding that 12% of opioid users misuse prescription opioids is striking, but it is critical to understand how misuse is defined to contextualize the problem. The terms “misuse” and “abuse” are often used interchangeably, and there is not one agreed on definition. NSDUH’s definition of misuse is “use in any way not directed by a doctor.” This includes using someone else’s prescription and using the prescription in greater amounts, more often, or longer than prescribed. Importantly, misuse, as defined here, includes a number of practices that do not necessarily imply recreational use of opioids.

Indeed, the authors found that relieving pain was the most commonly reported reason for prescription misuse across all misuse categories and was cited by 81.5% of misusers who exclusively misused their own prescription. Only 11.4% of those who exclusively misused their own prescription, 19.8% of those who exclusively misused without a prescription, and 28.8% of those who misused both ways did so with the stated reason to “feel good or get high.” These results highlight the need for caution when characterizing prescription opioid misusers and for recognizing that many have unmet pain management needs. Also worth considering is that, as policies encourage or mandate lower dose prescribing,⁴ patients who continue to take the same dose of opioids they were previously prescribed may suddenly find themselves classified as misusers on the basis of a change in their doctor’s direction, not their own behavior.

Despite these cautions, however, the data showed that polysubstance use is still a substantial problem among opioid misusers. For example, misusers in all three groups had relatively high rates of cocaine (6.9%–21.7%) and marijuana (26.8%–42.8%) use. Heroin use was low among those who exclusively misused their own prescriptions (1.7%), but higher among the other groups (5.1% among those who exclusively misused without a prescription and 10.6% who misused both ways).

POLICIES ON PRESCRIPTION OPIOIDS

Several of the study’s results have interesting policy implications. For example, Griesler et al. found that only 27% of opioid misusers exclusively misuse their own prescription. In general, prescription opioid policies (and evaluations of these policies) largely operate under the assumption that patients are using their own opioid prescriptions. For example, several policies require patients receiving high doses of opioids to visit a pain specialist or receive counseling.⁴ These results suggest that policies addressing opioid prescribing may be missing a large segment of prescription opioid misusers.

Another interesting finding is that most (88%) of those who misuse only without a prescription obtained their last dose from a friend or relative, as opposed to stealing prescriptions or purchasing them from a drug dealer. That this type of prescription opioid diversion is so common indicates that many Americans still do not understand the dangers of sharing prescription medications, despite education efforts in recent years. New policies have been implemented that directly or indirectly address diversion. For example, some communities have organized prescription takeback events or developed safe disposal sites.⁵ Other states have limited the maximum allowable day’s supply of prescription opioids, which, in theory, may reduce diversion.⁶

Although the results of this study raise important policy questions, the cross-sectional data are unfortunately not suited to evaluate policy effects. For example, it would be beneficial to understand how sources of prescription opioids for misuse have changed over time in states with policies intended to address diversion. Similarly, Griesler et al. state that, of individuals who exclusively misused their own prescription, 97.5% used prescriptions from one doctor the last time they misused. This statistic on its own is not very informative, as it does not cover multiple episodes of use. It is possible that the high percentage is a sign that efforts to combat doctor shopping through prescription drug–monitoring programs have been effective, but this is impossible to prove without additional data.

The article by Griesler et al. shines a light on prescription opioid misuse and provides valuable insight into why individuals misuse opioids and where they obtain them. The findings point to potential areas for intervention, such as diversion control and pain management support.