The Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System describe the diversion and abuse of prescription opioid analgesics, using data from January 2002 through December 2013. Because drug abuse is an illegal activity that is often concealed from authorities, the RADARS System uses a “mosaic” approach, measuring abuse and diversion from multiple perspectives, to describe this hidden phenomenon as comprehensively as possible.
The rate of death from overdoses of prescription opioids in the United States more than quadrupled between 1999 and 2010 Opioid Sales, Admissions for Opioid-Abuse Treatment, and Deaths Due to Opioid Overdose in the United States, 1999–2010.Data are from the National Vital Statistics System of the Centers for Disease Control and Prevention, the Treatment Episode Data Set of the Substance Abuse and Mental Health Services Administration, and the Automation of Reports and Consolidated Orders System of the Drug Enforcement Administration. , far exceeding the combined death toll from cocaine and heroin overdoses. In 2010 alone, prescription opioids were involved in 16,651 overdose deaths, whereas heroin was implicated in 3036. Some 82% of the deaths due to prescription opioids and 92% of those due to heroin were classified as unintentional, with the remainder being attributed predominantly to suicide or “undetermined intent.”
Whatever the measure, the past two decades have been characterized by increasing abuse and diversion of prescription drugs, including opioid medications, in the United States. An estimated 25 million people initiated nonmedical use of pain relievers between 2002 and 2011. In response to the epidemic, hundreds of local, regional, state, and federal interventions have been implemented. For example, 49 states have enacted legislation to create prescription-drug monitoring programs. The U.S. Office of National Drug Control Policy has responded to the epidemic with numerous recommendations, including the need to evaluate “current databases that measure the extent of prescription drug use, misuse, and toxicity.” In 2013, a Pew Research Center survey showed that only 16% of Americans believed that the United States was making progress in reducing prescription-drug abuse.
The impressive response to the epidemic is heartening, but the effect of these programs is not yet known. Some local and state interventions have described a reduction in the abuse and diversion of prescription opioids after the enactment of state legislation. A number of barriers contribute to low access to and utilization of MATs, including a paucity of trained prescribers and negative attitudes and misunderstandings about addiction medications held by the public, providers, and patients. For decades, a common concern has been that MATs merely replace one addiction with another. Many treatment-facility managers and staff favor an abstinence model, and provider skepticism may contribute to low adoption of MATs. Systematic prescription of inadequate doses further reinforces the lack of faith in MATs, since the resulting return to opioid use perpetuates a belief in their ineffectiveness.
Whatever the precise cause, changes in rates of opioid analgesic abuse are associated with increasing heroin-related mortality. The similarities between data from the National Survey on Drug Use and Health and data from the National Poison Data System with respect to heroin use and adverse consequences are striking. A better understanding of the relation between prescription opioid abuse and heroin use is crucial for developing public health policy as well as guiding prevention and treatment initiatives.
A key driver of the overdose epidemic is underlying substance-use disorder. Consequently, expanding access to addiction-treatment services is an essential component of a comprehensive response. Like other chronic diseases such as diabetes and hypertension, addiction is generally refractory to cure, but effective treatment and functional recovery are possible. Fortunately, clinicians have three types of medication-assisted therapies (MATs) for treating patients with opioid addiction: methadone, buprenorphine, and naltrexone. (Characteristics of Medications for Opioid-Addiction Treatment.). Yet these medications are markedly underutilized. Of the 2.5 million Americans 12 years of age or older who abused or were dependent on opioids in 2012 (according to the National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration [SAMHSA]), fewer than 1 million received MAT.
The epidemic of prescription-opioid overdose is complex. Expanding access to MATs is a crucial component of the effort to help patients recover. It is also necessary, however, to implement primary prevention policies that curb the inappropriate prescribing of opioid analgesics the key upstream driver of the epidemic while avoiding jeopardizing critical or even lifesaving opioid treatment when it is needed. Essential steps for physicians will be to reduce unnecessary or excessive opioid prescribing, routinely check data from prescription-drug–monitoring programs to identify patients who may be misusing opioids, and take full advantage of effective MATs for people with opioid addiction. The results suggest that the United States is making progress in combating the abuse of prescription opioid analgesics. If the observation of decreased abuse is confirmed, changes in public health policy and strategy will be needed.