Why is opioid addiction on the rise despite a decline in prescriptions?

Opioid prescription rates have fallen continuously since their peak in 2010. Prescriptions, which had more than quadrupled from 180 morphine milligram equivalents per-capita in 1999 to 782 in 2010, were down to 640 in 2015. That’s good news.

Unfortunately, the catchall category of “opioids” does not allow us to track which specific drugs are being prescribed. The answer to that question, rather than their sheer volume, is far more important when it comes to curbing their misuse.

The fact is that almost 90 percent of the prescribed opioids dispensed in 2016 are immediate-release generics, rendering the decrease in total opioid prescriptions nearly irrelevant. Thanks to a combination of price and efficacy, the most abusable opioids are also the most prescribed. This means we are still failing.

{mosads}Patience may be a virtue, but the huge increases in overdose deaths that we are seeing in the opioid epidemic means we’re running out of time to wait to see whether policy initiatives like new prescription guidelines that limit how much can be dispensed or monitoring programs that seek to prevent “doctor shopping” are effective.

It makes sense to revisit how opioids are prescribed in this country, but physicians need to continue to advocate for those who suffer from chronic pain. For their part, policymakers need to realize that the opioid epidemic is not driven by people in need of pain relief. The Substance Abuse and Mental Health Services Administration reported earlier this year that nearly 80 percent of misused prescription opioids were either obtained (with or without consent) from someone with a prescription or were bought from a drug dealer. This suggests that treatment of acute or chronic pain is not the primary means that people are initiated to opioid abuse.

While neither is perfect, newer extended-release and abuse-deterrent formulations are designed to mitigate the potential for opioid users to transition to addiction. Extended-release formulations work by engineering a pill to dissolve in various stages after being taken orally. There is an immediate release of some of the drug contained on the top layer of the capsule, followed by slower release of the rest of the drug that is less susceptible to dissolving in the gut. This prevents the spikes and valleys of pain relief and withdrawal that are associated with quick-acting, immediate-release formulations. Extended release can protect a user from addiction by putting distance between taking the pill and feeling “good,” and diminishing the association between the two. They also prevent the quick drop in opioid blood levels that precedes withdrawal and are, therefore, less reinforcing when you take your next dose.

Abuse-deterrent formulations are designed to prevent tampering with a pill or capsule. New abuse-deterrent formulations of prescription opioids work – and are fascinating to study. They can include naloxone, a “blocker” that prevents the opioid from binding to the opioid receptor. In the pill, naloxone is protected from dissolving in your gut, but is released when the capsules are crushed. Abuse-deterrent formulations can also be pH sensitive so they “know” to turn into unusable paste when they don’t dissolve in the gut; they can be formulated to have “sticky” binders that prevent snorting, or can have crush-proof outer coatings.

Extended release and abuse-deterrent formulations are designed to prevent both unintentional and intentional misuse from improper dosing or tampering and are most effective in preventing first-time opioid users from initiating abuse. While it’s true that veteran users can generally find a way around these roadblocks, it’s important to note that, within three years of its being reformulated in 2010, nonmedical use of OxyContin already had dropped significantly. 

If the current heroin epidemic is, in fact, the result of initiation from easy-to-abuse opioids, decreasing the availability of immediate-release formulations and replacing them with extended-release and abuse-deterrent versions should result in less heroin use and opioid overdoses down the road. By tracking these prescriptions, we can predict positive outcomes from pain management, such as fewer people who transition to addiction and fewer people who are able to misuse other people’s prescribed drugs.

Carrie Wade (@CarrieLWade) is the director of Harm Reduction Policy at the R Street Institute, a nonprofit aimed at promoting limited government in Washington D.C.