Prescription opioid (PO) misuse – defined as intentional use of POs other than as prescribed—has risen sharply in the US, particularly among young adults in rural, suburban and urban communities. Currently, an estimated 4.2% of the US population reports past-year misuse of prescription opioids, and 1.9 million persons report PO dependence in the last year . The amount of POs prescribed has quadrupled since 1999, as have unintentional overdose deaths involving POs . PO misuse has been linked to increased incidence of injection drug use, HIV and HCV (due to the sharing of injection equipment), and fatal and non-fatal drug overdoses [3-7].
A broad range of policies have been proposed or implemented by a number of US states that focus on reducing access to POs, including Prescription Drug Monitoring Programs, prescriber education and prescribing guidelines, and laws restricting “pill mills”. In addition, some POs have been reformulated to deter abuse or injection. The impact of these policies on trends in PO misuse and its health consequences is unclear. Overdose education and naloxone distribution programs and Good Samaritan laws granting legal immunity to people who overdose or seek medical help for an overdose have been enacted in several states, and these are associated with reductions in overdose deaths . Currently there is evidence for the following recommendations.
1. Improved surveillance is needed to monitor PO misuse, and innovative efforts to reach PO misusers must be undertaken
Surges in PO misuse are usually detected when there is a rise in overdose deaths, or outbreaks of HIV or HCV . Earlier identification of the problem would avert many preventable deaths and the long-term health consequences of chronic viral infections. Many PO misusers are not the traditional opiate-using populations that substance use interventions have targeted [9,10], and programs tailored to reach these new populations are needed.
2. Evidence-based interventions (EBI) can reduce the negative consequences of PO misuse, and must be implemented in combination
a. Expansion of medication-assisted treatment (MAT), including low-threshold MAT, is needed to prevent PO misusers from escalating to abuse and dependence and from transitioning to heroin use and drug injection.
b. Access to sterile injection equipment through needle/syringe programs (NSPs), in combination with HIV and/or HCV treatment for those who are infected, can reduce HIV and HCV transmission among those who have progressed to injection drug use.
MAT (e.g., methadone or buprenorphine maintenance) has been shown to reduce illicit opioid use and injection risk behaviors . Access to sterile injection equipment reduces HIV and HCV transmission among people who inject drugs . When combined, MAT and NSPs are especially effective .
3. Research is needed to evaluate the impact of laws and policies that focus on restricting access to POs, including possible negative consequences
As misuse escalates to abuse and dependence, reduced access to POs may lead some misusers to begin to use heroin or to transition to injection (a more efficient way to achieve the same drug-effects). Heroin use and injection introduces new risks including increased likelihood of overdose and HIV and HCV infection. Thus, consequences of policies must be considered before their implementation and remedies for possible negative consequences should be in place (such as MAT and NSP) beforehand.
4. Expand overdose prevention programs to target PO misusers
Despite very strong evidence that overdose education, naloxone distribution, and Good Samaritan laws reduce deaths due to overdose, these programs are not implemented at sufficient scale to meet the needs of PO and other opioid misusers .
PO misuse has been called “one of the worst manmade epidemics in history” . The seriousness of this problem, and its potential to undermine the progress that has been made to end the HIV epidemic and control HCV among drug users in the US, requires immediate attention. There is clear scientific evidence that multiple efforts will be needed to address the individual, community, health care, and policy issues associated with PO misuse. Policy research priorities center on how to: 1) reduce access to POs, 2) expand MAT, 3) provide access to syringes and other injection equipment, 4) expand overdose prevention, and 5) conduct outreach and monitoring to reach those at risk of PO misuse. Moreover, the impacts of PO-related policies should be assessed, with particular attention paid to potential unintended negative and positive consequences of these structural interventions. This work must be amplified quickly to address this expanding problem.
For further information on this Brief contact CDUHR at CDUHR.firstname.lastname@example.org
This Brief was prepared by CDUHR. We thank Mr. Daniel Raymond (Harm Reduction Coalition), Dr. Pedro Mateu-Gelabert (National Development and Research Institutes), Dr. Jennifer Havens (University of Kentucky), and Dr. Judith Auerbach (UCSF) for reviewing an earlier draft of this Brief.
- Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration;2014.
- Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
- Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses–a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10-13.
- Conrad C, Bradley HM, Broz D, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone—Indiana, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(16):443-444.
- Hadland SE, Debeck K, Kerr T, Feng C, Montaner JS, Wood E. Risk of hepatitis C among heroin and prescription opioid-injecting youth. Journal of Adolescent Health. 2013;52(2):S1-S2.
- Young AM, Havens JR. Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: a cross-sectional comparison and retrospective survival analysis. Addiction. 2012;107(3):587-596.
- Mateu-Gelabert P, Guarino H, Jessell L, Teper A. Injection and sexual HIV/HCV risk behaviors associated with nonmedical use of prescription opioids among young adults in New York City. J Subst Abuse Treat. 2015;48(1):13-20.
- Wheeler E, Jones TS, Gilbert MK, Davidson PJ, Centers for Disease C, Prevention. Opioid overdose prevention programs providing naloxone to laypersons – United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(23):631-635.
- Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.
- Frank D, Mateu-Gelabert P, Guarino H, et al. High risk and little knowledge: Overdose experiences and knowledge among young adult nonmedical prescription opioid users. Int J Drug Policy. 2015;26(1):84-91.
- MacArthur GJ, van Velzen E, Palmateer N, et al. Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. Int J Drug Policy. 2014;25(1):34-52.
- Hagan H, Pouget ER, Des Jarlais DC. A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs. J Infect Dis. 2011;204(1):74-83.
- Banta-Green CJ, Beletsky L, Schoeppe JA, Coffin PO, Kuszler PC. Police officers’ and paramedics’ experiences with overdose and their knowledge and opinions of Washington State’s drug overdose-naloxone-Good Samaritan law. J Urban Health. 2013;90(6):1102-1111.
- Franklin G, Sabel J, Jones CM, et al. A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned. Am J Public Health. 2015;105(3):463-469.
Center for Drug Use and HIV Research (2015, November).
Prescription Opioid Misuse: Addressing a potential threat to progress in ending the HIV and HCV epidemics (Research for Implementation Brief #2). New York, NY: Author.