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.email@example.com
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.
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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.