The Changing Use of Opioids in the U.S from 2017 to Early 2020

Rachel Gifeisman1†‡, Aneesha Morris1†‡, Bianca Sanchez1†‡, Kenneth L McCall2, and Brian J Piper1,3

¹Geisinger Commonwealth School of Medicine, Scranton PA 18509 ²Department of Pharmacy Practice, University of New England, Portland, ME 04103 3Center for Pharmacy Innovation and Outcomes, Geisinger Precision Health Center, Forty Fort, PA 18704 †Doctor of Medicine Program ‡Authors contributed equally Correspondence: rgifeisman@som.geisinger.edu

Abstract

Background: The U.S. has been experiencing an opioid epidemic for over 3 decades, with previous data showing that prescription opioid use had been decreasing from 2006 to 2016. The COVID-19 pandemic has been a large disturbance in American health care, and public health scientists are curious if it will impact the opioid epidemic. This study provided a nationwide examination of opioid prescription trends in the 2 years leading up to the pandemic and in the first 2 quarters during it.

Methods: Data were acquired from the U.S. Drug Enforcement Administration Automation of Reports and Consolidated Orders System (ARCOS) for 2017 through Q1 and Q2 of 2020. Analysis included amounts by mass of 10 opioids legally dispensed nationwide. Data were converted to morphine milligram equivalents per person, values for all 10 opioids were summed, and percent change between each of the consecutive years was calculated. Results: While total opioid prescription decreased from 2017 to 2018 (- 6.1%) and 2018 to 2019 (-2.1%), it increased from Q1 of 2019 to Q2 of 2020 (+2.4%). A paired t-test found a significant difference between the mean percent change from 2018 to 2019 and 2019 to 2020 (p<0.0005). Out of 29 states that had been decreasing opioid prescriptions in 2018 and 2019, 19 saw an increase in 2020. Among these 19 states, those with the largest reverse in prescription pattern included Arkansas, Montana, Oklahoma, and Tennessee. Conclusion: Overall, there appears to be an increase in opioid prescription from 2019 to 2020 following a decreasing trend in previous years. More research is needed to determine whether this was due to the COVID-19 pandemic.

Introduction

It quickly became evident how the COVID-19 pandemic infiltrated every facet of our lives and demonstrated the glaring faults in our health care system and way of life, targeting mostly underrepresented groups of people. This includes those suffering from opioid use disorder (OUD), as treatment clinics had to change protocols or shut down entirely in order to adhere to the pandemic guidelines. In 2018, prescription opioid deaths in America fell for the first time in 25 years, with an overall decrease in opioid prescriptions from 2018 to 2019 (1). Using the Drug Enforcement Administration’s (DEA) Automated Reports and Consolidated Ordering System (ARCOS), our data showed increasing rates of opioid prescription, particularly in Kentucky, from 2017 to 2020. It became increasingly difficult to adjust to the pandemic, especially for those struggling with addiction to comply with their treatment programs. In conjunction with the rise in opioid prescriptions, likely attributed to the ease the discomfort of patients with acute respiratory distress syndrome (ARDS) (2), there could be a new wave of demand for opioid prescriptions to manage the potentially chronic pains the disease may induce. Additionally, the COVID-19 pandemic may have disproportionately impacted those struggling with OUD as treatment clinics shut down, enabling patients to partake in opioid consumption in unsafe, coronavirus-unfriendly environments. In turn, this study aimed to track opioid prescription trends in the U.S. in order to better understand how the COVID-19 pandemic specifically affected the treatment and abuse of pharmacological pain management.

Methods

Data sources

National prescription quantities of 10 opioids were obtained from the Drug Enforcement Administration’s (DEA) Automated Reports and Consolidated Ordering System (ARCOS) for 2017 through the first and second quarter (June) of 2020. The 10 opioids included were buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, oxymorphone, and tapentadol. Data were collected for all 50 states and Washington D.C.; data were unavailable for the U.S. territories of Guam, Puerto Rico, American Samoa, and the Virgin Islands. ARCOS is a comprehensive drug reporting system created as a result of the 1970 Controlled Substances Act. It reports on controlled substances in Schedules I to III distributed by hospitals, pharmacies, practitioners, and narcotic treatment programs (3). ARCOS data files consist of three different reports. Report two (“grams retail drug distribution by state within drug code”) was used for analysis. Population data for each of the 50 U.S. states was obtained from the annual American Community Survey and U.S. Census Bureau and used to normalize the state prescription data acquired from ARCOS (4). This study was deemed exempt from review by the Geisinger Institutional Review Board.

Data analysis The total morphine milligram equivalent (MME) was calculated (in milligrams) for each of the 10 opioids per state per quarter of each year. To account for the relative potency of each agent, MME conversions were performed with drug-specific multipliers: buprenorphine 10, codeine 0.15, fentanyl 75, hydrocodone 1, hydromorphone 4, meperidine 0.1, morphine 1, oxycodone 1.5, oxymorphone 3, tapentadol 0.4. MME values

Figure 1. Percent change in opioid prescription per capita for 10 opioids (buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, morphine, oxycodone, oxymorphone, and tapentadol) as reported by the Drug Enforcement Administration from (A) 2017 to 2018 (B) 2018 to 2019 and (C) 2019 to mid-2020.

were divided by the populations of the respective states to obtain the MME per person. Then the values for all 10 drugs were added together to obtain the sum opioid prescription per state per person per quarter. The sum MME per capita data was used to calculate the percent change ([later year – earlier year]/earlier year) per state between the first quarter of 2017 and the first quarter of 2018, the first quarter of 2018 and the first quarter of 2019, the first quarter of 2019 and the second quarter of 2020, and the first quarter of 2017 and the second quarter of 2020. Percent changes for all 50 states were averaged to obtain a mean percent change between each of the years. Paired T-tests were performed to compare the percent change between 2017 and

Figure 2. (A) Percent change in opioid prescription per capita per 3 months from 2017 to mid-2020. (B) Comparison of total opioids in MME per state in 2017 vs mid-2020, with arrows pointing to states with the largest increase in prescription: Indiana, Kentucky, Maine, and West Virginia.

2018 to the percent change between 2018 and 2019 and the percent change between 2018 and 2019 to the percent change between 2019 to 2020. States with large reversal in prescription patterns, as well as states with the largest increase in total MME of opioids prescribed between 2017 and 2020, were identified. The fraction of buprenorphine was calculated by dividing the total amount of buprenorphine by the total amount of all summed opioids in MME prescribed in the U.S. per quarter. Excel and GraphPad Prism 9.1.0 were used for data analysis, graph generation, and statistical analysis.

Results

From 2017 to 2018, the total amount of opioids prescribed decreased by 6.1% (Figure 1A) and from 2018 to 2017 opioid prescription decreased by -2.1% (Figure 1B). By comparison, the prescriptions from 2019 to mid-2020 increased by +2.4% (Figure 1C). A paired t-test found a significant difference between the mean percent change from 2018 to 2019 and 2019 to 2020 (p < 0.0005). Out of the 29 states that had decreasing opioid prescriptions in 2018 and 2019, 19 saw an increase in 2020. Among those 19 states, those with the largest reverse in prescription pattern included Arkansas (from -7.79% to +3.75%), Montana (from -1.65% to +10.48%), Oklahoma (from -8.18% to +4.15%), and Tennessee (from -5.44% to +7.62%). From 2017 to mid-2020, the total percent change calculated was -0.05%. States with the largest increases in amounts of opioids prescribed were Maine (+0.31%), Kentucky (+0.15%), Indiana (+0.15), West Virginia (+0.12), and Washington (+0.12) (Figure 2a). Maine prescribed 317.26 MME in early 2017 and 416.33 MME in mid-2020. Kentucky increased from 383.68 MME prescribed in the first quarter of 2017 to 441.46 MME in the second quarter of 2020, West Virginia increased from 403.600 MME to 450.82 MME, and Washington from 191.28 MME to 213.67 MME (Figure 2b). Adding together all of the opioids prescribed in a given quarter and plotting the MME against time demonstrates a decrease in the amount prescribed throughout 2017, a plateau in 2018 and the first two quarters of 2019, and an increasing trend in the final two quarters of 2019 and the first two quarters of 2020. A line of best fit for the data from the first quarter of 2018 through the second quarter of 2020 was increasing with an R2 of 0.6244 (Figure 3A). Of the total opioids prescribed,

Figure 3. Total U.S. opioids prescribed summed across states and drug type plotted (A) per quarter with a line of best fit for data from all four quarters of 2018 and 2019 and the first two quarters of 2020 and (B) as a comparison of totals with and without buprenorphine included in the calculation. (C) Percentage that buprenorphine is of total U.S. opioid prescription calculated and plotted against all four quarters of 2017, 2018, and 2019 and the first two quarters of 2020.

buprenorphine made up a large portion every year (Figure 3B). The portion increased every quarter from the first quarter of 2017 (40.3% buprenorphine) to the second quarter of 2020 (63.3% buprenorphine) (Figure 3C).

Discussion

After a previous decline in opioid prescriptions across the U.S. from 2006 to 2016, our data showed an increase from 2017 to early 2020 with marked increase in Kentucky, Maine, Indiana, West Virginia, and Washington. The biggest reversal in opioid prescription rates were seen in Tennessee, Oklahoma, Montana, and Arkansas. In this study, we tracked a slowly increasing percent change in opioid prescriptions from 2017 to 2018, which included more states showing a positive percent change from 2018 to 2019 and an even steeper increase in the positive percent change among states from 2019 to early 2020. Tennessee, which showed the greatest increase in percent change, did not see a positive percent change until 2019. However, Kentucky, which had the largest overall increase in opioid prescriptions, saw a positive percent change in 2017. Multiple conditions likely contributed to the increase in prescription rates seen across the U.S., with COVID-19 potentially exacerbating this upsurge. Additionally, the route of delivery was not tracked by ARCOS, therefore confounding the data, as it is unclear whether the increase was solely for take-home prescriptions or for hospital-based prescriptions. However, with the data showing a marked increase in most states from 2019 to early 2020, it can be inferred that the COVID-19 pandemic contributed to the change. As patients diagnosed with SARS-COV-2 conditions’ worsened, it was found that awake proning delayed the need for ventilation and better oxygenated patients than those in supine position (2). The

need for awake proning, in addition to the cough and myalgia experienced by the patients, made positional treatment difficult and necessitated the prescription of IV or parenteral fentanyl, morphine, and hydromorphone to ease patients’ discomfort (2, 5). The need to begin opioid use among patients with COVID-19 could increase the population risk for addiction and aggravate the already worsening opioid pandemic. In Ontario, Canada, between January and September of 2020 there was a 108% increase in fentanyl use among OUD treatment patients, which was largely attributed to the disruption of treatment, medication diversion, and isolation during the pandemic (6) . This study demonstrated that the persistent increase of fentanyl exposure decreased the effectiveness of opioid agonist treatment (6). While OUD treatment in the U.S. is in clear need of expansion for greater availability of FDA-approved medications (7), it is possible that the pandemic-induced protocol changes to COVID-friendly practices in OUD treatment programs led to an increase in patient relapse. However, a case report of two OUD patients receiving buprenorphine/naloxone treatment via telemedicine in combination with street outreach during the pandemic provided alternative, lifesaving treatment options (8). In support of this, our data showed a steady increase in buprenorphine prescriptions over the years, with a noticeable uptick between Q4 2019 and Q1 2020. Further research is required to determine if one or both of these probable causes are implicated in the increase of opioid prescriptions from 2019-2020. As seen in emergency departments across the country in response to the pandemic, Kentucky reported a marked increase in opioid overdose emergency medical service (EMS) responses after declaring a state of emergency while also witnessing a decrease in all other EMS runs (9).This, in conjunction with our data showing that Kentucky had the largest increase in opioid prescriptions, implies the pandemic exacerbated the opioid epidemic. While more research needs to be done to determine the overlap of opioid overdoses to opioid prescription rates, it is clear there is a potential link between the coronavirus pandemic and the worsening opioid epidemic.

Conclusion

During a time when the volatile social and economic environment of the U.S. continues to impact the opioid epidemic, our results shed light on the rapidly developing state of opioid distribution. These findings indicate that the previous trend of decreasing opioid prescriptions nationwide may have reversed in the second half of 2019 and the first half of 2020. Buprenorphine accounted for the largest fraction of total opioids prescribed, increasing consistently over the last 3 years. Thus, the recent reversal in opioid prescription trends might be due in part to the increased use of buprenorphine for the treatment of overdose and addiction recovery. This study suggests that prescribers are taking a more active role in managing overdose and addiction by increasing prescriptions of buprenorphine.

Disclosures

B.J.P is supported by Fahs-Beck Fund for Research and Experimentation and supported by Pfizer and Health Resources Services Administration. The other authors have no relevant disclosures. The funders had no role in the design of the study; collection, analysis, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

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