Opioid policy changes associated with decreased prescription overdose, increased heroin overdose

1. Amongst a cohort of a large, national health insurance company, after the 2010 discontinuation of propoxyphene and the introduction of abuse-deterrent OxyContin, there was a deceleration in the dispensing rates of opioids, including the long-acting oxycodone formulation, along with a deceleration in the overdose rate from prescription opioids.

2. However, after this change in policy, there was an acceleration noted in the rate of heroin overdose.

Evidence Rating Level: 2 (Good)       

Study Rundown: In the first decade of the twenty-first century, overdose related to prescription narcotics quadrupled. This was in conjunction with the significant increase in the sales of prescription narcotics. In 2010, abuse-deterrent, long-acting formulation of oxycodone (OxyContin) was released, and concurrently, the highly abused opioid propoxyphene was removed from the market. This study was conducted to determine if these two events had any significant correlation with opioid supply and overdoses, and deaths related to non-prescription opioids (i.e., heroin). The results of the study showed that two years after this intervention, there was a deceleration in the dispensing rates of opioids, including the long-acting oxycodone formulation, along with a deceleration in the overdose rate from prescription opioids. However, there was an acceleration noted in the rate of heroin overdose after the intervention.

The strength of the study is the large size of the cohort, which had enough members to monitor trends over this time period. However, the study population may be somewhat biased given that only those with access to health insurance, specifically one company, could be included in the study. Also, the length of time in the study after the policy change was relatively short, so it is possible that some of the changes may have corrected over a longer period of time.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Reductions in reported deaths following the introduction of extended-release oxycodone (OxyContin) with an abuse-deterrent formulation

In-Depth [retrospective cohort]: The study population was derived from a cohort of patients from a single, large national insurer with members in all states. The study period lasted from 2003 to 2012 to include patterns before and after the opioid market interventions occurred (i.e., release of abuse-deterrent OxyContin and withdrawal of propoxyphene both occurred in 2010). Drug entry data was used to determine the type and frequency of prescription opioids filled by the cohort, and ICD9 codes were used for overdoses related to prescription and non-prescription opioids. Opioid dispensing was measured via a universal conversion factor to morphine-equivalent dose (MED).

A total of 31 316 598 adults were included in the study. There were 13 816 opioid overdoses recorded during the study period, 12 164 (88%) from prescription opioids, and 1 823 (13.2%) from heroin. After the change in policy, the rates of all opioid dispensing decreased by 19% from expected trajectory (-32.2 mg MEDs per member per quarter; 95%CI -38.1 to -26.3). Similarly, the dispensing rates of extended release oxycodone decreased by 39% from expected (-11.3 MEDs per member per quarter; 95%CI -12.4 to -10.1). In terms of prescription opioid overdoses two years after the policy change, there was a 20% decrease from expected (-1.1 per 100,000 members per quarter; 95%CI -1.47 to -0.74). After the policy change, there was non-statistically significant trend to towards accelerated rates of heroin overdose by 23% (0.26 per 100,000 members per quarter; 95%CI -0.01 – 0.53).

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