Two compelling public health trends have become entwined – (i) increased attention to under-treated pain, which increased prescribing of opioid analgesics, and (ii) increased opioid misuse, abuse, and overdose.1

Undertreated Pain: According to the World Health Organization, under-treated pain is the number one health problem in America, while over 150 countries also report severe under-treatment of pain. More Americans are affected by pain than cancer, heart disease, and diabetes combined.2 Chronic pain alone is estimated to cost the United States up to $635 billion each year in medical treatment and lost productivity.3 The use of opioid agonists is expected to continue to be the dominant pain therapy due to their unmatched efficacy. The overall global opioid market for seven indications – fibromyalgia, neuropathic pain, cancer pain, osteoarthritis pain, rheumatoid arthritis pain, low back pain, and post-operative pain – was valued at $11.2 billion in 2010.4 A recent report from business intelligence provider GVR states that the North American market for opioids is expected to grow from $12.4 billion in 2015 to ~$18 billion by 2024, at a compound annual growth rate of 4.6%.5

Prescription Opioid Abuse and Overdose: The growing emphasis on improved pain treatment has sparked a dramatic escalation in opioid prescriptions. Opioid analgesics are currently the most prescribed class of prescription medications in the United States.6 Unfortunately, one of the main factors that contributes to the popularity of a drug is its availability. The extensive “environmental availability” of opioids is associated with increased use and overdose.7 From 1991 to 2013, there was a near tripling of opioid prescriptions dispensed by U.S. pharmacies: from 76 million to 207 million prescriptions.8 In parallel with this increase, there was also a near tripling of opioid-related deaths over the same time-period. The National Institute on Drug Abuse, National Institutes of Health, the Food and Drug Administration, and the Centers for Disease Control and Prevention have identified the non-medical use of prescription opioids as a major public health issue in the United States, because of the overall high prevalence and the marked increases in associated morbidity and mortality.9,10


Prevalence/Morbidity: According to the Office of National Drug Control Policy (ONDCP), prescription drug abuse is the Nation’s fastest-growing drug problem, and reducing such abuse is a national priority.11

· In 2015, 12.5 million people reported using prescription opioids non-medically (i.e., using medications that were not prescribed to them or were taken only for the experience or feeling that they caused).12

· In 2012, over 5% of the US population aged 12 years or older used opioid pain relievers non-medically.13

· Nearly 1 in 23 high school seniors reported misusing the opioid pain reliever Vicodin in 2015.14

· Of the 20.5 million Americans 12 years or older that had a substance use disorder in 2015, 2 million had a substance use disorder involving prescription pain relievers.15 

· Emergency department visits involving misuse or abuse of prescription opioids increased 153% between 2004 and 2011.16,17

· From 2002 to 2012, hospitalizations related to opioid use increased 72 percent,18 and admissions to substance-abuse treatment programs linked to prescription opioids more than quadrupled.19,20

· There is also growing evidence to suggest a relationship between increased non-medical use of opioid analgesics and heroin abuse in the United States.21 

· Four in five new heroin users started out by misusing prescription painkillers.22

· Heroin use among individuals who reported prior nonmedical use of prescription opioids was 19 times higher than the incidence among individuals who reported no previous nonmedical use.23 


Mortality: The Centers for Disease Control and Prevention (CDC) has reported that prescription opioid abuse is a deadly epidemic:

· Between 2000 and 2014, the rates of death from prescription-opioid overdoses nearly quadrupled (from 1.5 to 5.9 deaths per 100,000 persons).24 

· Opioids (including prescription opioids and heroin) killed more than 33,000 people in 2015, more than any year on record. In 2015, deaths that involved prescription opioids (17,536) rose 4%.

· Prescription pain reliever overdose deaths among women increased more than 400% from 1999 to 2010, compared to 237% among men.25

· More than 1,700 young adults (ages 18-24) died from prescription overdose in 2014, a four-fold increase since 1999.26

· While IMS Health data reveals that there has been a 12 percent decrease in opioid prescriptions since 2012, fewer prescriptions have not led to fewer deaths.27


Cost: Opioid abuse places a significant burden on our healthcare system and drives significant costs. 

· For every prescription opioid related death, there are (i) 10 treatment admissions for abuse28; (ii) 32 ER visits for misuse or abuse29; (iii) 130 people who are dependent abusers30; and (iv) 825 people who take prescription painkillers for non-medical use.31

· In 2013 the economic burden relating to opioid overdose, abuse, and dependence was estimated to be $78.5 billion, with over 33% due to increased health care and substance abuse treatment costs ($28.9 billion).32

· Inpatient costs for hospitalizations related to opioid abuse over the decade from 2002 to 2012 quadrupled.33

references

1 Scott M. Fishman, MD, The Clinician’s Dilemma: Under-Treated Pain Versus Prescription Drug Misuse, 2012

2 National Institute of Health, Research Portfolio Online Reporting Tools (Report): Pain Management (accessed Sept. 17, 2013). http://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57

3 Institute of Medicine, Relieving Pain in America, 2011.

4  GBI Research, Opioids Market to 2017 – Steady Uptake of OxyContin and High Incidence of Diseases Such as Cancer and Arthritis to Drive the Market, June 1, 2011

5  Grand View Research, N. America Opioid Market Analysis by Product, By Application, and Segment Forecasts to 2024, August 2016. http://www.grandviewresearch.com/industry-analysis/north-america-opioid-market

6  Scott M. Fishman, MD, The Clinician’s Dilemma: Under-Treated Pain Versus Prescription Drug Misuse, 2012

7  Compton, MD MPE, Jones, PharmD MPH, and Baldwin, PhD MPH, Relationships between Nonmedical Prescription-Opioid Use and Heroin Use, N Engl J Med 2016;374:154-63. 

8  International Narcotics Control Board Report 2008. United Nations Pubns. 2009. p. 20

9  Epidemic: responding to America’s prescription drug abuse crisis. Washington, DC: Office of National Drug Control Policy Executive, Office of the President of the United States, 2011 (http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf).

10  Compton, MD MPE, Jones, PharmD MPH, and Baldwin, PhD MPH, Relationships between Nonmedical Prescription-Opioid Use and Heroin Use, N Engl J Med 2016;374:154-63. 

11 The White House ONDCP, Epidemic: Responding to America’s Prescription Drug Abuse Crisis, 2011 (accessed Sept. 16, 2013). http://www.whitehouse.gov/sites/default/files/ondcp/policy-and-research/rx_abuse_plan.pdf

12  Center for Behavioral Health Statistics and Quality. 2015 National Survey on Drug Use and Health: detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016.

13  SAMHSA: Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings and Detailed Tables

14  The University of Michigan Institute for Social Research. Monitoring the Future national survey results on drug use, 1975-2015: Overview, key findings on adolescent drug use. February 2016. (http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2015.pdf)

15  Center for Behavioral Health Statistics and Quality. (2016). Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). http://www.samhsa.gov/data/.

16  The DAWN report: highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2013.

17  Treatment episode data set, 2002-2012; national admissions to substance abuse treatment services. BHSIS series S-71, HS publication no. (SMA) 14-4850. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2014. 

18  Ronan MV, Herzig SJ. Hospitalizations Related to Opioid Abuse/Dependence and Associated Serious Infections Increased Sharply, 2002-12. Health Aff (Millwood). 2016;35(5): 832-837.doi:10.1377/hlthaff.2015.1424.

19  The DAWN report: highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2013.

20  Treatment episode data set, 2002-2012; national admissions to substance abuse treatment services. BHSIS series S-71, HS publication no. (SMA) 14-4850. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2014. 

21 Pradip et al. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the US. Center for behavioral Health Statistics and Quality Data Review. SAMHSA (2013) http://www.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.htm

22 Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers - United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013 Sep 1;132(1-2):95-100. 

23 Muhuri PK, Gfroerer JC, Davies C. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review, 2013 (http://archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf)

24  Centers for Disease Control and Prevention. Wide-ranging Online Data for Epidemiologic Research (WONDER), Multiple-Cause-of-Death file, 2000–2014. 2015 (http://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf).

25 Center for Disease Control and Prevention. (2013). Prescription Painkiller Overdoses: A Growing Epidemic, Especially Among Women. Atlanta, GA: Centers for Disease Control and Prevention http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html. 

26 Centers for Disease Control and Prevention. Wide-ranging Online Data for Epidemiologic Research (WONDER), Multiple-Cause-of-Death file, 2000–2014. 2015

27 Goodnough and Tavernise, Opioid Prescriptions Drop for the First Time in Two Decades, The New York Times, May 20, 2016. http://www.nytimes.com/2016/05/21/health/opioid-prescriptions-drop-for-first-time-in-two-decades.html?_r=0

28 Substance abuse treatment admissions by primary substance of abuse, according to sex, age group, race, and ethnicity 2009 (Treatment Episode Data Set). http://wwwdasis.samhsa.gov/webt/quicklink/US09.htm

29 Drug Abuse Warning Network: selected tables of national estimates of drug-related emergency department visits. Rockville, MD: Center for Behavioral Health Statistics and Quality, SAMHSA; 2010.

30 Results from the 2010 National Survey on Drug Use and Health: volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2011. Available from http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16

31 Results from the 2010 National Survey on Drug Use and Health: volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2011. Available from http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16

32 Florence CS, ZhouC, Luo F, Xu L, The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013, Med Care 2016 Oct;54(10):901-6

33 Ronan MV, Herzig SJ. Hospitalizations Related to Opioid Abuse/Dependence and Associated Serious Infections Increased Sharply, 2002-12. Health Aff (Millwood). 2016;35(5):832-837.doi:10.1377/hlthaff.2015.1424.