The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis

Abstract

Background Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use. Methods We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use. Results The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection. Conclusions A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.

New opioid prescription claims and their clinical indications: results from health administrative data in Quebec, Canada, over 14 years

“…But, this decrease and lowest rate of opioid initiation can reversely motivate the illicit opioid seeking by some patients in need of strong pain reliever. 60 This study suggests that administrative data can help to monitor opioid initiation and their clinical indications. In a perspective of optimising opioid prescribing, a patient's first-opioid prescription and its clinical indication are critically important.…”

Dynamic Changes in the Distribution of Hydrocodone and Oxycodone in Florida from 2006 to 2021

“…Tampa and Ft. Lauderdale, cities in two of our top three counties, had some of the highest rates of fentanyl deaths in the state in 2021 [ 49 ]. A 2022 study interviewed 148 opioid users from three states to explore their switch from oral opioid use to injection of heroin and fentanyl [ 50 ]. Nearly half (48%) of the participants began with prescribed oral opioids [ 50 ].…”

“…A 2022 study interviewed 148 opioid users from three states to explore their switch from oral opioid use to injection of heroin and fentanyl [ 50 ]. Nearly half (48%) of the participants began with prescribed oral opioids [ 50 ]. The common thread in the participants’ accounts described by the authors was that when states began regulating prescription opioids more strictly, doctors stopped prescribing, and oral opioids became more scarce and therefore more expensive [ 50 ].…”

Ethical considerations and decision making in opioid prescribing for chronic pain: A case study in rheumatology practice

“…In cases in which a patient is meeting functional goals and has no side effects or aberrant behaviors, aggressive clinician tapering, discontinuing the prescribed opioids entirely, or nonopioid prescribing may introduce additional patient harms, such as increased risk for suicide, overdose, or use of heroin or illicit opioids (Coffin & Barreveld, 2022). Moreover, opioid tapering by 10–15% MME every month has been associated with termination of care in the year following the tapering regimen (Hill et al, 2022); therefore, in the context of an OrT, unnecessary or systematic opioid tapering may be considered patient abandonment on the part of the clinician (Keller et al, 2020) and could lead to illicit drug use on the part of the patient (Dickson-Gomez et al, 2022). The clinician's duty of nonmaleficence might therefore support continuing opioid prescription to avoid these possible harms.…”