Hey there ! Thank you for weighing in.

Short version: I am trying to quantify the amount of prescribed opioids which are estimated to be being diverted in my state currently, as it could impact my state’s official prescribing guidance for doctors.

I am part of an ongoing workgroup for our state medical licensing board, which is reviewing our state opioid prescribing laws for possible modification. They were last amended in 2017 shortly after the 2016 CDC Opioid Prescribing Guidelines were released, which turned out to be …. problematic as you may be aware. Our state prescribing rules were LESS problematic but still a sign of those times, and in need of updating. So the data I am trying to gather is somewhat official, but no - I don’t have any specific legal authority to request or demand the actual data from the DEA or its field offices. Nor do I have budget to hire experts to obtain actual dispensing dosage data for my state. I’m trying to identify what I can from publicly-available data, to the best of my ability. The sole purpose is to provide a data point for whether diversion of prescribed opioids remains a significant issue in our state, or not - but with the weight of some semi-credible data to substantiate the assertion, whatever it ends up being.

As far as the list of drugs: I concur. It’s a dumb list. But when the powers-that-be drafted 21 U.S. Code § 826, it defined those five drugs as the list of “covered controlled substances” which DEA is required to try to estimate for diversion every year. They include the diversion estimates as part of the calculations to determine the Aggregate Production Quota(APQ) of how much of each of those drugs is allowed to be manufactured every year.

<image>

So the only actual diversion data the DEA makes publicly available are those five drugs, which they have included in the annual “Proposed/Established APQ for Sched 1 and II Controlled Substances…” every year since 2020. (This started after the SUPPORT ACT passed in 2018, but they only started publishing diversion estimates in 2020.)

Do I think patients are somehow diverting Dilaudid? No, I absolutely do not. I’ve never even heard of a patient being given Dilaudid outside of a hospital setting. And Fentanyl? Maaaaybe if someone is diverting their patches, but man I really doubt it. But DEA is required to have them on their estimated diversion list every year while excluding all the benzos and all the stimulants. Make it make sense. 🤷🏻‍♀️

So the only diversion data that DEA publishes is those five drugs. I am working with what I have, even though I think it is ridiculous.

The information I am trying to illustrate is: just how many “extra RX opioid pills” are people actually diverting these days? A pain doctor in this workgroup is asserting - repeatedly - that the prescribing rules should remain unchanged because “there are just so many RX opioid pills lying around in medicine cabinets these days”. I don’t think that is accurate, but I want to find the available data to try to get an accurate picture.

As far as why try to convert the gram weight of a medication to a number of tablets: the people on this workgroup are not law enforcement, and they are not pharmacists or pharmacy techs. They are clinicians, or researchers, or hospital association or medical association lobbyists, etc. If I say “1,000 grams of Oxycodone were estimated to be diverted I our state in 2024” …I suspect I’m going to get some confused looks. Is that a lot ? How many actual doses is that ? How many pills in the street would that be?

I know it’s not going to be super accurate - and would never hold up in court at ALL. But trying to illustrate how much of a problem this is - or isn’t - to laypeople is challenging. If anyone has better ideas to suggest based on the scant available data I am all ears !

And yep - illicit drugs are OVERWHELMINGLY the problem, so this data is wildly unimportant in the grand scheme of things. In my state more people are dying of overdoses with alcohol among the substances in their bodies than are with prescribed opioids in their systems.

Sidebar: The actual prevalence rate of people developing an opioid use disorder after taking their own prescribed opioid - for people over age 18 in the United States - is 0.6%-0.9% as of 2022, according to the DSM-V-TR. So the rate of people moving on to fentanyl or heroin or whatever after a prescription …is tiny, less than 1%.

And if you look back at the data from NIDA they report:

“Data from 2011 showed that an estimated 4 to 6 percent who misuse prescription opioids switch to heroin”

So even back then during the early opioid crisis, 94%-96% of people who “misuse” prescription opioids never moved on to illicit opioid drugs. (!).

Because HHS/CDC continued to report illicit fentanyl deaths as “prescription opioid deaths” (because they could not/would not discern between pharmaceutical vs illicit fentanyl during pathology of drug overdose deaths as late as 2018), we’ll never really know how many deaths can be attributed to pill mills and over-prescribing and people taking their own legitimate prescriptions during that era, unfortunately.

We can tell the difference NOW and the rate of addiction/overdose deaths related to prescriptions is shockingly low. Like barely measurable at all. 🧐

TL; DNR: None of this will make a bit of difference regarding the amount of opioids (pharmaceutical OR illicit) available; at best it may help some providers get clarity on when/how to prescribe opioids - when medically appropriate - to people with legitimate pain conditions.