State-level variation in distribution of oxycodone and opioid-related deaths from 2000 to 2021: an ecological study of ARCOS and CDC WONDER data in the USA

Abstract

Objectives: This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021.

Design: This is an observational study.

Setting: More than 80 000 Americans died of an opioid overdose in 2021 as the USA continues to struggle with an opioid crisis. Prescription opioids play a substantial role, introducing patients to opioids and providing a supply of drugs that can be redirected to those seeking to misuse them.

Methods: The Drug Enforcement Administration annual summary reports from the Automation of Reports and Consolidated Orders System provided weights of oxycodone distributed per state by business type (pharmacies, hospitals and practitioners). Weights were converted to morphine milligram equivalents (MME) per capita and normalised for population. The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research provided mortality data for heroin, other opioids, methadone, other synthetic narcotics and other/unspecified narcotics.

Results: There was a sharp 280.13% increase in total MME/person of oxycodone from 2000 to 2010, followed by a slower 54.34% decrease from 2010 to 2021. Florida (2007-2011), Delaware (2003-2020) and Tennessee (2012-2021) displayed consistent and substantial elevations in combined MME/person compared with other states. In the peak year (2010), there was a 15-fold difference between the highest and lowest states. MME/person from only pharmacies, which constituted >94% of the total, showed similar results. Hospitals in Alaska (2000-2001, 2008, 2010-2021), Colorado (2008-2021) and DC (2000-2011) distributed substantially more MME/person over many years compared with other states. Florida stood out in practitioner-distributed oxycodone, with an elevation of almost 15-fold the average state from 2006 to 2010. Opioid-related deaths increased +806% from 2000 to 2021, largely driven by heroin, other opioids and other synthetic narcotics.

Conclusions: Oxycodone distribution across the USA showed marked differences between states and business types over time. Investigation of opioid policies in states of interest may provide insight for future actions to mitigate opioid misuse.

Keywords: Chronic Pain; EPIDEMIOLOGIC STUDIES; EPIDEMIOLOGY; PALLIATIVE CARE; PUBLIC HEALTH.

Figure 1

Total oxycodone distribution in total and by business activity in the USA from 2000 to 2021 as reported by the Drug Enforcement Administration’s Automated Reports and Consolidated Orders System. MME, morphine milligram equivalents.

Figure 2

Morphine mg equivalent (MME) per person of oxycodone by business type 2000–2021 as reported by the US Drug Enforcement Administration’s Automated Reports and Consolidated Orders System for (A) all business types, (B) pharmacies, (C) hospitals and (D) practitioners. Areas outside ±1.96 SD of the average state are in grey.

Figure 3

Choropleth map of the morphine mg equivalent (MME) per person in the peak year (2010) as reported by the Drug Enforcement Administration’s Automated Reports and Consolidated Orders System (A). Bar graphs showing the per cent increase from 2000 to 2010 (B) and per cent decrease from 2010 to 2021 (C). States outside ^*±1.96 or ^#±1.0 SD of the mean.

Figure 4

Opioid-related deaths from 2000 to 2021 by diagnosis codes T40.1 (heroin), T40.2 (other opioids), T40.3 (methadone), T40.4 (other synthetic narcotics) and T40.5 (other and unspecified narcotics) as reported by the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database.