Abuse risks and routes of administration of different prescription opioid compounds and formulations

Abstract

BackgroundEvaluation of tamper resistant formulations (TRFs) and classwide Risk Evaluation and Mitigation Strategies (REMS) for prescription opioid analgesics will require baseline descriptions of abuse patterns of existing opioid analgesics, including the relative risk of abuse of existing prescription opioids and characteristic patterns of abuse by alternate routes of administration (ROAs). This article presents, for one population at high risk for abuse of prescription opioids, the unadjusted relative risk of abuse of hydrocodone, immediate release (IR) and extended release (ER) oxycodone, methadone, IR and ER morphine, hydromorphone, IR and ER fentanyl, IR and ER oxymorphone. How relative risks change when adjusted for prescription volume of the products was examined along with patterns of abuse via ROAs for the products.MethodsUsing data on prescription opioid abuse and ROAs used from 2009 Addiction Severity Index-Multimedia Version (ASI-MV®) Connect assessments of 59,792 patients entering treatment for substance use disorders at 464 treatment facilities in 34 states and prescription volume data from SDI Health LLC, unadjusted and adjusted risk for abuse were estimated using log-binomial regression models. A random effects binary logistic regression model estimated the predicted probabilities of abusing a product by one of five ROAs, intended ROA (i.e., swallowing whole), snorting, injection, chewing, and other.ResultsUnadjusted relative risk of abuse for the 11 compound/formulations determined hydrocodone and IR oxycodone to be most highly abused while IR oxymorphone and IR fentanyl were least often abused. Adjusting for prescription volume suggested hydrocodone and IR oxycodone were least often abused on a prescription-by-prescription basis. Methadone and morphine, especially IR morphine, showed increases in relative risk of abuse. Examination of the data without methadone revealed ER oxycodone as the drug with greatest risk after adjusting for prescription volume. Specific ROA patterns were identified for the compounds/formulations, with morphine and hydromorphone most likely to be injected.ConclusionsUnadjusted risks observed here were consistent with rankings of prescription opioid abuse obtained by others using different populations/methods. Adjusted risk estimates suggest that some, less widely prescribed analgesics are more often abused than prescription volume would predict. The compounds/formulations investigated evidenced unique ROA patterns. Baseline abuse patterns will be important for future evaluations of TRFs and REMS.

Oxymorphone Insufflation Associated with Acute Sensorineural Hearing Loss: Case Files of the University of Massachusetts Medical Toxicology Fellowship

“…Its potency is due to its high lipid solubility, allowing it to reach its maximum plasma concentration in a shorter amount of time [36]. Oxymorphone can be abused by insufflation of crushed tablets, which increases its bioavailability from 10 % by the oral route to 40 % by the intranasal route [36,38]. The bioavailability of oxymorphone is also significantly increased by coingestion of ethanol [36].…”

Routes of abuse of prescription opioid analgesics: a review and assessment of the potential impact of abuse-deterrent formulations

“…However, rates of abuse via chewing were relatively consistent across the different opioid formulations (8-20%). [29] Compared with other drugs, hydromorphone and both immediate-and extended-release morphine were more likely to be abused via injection (58, 57 and 48%, respectively, vs 25% for extended-release oxycodone, 22% for transdermal fentanyl, 20% for immediate-release oxymorphone, 10% for sublingual fentanyl, 8% for extended-release oxymorphone, 6% for immediate-release oxycodone, and only 1% for immediate-release hydrocodone). [29] Oxymorphone was more likely to be abused via inhalation than other opioid formulations (77% for extended-release oxymorphone and 60% for immediate-release oxymorphone vs 46% for extended-release oxycodone, 28% for immediate-release oxycodone, 28% for extended-release morphine, 20% for immediate-release morphine, 24% for immediate-release hydromorphone, 19% for immediate-release hydrocodone, 18% for sublingual fentanyl, and 2% for transdermal fentanyl).…”

“…[37] The most recent data from the US National Addictions Vigilance Intervention and Prevention Program for individuals entering substance-abuse treatment facilities clearly highlight the differences in route of abuse between different prescription opioid analgesic formulations ( Figure 2). [29] Immediate-release formulations of hydrocodone and oxycodone were most likely to be abused via their intended route of administration (89 and 81%, respectively, compared with 62% for extended-release oxycodone, 47% for immediate-release oxymorphone, 42% for extended-release morphine, 36% for immediate-release morphine, 33% for hydromorphone, 32% for extended-release oxymorphone, 13% for sublingual fentanyl and 9% for transdermal fentanyl). However, rates of abuse via chewing were relatively consistent across the different opioid formulations (8-20%).…”

“…[16] Available data suggest that immediate-release formulations are more often abused intact (e.g., by over-ingestion), whereas extended-release formulations are more likely to be manipulated and then swallowed, inhaled or injected. [15,29] Eightythree percent of individuals with a history of prescription opioid abuse reported oral abuse for an immediate-release formulation of oxycodone/acetaminophen (swallowing intact tablets and chewing combined), with inhalation reported by 44% and injection by 0.5%. [36] Similarly, 89% of individuals abusing immediate-release hydrocodone/acetaminophen used the oral route, with inhalation reported by 40% and injection by 1%.…”

“…Available data suggest that ingestion (with or without manipulation of the prescribed formulation) is the most prevalent route of abuse of prescription opioid analgesics, followed by inhalation and injection. [6,11,[22][23][24][25][26][27][28][29][30][31] Comprehensive data on methods of manipulation and routes of abuse of prescription opioid analgesics have been generated through the US National Health and Wellness Survey. [31] The prevalence of prescription opioid analgesic abuse in the 3 months before the survey was estimated at 1.3% of the adult population in the USA.…”