or family ( 16 percent), purchased from a drug dealer
( 4 percent), or they are provided to users in some
other way ( 6 percent), with the rest of the population
misusing opioids prescribed by their physician ( 20 percent).
15 Deaths related to synthetic opioid overdoses
rose by 72 percent from 5,544 in 2014 to 9,580 in 2015,
and deaths from natural and semi-synthetic opioids
rose 2. 6 percent to 12,727 in 2015.2 Heroin overdoses
also have risen by 21 percent during the same time,
reaching 12,989 deaths in 2015.2 Analyzing 2002–2011
data from the U.S. National Survey on Drug Use and
Health, up to four out of five heroin users in the U.S.
have misused prescription opioids before using heroin,
underscoring the importance of preventing initial prescription opioid misuse.
Surgeon prescribing practices are germane to any
discussion of the opioid epidemic, as more than one-third of the average surgeon’s prescriptions are for
17 Surgeons prescribed opioids to approximately
80 percent of patients who underwent an elective,
low-risk operation such as a knee arthroscopy, with
increases in prescriptions and dosages from 2004 to
2012.18 Furthermore, studies examining patients who
underwent low-risk procedures revealed that opioid
prescriptions were associated with a greater likelihood
of long-term use.
19, 20 A study of 1. 3 million opioid-naive noncancer patients with acute pain indicated
that patients with an opioid prescription for at least
one day had a 6 percent chance of continued opioid
use after one year and a 3 percent likelihood after
21 In a study of 39,000 patients who underwent a major operation such as coronary artery bypass
graft surgery via sternotomy, 3 percent of opioid-naive
patients continued to use opioids more than 90 days
after their operation.
22 Because of the risk of chronic
dependence, the opioid prescribing patterns of surgeons are now the subject of close examination, and
state regulations are being implemented with or without surgeon involvement.
Policies that have affected opioid prescribing pat-
terns, such as mandatory use of a PDMP, have shown
notable success for chronic opioid use at the state
23 Another policy that affects opioid prescribing
patterns is the development of guidelines that instruct
physicians in appropriate use of prescription opioids
for chronic pain.
24 However, guidelines for the man-
agement of acute postoperative pain require further
Regulations pertaining to prescription opioid medications have been enacted at both the federal and state
The U.S. Drug Enforcement Administration (DEA)
has implemented several important opioid-related
policy changes. In October 2014, the DEA rescheduled
hydrocodone from Schedule III to a more restrictive
Schedule II substance under the Controlled Substances
Act. Prescriptions for hydrocodone decreased by 22
percent in the first year after the change.
25 Then, in
October 2016, the DEA reduced the amount of Schedule II opioid medications that can be manufactured by
25 percent or more, thereby decreasing the total supply
of these medications available for distribution.
In response to a July 2012 petition from the Physicians for Responsible Opioid Prescribing, the U.S.
Food and Drug Administration (FDA) changed the
mandatory labeling for extended-release or long-acting
opioids, removing the previously accepted treatment
indication for moderate pain.
27 As of May 2014, the
new indication for these medications is for pain “severe
enough to require daily, around-the-clock, long-term
opioid treatment and for which alternative treatments
27 Additionally, the FDA has called for
further post-marketing surveillance studies on these
agents by the manufacturers, as well as mandatory
provider education programs.
28 Other federal interventions were included in the Affordable Care Act, calling
for states to develop PDMPs and increase funding for
substance abuse treatment programs.
On July 22, 2016, President Obama signed the Comprehensive Addiction and Recovery Act, which calls for
implementing incremental steps to combat the opioid