Scoring the best deal: Quantity discounts and street price variation of diverted oxycodone and oxymorphone.

PURPOSE: Diverted prescription opioids are significant contributors to drug overdose mortality. Street price has been suggested as an economic metric of the diverted prescription opioid black market. This study examined variables that may influence the street price of diverted oxycodone and oxymorphone. METHODS: A cross-sectional study was conducted utilizing data from the previously validated, crowdsourcing website StreetRx. Street price reports of selected oxycodone and oxymorphone products, between August 22, 2014 and June 30, 2016, were considered for analysis. Geometric means and 95% confidence intervals were calculated comparing prices per milligram of drug in US dollars. Univariate and multivariable regressions were used to examine the influence of dosage strength, drug formulation, and bulk purchasing on street price. RESULTS: A total of 5611 oxycodone and 1420 oxymorphone reports were analyzed. Across various dosages and formulations, geometric mean prices per milligram ranged between $0.12 and $1.07 for oxycodone and $0.73 and $2.90 for oxymorphone. For a 2-fold increase in dosage strength, there is a 24.0% (95% CI: -28.1%, -19.6%, P < 0.001) and a 22.5% (95% CI: -24.2%, -20.8%, P < 0.001) decrease on average in price per milligram for oxycodone and oxymorphone, respectively. Lower potency, high dosage strength, crush-resistant opioids, and those purchased in bulk were significantly cheaper. CONCLUSION: Street prices for diverted oxycodone and oxymorphone are influenced by multiple factors including potency, dosage, formulation, and bulk purchasing. Buyers who purchase large quantities of low potency, large dosage, crush-resistant formulation prescription opioids can expect to achieve the lowest price.

Silicon to syringe: Cryptomarkets and disruptive innovation in opioid supply chains.

Cryptomarkets offer insight into the evolving interplay between online black markets and cartel-based distribution. The types and forms of heroin, fentanyl, and prescription drugs show wide diversification. In this commentary we describe changes in the conceptualizations, technologies and structures of drug supply chains in the 21st Century, with special attention to the role of cryptomarkets as tools, contexts, and drivers of innovation in public health research.

The Impact of Misuse and Diversion of Opioid Substitution Treatment Medicines: Evidence Review and Expert Consensus.

BACKGROUND/AIMS: Opioid substitution treatment (OST) improves outcomes in opioid dependence. However, controlled drugs used in treatment may be misused or diverted, resulting in negative treatment outcomes. This review defines a framework to assess the impact of misuse and diversion. METHODS: A systematic review of published studies of misuse and diversion of OST medicines was completed; this evidence was paired with expert real-world experience to better understand the impact of misuse and diversion on the individual and on society. RESULTS: Direct impact to the individual includes failure to progress in recovery and negative effects on health (overdose, health risks associated with injecting behaviour). Diversion of OST has impacts on a community that is beyond the intended OST recipient. The direct impact includes risk to others (unsupervised use; unintended exposure of children to diverted medication) and drug-related criminal behavior. The indirect impact includes the economic costs of untreated opioid dependence, crime and loss of productivity. CONCLUSION: While treatment for opioid dependence is essential and must be supported, it is vital to reduce misuse and diversion while ensuring the best possible care. Understanding the impact of OST misuse and diversion is key to defining strategies to address these issues.

El tráfico inverso de medicamentos. Experiencia en Galicia / The reverse traffic of drugs phenomenon. Experience in Galicia, Spain

La circulación intracomunitaria de medicamentos entre países de la Unión Europea realizada por laboratorios farmacéuticos y almacenes mayoristas es una actividad permitida denominada comercio paralelo. Como España se encuentra entre los Estados con menor precio de estos productos, su actividad principal es el envío a otros países. Sin embargo, en la adquisición de fármacos con este objeto ha emergido un fenómeno denominado 'tráfico inverso de medicamentos', que se desarrolla sin observar la normativa sanitaria en el canal legal de distribución en nuestro país. Consiste en que los almacenes mayoristas obtienen los medicamentos de las oficinas de farmacia, en lugar de obtenerlos de otros almacenes o de laboratorios farmacéuticos conforme a la legislación vigente, invirtiendo de esta forma el circuito legal de suministro, ya que las oficinas de farmacia no los dispensan al público. Este trabajo profundiza en los riesgos que para la salud pública ocasionan estas prácticas, detalla los resultados de la inspección de servicios sanitarios en Galicia que, en relación al total de procedimientos sancionadores a establecimientos farmacéuticos del período 2011-2014, fueron saniconados por esta causa 15 oficinas de farmacia y 5 almacenes, correspondiendo las máximas multas a la red formada por un almacén farmacéutico (1.000.000 Euros y cierre por 3 años) y 4 oficinas de farmacia (2.400.000 Euros). Así mismo, se especifica la metodología de actuación y se identifica el escenario de adquisición ilegal para realizar este comercio exterior con mayores beneficios económicos, y se destacan los puntos fuertes de éxito y nuevas acciones para mejorar su abordaje (AU)

Interstate movement of drugs between EU countries by pharmaceutical companies and distribution warehouses is a permitted activity called parallel trade. As Spain is among the states with lower price of these products, its main activity is shipping to other countries ; however, a phenomenon has emerged in acquiring drugs for this purpose, called 'reverse traffic' that develops without observing the health regulations in the legal distribution channel in our country; in which, the pharmaceutical distribution warehouses, rather than getting drugs from other pharmaceutical companies or pharmaceutical distribution warehouses under the current legislation, obtain them from community pharmacies, thus reversing the legal supply circuit, as this drugs do not end dispensed to the public. This paper studies the risks to public health caused by these practices, detailing the results of health inspections in Galicia, where in relation to the total pharmaceutical establishments sanctioning procedures in the period 2011-2014, were sanctioned for this reason 15 community pharmacies and 5 distribution warehouses, the maximum fines belonging to a network consisting of a pharmaceutical distribution warehouse, with a 1,000,000 Euros fine and closure for 3 years, and 4 community pharmacies, with 2,400,000 Euros total fine; It also specifies the methodology of action, identifies the scene of illegal acquisition to make this trade with the greatest economic benefits, highlights the strengths of the success and further action to improve its approach (AU)

Diversion of methadone and buprenorphine from opioid substitution treatment: patients who regularly sell or share their medication.

Diversion-the practice of patients selling or sharing their medication-is a much debated problem of opioid substitution treatment. Regular diversion by patients was studied at 11 opioid substitution treatment programs in the south of Sweden. Using quantitative and qualitative data, it was investigated whether those patients differ from other patients, their motives for and means of diversion, and who the recipients are. Regular diverters are a small, yet heterogeneous group. Continued illicit drug use, however, stands out as a common risk factor. Pecuniary need and a desire to help friends are other important motives. The client base mainly consists of people from the regular diverters' own drug milieus.

The diversion and injection of a buprenorphine-naloxone soluble film formulation.

BACKGROUND: We compared the diversion and injection of a new formulation of buprenorphine, a buprenorphine-naloxone film product (BNX film), with buprenorphine-naloxone tablets (BNX tablets), mono-buprenorphine (BPN) and methadone (MET) in Australia. METHODS: Surveys were conducted with people who inject drugs regularly (PWID) (2004-2012) and opioid substitution treatment (OST) clients (2012, N=543). Key outcome measures: the unsanctioned removal of supervised doses, diversion, injection, motivations, drug liking and street price. Levels of injection among PWID were adjusted for background availability of medication using sales data. Doses not taken as directed by OST clients were adjusted by total number of daily doses dispensed. RESULTS: Among out-of-treatment PWID, levels of injection for BNX film were comparable to those for MET and BNX tablet formulations, adjusting for background availability; BPN injecting levels were higher. Among OST clients, recent injecting of one's medication was similar among clients in all OST types; weekly or more frequent injection of prescribed doses was reported by fewer BNX film clients (3%; 95% CI: 1-6) than BPN clients (11%; 95% CI: 3-17), but at levels similar to those observed among MET and BNX tablet clients. The proportion of BNX film doses injected was lower than that for BPN and BNX tablets, and equivalent to that for MET. The majority of BNX film doses injected by OST clients were unsupervised doses, although some injection of supervised doses of BNX film did occur. The median price of all buprenorphine forms on the illicit market was the same. CONCLUSIONS: Non-adherence and diversion of the BNX film formulation was similar to MET and BNX tablet formulations; BPN had higher levels of all indicators of non-adherence and diversion.

Diversion of prescribed opioids by people living with chronic pain: results from an Australian community sample.

INTRODUCTION AND AIMS: There has been an increase in prescription of opioids for chronic non-cancer pain, and concern exists over possible diversion of prescription opioids to the illicit marketplace. Recent media coverage suggests that elderly patients sell their prescribed opioids for additional income. This study investigated the extent to which an Australian community sample of chronic pain patients prescribed opioids reported supplying their prescribed opioids to others. DESIGN AND METHODS: Participants living with chronic non-cancer pain and prescribed opioids for their pain (n=952) were recruited across Australia via advertisements at pharmacies. A telephone interview included questions about their pain condition and opioid medication. RESULTS: Participants had been living with pain for a mean of 14.2 years; most common conditions included chronic back/neck problems and arthritis/rheumatism. Around half (43%) were currently prescribed one opioid, and 55% had been prescribed 2-5 opioids; the most common was oxycodone. Forty-two participants (4%) reported ever supplying prescribed opioids to another person; one participant reported receiving payment. Participants who supplied opioids to others were younger (odds ratio 0.97, 95% confidence interval 0.95-0.99) and engaged in a greater number of aberrant behaviours relating to their opioid medication (odds ratio 1.77, 95% confidence interval 1.45-2.17), including tampering with doses, taking opioids by alternative routes, seeing doctors to obtain extra opioids and refilling prescriptions early. DISCUSSION AND CONCLUSION: Few people with chronic non-cancer pain divert their opioids to others. Media reports of elderly patients selling their opioids to supplement their income may be reflective of exceptional cases. Future studies may investigate the extent to which other patient groups divert prescription opioids to the illicit marketplace.