Dynamic Changes and Pronounced State Level Disparities in Controlled Substance Distribution by US Advanced Practice Providers From 2006 to 2023

Objective: To evaluate the changing pattern of the distribution of Schedule II and III opioids, stimulants, and barbiturates by advanced practice providers (APP; i.e., physician assistants and nurse practitioners) in the United States (US). Design: Retrospective study. Sample: Advanced practice providers from every US state (and DC) that directly dispense Schedule II/III drugs to patients. Procedures: Controlled substances distributed by APP was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Orders System (DEA's ARCOS) for opioids (e.g., hydrocodone, fentanyl, buprenorphine), barbiturates (pentobarbital, butalbital), and stimulants (amphetamine, methylphenidate, lisdexamfetamine) from 2006-2023. Opioids were converted to their morphine milligram equivalents (MME), stimulants converted to daily doses, and barbiturates to kilograms. Opioid use by state in three selected years (2013, 2020, 2023) was further analyzed. Results: The total weight of controlled substances as distributed exhibited both overall and drug-specific changes since 2006. Buprenorphine accounted for only a modest amount (0.6%) in 2013 but the preponderance (94.6%) of opioids distributed by MME in 2023 nationally. Examination of the opioid MME per state and corrected for population revealed the states with the highest reported use for 2013 (Nevada), 2020 (North Dakota), and 2023 (Maine). There has been an overall modest decline in stimulant (-97.9%) and barbiturate (-64.1%) since 2010. Conclusions and Clinical Relevance: The use of Schedule II/III drugs as distributed to APP has fluctuated yet overall increased in the past decades. Opioids by total MME have had rather small changes throughout the years, except for buprenorphine. APP direct distribution has transitioned from treating pain to Opioid Use Disorder. Future research should discover the causes underlying the yearly and state level disparities for opioid, stimulant, and barbiturate use.