The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: A qualitative analysis

Background: Beginning in the 1990s, non-medical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and misuse of POs including prescription drug monitoring programs (PDMPs), closing “pill mills” (unethical doctors or clinics that knowingly dispensed large amounts of pain medications knowing these medications were being misused and diverted) , disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. Methods: We conducted in-depth-interviews with people who use prescription opioids, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with PWUO focused on how they initiated their opioid use and any transitions they made from prescription opioid use to heroin, fentanyl or injection drug use. Results: The majority of participants reported initiating use with prescription opioids, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl increased. As more policies were passed to limit opioid prescription, participants noticed that doctors were less likely to prescribe or refill prescription opioids. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions increased risk of overdose and HIV/HCV infection. Conclusions: A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. They also reveal ways we can mitigate harms that have already occurred and treat people who use opioids with compassion and respect, not stigma and punishment.