Page 8
Administration. Past year opioid misuse is measured based on whether the respondent affirmed using heroin (survey item HERYR), or had non-medical use of a prescription painkiller (survey item PNRNMYR). Past year opioid use disorder is based on criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Respondents were defined as having an opioid use disorder if they met criteria for either dependency or abuse. A respondent is coded as having a dependency if the respondent responded positively to three or more of the following criteria: 1. Spent a great deal of time over a period of a month getting, using, or getting over the effects of the substance. 2. Unable to keep set limits on substance use or used more often than intended. 3. Needed to use the substance more than before to get desired effects or noticed that using the same amount had less effect than before. 4. Unable to cut down or stop using the substance every time he or she tried or wanted to. 5. Continued to use substance even though it was causing problems with emotions, nerves, mental health, or physical problems. 6. Reduced or gave up participation in important activities due to substance use. Respondents were defined as abusing a substance if they reported a positive response to one of four abuse criteria, including: 1. Having a serious problem due to substance use at home, work or school. 2. Using substance regularly and then did something where substance use might have put them in physical danger. 3. Substance use causing actions that repeatedly got them in trouble with the law. 4. Having problems caused by substance use with family or friends and continued to use a substance even though it was thought to be causing problems with family and friends. Respondents were coded as having an opioid use disorder if they responded in the affirmative to survey items for dependency on prescription opioids (DEPNDPYRPNR) or heroin (DEPNDHER), or abuse of prescription opioids (UDPYPNR) or heroin (ABODHER). County Prevalence Measures Data for measures of county prevalence of prescription opioids and substance use come from four different sources. Retail Prescription Opioid Sales Data on retail prescription opioid sales come from the Drug Enforcement Administration’s (DEA) Automation of Reports and Consolidated Orders System (ARCOS). Data are available for 2006 through 13 2016 for all counties in the United States. ARCOS reports are collected quarterly, and contain information on the inventories, acquisitions, and dispositions of certain controlled pharmaceuticals. Narcotics (including opioids) that are schedule III controlled substances are reported into ARCOS. Other data sources on retail opioid sales may provide more accurate estimates, but were not available for this analysis. These include commercial data from IQVIA, used by the CDC11 and the Food and Drug Administration15, and data from prescription drug monitoring programs. Aggregate national trends of ARCOS data and these data sources are comparable, though not exactly identical. We selected commonly prescribed and misused opioids, and which have been consistently reported to ARCOS over the time period of study. These include dextropropoxyphene, dihydrocodeine, fentanyl, hydrocodone, hydromorphone, levorphanol, meperidine, morphine, oxycodone, oxymorphone, and tapentadol. Buprenorphine and methadone were excluded, as they are more commonly used to treat opioid use disorder, though both are prescribed for other purposes. ARCOS reports the weight of sales of each drug, and we converted those weights to morphine equivalents using conversion factors provided by FDA. The DEA publishes ARCOS data for all three-digit zip codes (e.g. 209 would include zip codes 20902 and 20906). To convert to counties, the three digit zip codes were first converted to five-digit zip codes by distributing the share of opioid sales across the appropriate zip codes based on population proportions. This makes the assumption that the distribution of prescription opioids follows the same distribution as the population. Zip codes were then converted to counties using a zip code-county