Pronounced Declines in Licit Fentanyl Utilization and Changes in Prescribing and Reimbursement Practices in the United States, 2010-2019

Background: Fentanyl and its derivatives are highly utilized opioid-based analgesics provided to patients in various formulations. The evolving opioid crisis over the past decade has increased pressure on the health care industry to monitor opioid production. Different policies and procedures implemented to contain the crisis from a controlled substance standpoint have changed the utilization patterns of some opioids. A prior report identified 3-fold differences between states in fentanyl use. This study explored fentanyl distribution patterns from 2010 and 2019. Methods: The amount of fentanyl base distributed from 2010 to 2019 was obtained from the Drug Enforcement Administration. Sufentanil, alfentanil, and remifentanil were also analyzed from 2010 to 2017, the most recent year reported. Prescriptions, units, and reimbursement for 2010 and 2019 were obtained from Medicaid and fentanyl prescriber specialty from Medicare Part D. Results: There was a 65.5% decrease in the milligrams of fentanyl per person distributed when correcting for population. From a regional perspective, Ohio had the greatest decrease (-79.3%) while Mississippi saw the smallest (-44.5%). There was a 6.8-fold regional difference in the quantity of fentanyl distributed in 2019 from hospitals (South Dakota = 775.2, Alabama = 113.2 ug/person). The regional difference was also sizeable for pharmacies (6.2-fold, Mississippi = 1,025.3, Washington, D.C. = 165.6). Medicaid reimbursement in 2019 was $165 million for over eight hundred-thousand prescriptions with the majority for generic (99.7%) and injectable (77.6%) formulations. Interventional pain management and anesthesia were overrepresented, and hematology/oncology significantly underrepresented for fentanyl in Medicare. Conclusion: The production and distribution of fentanyl-based substances decreased, although not uniformly, in the United States over the last decade. Additionally, the most prescribed formulations of fentanyl have transitioned away from transdermal, potentially in an effort to regulate its availability. Although impactful, overdose deaths attributed to synthetic opioid deaths continue to increase, highlighting the need for targeted public health interventions beyond the pharmaceutical and medical communities.