Using our interactive chartsARCOS data capture distribution of drugs to hospitals and pharmacies reported to the Drug Enforcement Administration. Data are presented in typical daily doses or morphine-equivalent weights, described in detail at the bottom of the page.
All opioids can be used for pain management, while methadone and buprenorphine can also be used in the treatment of opioid use disorder. Fentanyl here refers only to fentanyl itself, used most commonly in surgery or chronic pain management, and not any of the many fentanyl analogues, some of which are approved for use in humans or animals in the U.S. (These data, of course, do not include illicitly manufactured fentanyl.) The different lines for methadone reflect the addition after 2005 of methadone distributed to opiate treatment programs (OTPs) to methadone totals reported in ARCOS. The "all Rx opioids" series starts in 2005 because buprenorphine did not appear in ARCOS before then. That series assumes meperidine, missing until 2009, had essentially no distribution before then. The "common opioid pain Rx" series sums across all prescription opioids presented except methadone and buprenorphine, which are occasionally used for pain but mostly as medications for opioid use disorder. Methadone, however, was used more often for pain during the 2000s. Data are missing for some of the common opioid pain Rx components in 2000 and 2002. These data represent the legal distribution of pharmaceutical opioids in the State. These opioids could subsequently be used as prescribed or beyond what was prescribed, go unused, or be illegally sold, given away, or stolen.
To see less common drugs in more detail, turn off aggregate series (e.g., all Rx opioids, which sums all the opioids shown) or more common series e.g., (hydrocodone) by clicking the series name(s) in the legend below the chart. This will change the scale so that smaller numbers are much easier to see.
To show how trends may or may not have moved together over time, we show rates (per 100,000 residents) of deaths and crime lab cases associated with prescription-type and other opioids for comparison. ("Other" in the series names refers to opioids beside heroin.) We present the data for opioid distribution as doses per person in Washington (doses pp) or as morphine-equivalent grams per person (see the details at the bottom of the page), similar but non-equivalent ways to account for the highly variable "strength" of different opioids. Select one or the other below.
The amount of methadone reported in ARCOS includes both methadone for pain, almost always prescribed, and methadone dispensed for opioid use disorder (OUD) via opioid treatment programs (OTPs). Below, we estimate the different indications for use by subtracting the mass of methadone reported as prescribed and dispensed from the state Prescription Monitoring Program (PMP) from the total amount reported in ARCOS as sold to hospitals, pharmacies, and OTPs to estimate the amount that went to OTPs for treatment of OUD. This simple split assumes two uses and sources of methadone: pain/prescription versus OUD treatment/OTPs. (It ignores what is likely a relatively very small amount of methadone administered in hospitals.)
The results of this data analysis indicate that the methadone total in the ARCOS graph above is composed of a decline in methadone for pain and an increase in methadone for treatment of OUD. The data series below are scaled differently than the ARCOS methadone series above, presented as milligrams per person in the state. Note that the average daily dose for pain in the PMP has decreased from 50 mg per day in 2013 to 31 mg per day in 2020. The decline in methadone for pain is in part the result of lower doses, but likely also some combination of fewer people prescribed methadone and fewer days supply in each prescription. The average dose in OTPs in Washington state on 1 December 2021 was 97 mg per day, which is generally similar to the average dose in the prior decade. The decline in methadone for pain and increases for OUD are expected based on State and National efforts to reduce opioid use for chronic pain generally, and methadone in particular, while at the same time increase the number of people on methadone for OUD.
ARCOS is a DEA database for monitoring the flow of prescription controlled substances from manufacture up to the point of sale or dispensing. The data are generated from manufacturers and distributors, and reflect the amount of drugs distributed to (but not at) the retail level (i.e. to hospitals and pharmacies). Geography is assigned based upon the registration of the purchasing retail outlet or facility.
For easier comparison of drugs with very different potencies, masses are converted to usual daily doses by dividing total grams reported by a usual grams per daily dose value (from the World Health Organization). For example, 100 grams of meperidine, divided by 0.4 g/dose (400mg/dose), results in 250 doses. The dosage information allows for easier comparison of very potent opioids (e.g., fentanyl, 1.2 mg per day) to less potent opioids (e.g., codeine, 100 mg per day) in terms of usual daily dosage. Where multiple dosage equivalents are available, we use the most common route, usually oral. Note, of course, that individual prescribers and patients may select different dosages. Morphine equivalence is a different way to compare potency, provided for reference. A "morphine-equivalent gram" expresses the amount of the given opioid as the equal-strength amount of morphine.
| Drug | mg per daily dose | morphine equivalence ratio |
|---|---|---|
| codeine | 100 | 0.15 |
| oxycodone | 75 | 1.5 |
| hydromorphone | 20 | 4 |
| hydrocodone | 15 | 1 |
| meperidine (a.k.a. pethidine) | 400 | 0.1 |
| methadone | 25 | 8 |
| morphine | 100 | 1 |
| fentanyl base | 1.2 | 75 |
| buprenorphine | 8 | 10 |
| Defined daily doses are from the World Health Organization Collaborating Centre for Drug Statistics Methodology and reflect "the assumed average maintenance dose per day for a drug used for its main indication in adults." Table is not for prescribing purposes. Morphine-equivalent weight ratios are from the Washington State Agency Medical Directors' Group and the federal Centers for Medicare & Medicaid Services. Methadone conversion to morphine assumes a dose of 25 mg. | ||