Opioid distribution trends (2006–2017) in the US territories

Fedor F. Cabrera, Geisinger Commonwealth School of Medicine
Erik R. Gamarra, Geisinger Commonwealth School of Medicine
Tiffany E. Garcia, Geisinger Commonwealth School of Medicine
Ashanti D. Littlejohn, Geisinger Commonwealth School of Medicine
Poul A. Chinga, The University of Scranton
Luis D. Pinentel-Morillo, Pennsylvania State University
Jorge R. Tirado, Elizabethtown College
Daniel Y. Chung, Geisinger Commonwealth School of Medicine
Leana J. Pande, Wilkes University
Kenneth L. McCall, University of New England, USA
Stephanie D. Nichols, Husson University
Brian J. Piper, Geisinger Commonwealth School of Medicine


Background. The US mainland is experiencing an epidemic of opioid overdoses. Unfortunately, the US Territories (Guam, Puerto Rico, and the Virgin Islands) have often been overlooked in opioid pharmacoepidemiology research. This study examined common prescription opioids over the last decade. Methods. The United States Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) was used to report on ten medical opioids: buprenorphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, and oxymorphone, by weight from 2006 to 2017. Florida and Hawaii were selected as comparison areas. Results. Puerto Rico had the greatest Territorial oral morphine mg equivalent (MME) per capita (421.5) which was significantly higher (p < .005) than the Virgin Islands (139.2) and Guam (118.9) but significantly lower than that of Hawaii (794.6) or Florida (1,509.8). Methadone was the largest opioid by MMEs in 2017 in most municipalities, accounting for 41.1% of the total in the Virgin Islands, 37.9% in Florida, 36.6% in Hawaii but 80.8% in Puerto Rico. Puerto Rico and Florida showed pronounced differences in the distribution patterns by pharmacies, hospitals, and narcotic treatment programs for opioids. Conclusions. Continued monitoring of the US Territories is needed to provide a balance between appropriate access to these important agents for cancer related and acute pain while also minimizing diversion and avoiding the opioid epidemic which has adversely impacted the US mainland.