We have been tracking street prices of opioids in the United States, with the hope that they may be useful to both clinicians and researchers in determining optimal Dx, Tx and Rx strategies for SUBSTANCE USE DISORDERS (e.g. some clinicians are reluctant to prescribe buprenorphine because they know that patients can sell it at substantial value, etc)
We have found, for example, that oxycodone in almost any formulation (e.g. mixed with acetaminophen as brand name Percocet) costs about $1/mg almost everywhere in the US; in pure form (instant release) it can cost more in low doses (e.g. a 30mg pill of oxycodone can cost as much as $50 but usually costs $30) and in high doses (e.g. an 80mg pill of oxycodone sold as Oxycontin with OROS REMS "abuse" prevention costs only $50 as it is not easily converted into an IV formulation). By contrast, the street price of tramadol is low, but so is its relative psychoactive effect on a per-milligram basis (orally).
The dataset is small now, but our hypothesis is that (at least with opioids) STREET PRICES reflect the IV-morphine-equivalence of a dose of an opioid, and thereby its "desirability" for misuse by an individual with opioid use disorder (DSM Dx 304.xx, ICD-10 F-11.20).
Does anyone have anecdotal or statistical data they could (or would) contribute to this dataset? Likewise, we are interested in the addiction medicine community's opinion of the value of tracking street prices as a predictor of misuse potential.
This data will also be used to study the prevailing view (in the popular press and some academic articles) that pharmaceutical opioid users switch to "illegal" (Schedule I in the US) opioids (primarily diacetylmorphine) because they are cheaper for the same morphine-equivalent dosage.
Our goal is to create a "live" street price dataset that will be freely available to researchers and clinicians. The difference between the retail price of pharmaceutical opioids and their street prices is substantial - often by an order of magnitude. Again, the hypothesis is that street prices reflect "demand" which reflects the misuse potential. We also think this could be useful clinically, for both addiction medicine and pain management - clinicians should be aware when, for example, they prescribe a bottle Percocet 10/325 TID #90, which has a street value of $900, but costs a Medicare (part D) patient only $10 at the pharmacy.
[NB1 Buprenorphine defies this rule - it's morphine-equivalency is low as it is an agonist/antagonist etc, but it still costs $8 on the street for an 8mg pill. Any theories here? NB2 We define "street" as anything other than legal pharmacy purchases; obviously, this data is reported by SUD patients/ISDs but we see such little variation that we believe it is accurate. We also don't see why a patient would exaggerate or minimize this cost when speaking with their caregiver/clinician. ALL FEEDBACK WELCOME.]
I´m shure you are completely right: street prices reflect the needs of addicted, but there are some limitations: in Berlin benzodiazepines are the big problem, in Hamburg or Frankfurt/Main it is "crack". We still do not know, why there are those geographic differences in consumers needs.
Also prices can differ in special groups: methamphetamine is untill now a rarity in IVDUs, but more common in the partyscene and in the gay community.
buprenorphine is about 10.-€/8mg, buprenorhine/naloxone is cheaper.
Street prices of drugs follows many factors such as supply reduction efforts and police missions as well as the season and also demand of drug users, but regarding the effect of the price on risk taking behavior, our experiences in Iran at the time of Taliban in Afghanistan was very interesting, at that time opium cultivation in Afghanistan decreased dramatically, then the price of opium in Iran raised 4 time and in the same time price of heroin was fix! BUT The quality of heroin in the street decrease so much that snorting has no effect and only in injection was useful for drug users. Many of Iranian opium users and heroin smokers shifted to heroin injection with an increase in overdose death.
Something else to consider is that a large portion of the illegal sale of prescription narcotics takes place in transactions where the dealer is not necessarily a formal drug dealer but rather is a low cost distributor. For example, in our area, the figure of $1.00 per mg is accurate as a street price. If one were to go to a conventional dealer in narcotics, that is roughly the equivalent you would pay, as the dealer is selling to make maximum profits. However many sales occur between closer acquaintances, the dealer being one whose circumstances leave them flush with narcotics. Not all chronic pain suffers use all their pills before getting another (low cost) refill. When the relationship between parties is closer and the initial seller's cost of the drugs is low, you more often will see these friendly transactions conducted at a much lower price, for example a 15 mg of IR morphine may sell for $5.00 or 30 mg for $10. As was noted when the cost is $10,00 a bottle, these casual (but frequent) sellers can make tidy profits while still providing low cost narcotics to their client/acquaintance base.
That is an important point - many ISDs (Individuals with Substance Disorder) do obtain prescription narcotics by an illegal transfer from a closer acquaintance, and not from a "true drug dealer". I suppose some ISDs even get their substances of misuse for FREE from friends with extra supply, e.g. a pain management patient with "extra" pills who just gives them away. That would suggest a continuum of prices, from very low to "anonymous" street transactions, which carry the highest risk for both parties, and thus the highest prices. We have found that the "informal" supplies are rarely sufficient for the ISD in the "long run" because they simply cannot find enough "friendly sellers" who are not seeking to maximize profit (or not charging as much simply because the risk of criminal consequences to the seller is much lower when they know the buyer well).
At present we are just tracking "formal dealer" prices -- it is interesting that you are seeing the same prices (presumably in North Dakota) that we are seeing on the East Coast. Unfortunately, the price for the morphine-equivalent dose of diacetylmorphine/heroin is much lower, and thus many ISDs switch to it. We are trying to figure out WHY it is lower, given that diacetylmorphine is just another opioid that happens to be Schedule I in the US.
in contrary to the feelings of a lot of people, especially in cities in germany crime is decreasing: car theft, violence, organised crime, drug releated crime... we think methadone programs and harm reduction is one of the reasons why crime is decreasing.
I think it is pretty well-documented, at least here in the US, that harm reduction (methadone and buprenorphine are the only legal harm reduction meds here) substantially reduces crime because substance users no longer need to resort to crime to pay for their use. There is a widespread misperception that methadone contributes to crime, but the data (that I have seen) just does not support that conclusion.
Interesting. It is not uncommon for my patients to tell me that the increasing street price of a prescription opioids led them to convert to heroin. Also, street buprenorphine, in my patients, has not been used to get high but to get out of or prevent withdrawal when other opioids were not available. On the other hand, they use full mu-agonists to both get high and escape withdrawal. So, there does seem to be a difference in the way street buprenorphine is used by addicts and I think they think about it differently than full mu-agonists.
Working in the ED over the past 7 years I saw a dramatic increase of heroin use as the prices for prescribed opioid increased on the street. Patients described their addiction to opioid starting and then not being able to afford the cost or were unable to obtain because of stricter prescribing from pain management, and family physicians. The street prices in Medina county Ohio range from $1.00 per mg for percocet to $5.00 per mg for Oxycontin.
The Ohio pharmacy board has increased their watchdog efforts on suspicious increased prescribing by physicians reducing the availability of these drugs on the street and increasing prices. This is because prescription drug overdose surpassed accidents as the number one cause of death in the State of Ohio for the ages 15-35 years of age.
The increase of heroin use and overdose deaths has increased at an alarming rate throughout the state as well. With no real treatment facilities available for heroin addicts in our tri-county area this trend will unfortunately continue to increase at alarming rates. It is my belief that this trend is a public safety issue and needs addressed.
Christina M. Blanton RN, BSN
Not the original topic but in respone to Christina.
In response to the deaths by overdose figures the Scottish Government has funded a national programme of training drug users, family members and staff coming into contact with drug users in the use of Naloxone and met the cost of issuing Naloxone kits (Pre-filled syringe naloxone Injection for intramuscular, use: 2 mg/2 mL syringe.) to eveyone who is trained..
There is a similar initiative in the US, where the view is trending to the point that there should be IM naloxone "in every medicine cabinet". As far as I know, naloxone is safe, unabusable, and can save lives of opioid users if administered before an overdose engenders severe respiratory depression. I am glad to see Scotland is also pursuing this policy. The IM injection is not hard to administer and can time is of the essence, so waiting until the patient is in A&E is often too late.
naloxone research: http://www.ihra.net/contents/717 and: harm-reduction coalition: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/understanding-naloxone/
Scotland is also examining the effectiveness of utlising Naloxone via nasal adminstration rather than injecting. Some drug users are reluctant re carrying Naloxone kit with needle+ +syringe also it may be possible for police officers to adminster via nasal rather than injecting. In rural areas it is often police officers who arrive at scene before paramedics. I have not yet seen any evaluation of this yet. though.
Yes, nasal administration is preferable from an ease-of-use standpoint and for police officers not trained in IM injection. HOWEVER, an IM injection delivers the naloxone into the bloodstream faster and more reliably, so it is preferable when a patient is unconscious or has very severe respiratory depression (in which case it is harder to get absorption nasally). In any case, I agree with you that nasal administration is superior from a public policy standpoint - no training required, simply insert in nose and squeeze bottle...
You might find this publication interesting:
Am J Health Syst Pharm. 2014 Dec 15;71(24):2129-35. doi: 10.2146/ajhp130798.
Intranasal naloxone administration for treatment of opioid overdose.
Robinson A1, Wermeling DP2.
Author information
Abstract
PURPOSE:
The pharmacology, pharmaco-kinetic properties, and clinical efficacy of naloxone injection administered intranasally for the reversal of opioid overdose are reviewed.
SUMMARY:
Naloxone is an opioid-receptor antagonist that is used in the treatment of opioid overdose to reverse the respiratory and central nervous system-depressant effects of the opioid. Naloxone injection is traditionally given by intravenous, intramuscular, and subcutaneous routes. Paramedics also administer naloxone injection intranasally in the prehospital setting to treat suspected opioid overdose. The nasal mucosa has a rich blood supply that allows for efficient drug absorption and the avoidance of first-pass hepatic metabolism that would be seen with oral administration. Obtaining vascular access can be difficult in known drug users, prolonging the time required to administer the antidote. Patients awakening from an overdose may be agitated, confused, and even combative, thus increasing the risk of needle-stick injury to first responders. The intranasal route avoids the need for establishing vascular access and can be associated with speedier patient recovery. In two randomized controlled trials, intranasal naloxone alone was shown to be sufficient for reversing opioid-induced respiratory depression in 74% and 72% of the respective study populations of patients experiencing opioid overdose. In addition, the safety profile of intranasal naloxone appears to be no different than that of naloxone injection in the treatment of opioid overdose in the prehospital setting.
CONCLUSION:
Intranasal administration of naloxone appears to be effective in treatment of opioid overdose when i.v. administration is impossible or undesirable.
Copyright © 2014 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
I made my account after reading this to offer a little insight because of some misinformation present. Where I live, the value of anything that's not pure oxycocode or hydromorphone, aka anything that is combined with APAP or tylonol is much less valuable. The reason for this is that most heavy users are putting the drugs directly into their blood stream. Nothing that is mixed can be injected, making it significantly less valuable to all but the very very end user (the people who are also most likely to be willing to diviluge information to authorities or researchers) I know personally many drug users unfortunately, as drugs are a huge problem in my home town. I dont know anyone who will pay more than 5 for a 10/325 percocet (thats a percocet with 10mg oxycodone and 325mg APAP.)
Also the Buprenorphine in my area (8 mg suboxone strips containing narlaxone) go for 10 on average although some get 15. The reason is that while they are not full agonists, and they have a ceiling effect, 8mg of Buprenorphine is much stronger and has a much higher affinity to the receptors that 8 mg of oxycodone, or even hydromorphone. One 8mg strip will last an addict 2-4 days while they may need 3-4 oxycodone pills to get through one day.
Much of the information is accurate, in many states an oxycodone 30 could sell for 50-70 dollars although in FL they are 30-35 for most users. I think as i stated before that the reason your being informed that something with APAP is also worth up to $1 per mg is because a majority of people who are willing to give you information are the highschool level young inexperienced users who dont understand the difference between injectable drugs and non injectable drugs. I know for a %100 fact that a perc 10 has a street value of $5 in my area and thats when buying singles, doscounts are usually given for bulk purchases, going as low as 2-3 dollars. Keep in mind that the end result of addiction is death, and that the biggest step between someone who will recover and someone who will die is when they start puncturing their veins. Those users are looking exclusively for drugs that can be injected from the first time they cross that line, which raises the value of those drugs significantly. This is a message from someone who used to live a very different life from the one I live now. My knowledge of the streets comes from the streets, and while I dont live that life anymore, I still have many acquaintences who are unfortunately on a downward spiral that gets out of control fast. Obviously this will differ from state to state and even county to county, and every person will have different experiences, but I spent years on the wrong side of the law and the wrong side of drugs before I decided to make something out of my life and I bring that wisdom with me wherever I go although I am not proud of everything I have been through.
Your perspective is interesting, and points to the many things we don't know about the microeconomics of illicit substance prices. Our hope was that tracking "street" prices would reveal something meaningful about desirability. You correctly point out that an oxycodone/APAP mixture (PercocetTM) would seem to be less desirable because it is not injectable (although some patients have tried anyway!) but other factors come into play. For example, the reason for the lower price may be higher supply - Percocet 10/325 is prescribed in far greater quantities than pure oxycodone IR (under many brands), and most diversion to the street is through this high level of prescription. There are far fewer prescriptions written for oxycodone IR than for oxycodone/APAP 10/325. But you correctly point out that the price in your area may be lower because the demand is lower because of non-injectability of APAP formulations. That said, as of March 2015 we have still been getting reports of oxycodone - in any formulation - coming in around $1/mg. For example, looking at some of our data - in Philadelphia, PA, in Q1 2015, a Percocet 10/325 cost $10, and there were no quantity discounts (multiple reports from patients of all ages)...and the cost of a 30mg pill of oxycodone without APAP was $30 across the board. I don't know how to explain this anomaly, but i do think that street prices must contain some information that can help us track demand. That said, there are probably too many variables at play for the price to mean much in itself, but we may be able to tease out some interesting conclusions from time to time. Did you know, by the way, that the US consumes 85% of the world's oxycodone production, and that imports have increased by dramatically since 1995 -- from almost nothing to hundreds of metric tons of the substance. [The cite for this is in a recent WHO report - I'd be happy to dig it up and post it - but I was surprised to find that oxycodone, which has a 1.5x morphine-equivalency potency, e.g. very high binding to the opioid receptors, is predominantly a US phenomenon. That may be because diacetylmorphine (Heroin is actually the brand name as introduced by Bayer in the 1920s) is a legal pharmaceutical in many countries but it is banned in the US. This is all very speculative, but I think a potential interesting source of information - that is - street prices and how they correlate to mini-epidemics, desirability, etc.
The price of Buprenorphine is high due to it's lack of availability. It's simple supply and demand. I've seen Suboxone films sell for as much as 30 for a 8mg strip in Missouri. I think the motivation of the purchaser comes into play as well. The vast majority of people who purchase Buprenorphine products illicitly are using the medication in a therapeutic manner rather than trying to get high which is why it's street value seems to be "upside down". I'm attaching two studies of Buprenorphine diversion which both attest to the motives of people purchasing Buprenorphine illegally.
When you say "therapeutic" manner are you referring to maintenance (and/or to avoid withdrawal symptoms) or for the opioid reversal processes of the 2mg of naloxone in every Suboxone 8mg pill? I assume the former...in which case it raises the question: Are users merely "bridging" between access to stronger opioid agonists, or are they really purchasing bupe/naloxone (Suboxone 8/2 or 2/.5) in order to self-administer substitution therapy?
Be sure to see the recent article entitled "Death Matters..." by John Strang in the journal Addiction, most recent issue (October 2015) - it addresses the naloxone issue in historical and present context.
When saying therapeutic I mean either to detox themselves or to use as a maintenance medication. Some are surely only using it as a bridge between doses of their preferred opiate but as it's shown in the Appalachian study this is a smaller percentage. Also the high affinity of Buprenorphine for the mu receptor discourages users from bridging because once they take their preferred opiate if there is still much Buprenorphine attached to the receptors it'll block the other opiate. The Naloxone has no therapeutic purpose in the Suboxone formulation. It's included entirely to discourage misuse. Due to it's poor sublingual bioavailability practically none of the Naloxone makes it into a persons blood when Suboxone is taken as prescribed.
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