Changes in the Street Prices of Prescription Opioids During the COVID-19 Pandemic

The Researched Abuse, Diversion and Addiction-Related Surveillance (RADARS) System StreetRx Program is based on crowdsourcing street prices of drugs (5). Individuals can navigate to a website (https://streetrx.com) and enter the price paid for a drug sale on the street. Site visitors spontaneously and anonymously submit the street prices they paid, or heard were paid, for diverted prescription drugs; visitors are not compensated for the information they provide.

To statistically test whether prices per milligram of eight prescription opioids (pill forms only) changed during the COVID-19 period, percentage change in prices per milligram with 95% confidence intervals (CIs) were calculated by using linear regression for the period of April 2020 to December of 2020 compared with the same months in 2019. Prices per milligram were log transformed for regression to satisfy normality and heteroskedasticity assumptions. To understand changes during the pandemic within the larger secular trends in street price, a descriptive analysis of prices per milligram over time was conducted. Mean prices were calculated for each calendar quarter from 2015 to 2021. To limit the number of statistical tests, we describe secular trends only visually. For each opioid, total submissions and the percentage of submissions for that substance out of all prescription opioid submissions are reported. The analysis was performed with SAS 9.4 software.

During the last three quarters of 2020, oxycodone was the most reported opioid (N=2,571; 40%) and hydrocodone ranked second (N=1,095; 17%); the least reported was oxymorphone (N=57; 1%). Mean prices per milligram during the last three quarters of 2020 were $4.52 for hydromorphone, $3.27 for buprenorphine, $2.35 for oxymorphone, $1.54 for oxycodone, $1.18 for hydrocodone, $1.00 for methadone, $0.71 for morphine, and $0.13 for tramadol. The prices per milligram for hydrocodone, hydromorphone, morphine, and oxycodone were significantly higher in the pandemic period of 2020 than in the same period in 2019, prepandemic. The street price of hydrocodone increased 9% (95% CI=2.1–15.2; p=0.008). The street price of hydromorphone increased 23% (95% CI=9.4–39.2; p=0.006). The street price of morphine increased 12% (95% CI=0.5–24.3; p=0.039), and oxycodone had a 12% increase (95% CI=5.6–18.2; p<0.001) in street price. Although percentage changes on the log scale were notable and significant, they represent small absolute differences in mean price per milligram. Observed absolute differences between the last three quarters of 2020 and the same period in 2019 ranged from $0.03 for hydrocodone to $0.90 for hydromorphone. No significant changes were observed with buprenorphine, methadone, oxymorphone, or tramadol.

Mean street price trends are shown in Figure 1 for years leading up to and during the pandemic, through 2021. Although not statistically tested, there appeared to be multiyear increasing secular trends in prices per milligram for hydrocodone, hydromorphone, morphine, and oxycodone since 2017 or earlier. After 2020, prices per milligram for hydromorphone and hydrocodone have remained elevated while those for oxycodone and morphine appear to have experienced decreases.

From March 2020 to May 2020, the number of prescriptions for opioid analgesics decreased because distribution to new patients was severely decreased (6). Observed increases in street prices could reflect the decreased supply of analgesics and increased demand from illicit sources because some patients needing treatment for opioid use disorder were disconnected from treatment and other supports at a time when the stresses of the pandemic were possibly contributing to increased demand for opioids (7). Higher street prices of prescription drugs could have caused an increase in substituting illicitly manufactured opioids, especially fentanyl, which can be produced cheaply because it is a synthetic opioid. The high potency of fentanyl also allows it to be transported in small quantities, which keeps its cost low (8). Frequently dispensed opioids (e.g., morphine, oxycodone), which would be the most limited during the pandemic and create shortages, increased in price in 2020. Prices for these drugs then seemed to decrease by 2021 when dispensing potentially returned to previous patterns. Both high-potency opioid analgesics (oxycodone and hydromorphone) and low-potency opioids (morphine and hydrocodone) increased in street price per milligram. Although absolute differences in price per milligram appeared small, differences could be substantial for high-potency, extended-release opioids, such as 32-mg hydromorphone or 80-mg oxycodone, or if many pills are purchased at once. Disruptions to analgesic and postoperative medication availability may have contributed to increased nonmedical substance use, potentially directly through diverted drug use or indirectly through limiting patient access to needed care, causing patients to seek other options. Notably, changes in street prices per milligram for medications for opioid use disorder (buprenorphine and methadone) were not significant. Researchers had hypothesized that increased availability of take-home medications, as part of measures taken during the pandemic, would increase their availability and decrease their price (6, 9). However, the importance of these medications to combat rising mortality may warrant further investigation into their ongoing diversion and price, particularly when evaluating nonpill forms of these drugs. One notable limitation of this study was that drug prices relied on self-reported data, and the prevalence of counterfeit products, possibly adulterated with other drugs such as fentanyl, can result in misclassification of sales to the incorrect drug or an incorrect attribution of the milligram strength of the drug in the RADARS System StreetRx Program. There was an increase in overdose deaths involving prescription opioids in 2020 (1). Continued monitoring of street prices of prescription opioids may provide insight into future factors affecting the opioid crisis.