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Oxycontin Tweak Helped Turn Addicts to Heroin

heroin addicts on skid row

Lawmakers trying to combat the epidemic of opioid addiction might want to take note of the law of unintended consequences.

It can lead to the most unfortunate results.

A case in point is getting prescription painkillers off the streets might not have the effect of reducing addiction deaths. It might instead merely move the problem. At least that's the finding of some recently published research from the National Bureau of Economic Research.

Take, for instance, last week’s announcement of a bipartisan effort to combat the prescription drug scourge. Sens. Joni Ernst (R-Iowa), Chuck Grassley (R-Iowa), and Richard Blumenthal (D-Conn.) are pushing to make it easier to dispose of unused opioid pain relievers by alleviating the cost for pharmacies to collect the pills and destroy them. The senators are introducing the Access to Increased Drug Disposal (AIDD) Act of 2018 to make it happen.

It all sounds good. With fewer pills available, then surely there will be fewer drugs deaths, right? Wrong, at least based on the evidence of history.

Take a look at what happened after the 2010 reformulation of the uber-successful opioid painkiller OxyContin by the pharmaceutical company Purdue Pharma. The rejigged pills were cleverly designed so that they couldn’t and therefore wouldn’t be abused by addicts looking for an illicit high. At the same time, the medicine could still be useful for its prescribed use of combating pain. Just like with this month’s bipartisan push to stop opioid addiction, it sounded great.

Also similar to now, the problem facing the U.S. was that deaths from so-called semi-synthetic opioids, such as oxycodone (the drug in OxyContin) and hydrocodone, ballooned to more than 10,000 in 2010 -- up from fewer than 3,000 a decade before, according to data from the Kaiser Family Foundation.

The part of the plan to get addicts off OxyContin worked reasonably well, at least initially. Many addicts no longer abused the reformulated medication.

But it didn’t necessarily result in a happily-ever-after scenario.

Instead, the junkies quickly switched to heroin, according to the NBER research.

“The reformulation did not generate a reduction in combined heroin and opioid mortality — each prevented opioid death was replaced with a heroin death,” states an April-dated paper titled “How the Reformulation of Oxycontin Ignited the Heroin Epidemic.”

“We attribute the recent quadrupling of heroin death rates to the August 2010 reformulation of an oft-abused prescription opioid, OxyContin,” continues the report, authored by William Evans and Ethan Lieber, both from the University of Notre Dame, and Patrick Power from Boston University.

Deaths from heroin jumped to more than 15,000 in 2016, up from around 3,000 in 2010, according to the KFF data. And the fatalities from semisynthetic opioids stayed relatively flat for a few years and then grew, but much more slowly than previously.

The major issue is that there is an ever-present appetite for drugs, says Roy Robertson, professor of addiction medicine at the University of Edinburgh in Scotland.

“Patterns of drug use tend to emerge depending upon what is in ready supply,” he says. “Heroin flooded Western Europe after the [Iranian] Islamic revolution in 1979.”

In other words, addicts get drawn toward whatever drugs are available. If some types of illicit drugs aren’t an option, then the junkies gravitate toward what they can purchase.

Over the past few decades what became increasingly accessible in the U.S. was heroin. Its price dropped like a stone, according to the NBER report. In 1981 a gram of pure heroin would fetch $3,000, but that had fallen to $500 by 2012. In addition to its increased availability, the drug has become easier to use because its purity is higher. In the 1970s, injecting the drug was the modus operandi but it can now be inhaled or smoked, a much more straightforward proposition for those looking for an alternative high, the report explains.

All of this means that although the proposed legislation from the senators isn’t exactly a bad thing, should we expect it to have much effect on drug deaths?

Maybe not, although the NBER report's authors do have some caveats. They remind us that the OxyCodine rejig was just one example of a drug reformulation and that others may have different results. But perhaps the more significant thing is that the study looked only at short-term effects of the change in the prescription drug. If the long-term effect is fewer pill-poppers, then it is also likely that there will be fewer heroin users, the report says. Currently, that is yet to be determined.

In response to a request for comment, a spokesperson for Purdue Pharma issued a statement that said in part, "Although our products account for less than 2 percent of the total opioid prescriptions, we believe it is essential that those who prescribe our medicines fully understand their risks, even when used appropriately."

"While opioids with abuse-deterrent properties cannot solely solve the problem of prescription opioid abuse, they along with other initiatives play an important role in a comprehensive approach to addressing the problem," the statement added. "It is unfortunate and tragic that reformulating an opioid pain medication that was being abused may have led some of the individuals abusing that medication to abuse alternative substances, including heroin."