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. The new abuse-deterrent formulation led many consumers to substitute to an inexpensive alternative, heroin. Using structural break techniques and a difference-in-differences analysis, we find that opioid consumption stops rising in August, 2010, heroin deaths begin climbing the following month, and growth in heroin deaths was greater in areas more likely to substitute from opioids to heroin. The reformulation did not generate a reduction in combined heroin and opioid mortality—each prevented opioid death was replaced with a heroin death.

.. OxyContin is a name-brand opioid pain killer marketed by Purdue Pharma.13 The active ingredient in OxyContin is Oxycodone, an opioid that has been in clinical use since 1917 (Kalso, 2005) and is the active ingredient in such pharmaceuticals as Percodan (Oxycodone and aspirin) and Percocet (Oxycodone and Tylenol). OxyContin is an extended-release formulation that allows for up to 12 hours of pain relief and hence there is typically a high milligram (mg) content of Oxycodone in the pills.14 Since its release in 1996, OxyContin has been one of the most successful pharmaceuticals of all time with worldwide sales totaling $35 billion.15

.. OxyContin was introduced at a time when the medical profession was beginning to re-evaluate its use of opioid-based pain killers. Historically, opioids were reserved for those with acute pain such as postsurgical and cancer patients. Given the limited use of opioids, pain from chronic conditions often went untreated. This was viewed by many as a failure of the medical profession. In the middle 1990s, a number of physicians began to argue for much greater use of opioids for patients with chronic pain. In the 1995 presidential address of the American Pain Society, James Campbell introduced the notion that pain is the “5th vital sign.” Campbell (1995) argued that “Quality care means pain is measured. Quality of care means pain is treated.”

.. an important study used by Purdue Pharma in their advertising materials, Porter and Jick (1980), reported that of “11,882 patients who received at least one narcotic preparation [opioid], there were only four cases of reasonably well documented addiction in patients who had no history of addiction.”

.. This “study” was in actuality a 100-word letter to the editor in the New England Journal of Medicine, the entire substance of which is contained in the quote above.

.. in 1996, the FDA allowed Purdue Pharma to claim that addiction was rare if opioids were legitimately used in the treatment of pain.

.. Between 1996, when OxyContin was released, and 2003, sales of OxyContin increased from $44.8 million to $1.5 billion per year (United States General Accounting Office, 2003)

.. The movement to an abuse-deterrent formulation made OxyContin less desirable for recreational use.

.. Of confiscated heroin, 79 percent is now from Mexico

.. The price has fallen from more than $3,000 per pure gram in 1981 to less than $500 in 2012

.. Groups like the Xalisco Boys have transformed the supply of heroin to suburban and rural US markets. Within their distribution network, independent “cells” within a city are operated by cell managers and each cell is supplied with high-quality Mexican heroin by the cell’s owner. The cell manager employs a telephone operator who receives orders and then relays those orders to the drivers. A driver meets the client at a designated spot or delivers the drugs directly to the customer’s location. Each cell operates almost completely independently and constantly cycles through lower level employees to help prevent detection by authorities.

.. 30 years ago, the typical heroin user was an urban resident. Heroin use in the 1990s and 2000s has now “spread to users in suburban and rural areas, more affluent users, younger users, and users of a wider range of ages. There is no longer a typical heroin user.” The entry into heroin is now much easier because of the purity level. In the 1970s, heroin was mostly an injected drug. Because of increased purity, the drug can now be smoked or inhaled, decreasing the cost of drug initiation

.. the costs of the opioid crisis seem to be driven primarily by the costs associated with mortality. Inocencio et al. (2013) put the total costs at $20.4 billion in 2011 dollars, but 89 percent of these costs, more than $18 billion, are due to lost earnings from higher mortality. Although we do not do a formal cost-benefit analysis, the fact is that Purdue Pharma’s abuse-deterrent formulation of OxyContin was unable to affect the vast majority of the crisis’s costs.

.. While some individuals die from heroin overdoses shortly after initiation, on average, it takes between 5 and 10 years for a heroin user to overdose and die