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The Washington Post

The reformulation of the powerful painkiller OxyContin in 2010 is the chief driver of the explosion in heroin overdose deaths in subsequent years, according to a new working paper from researchers at the RAND Corp. and the Wharton School.

OxyContin, released by Purdue Pharma in 1996, is a powerful extended-release opioid designed to provide 12-hour relief to patients suffering from severe pain. The original formulation was particularly prone to abuse, as drug users found that they could crush the pills and chew, snort or inject them in order to deliver 12 hours of powerful painkiller dosage all at once.

In 2007, Purdue pleaded guilty to misleading consumers about the risk of abuse associated with the drug. The company paid $600 million in fines, and in 2010 it released a new formulation of the drug that made it extremely difficult to crush or dissolve the pills in an attempt to make it harder to abuse. It was the first drug to receive an “abuse-deterrent” designation from the FDA.

That reformulation was one of a number of steps taken by authorities across the country to limit the number of prescription painkiller overdose deaths, which by then had been trending sharply upward for more than a decade. Other interventions included the use of Prescription Drug Monitoring Programs to track the sale of prescription painkillers, and a “pill mill” law in Florida passed in 2010 putting tighter regulations on pain clinics that in some cases dispensed painkillers recklessly.

Taken together, these interventions have been widely credited with staving off the rise of prescription painkiller deaths. But they came with an unintended side effect: a subsequent heroin epidemic that now kills more people each year than most prescription painkillers combined.

The working paper, published this week by the National Bureau of Economic Research, shows that the OxyContin reformulation was by far the single largest driver of the shift to heroin, accounting for “as much as 80 percent of the three-fold increase in heroin mortality since 2010,” the authors found.

They arrived at this estimate by looking at the differences in heroin deaths, post-2010, in states that had differing rates of OxyContin abuse before the 2010 reformulation.

If heroin deaths increased more in states that had large rates of OxyContin abuse before 2010, the authors reasoned, that would be a strong indicator that the reformulation drove more OxyContin users to abuse heroin. And that’s exactly what they found.

“States with the highest initial rates of OxyContin misuse experienced the largest increases in heroin deaths,” they write. “Results show that this differential increase in heroin deaths began precisely in the year following reformulation.”

Moreover, prior to 2010, there was no correlation between OxyContin abuse and heroin mortality. “Both the levels and trends in heroin deaths were nearly identical across states with high or low initial rates of OxyContin misuse before 2010,” the study found.

The study determined that the OxyContin reformulation was indeed successful at reducing OxyContin abuse. But, “each percentage point reduction in the rate of OxyContin misuse due to reformulation leads to 3.1 more heroin-related deaths per 100,000.”

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