Today, the New England Journal of Medicine (NEJM) released research showing that the recent introduction of the reformulated, abuse-deterrent version of OxyContin by Purdue is linked to increases in heroin use.
In the letter to the editor appearing in the Journal, Theodore Cicero, Ph.D., Matthew Ellis, M.P.E., and Hilary Surratt, Ph.D., wrote:
"Our data show that an abuse-deterrent formulation successfully reduced abuse of a specific drug but also generated an unanticipated outcome: replacement of the abuse-deterrent formulation with alternative opioid medications and heroin, a drug that may pose a much greater overall risk to public health than OxyContin."
Not surprisingly, it turns out that making one particular drug harder to abuse does not suddenly cause a drug-free life for people addicted to OxyContin. If only it were that simple, but it's not.
What is surprising is the fact that so many people failed to anticipate the very obvious likely outcomes of Purdue's strategy to frustrate all attempts to abuse this prescription opioid. Without any back-up plan in place, and with no alternatives being offered, what did people suppose would happen to people physically dependent on OxyContin? It's a bit like not anticipating that someone will exhale sharply when punched in the gut. Physical addiction is real. It's like thirst or hunger. It's a primal, powerful, physical need for a substance.
Cicero, Ellis and Surratt collected data quarterly from more than 2,500 opioid users entering drug treatment programs across the country from July 2009 through March 2012. While the selection of OxyContin as the primary drug of abuse use did indeed decrease during that time, selection of high-potency fentanyl and hydromorphone "rose markedly," according to Cicero and Ellis. Their research indicates that heroin use nearly doubled.
Is it even possible that truly no one at all thought to radically expand access to free drug treatment or free methadone when the new Oxy formula hit the market? Or did everyone choose to close their eyes and cross their fingers that this would all somehow work out for the best? With so many states passing anti-"pill mill" legislation, and more states increasingly cracking down on "doctor shopping," what do we expect will happen to all of those people who are not being offered immediate, low-cost or free methadone, or long-term in-patient drug treatment at realistic prices? What do we think is going to happen to all of those people?
We need long-term thinking and long-term strategies, not reformulations of the same old thing. "Abuse-deterrent formulations may not be the 'magic bullets' that many hoped they would be in solving the growing problem of opioid abuse," said the researchers in their letter.
We need a bolder, stronger vision of how to wrap our national head around the fact that people use drugs. We need realistic, fact-based drug education for our young people. We need to acknowledge that some people will always use drugs. We need to acknowledge that lifelong perfect abstinence is not possible (or desirable) for many people. We need a better way to handle the realities and complexities of drug use. Europe has drug consumption rooms, supervised injecting facilities, medically-supervised heroin maintenance treatment, and a wide array of innovative, effective programs to address drug use. They don't demand abstinence, and yet they achieve real results. Countries all over the world have a more realistic, practical approach to managing drug use, including decriminalizing small amounts of all kinds of drugs.
Purdue should be applauded for taking steps to reduce the misuse of their most (in-)famous product. They did the right thing. But clearly, someone somewhere failed all of those people who are now addicted to heroin because of the introduction of the new "abuse-deterrent" OxyContin. To borrow a pop culture expression, it was clearly an epic fail for thousands of them.
Meghan Ralston is the harm reduction coordinator for the Drug Policy Alliance.