In August 2010, the maker of the prescription painkiller OxyContin released an abuse-resistant formulation of the drug to deter addicts from crushing it and inhaling or injecting it. The new pill had a dramatic effect: OxyContin went from being the primary drug of abuse for 36% of prescription-drug misusers to just 13% about 21 months later, according to a letter published Wednesday in the New England Journal of Medicine (NEJM).
Problem is, this didn’t mean that drug users quit when they stopped getting high on OxyContin. Instead, they simply switched drugs. As abuse of OxyContin (oxycodone) fell, other opioids moved in to fill the gap: drug users choosing high-potency fentanyl and hydromorphone rose from 20% to 32%, according to the NEJM survey. When asked about the drugs used to “get high in the past 30 days at least once,” OxyContin fell from 47% of respondents to 30%, while heroin use nearly doubled.
As USA Today reports, the opioid Opana (oxymorphone), which was introduced in 2006 without a mechanism to deter misuse, is now more commonly used than OxyContin. But in June, a new abuse-resistant version of Opana hit the U.S. market. Experts say the move will simply cause drug addicts to shift again, not to quit. As the NEJM article shows, illegal heroin use will rise to meet opioid demand when prescription drugs become undesirable, too expensive or scarce. The authors quote one survey respondent as saying: “Most people that I know don’t use OxyContin to get high anymore. They have moved on to heroin [because] it is easier to use, much cheaper and easily available.”
The study included nearly 2,600 people who entered treatment programs around the country for prescription opioid addiction between July 2009 and March 2012. At admission, they were surveyed about their drugs of choice. Based on the data, the authors conclude:
[A]n 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. Thus, abuse-deterrent formulations may not be the “magic bullets” that many hoped they would be in solving the growing problem of opioid abuse.
The finding should be entirely predictable for anyone who knows anything about addiction. While it may be possible to prevent some new cases of addiction by reducing the supply of particular drugs, the strategy does nothing for existing cases, and it may simply cause people who would have become addicted to one drug to become addicted to another.
That’s because addiction doesn’t reside in a drug. Rather, it results when the widespread human desire to manage emotions becomes dysfunctional in some cases of some people meeting some drugs in some circumstances. That dysfunctional coping strategy, which leads to addiction, isn’t “cured” merely by removing one of the tools it relies on. In other words, the problem is not the drug, but the need for it.
When doctors simply cut off patients whom they discover to be misusing drugs, or when pharmaceutical companies introduce abuse-deterrent formulas, the need that drives addiction remains unaddressed. Pushing addicted people into the market for street drugs actually worsens the situation: they are now out of contact with the medical system, the drugs they get are far more likely to be adulterated or even poisonous, and they no longer have good knowledge of the dose they’re getting, which increases overdose risk.
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The dirty secret, therefore, is that prescription drug misuse is safer than heroin use — not because the inherent overdose or addiction risk is any lower with prescription opioids, but because these drugs come in known doses with specific ingredients and often involve contact with a medical doctor. Consequently, instead of viewing addicts as criminals who con doctors and deserve to be cut off — and instead of focusing on clever technologies to defeat their attempts to get high — we should be looking at why they so desperately want to take drugs to escape in the first place.
The most effective known treatment for opioid addiction is maintenance treatment with another opioid, typically methadone or buprenorphine (Suboxone, Subutex). Such treatment reduces the spread of blood-borne disease, cuts crime and saves lives better than any other known method. It may be that the maintenance opioids help treat depression or act as a salve for some other underlying problem, allowing some people to function better on the drugs than off. Whatever the case, people can and do lead full, productive loving lives of recovery while taking these medications. Add appropriate counseling, job training and psychiatric medication where needed and you can sometimes see even better results.
Rather than driving prescription opioid misusers to the illegal heroin market, then, we should be pushing them in the other direction: trying to get as many opioid addicts as possible into the medical system and using opioids themselves in treatment when necessary. It may seem counterintuitive, but effective strategies often are.