Making opioids harder to abuse led to a spike in heroin overdoses
A 2010 effort to deter opioid abuse led to a surge in heroin overdoses, according to a new working paper in NBER. The painkiller OxyContin was reformulated in 2010, and while it became harder to abuse, "each prevented opioid death was replaced with a heroin death," the paper says.
Adapted from Evans et. al., 2018, "How the Reformation of OxyContin Ignited the Heroin Epidemic", The National Bureau of Economic Research; Note: "Opioids" includes all opioid related deaths aside from those that are exclusively attributed to heroin; Chart: Axios Visuals
Why it matters: This underlines yet another reason why the opioid epidemic is so difficult to address. Even common-sense solutions may have unintended consequences.
More from the paper:
The Food and Drug Administration "has promoted the development of abuse-deterrent opioids ... Despite the enthusiasm for [abuse-deterrent formulations], our results suggest that the benefits of the reformulation are easily undone when there are readily-available substitutes."
The FDA's response: “The lowest cost substitute for individuals suffering from substance use disorder is often street drugs like heroin, or increasingly synthetic fentanyl products being shipped into the U.S. from other countries. Abuse deterrent formulations are not a silver bullet solution to the opioid crisis," FDA Commissioner Scott Gottlieb said.
This, he said, is why the agency has been pushing so hard for more funding and resources dedicated to its work at international mail facilities, as illegal opioids increasingly arrive to the U.S. in the mail.
Data note: While the authors argue that there "appears to have been one-for-one substitution of heroin deaths for opioid deaths" after the 2010 reformulation, the raw numbers seem to show more fluctuation. I asked the researchers why:
"From 2004-August 2010, you get a relatively steady increase. Then from August 2010 through the end of 2013, things are flat or decreasing slightly," said Ethan Lieber, an economics professor at the University of Notre Dame.
"We do see a rise in opioid death rates starting at the end of 2013, but that's due to a separate event, the adulteration of opioids and heroin with fentanyl (which makes using these things far more dangerous) ... Prior to fentanyl, opioid death rates appeared to have leveled off."
German Chancellor Angela Merkel will arrive in Washington tomorrow a diminished figure — limping into her fourth term after six months of torturous coalition talks and touching down in the afterglow of Emmanuel Macron’s state visit.
Flashback: Days after Trump’s election in November 2016, Barack Obama flew to Germany and hailed Merkel — then TIME’s reigning Person of the Year — as “my closest international partner these last eight years.” Headlines declared that she had, however reluctantly, become the "leader of the free world."
Flash forward: Since losing ground in September’s election, Merkel has been in something of a strategic retreat internationally. A recent Der Speigel cover story bemoaned “Germany’s Incredibly Shrinking Role on the World Stage.”
According to Erik Brattberg, director of the Carnegie Endowment’s Europe program, that retreat involved leaving some distance between her and a U.S. president who is toxic in Germany — though cold air was clearly flowing in both directions.
While she’ll never match Macron’s chummy relationship with Trump, she’ll have more freedom to engage with him now that she has formed a government.
With Macron having moved the ball as far as he could on the Iran deal, and an E.U. exemption from Trump’s steel and aluminum tariffs expiring Tuesday, her chief focus is likely to be trade.
Peter Foster, the Telegraph’s Europe editor, says that if Merkel makes progress there, it will be a characteristic "triumph of substance over style."
"After Macron, Merkel will inevitably look ponderous, dour even. But she has been around long enough to know that the Trumps and Macrons of this world have a habit of coming and going."
"Even as she enters the endgame of her political life, she will be quietly confident about whose legacy will endure. She will note that Macron may have upstaged her on the back-slapping stakes, but to scant effect — it looks certain that Trump will pull out of the Iran deal. Merkel still has the chance to pull off a substantive diplomatic achievement."
The bigger picture: With perhaps 3 years left as chancellor, and more than a dozen behind her, don't expect Merkel to take drastic steps to burnish her legacy.
“She sees her legacy as keeping Europe and the West together at a difficult time. That’s how she wants to go down in history.”
