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."