When the makers of OxyContin reformulated the drug to minimize abuse in 2010, the sudden unattractiveness of one of the most widely abused painkillers prompted a dramatic surge in heroin abuse. Onlookers expected OxyContin to lose its huge following, but few expected such a widespread shift to heroin. Yet studies show that’s exactly what happened.
From 2010 to 2012, researchers from Washington University and Nova Southeastern University surveyed over 2,500 people seeking treatment for opiate addiction at 150 treatment centers throughout the country. They further interviewed 103 people who filled out anonymous surveys in an effort to assess how their drug habits had changed over time.
Much to their relief, the reformulation achieved an important goal: OxyContin went from being the primary drug of abuse for 36 percent of participants to just 13 percent less than two years later. But participants didn’t stop using drugs. As Oxy abuse fell, participants switched to other opioids. Use of potent painkillers fentanyl and hydromorphone rose from 20 percent to 32 percent, and the number of people abusing heroin in the past month doubled. Every single one of the 103 patients interviewed said they would replace OxyContin with something else.
Addressing Demand, Not Supply
To those of us in the field of addiction treatment, the switch to heroin and other prescription painkillers came as no surprise. That’s because, as I’ve described in previous posts, treating addiction is like a game of Whac-a-Mole. Take away one drug, another pops up in its place.
Changing supply does little to change demand when it comes to drugs of abuse. Why? Because addiction is a chronic brain disease that changes the function of the brain, and because people often use drugs to cope with painful emotions. Neither of these problems is cured by making drugs less available.
Few drug abusers are “sold” on just one drug. Most are opportunists who, driven by the changes that occur in the brain, will use whatever drug they can get their hands on to feel better. Heroin is a seemingly attractive option because it is cheaper and more readily available than OxyContin and other prescription painkillers.
One Step Forward, Two Steps Back
Unfortunately, heroin is also extremely dangerous for the individual and a much greater overall risk to public health than OxyContin. Users have to take it more frequently, rarely know the purity of what they’re taking (which increases the risk of overdose), and often end up engaging in high-risks behaviors like needle sharing and criminal activity to fund their habit. What’s more, they’re out of touch with the medical system. Instead of dealing with doctors, they’re scoring from street dealers.
Since some OxyContin users have switched to other prescription painkillers, experts are calling for additional slow-release formulations that can’t be abused. Of course, true to the nature of addiction, users would simply turn to heroin and other opiates. We saw this happen when an abuse-resistant form of Opana (oxymorphone) was released, which predictably prompted a switch to other opioids rather than a cessation of drug use. If addicts run out of prescription drugs, they’ll turn to heroin or other illicit substances. If they run out of illegal drugs, they’ll find someone synthesizing bath salts, synthetic marijuana or some other manufactured high.
Similar to drug reformulations are efforts to create an addiction vaccine. After nearly 40 years of research, scientists are getting closer to a vaccine against a number of addictive substances including heroin, meth, cocaine and nicotine. For some motivated people, vaccines may be an adequate deterrent from continued drug abuse. But for most addicts, even if these vaccines prove effective in blocking the pleasurable effects of certain drugs, they will not prevent users from circumventing the vaccine by taking extremely high doses, failing to comply with vaccination schedules, or switching to other drugs or compulsive behaviors. While vaccines rightly approach addiction as a medical disease, they simply cannot address the mental, behavioral and spiritual issues that led to addiction in the first place.
Getting Back to What Works
People aren’t going to stop using drugs because we change the formulation. They aren’t going to quit because we create harsher drug laws. Even a vaccine won’t put an end to drug abuse. What will make drug abuse a thing of the past? The same solutions that apply to other chronic illnesses: prevention and long-term treatment that addresses the underlying issues that fuel the need to self-medicate with drugs.
Instead of criminalizing addiction, encouraging doctors to stop providing care to people who may be addicted to prescription drugs, and focusing the majority of our research and resources on finding new formulations, vaccines and pills to defeat people’s attempts to get high, we need to address the much deeper issues at work in addiction.
David Sack, M.D., is board certified in psychiatry, addiction psychiatry and addiction medicine. Dr. Sack currently serves as CEO of Elements Behavioral Health, a network of addiction treatment centers that includes Promises Treatment Centers, The Ranch, Sexual Recovery Institute, The Recovery Place, Right Step, Promises Austin, Lucida, Journey, Sundance, and Clarity Way.
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Last reviewed: 9 Jun 2014