Unintended Consequences

I saw a patient from up north earlier today, and we tallked about the economy in his part of Wisconsin and in the Michigan Upper Peninsula.  From what he had to say, things are the ‘same old same old;’ i.e. jobs are few and far-between.  Seems as if it has been that way for a long time now.  And it’s hard to imagine any industry doing well enough in the current economy to make a dramatic change up there.
One change that HAS become apparent over the past year is the increased availability of heroin, now easily found in small towns throughout the upper Midwest.  I’ve seen the same trend closer to my practice, where heroin use has grown from a Milwaukee phenomenon to just another high school temptation.  And a troubling comment pops up more and more during my discussions with people actively addicted to opioids:  “Now that O-C’s are abuse-proof, we gotta’ use heroin.”
I’ve mentioned the requirement for REMS– Risk Evaluation and Mitigation Strategies– for opioids announced by the FDA about a year ago.  The requirement for REMS on a class-wide basis– a novel use of the FDA’s regulatory powers– places pressure on the manufacturers of opioids to find solutions to the epidemic of opioid dependence. One result has been the development of medications with lower abuse potential, such as the new formulation of oxycontin, which when crushed (a feat by itself) yields a gooey mess that clogs nasal passages and needles if taken by those routes.  But the law of unintended consequences applies to this domain, as one would expect, given the tangled mess of political, societal, and economic forces involved in the epidemic of opioid dependence.  There are many addicts out there, each subject to severe withdrawal in the absence of their daily dose of oxycodone;  what would a reasonable person expect them to do, knowing the intensity of their desire for opioids– and their fear of withdrawal?  Are they just going to stop?
My last patient explained it just fine… and he isn’t even a D.C. social worker.   “Oxycontin or heroin–  it really doesn’t make no difference.  It’s all the same thing– one just isn’t around anymore.”
Unfortunately, he wasn’t referring to heroin.
I do have a question– a genuine question, not a facetious one.  At least in Wisconsin, diverted Oxycontin is often used nasally, and heroin used by needle.  I’m sure that part of  the reason for that different route of use is because heroin has tended (at least until now) to be used later in the course of addiction, and there is a progression to parenteral use of substances over time, as addicts seek more efficient means of using.  My question– are there other reasons that heroin users favor intravenous over nasal use?  To frame the question a bit differently– it appears that the prevention efforts aimed at Oxycontin have caused an increase in the use of heroin.  Did they cause in increase in intravenous drug use as well?

2 thoughts on “Unintended Consequences”

  1. hi doc,when oc’s became tamper proof the shift from snorting them will definitely drive illegal drug buyers to one of three places.Illegal Suboxone,where most addicts can buy them for $10/pill.then they are buying benzo’s cause suboxone on it’s own has no high to speak of after a few days. then we have the oc addicts who will try to get into a detox.And we all know what the numbers on staying sober are after 1month,3 months,well you get the idea.when insurance companies are fed up with them revolving door detox centers.the shift to heroin and all them things that most oc users said they would never do and the speed at witch high quality heroin showed up on the streets can not be put down to coincident.then we have the rest of them people who would love to blame anyone but themselves.Suboxone doctors and methadone clinics are the only places left.so now these “pretty addicts” who would have nothing to do with heroin or god forbid shooting up. Now,most will tell you they “pretty addicts” will never do heroin.but I think given enough time we will be seeing a whole new generation of heroin addicts.An increase in Crime,aids and drug related deaths.who knows? God help us all…pete

  2. Why not just use the generic oxycodone 30mg tablets? Or switch to dilaudid (hydromorphone) in 4mg or 8mg tablets (dissolve easily in water). Many opiate addicts prefer hydromorphone to oxycodone. There are a plethora of pharmaceutical options so heroin seems like a lousy alternative given purity issues. I think oxycodone HCL addicts are resourceful enough to get their drug of choice and continue shooting it or snorting it. I don’t think the new formulation will cause a big switch to heroin. I think REMS will be a complete failure because addicts will always figure out ways to beat new formulations or find alternative formulations. The FDA clearly doesn’t understand addiction very well if they think new formulations and “lower abuse potential” drugs (whatever those are!?) will solve the problem. To paraphrase Dr. Junig, the only way to beat addiction is either (a) serious desperation-induced recovery efforts, e.g. residential treatment + meetings and step work for life or (b) buprenorphine or methadone for life. Case in point for how clueless the FDA is: just this year they approved EXALGO, a “slow release” hydromorphone (dilaudid) that I predict will be the next Oxycontin. REMS is just symbolic action that allows the FDA to continue approving drugs that cause addiction epidemics. This is all driven by pharmaceutical manufacturer profits. There is no better product than an addictive opiate, especially an expensive (on patent) one. New formulations (e.g. suboxone instead of generic buprenorphine; oxycontin instead of generic oxycodone; exalgo instead of generic hydromorphone) just allow the drug manufacturers to start printing money again on drugs that have been around for decades and are cheap in generic form. But they also do a ton of damage. Let’s remember that diacetylmorphine (heroin) was originally marketed as a “non-addictive” substitute for morphine! A lot of people started taking prescribed oxycontin because Purdue claimed that the slow release formulation made it less addictive. Now we have an epidemic on our hands because oxycodone is arguably cleaner/more addictive/etc to diacetylmorphine in many ways. I think the same thing will happen with EXALGO/hydromorphone and we’ll have yet another pharmaceutical dope plague largely induced by the pharmaceutical manufacturers and the FDA. Opiate addiction is so profitable to the suppliers (legal and illicit) that you’ll never control it on the supply side. The only way to slow addiction is to reduce demand. New formulations just create new addicts. It’s completely delusional on the part of the FDA to think they can control addiction with better formulations/drug combinations/etc. In fact they are contributing to the problem with REMS because it creates a false sense of safety in taking powerful opiates that will induce addiction in many people who take them for medical reasons.

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