Are Rx Drugs Responsible for the Opioid Epidemic?

I remember starting uniform patrol in 1970 and quickly finding out about the incredible problem of heroin in the inner city of Cincinnati, Ohio. The heroin was less than 10% pure and always injected, but it still managed to lead to the demise of many addicts. It was concentrated in the African American community, though there were exceptions.

Prescription drugs were also a problem on the streets. Brand names of oxycodone included Percocet, Percodan, Tylox, and, of course, the hydromorphone product Dilaudid. In our area of town, we had many prescription drug addicts, but most did not go back and forth between prescription drugs and heroin. In fact, the prescription drug abuse in those days tended to be among white residents, with heroin being con- sumed mostly by African Americans.

The street drug of abuse eventually was cocaine, the powder kind that was snorted and sometimes injected. A derivative of this drug was crack cocaine, a harder form that was commonly smoked. During this period, prescription drugs continued to be present but were not abused at the same level that cocaine was. Cocaine abuse was a problem that did not discriminate, hurting the poor and the rich.

The late 1990s saw an influx of prescription drug abuse. Pain medication prescribing was up because of the perceived underestimation of patients with pain in the United States. Purdue Pharma developed a drug called OxyContin, one of the best pain medications ever produced for patients with legitimate pain. But the milligrams of oxycodone inside the pill could be easily extracted. This was reportedly discovered by a Maine resident, and the abuse spread down the East Coast and into Appalachia.

Hydrocodone products were also being abused at record rates, and prescription drug addiction and death continued unabated for about 10 years. During that time, generic drug manufacturers began making oxycodone, hydrocodone, and even hydromorphone for the growing number of patients seeking pain treatment. Drug seekers realized that generic drugs worked as well as the old brand-name versions, and they cost less at the retail pharmacy.

In August 2010, Purdue Pharma changed everything for the future of extended-release products with its new, abuse-deterrent OxyContin formulation. Abuse levels for this once-most-abused pharmaceutical began to plunge. There are large amounts of data from multiple sources, some of them from law enforcement and some not, that show that the abuse level started dropping almost immediately after that and has stabilized at a fraction of the levels of the late 1990s and early 2000s.

In our part of the country, the introduction of relatively cheap heroin by the Mexican cartels happened almost simultaneously with the reformulation of OxyContin. Coincidence? I do not think so. The cartels are not stupid. They saw that if this reformulation was successful, it would mean a potential increase in addicted customers now looking for a replacement.

Since the start of the latest heroin epidemic in 2010, a significant transformation has occurred, starting with prescription drugs to heroin, then clandestine fentanyl mixed with heroin and, of course, carfentanil. The influx of clandestine carfentanil and fentanyl made heroin much deadlier and more potent. The heroin was already 5 to 6 times more potent than the heroin of the early 1970s. With the increased potency from fentanyl and carfentanil, the number of overdose deaths skyrocketed.

Law enforcement learned how to administer nasal naloxone, and countless lives have been saved because of this drug and the ability of police officers to use it. I cannot fathom the number of overdose deaths that would have occurred had this drug not been available to law enforcement and medical personnel.

So do some people get hooked on prescription drugs and then gravitate toward fentanyl and heroin? I would say that some of them do, but certainly not all of them. Finding gateway drugs is always tricky because it can be very different for each person. Based on coroners’ reports, there are often multiple drugs in the deceased’s system, making it impossible to determine which substance caused the death. Polysubstance abuse is commonplace.

Some of this makes accurate statistics difficult, but I can tell you from monitoring the street drug problem over many years that overdose deaths in the past 5 years or so are much more attributable to heroin, and clandestine carfentanil and fentanyl, than to prescription opioids. This becomes important as we see the continued demonization of pharmaceuticals to the point that patients with pain are suffering even more. We need to get back to a sensible look at the opioid problem and put the blame where it belongs, not necessarily on who has the deepest legally accessible pockets.

Cmdr. John Burke is a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and co-founder of the International Health Facility Diversion Association. He can be reached by email at burke@rxdiversion.com or via rxdiversion.com.