MedicalResearch: What is the background for this study? What are the main findings?
Dr. Cicero: Prescription opiate abuse (eg Vicodin, Percocet, OxyContin) has reached epidemic proportions in this country over the past decade. Although most people swallow the drugs whole, a relatively large number either chew the drugs to produce an immediate delivery of large quantities of drugs or they crush them and/or dissolve them in some solvent which makes them useful for intranasal (eg snorting) or intravenous administration. Non-oral routes, particularly injection, represent the most serious public health risk due to a high incidence of infection, including Hepatitis C and HIV, and the much greater severity of abuse. In an effort to reduce these practices, drug companies are introducing so-called abuse deterrent formulations (ADF) which are resistant to crushing or dissolving in an aqueous solution. In one such important effort, the company responsible for distributing one of the most widely abused prescription opiates, OxyContin, introduced an ADF in 2010. Although the abuse deterrent formulations was highly successful in reducing abuse of OxyContin by either chewing, crushing, or dissolving in water, there was none-the-less a clear limit to how effective it was. For example, some people simply switched to the oral route of administration or never did snort or inject the drug, whereas a small number found ways to defeat the abuse deterrent formulations and persisted in harmful patterns of abuse. Unfortunately, there was also an unintended result. ADF-OxyContin caused many individuals to abandon the use of OxyContin – a good thing – in favor of other opiates (a bad thing). Most serious, however, was that 70% of those who switched drugs moved from OxyContin to heroin abuse. Although by no means the only factor, the abuse deterrent formulations has contributed to the wide-spread reports of heroin abuse in suburban and rural Caucasian male and females, a group here-to-fore not the typical heroin users (i.e. poor minorities, living in large urban centers).
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Cicero: Physicians should be aware of the potential for abuse of any opiate medication for pain, and abuse deterrent formulations when available should be prescribed. However, it needs to be recognized that some users will continue to misuse their medication no matter what formulation is used. Patients also need to be aware that ADFs do not prevent abuse and care should be taken in their use. In a broader sense, it needs to be understood that abuse-deterrent formulations can have the intended purpose of curtailing abuse, but the extent of their effectiveness has clear limits, resulting in a significant level of residual abuse. Consequently, although drug abuse policy should focus on limiting supplies of prescription analgesics for abuse, including abuse deterrent formulations technology, efforts to reduce supply alone will not mitigate the opioid abuse problem in this country. Rather, demand reduction must be a part of any comprehensive effort to curb the epidemic of licit and illicit opiate use.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Cicero: Efforts need to be made to better understand the demand for opiates-what needs do they meet in abusers-since supply-side efforts to reduce abuse and drug availability, while important, are not the definitive answer to our current epidemic of prescription drug use. Much more systematic efforts need to be undertaken to determine what drives the demand for these drugs.
Cicero TJ, Ellis MS. Abuse-Deterrent Formulations and the Prescription Opioid Abuse Epidemic in the United States: Lessons Learned From OxyContin. JAMA Psychiatry. Published online March 11, 2015. doi:10.1001/jamapsychiatry.2014.3043.
MedicalResearch.com Interview with: Theodore J. Cicero, PhD (2015). Abuse Deterrent Opioids Inadvertently Led To Increased Heroin Use