Purdue Pharma’s 2010 reformulation of OxyContin as an abuse-resistant pill was supposed to be a breakthrough in battling the burgeoning opioid epidemic. Purdue executives and policymakers touted the reformulation as a way to dampen the supply of abusable drugs, thereby reducing opioid addiction and death. Nearly a decade later, it appears that the policy had several serious unintended consequences. Reformulated OxyContin led to large-scale substitution to more dangerous opioids, including illegal heroin and fentanyl. By 2017, opioid-related deaths more than doubled to over 47,000.   

But the true cost of the heroin epidemic goes beyond overdose deaths and opioid addiction. A new study from LDI Senior Fellow Abby Alpert (Wharton), David Powell (RAND), and Rosalie Pacula (RAND) links OxyContin reformulation to a national epidemic of hepatitis C, which kills more than 20,000 Americans a year and infects tens of thousands more.  

Hepatitis C is a highly infectious liver disease that causes cirrhosis, liver failure, and death over several decades. Like HIV, the hepatitis C virus (HCV) spreads through blood contact, but HCV is 10 times more infectious than HIV. The most common mode of infection in the United States is injecting drugs with contaminated needles. The Centers for Disease Control and Prevention (CDC) estimates that about 1% of the adult population—2.4 million people—are living with hepatitis C. Half do not know they are infected. The lifetime treatment costs exceed $200,000 per patient.

Policymakers and researchers have long noted a spike in new hepatitis C cases since 2010. In 2016, the CDC estimated that there were 41,200 acute Hep C cases in 2016, an incidence rate that more than tripled since 2010.

It isn’t hard to connect the dots. When OxyContin becomes difficult to abuse, people who are addicted may switch to injectable heroin, which exposes them to hepatitis C, causing a rise in Hep C transmission through intravenous needles. In 2017 the CDC linked increasing hepatitis C infections to the worsening opioid crisis. But how significant is the relationship?

Powell, Alpert, and Pacula sought to quantify the effect of OxyContin reformulation on hepatitis C infection rates. They compared changes in hepatitis C infection in states with above average OxyContin misuse to states with below average OxyContin misuse before and after introduction of reformulated opioid painkillers. Although hepatitis C infection rates rose in all states after 2010, the difference in growth is staggering. After 2010, states with below-average rates of OxyContin abuse experienced a 75% rise in hepatitis C infection rates. In states with above average OxyContin use, hepatitis C infection rates increased 222% after 2010.

The effect was observable even after the researchers considered other possible causes of rising or falling drug abuse and hepatitis C rates—including prescription drug monitoring programs, rates of abuse of other painkillers, unemployment rates, the introduction of drugs to treat hepatitis C, and state regulation of pain clinics. The findings are the strongest evidence to date of a significant relationship between attempts to reduce access to OxyContin and a rise in hepatitis C infections.

This research demonstrates the danger of policies that focus only on reducing the supply of prescription opioids. Earlier research shows that states with above average OxyContin abuse prior to drug reformulation saw even greater spikes in heroin abuse and deaths after Purdue reformulated the drug. The hard pill to swallow is that the only way to effectively tackle the opioid epidemic at scale is to focus on policies that target both the supply of abusable drugs as well as the demand for drugs, such as medication assisted treatment. No matter which approach is taken, the nature of drug addiction requires patient, long-term treatment, and watchful eye for unintended consequences.