OxyContin Reformulation and the Rise in Hepatitis C

What is the headline saying?
Link to article Study: OxyContin Reformulation Led to Rise in Hepatitis C Rates

Reformulating OxyContin in order to make it more difficult to abuse has inadvertently led to an increase in acute Hepatitis C cases.

What is the news article saying?
Although reformulating OxyContin may lead to a decrease in OxyContin abuse, it has encouraged people to seek out other cheaper drugs like heroin. Hepatitis C is on the rise (it has in fact tripled after falling to stable rates prior to 2010). This is associated with the reformulation of OxyContin and subsequent use of heroin/injectable drugs.

Does the headline ultimately support claims made by the news article? Does it truly summarize the key points of the news article?
Yes.

What are the implications of this headline?
Measures that were taken to curb the opioid crisis have had unexpected and detrimental public health effects.

What are the implications of this news article?
Efforts to curb opioid abuse have led desperate addicts to switch to cheaper, readily available alternatives such as heroin. This has resulted in an increase in hepatitis C cases that are being reported throughout the United States based on data from the CDC.

What evidence currently exists to counter or support these implications?
Countering views:
An influx of cheap heroin from Mexico may have contributed to the rise in hepatitis C

Efforts to limit the availability of prescription opioids may have contributed to the rise in hepatitis C

Supporting views:

Research published by the National Bureau of Economic Research last year found that heroin deaths began climbing just a month after the new version of OxyContin hit the market in August 2010, and that “each prevented opioid death was replaced with a heroin death.” https://www.mitpressjournals.org/doi/abs/10.1162/rest_a_00755

CDC Press Release https://www.cdc.gov/nchhstp/newsroom/2017/hepatitis-surveillance-press-release.html

The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. https://www.ncbi.nlm.nih.gov/pubmed/28355458?dopt=Abstract 

Abuse-Deterrent Formulations and the Prescription Opioid Abuse Epidemic in the United States: Lessons Learned From OxyContin
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2174541

Changes in Prevalence of Prescription Opioid Abuse after Introduction of an Abuse-Deterrent Opioid Formulation
https://academic.oup.com/painmedicine/article/15/3/440/1846964

Changes in US Lifetime Heroin Use and Heroin Use Disorder Prevalence From 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2612444

Are there similar and/or opposing headlines from other news outlets? Do the news outlets only link back to other news outlets?
The news articles tie back to the same study.

What are the data sources (i.e. memo, official statement, official document, research study, validated surveillance system, official report, etc.) supporting the article?

Are these data sources credible when applied to the news story? Why or why not?
Yes. These are some of the most comprehensive and representative data that are available.

Methodology

To measure each state’s initial nonmedical use of OxyContin and other pain relievers, we used self-reported data from the public-use National Survey on Drug Use and Health, which provided aggregated state-level data in two-year waves. This nationally representative household survey of people ages twelve and older is administered by the Substance Abuse and Mental Health Services Administration and is the largest US survey on substance use disorder. The survey asks about “nonmedical OxyContin use” within the past year as well as about “nonmedical prescription pain reliever use.”

We computed the rate of OxyContin misuse in each state before the reformulation from 2004 (the first year for which data were available) through 2009. We pooled the pre-reformulation years to reduce measurement error. There is substantial geographic variation in this measure, as shown in online appendix A. The National Survey on Drug Use and Health is the only data source to specify both OxyContin (the exact drug product affected by the reformulation) and nonmedical use in the survey question. This measure has been shown to be strongly correlated with administrative measures of state oxycodone supply and state OxyContin prescriptions in verified claims data.

Analyses performed at the state level

Divided states into two groups and tested whether there was differential growth in hepatitis C infection rates after reformulation of OxyContin:

  1. States with above-median initial rates of OxyContin misuse were compared to
  2. States with below-median initial rates of OxyContin misuse

Also used a falsification exercise focused on the misuse of prescription pain relievers other than OxyContin

Estimated a difference-in-differences model- studied the relationship between changes in a state’s hepatitis C infection rate before vs. after reformulation

Testable assumption- OxyContin misuse rates were not predictive of hepatitis C infection trends before the reformulation. 

Fit a multivariate regression of state’s hepatitis C infection rates from 2004-2015 as a function of state and year indicators, and interactions of the state’s initial rate of OxyContin misuse with year indicators

Control variables- State unemployment rate, demographic composition variables (age, race, education), state policy variables that may independently affect Oxycontin and heroin use

Weighted regressions by state population size

Used Huber-White robust standard errors clustered at the state level to account for serial correlation

Limitations

  1. Hepatitis C infection rates from the National Notifiable Diseases Surveillance System are known to understate true infection rates
  2. Some states, especially those with increasing rates of hepatitis C infection, may have improved their reporting practices over time
  3. Misuse rates were based on self-reported data (always a possible source of bias in studies)
  4. Other events that occurred around the time of reformulation have been hypothesized to drive hepatitis C infection rates, however, Oxycontin reformulation occurred before these events and would not be correlated with a state’s initial OxyContin misuse rate

What are the data sources saying? Are they being interpreted correctly in the article and are limitations provided? Are there multiple ways to interpret the data or various conclusions that may been drawn from the data?

This study shows that the introduction of abuse-deterrent OxyContin played a leading role in the rapid increase in hepatitis C infections in the United States. The infections increased three times faster in states that were most affected by the reformulation—states with above-median rates of initial OxyContin misuse—than in states with below-median rates, and this differential increase began immediately after the reformulation in 2010. Before the reformulation, there was almost no difference in hepatitis C infection rates across the two groups of states.

In contrast, growth in hepatitis C infection rates was not associated with initial misuse rates of other pain relievers, which suggests that the source of the differential rise in the infection rates found in our analysis was unique to OxyContin. These patterns point to the OxyContin reformulation, and not to other policies that broadly affected opioids, as the primary driver of the differential growth. Finally, the results were not sensitive to controlling for other opioid policies such as the adoption of PDMPs and pain clinic regulations, or excluding Florida—which experienced a significant crackdown on pill mills around the time of reformulation.

Conclusion

The shift to injection drug use affects more than just overdose risk; it also raises the risk of spreading highly lethal diseases that will place an enormous burden on the health care system in the future.

What does this mean for the general public?

Making Oxycotin more difficult to abuse inadvertently led more people to start looking for alternatives and has caused a new public health crisis- a rise in acute Hepatitis C cases. Overall, medical and law enforcement communities must recognize the critical transition from prescription drugs to other drugs that may be injected. Additional interventions must be considered- a safer in-between drug perhaps or develop policies that will alleviate the harms associated with illicit drug use.

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