Origins of the Opioid Crisis and Its Enduring Impacts

Abstract

Overdose deaths involving opioids have increased dramatically since the mid-1990s, leading to the worst drug overdose epidemic in U.S. history, but there is limited empirical evidence on the initial causes. In this paper, we examine the role of the 1996 introduction and marketing of OxyContin as a potential leading cause of the opioid crisis. We leverage cross-state variation in exposure to OxyContin's introduction due to a state policy that substantially limited OxyContin's early entry and marketing in select states. Recently-unsealed court documents involving Purdue Pharma show that state-based triplicate prescription programs posed a major obstacle to sales of OxyContin and suggest that less marketing was targeted to states with these programs. We find that OxyContin distribution was about 50% lower in "triplicate states" in the years after the launch. While triplicate states had higher rates of overdose deaths prior to 1996, this relationship flipped shortly after the launch and triplicate states saw substantially slower growth in overdose deaths, continuing even twenty years after OxyContin's introduction. Our results show that the introduction and marketing of OxyContin explain a substantial share of overdose deaths over the last two decades.

The Economic Underpinnings of the Drug Epidemic

“…As an alternative strategy, I additionally test for differences across states that had implemented "triplicate" programsearly versions of PDMPs in the 1990s. States with triplicate policies have experienced slower growth in opioid overdose deaths over the past two decades, largely the result of receiving a smaller supply of prescription opioids than non-triplicate states (Alpert et al 2019).…”

“…Triplicate ProgramsAlpert et al (2019) find extensive state-level variation in the growth of opioid overdose deaths according to whether state triplicate policies had been adopted prior to the introduction of OxyContin by Purdue Pharma in 1996. To evaluate whether the association between manufacturing decline and the rise of opioid overdose deaths persists regardless of state-level policies that limited the widescale prescribing of opioid medication, I estimated models that tested for differences across triplicate and non-triplicate states…”

“…I also include Indiana and Michigan which had triplicate programs that were discontinued in 1994, two years prior to the introduction of OxyContin. These former triplicate states had long-term trends in OxyContin supply and promotional payments to physicians by Purdue Pharma that more closely resembled states with triplicate programs than states that never had triplicate programs(Alpert et al 2019).5 This is a measure of pill quantity and not prescription strength (i.e. morphine milligram equivalents).…”

The Evolving Consequences of OxyContin Reformulation on Drug Overdoses

“…The drug's wide market presence and its abuse potential stimulated extensive diversion to non-medical use and there were concerns about widespread abuse of OxyContin as early as 2000 (Cicero et al, 2005). Many experts have implicated OxyContin as a key driver of the opioid epidemic (e.g., Kolodny et al, 2015) and recent work concludes that its introduction explains a significant share of the growth in overdoses since 1996 (Alpert et al, 2019), suggesting that its removal or reformulation could also have large effects.…”

Housing, housing policy, and deaths of despair

“…Since the mid‐1990s, rising midlife mortality rates have been driven in large part by deaths from drug overdose—predominantly prescription, illicit, and synthetic opioid overdose—and, to a lesser extent, deaths from suicide and alcohol‐related liver disease . Research on opioid overdose deaths has largely focused on the role of increased availability of prescription opioids . Case and Deaton recently spurred a second complementary line of inquiry, hypothesizing that elevated rates of opioid overdose, suicide, and alcohol‐related mortality—collectively referred to as “deaths of despair”—have resulted from compounding social and economic disadvantage over the life course .…”