Tamper-proof opioids won’t stop epidemics

Time to think outside the pill.
Time to think outside the pill.
Image: AP Photo/Patrick Sison
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Tamper-resistant or “abuse-deterrent” opioids have been held up by the pharmaceutical industry, government health agencies, state lawmakers, and health professionals as a potential solution to the opioid epidemic growing in the US. The problem is there’s little to no evidence abuse-deterrent pills actually deter abuse.

Opioid users often crush prescription pills because it disables the time-release mechanism of the drugs, giving users a quicker, bigger high. In some cases, users will heat the powder until it dissolves into a liquid that can then be injected with a needle. Tamper-proof opioids contain an extra plastic polymer, which causes them to break apart into chunks instead of powder when crushed. The polymer also makes it so when the pills are dissolved, the resulting liquid is too thick to use intravenously.

A new study published (paywall) Jan. 11 in the Lancet Psychiatry looks at the impact of introducing these tamper-resistant opioids to the Australian market. Australia isn’t battling an opioid epidemic as bad as the one in the US, but the painkillers are still a problem there. A heroin epidemic that began in the early 1990s, combined with prescription opioid abuse, killed 1,100 people at its height in 1999. Heroin use has since decreased, but opioids remain a scourge: In 2014, an estimated 93,000 Australians were misusing crushed prescription painkillers, and opioids were the leading cause of drug overdoses in the country. In April 2014, tamper-proof opioid painkillers were introduced as a possible solution—and since, there have been no other opioid-related policies instituted in the country.

That gave researchers a great real-world lab to test how effective tamper-resistant opioids actually are. An analysis of 17 studies and surveys of opioid use in Australia from 2011 to 2017 found that users weren’t snorting or injecting the tamper-proof pills. But that didn’t mean they were using opioids less—they were just taking low-dose pills in higher quantities. It turns out that after the tamper-resistant pills came on the market, doctors began to prescribe them, but mostly just in high doses, while also starting to prescribe more and more lower-dose regular release pills.

Perhaps most importantly, there was no change in the number of opioid overdoses.

To be sure, the data suggest that opioid abuse isn’t getting worse. “We found there was no increase in people seeking help for oxycodone, and no increase in emergency department data for overdoses,” Briony Larance, a psychologist at the University of New South Wales and lead author of the paper, told ABC. But the data show that tamper-proof pills didn’t have a tangible effect on opioid use in Australia.

It’s worth noting that this study was funded in part by Mundipharma, a pharmaceutical company that sells some of the extended release opioid painkillers in Australia, though the company had no oversight or input into the study design.

Other researchers have also concluded abuse-deterrent drugs alone can’t stop an epidemic. For one thing, these pills are generally more expensive: researchers found the best price available in the US for generic morphine (a popular opioid) was $43 compared to $500 to $1,000 for a comparable supply of abuse-deterrent morphine. Replacing all opioid prescriptions with tamper-resistant pills would be hugely expensive for patients and healthcare systems.

Addiction is more complicated than only a chemical dependency, writes Nabarun Dasgupta, a University of North Carolina researcher, in an accompanying commentary. So it’s not surprising that changing the drugs aren’t enough to curb abuse rates. Instead, Larance told ABC, doctors should be working with their patients to find alternative methods of treating chronic pain, and closely monitoring those patients who do need to take opioid painkillers for a short period of time.