Obscure state regulations gave birth to the opioid crisis

The start of an epidemic.
The start of an epidemic.
Image: REUTERS/George Frey
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This post has been updated.

In the last several years, life expectancy fell in America. It reversed decades long trends of Americans living longer, and is in spite of advances in medicine. The main reason why is what’s known as “deaths of despair,” with middle-aged men and women dying from obesity-related illness, suicide, and most notably, drug addiction from opioids.

The opioid epidemic, which claimed more than 400,000 lives between 1999 and 2017, has been a national tragedy, and yet no one could pinpoint a cause or why so many Americans turned to addictive drugs. Economists Angus Deaton and Anne Case were among the first to observe the trend of early deaths, and blamed poverty and income stagnation. Others point to a change in the medical profession where opioids were prescribed more freely to reduce pain, but with the consequence that many people became addicted and turned to harder drugs.

These two explanations are not mutually exclusive, but a new paper offers another theory. Economists at the universities of Notre Dame and Pennsylvania and at the RAND Corp. looked through unsealed court documents from a lawsuits against Purdue Pharma (the maker of Oxycontin) and noticed the company decided to focus its marketing on what they call “non-triplicate states.” Five states—California, Idaho, Illinois, New York, and Texas—had triplicate prescription programs in the 1990s. The program, which pre-dated the opioid crisis, mandated doctors use state-issued triplicate prescription forms when prescribing schedule II controlled substances such as Oxycontin and Vicodin. The doctor kept one copy, the pharmacy received another, and a state drug monitoring agency got the third copy. Evidence suggests the programs reduced prescriptions of the schedule II drugs because, according to the court documents, doctors did not want the government to have records of what they were prescribing and keeping track of the extra paperwork was a hassle.

As a result, Purdue Pharma focused its marketing efforts on non-triplicate states, where, without the additional paperwork, doctors were more likely to write prescriptions for opioids. Before the introduction of Oxycontin, overdose rates were higher in triplicate states, even after controlling for cocaine use which was popular in large cities. But once Oxycontin was introduced, more prescriptions were written in non-triplicate states, followed by higher rates of misuse, the use of other forms of heroin, and eventually more overdose deaths. The paper’s authors estimate that if all states had required triplicates there would be 36% fewer drug overdose deaths and 44% fewer opioid deaths. They blame Purdue Pharma’s marketing and targeting on non-triplicate states for 65% of the growth in overdose deaths since 1996.

The economists further argue the epidemic was not due to economic conditions. The increased trend in suicides and alcohol related deaths predates the introduction of Oxycontin and the trend continued, independent of opioids, after 1996, according to the authors. They conclude the opioid epidemic was caused mainly by the easy availability of opioids in certain states.

Triplicate programs ended in 2004, when they were replaced with an electronic version that made compliance easier. But the economists contend the impact was long lasting because Purdue’s marketing strategy in the early days included targeting physicians who prescribed the most Oxycontin, and then building relationships with them. Purdue continued to pursue these doctors in non-triplicate states even after triplicate states dropped the requirement. Purdue did not respond to a request for comment.

Of course, it’s not clear that it was solely the lack of triplicate programs in the states Purdue targeted that made the difference. It’s possible the triplicate states’ insistence on additional paperwork reflected an approach to public health that might have included other measures to prevent opioid addiction. The triplicate states also tend to be larger, wealthier and more urban, while economic dislocation in the other states probably also played a large role why opioids caught on like they did, even if they are not the reason for their initial popularity. But the research shows how critical simple regulations can be in preventing an epidemic.

Correction This article has been updated to correct the number of Americans who died in the opioid epidemic. An earlier version used a higher number which included all deaths from overdoses.