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Unintended Consequences

Posted Nov 15 2010 11:39pm

I saw a patient from up north earlier today, and we tallked about the economy in his part of Wisconsin and in the Michigan Upper Peninsula.  From what he had to say, things are the ‘same old same old;’ i.e. jobs are few and far-between.  Seems as if it has been that way for a long time now.  And it’s hard to imagine any industry doing well enough in the current economy to make a dramatic change up there.

One change that HAS become apparent over the past year is the increased availability of heroin, now easily found in small towns throughout the upper Midwest.  I’ve seen the same trend closer to my practice, where heroin use has grown from a Milwaukee phenomenon to just another high school temptation.  And a troubling comment pops up more and more during my discussions with people actively addicted to opioids:  “Now that O-C’s are abuse-proof, we gotta’ use heroin.”

I’ve mentioned the requirement for REMS– Risk Evaluation and Mitigation Strategies– for opioids announced by the FDA about a year ago.  The requirement for REMS on a class-wide basis– a novel use of the FDA’s regulatory powers– places pressure on the manufacturers of opioids to find solutions to the epidemic of opioid dependence. One result has been the development of medications with lower abuse potential, such as the new formulation of oxycontin, which when crushed (a feat by itself) yields a gooey mess that clogs nasal passages and needles if taken by those routes.  But the law of unintended consequences applies to this domain, as one would expect, given the tangled mess of political, societal, and economic forces involved in the epidemic of opioid dependence.  There are many addicts out there, each subject to severe withdrawal in the absence of their daily dose of oxycodone;  what would a reasonable person expect them to do, knowing the intensity of their desire for opioids– and their fear of withdrawal?  Are they just going to stop?

My last patient explained it just fine… and he isn’t even a D.C. social worker.   ”Oxycontin or heroin–  it really doesn’t make no difference.  It’s all the same thing– one just isn’t around anymore.”

Unfortunately, he wasn’t referring to heroin.

I do have a question– a genuine question, not a facetious one.  At least in Wisconsin, diverted Oxycontin is often used nasally, and heroin used by needle.  I’m sure that part of  the reason for that different route of use is because heroin has tended (at least until now) to be used later in the course of addiction, and there is a progression to parenteral use of substances over time, as addicts seek more efficient means of using.  My question– are there other reasons that heroin users favor intravenous over nasal use?  To frame the question a bit differently– it appears that the prevention efforts aimed at Oxycontin have caused an increase in the use of heroin.  Did they cause in increase in intravenous drug use as well?

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