The documents showed that the company largely avoided marketing OxyContin in states with “triplicate prescription programs.” Prescribers of Schedule II opioids like OxyContin in those states were required to produce three copies of each prescription: one to be retained by them, one by the pharmacy, and one forwarded to a state agency. In addition to the extra paperwork and record keeping, the mandated reporting in triplicate programs raised concerns among prescribers about law enforcement scrutiny.
Consistent with other research, Purdue’s own focus groups of prescribers revealed that these programs had a chilling effect on opioid prescribing. One study of a Texas hospital found that its state triplicate program reduced prescribing of drugs it targeted by 60 percent in the early 1980s. Another study of New York’s program found a comparable decline in the late 1980s.
The N.B.E.R. study compared changes over time in OxyContin prescribing and related overdose deaths in states with triplicate programs — California, Idaho, Illinois, New York and Texas — with that of other states, controlling for demographic and other differences across states. It found that in 2000 alone, OxyContin use per person was 250 percent higher in states with less regulation as reflected by the absence of triplicate programs. OxyContin misuse was also much higher in those more lightly regulated states, with deadly consequences.
Over 1996-2017, opioid overdose deaths would have been 44 percent lower in states had they used triplicate programs, the study estimated. And 65 percent of the growth in overdose death rates between 1996 and 2017 could be attributed to the introduction and marketing of OxyContin.
In 2010, Purdue discontinued the original formulation of OxyContin and released one that reduced abuse of the drug, potentially slowing the growth in opioid addiction. When crushed, the new formulation would not turn into a powder, so it could not as easily be snorted or injected. This did not avoid all harms, however. As studies show, many misusers of OxyContin turned to heroin, which brought a new set of risks.
The heroin overdose rate more than tripled in several years after the start of the new version of OxyContin. The extent to which the new formulation of the drug inadvertently caused harms from heroin depended in part on how frequently original OxyContin was being abused, which varied substantially across states.
Several studies leveraged this state variation to assess the new formulation’s impact. An analysis by three economists in the American Economic Journal: Economic Policy found that states with the highest rates of original OxyContin misuse had the largest increases in heroin deaths after reformulation. They found that as much as 80 percent of the threefold increase in heroin mortality between 2010 and 2013 could be attributed to the introduction of abuse-deterrent OxyContin. Over all, the study and others have found that the new version of the drug did not reduce total mortality, but shifted the cause of it from one drug to another.