I was reading about the price of heroin on The Recovery Village and they say:

Heroin pricing varies a lot depending on the region where it’s sold, and as drug cartels have seen people become addicted to expensive opiate pills, they’ve spoken to where they saw a need to fill. They created new production systems and networks so that they can provide heroin to people who are finding pills too expensive a habit. There’s really just a ton of heroin flooding the market, which keeps the price low.

To compare heroin to the cost of prescription pills, an 80-milligram tablet of something like OxyContin can run as high as $80 according to many reports. There have also been efforts to make these drugs harder to get and harder to abuse, so rather than just stopping, many people instead move to heroin.

This seems to be saying that when the government made new laws in an effort to curve the prescription opioid epidemic, it caused the price of pills to inflate and made them harder to get, so people began turning to much cheaper and easier to obtain heroin.

Do the recent changes in drug policy correlate with an increase in people moving from prescribed opioids to heroin?

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    Welcome to Skeptics! I am concerned about the big jump between "unnamed government policies are a factor" and "the government caused it". Would you accept: "Has there been a change in drug policy that has matched an increase in people moving from prescribed opiates to heroin?" – Oddthinking Aug 8 at 2:33
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    Whoops, I mean opioids, not opiates. – Oddthinking Aug 8 at 2:35
  • @Oddthinking Does that look better? I changed the language of your suggestion a little. – anonymouswho Aug 8 at 4:22
up vote 8 down vote accepted

There's a lot of literature on this apparently, and I've only looked at one (55-page) 2018 NBER paper. There is some (correlational) evidence that the "pill mill" crackdown contributed to the switch to heroin, although this paper favors the oxy reformulation as the key event.


We attribute the recent quadrupling of heroin death rates to the August, 2010 reformulation of an oft-abused prescription opioid, OxyContin. The new abuse-deterrent formulation led many consumers to substitute to an inexpensive alternative, heroin. Using structural break techniques and variation in substitution risk, we find that opioid consumption stops rising in August, 2010, heroin deaths begin climbing the following month, and growth in heroin deaths was greater in areas with greater pre-reformulation access to heroin and opioids. The reformulation did not generate a reduction in combined heroin and opioid mortality—each prevented opioid death was replaced with a heroin death.

Regarding pricing the say:

Coplan et al. (2016) note that although the formulation for OxyContin changed, its price did not. We find evidence consistent with this claim in the Truven Marketscan Research Database (Marketscan). This is a database of individual-level claims for inpatient, outpatient, and prescription drug use that by the end of our sample period provided information for over 37 million covered clients per month from 350 self-insured plans.18 Figure 4 reports the monthly time series of the total price and the price that patients pay out-of-pocket for oxycodone for 2006 through 2013. There is no large change in either price series at the time of the reformulation and so it is unlikely that changes in the legal price for oxycodone are driving substitution to heroin.

But I don't see discussion of the black market prices for oxy, only for heroin, which is indeed acknowledged as low.

They also reject some alternative hypotheses, including monitoring act(s):

A potentially important change in recent years has been the adoption of state-level PDMPs [ prescription drug monitoring programs ], which are databases of prescriptions that doctors have written for patients. By giving doctors, pharmacists, and in some cases law enforcement officials, access to this information, patients might have greater difficulty obtaining large amounts of prescription drugs that can be abused and doctors might be more conscious of their prescribing. A large body of research has studied the impacts of PDMPs on prescribing and come to mixed results. While some find that PDMPs reduce opioid overdose deaths (Kilby, 2015), others find no effects on prescribing patterns or effects for a very limited subset of PDMPs (Buchmueller and Carey, 2018). Figure 10 shows the heroin death rate separately for states that had passed PDMPs prior to 2010 and those that passed a PDMP in 2010 or later. Death rates for states with a PDMP before 2010 and states with a PDMP in 2010 or later have extremely similar heroin death rates over time. This suggests that PDMPs are unlikely to be causing the abrupt rise in heroin death rates at the end of 2010. In addition, states began passing PDMPs in 2004 and have continued fairly steadily since then (National Alliance for Model State Drug Laws, 2014). One was created in 2004, two in 2005, two in 2006, four in each of 2007, 2008, and 2009, two in 2010, four in 2011, and so on. Although the timing does not rule out the possibility that the PDMPs impacted opioid prescribing and heroin deaths, it does strongly suggest that the PDMPs are not responsible for the sharp, nationwide increase in heroin deaths that began at the end of 2010.

So they reject this monitoring issue in favor of their alternative (reformulation). Given that they say the body of research on monitoring is large, it's be worth looking for reviews of that for more detail.

And regarding pill mills... they have lot to say:

Beginning in 2009, a series of Federal and state programs were started that were designed to reduce the impact of Florida’s pill mills. A number of authors have documented with a variety of methods that the negative outcomes associated with opioids in Florida began to decline after the introduction of these efforts (Johnson et al., 2014; Delcher et al., 2015; Rutkow et al., 2015; Chang et al., 2016; Kennedy-Hendricks et al., 2016; and Meinhofer, 2016). If the Florida pill mills were a significant component of OxyContin supply throughout the country, then the crackdown could also be responsible for the shift to heroin in a way similar to the reformulation of OxyContin. We investigate the pill mill hypothesis and find mixed evidence. We briefly summarize two analyses that suggest the crackdown in Florida had little impact on the national increase in heroin deaths and two that suggest it might have; the analyses can be found in Appendix B. First, in Appendix Table B1, we provide a timeline of the significant events in the pill mill crackdown in Florida. As the dates in the table suggest, the majority and potentially most effective components of the pill mill crackdown did not go into effect until the second half of 2011, well after the shift to heroin occurred. Second, we graph the time series of oxycodone and the seven other opioids available in the ARCOS data for Florida and all other states. There does not appear to have been a reduction in any opioid in Florida starting in the third quarter of 2010 except for oxycodone (see Appendix Figures B1a – B1h). In fact, there appears to have been slight increases in the use of other opioids in Florida starting at that time. If the pill mill crackdown had been effective, then there should likely have been reductions in all opioids that were being abused, not just oxycodone. We do however find some evidence that states that were more exposed to the Florida pill mills, and thus are more likely to be affected by the crackdown, see differential changes in the growth of their heroin death rates. Our primary approach is based on anecdotal evidence from The OxyContin Express which suggests that individuals who traveled to Florida to obtain opioids for distribution in their home states were also using opioids. Using the universe of emergency department and hospital admissions in Florida from 2007 through the second quarter of 2010, for each state of residence, we calculate the admissions per capita for people aged 18-64 in Florida due to opioids (labeled as OPCs), the non-opioid per capita admissions for the same group (NOPCs), and generate the ratio, OPCs/NOPCs. We then designate states in the highest third of the distribution as being more exposed to Florida’s pill mills. Our procedure identifies all states served by The OxyContin Express, five states contiguous to these states (Alabama, Indiana, North Carolina, West Virginia, Pennsylvania), and six other states (Rhode Island, Maine, New Jersey, Maryland, Mississippi and New York) as likely affected by Florida’s pill mills. It is worth noting that the procedure suggests that no states west of the Mississippi are being served by Florida’s pill mills. In Figure 12, we graph the monthly heroin mortality for the states that are likely users of Florida pill mills (black line) and all other states (grey line). The time trend for both series is very similar prior to reformulation and both show a large change in slope starting near the August 2010 period. The increase in slope in the non-pill mill using states must be generated by some other factor – a factor common to both sets of states. Fitting our quadratic spline through the monthly data for the states unlikely to be pill mill users, the data suggests that the trend break occurs in August of 2010. There is a noticeable break in trend for the pill mill states at the same period but the trend break analysis suggests that the trend break occurs in October of 2011 – the month that all components of the Florida pill mill crackdown law go into effect. This graph suggests that the Florida reforms did not generate the initial shift to heroin but provides some evidence that the pill mill crackdown in Florida also encouraged a shift to heroin.

[...] There is suggestive but not statistically significant evidence that the pill mill crackdown in Florida appears to encourage more of a shift to heroin but only after October 2011 when the full set of reforms in Florida are in effect. That said, even in states that appear to have little access to Florida pill mills, heroin mortality increased by a factor of 3.5 between August 2010 and the end of 2014, compared to a factor of 4.5 in pill mill access states. This indicates that at most, the pill mill crackdown can explain 25 percent of the increase in heroin death rates in pill mill access states between reformulation and the end of 2014.

I haven't bothered uploading any figures because SE/imgur is broken.

  • That’s interesting, because according to this article from The Guardian Florida was the first state to crack down on pill mills in 2010- which is when your article says the problems began. – anonymouswho Aug 8 at 8:52
  • @anonymouswho: good point; this was a long paper, they eventually got to that issue as well. – Fizz Aug 8 at 9:21
  • I have to give this a +1. So are you saying that we can at least attribute 25% of the problem to the government crackdowns, but the other side of the problem is when the federal government’s FDA chose to pull the original OxyContin and replace it with an “abuse-resistant” formula? – anonymouswho Aug 8 at 10:12
  • @anonymouswho: according to this research, yes. – Fizz Aug 8 at 11:22
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    @anonymouswho: ; The NBER paper only mentions Kentucky once, as being in the zone affected by the Florida mills due to interstate 75. like I said, there's a lot of papers on this topic in general, you're more than welcome to add your own answer based on other papers. The NBER paper mentions that they don't all agree on the conclusions; see the "mixed evidence/results" statements highlighted above. – Fizz Aug 8 at 16:09

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