The Opioid Crisis in America

This blog is a part of our series, “Perspectives in Crime” where we explore leading academic studies that touch on crime data.

It is difficult to quantify the toll of the American opioid crisis. According to the CDC, more than 932,000 Americans have died of drug overdoses since 1999. In that time, opioid and synthetic opioid overdoses have increased by more than eight times. In 2020, opioid overdoses killed nearly 69,000 people and made up almost 75% of all drug overdoses. 

It is difficult to quantify the toll of the American opioid crisis. According to the CDC, more than 932,000 Americans have died of drug overdoses since 1999. In that time, opioid and synthetic opioid overdoses have increased by more than eight times. In 2020, opioid overdoses killed nearly 69,000 people and made up almost 75% of all drug overdoses. 

Opioids and the triplicate prescription program

A recent study “Origins of the Opioid Crisis and its Enduring Impacts” by Abby Alpert, William Evans, Ethan Lieber, and David Powell published in The Quarterly Journal of Economics identifies the significance of state-based triplicate prescription programs on the initial distribution of OxyContin and the long-term impact these programs have had on individual state outcomes throughout the crisis. 

The triplicate program mandated that for drugs federally classified as Schedule II substances, prescribing physicians would need triplicate paperwork, where one copy would be filed at the Doctor’s office, one would be filed with the pharmacy, and one would be filed with the state drug monitoring agency. Oxycodone, sold commercially as OxyContin, falls under this category of substances, which also includes hydromorphone, methadone, meperidine, and fentanyl. 

These programs were an early intervention in prescription drug misuse, and before the release of OxyContin, triplicate states actually had a higher rate of drug overdose deaths than non-triplicate states. Shortly after the release of OxyContin, this relationship of overdose rates flipped. Alpert et al.’s estimates imply that if non-triplicate states had used triplicate programs they would have had on average 36% fewer drug overdose deaths and 44% fewer opioid overdose deaths from 1996 through 2017. 

Figure 1 shows the progression of opioid overdose death rates in Triplicate and Non-Triplicate states. 

The researchers reviewed internal Perdue Pharmaceutical documents that found physicians would be less likely to prescribe OxyContin in triplicate states. Many physicians were resistant to writing these prescriptions because of the degree of government oversight it may invite into their practice, as well as the additional labor and storage burdens of maintaining the filed copies of prescriptions. As a result, Perdue Pharmaceutical invested less money into marketing targeting triplicate states, and the distribution of OxyContin was about 50% lower in these states. 

Long-term effects of drug oversight systems

Triplicate programs were discontinued in 2004, as more oversight systems became electronic, but the initial effect of the triplicate programs has had a long-running effect on individual state outcomes over the entirety of the American Opioid crisis, dramatically decreasing overdose deaths on the state level, with former triplicate states still experiencing some of the lowest overdose death rates in the country. 

Researchers used a variety of sources including the National Vital Statistics System Multiple Cause of Death mortality files and the Drug Enforcement Agency’s Automation of Report and Consolidated Orders System. The data they accessed contains specific insights on drug misuse data, with special coding for opioid-involved deaths, and the DEA resource provided information on the legal supplies of opioids within each state, presenting a window into active opioid demand throughout the study period. They also utilized data from the National Study of Drug Use and Health for self-reported rates of drug misuse. 

Schedule II, Schedule III, and drug use

In addition, researchers investigated the flow of hydrocodone (e.g., Vicodin), which is classified as a Schedule III drug and thereby not subject to triplicate programs. Throughout the study period, the distribution of hydrocodone was nearly the same in triplicate and non-triplicate states. In triplicate states, oxycodone and hydrocodone distribution were also almost identical, but in non-triplicate states, there was a significantly larger distribution of oxycodone than hydrocodone. Researchers found this mirrored in self-reported drug misuse data, finding the only significant differences in misuse between triplicate and non-triplicate states to occur with OxyContin. 

Alpert et al. found that by the year 2000, there was over two and a half more OxyContin distribution per capita in non-triplicate states compared to triplicate states. Within a few years of OxyContin’s launch, the trends for overdose deaths diverge as well. In 1997, one year after OxyContin’s launch, the overdoses in non-triplicate states increased by 0.25 deaths per 100,000 compared to triplicate states. By 2002, this difference had grown to 2.25 deaths per 100,000 in non-triplicate states. By the end of the study period in 2017, non-triplicate states led triplicate states by 11.41 deaths per 100,000. 

In 2010, a new version of OxyContin, designed to be abuse-deterrent, was released. In 2011, researchers found a sharp increase in overdose deaths attributed to heroin and fentanyl. States less exposed to OxyContin’s distribution were less affected by these trends. 

The rise of overdose deaths in non-triplicate states

The five states with active triplicate programs when OxyContin launched in 1996 were California, Idaho, Illinois, New York, and Texas. Four of these states, excluding Idaho, are among the most populous states in America. Researchers adjusted for population and additional factors to check the strength of their findings. Within these adjustments, the average rates of overdose deaths in non-triplicate states significantly lead the triplicate states.  

Figure 2 shows the population-adjusted difference in opioid overdose deaths in non-triplicate states. 

Researchers explored other differences in policy or circumstance that may have otherwise affected drug overdoses beyond the triplicate program. The five triplicate states transitioned away from triplicate programs, adopting other electronic oversight programs, during the late 90s and early 00s. Despite this, the initial footprint of OxyContin distribution had lasting outcomes for the long-term overdose story of each state. Alpert et al.’s findings imply that if non-triplicate states had the same level of initial exposure to OxyContin as the triplicate states, they would have experienced 36% fewer drug overdose deaths and 44% lower opioid overdose deaths on average each year from 1996-2017. 

The American opioid crisis is ongoing and has been credited with being the single largest reduction in average life expectancy in the modern era. The triplicate program demonstrates the efficacy of oversight policy, and how in the long run, these policies saved many lives.