The Law of Unintended Consequences: Illicit for Licit Narcotic Substitution

Author Affiliation
Martin R. Huecker, MD University of Louisville, Department of Emergency Medicine, Louisville, Kentucky
Hugh W. Shoff, MD, MS University of Louisville, Department of Emergency Medicine, Louisville, Kentucky

The dealers will not use it. Heroin dealers have explicit knowledge of the addictive properties of their product. The heroin addict is no longer the desperate character living under a bridge. She is a 17-year-old high school senior who runs out of her grandmother’s oxycodone. He is the stockbroker who weighs the economics of purchasing one oxymorphone on the street for $100 or ten doses of heroin for $200. Because these people are ingesting and injecting products of unknown composition and unfamiliar potency, they can potentially overdose. If lucky, they end up in the emergency department rather than the morgue.

Kentucky ranks third in the nation in drug overdose mortality rate per 100,000 persons, with opioid pills making up the majority.1 In response to these statistics, the State of Kentucky passed House Bill One (HB1) in April 2012, effective October 2012. Also known as “the pill mill bill,” HB1 contains provisions intended to limit opioid prescriptions by pain management physicians and by other acute care providers such as emergency physicians. To prescribe narcotic pain medications, physicians must perform a full history and physical, prescribe only a short course, educate the patient on risks of controlled substances, and obtain a report from a statewide prescription monitoring program (PMP) (Kentucky All Schedule Prescription Electronic Reporting [KASPER]).2

As a result, the number of registered KASPER users in Kentucky has gone from 7500 to 23,000 from December, 2011 to November, 2012. Reports are up from 3300 to 17000 in the same time frame.3According to the same press release, Kentucky witnessed a decrease of 10.4% total prescriptions in the first six months since HB1 was enacted.3

Mandating PMP reports, as sixteen states currently do, leads to an increase in reports, but so far no statistical difference in opioid overdose mortality.1,4,5,6 In fact, this legislation may not even lower the rate of opioid consumption, rather may shift which opioids are being prescribed.6

Researchers in Ohio looked at the impact of real time PMP information on opioid prescriptions. With PMP data, providers changed prescriptions in 41% of cases; 61% giving fewer opioids but 39% prescribing more opioids.7

House Bill One was intended to and has reduced opioid prescriptions in Kentucky. Forty-four pain clinics in Kentucky closed overnight.8 Preliminary analysis at a large, metropolitan emergency department has shown a decrease in prescriptions for hydrocodone and oxycodone, along with a decrease in ED administration of these medications. This type of “pill mill” legislation has been passed in Louisiana, Florida, Texas and California with varying results.9

Florida had a sharp decrease in opioid prescriptions after similar legislation. Having 90 of the top 100 physicians on the Drug Enforcement Agency (DEA) 2010 list of top opioid purchasers, Florida saw the number decrease to 13 in 2011, and zero as of April 2013.10 In 2011, Ohio passed a “pill mill bill” to crack down on pain management clinics.11 This legislation led to seizing of 91,000 prescription pills with 38 doctors and 13 pharmacists losing their medical licenses. In the end, 15 medical professionals were convicted on diversion charges.11 With all of this, pill overdose deaths began to decline, but heroin overdoses “skyrocketed.”11

The unintended but foreseeable consequence of such measures has been increase in distribution, abuse, and overdose of heroin. Heroin has gained market share in a similar way in the past. In 2010, Purdue Pharma began manufacturing a reformulated OxyContin after a $600 million fine for misrepresentation.12 Endo Pharmaceuticals Inc. followed in 2011 with an Opana ER reformulation. This resulted in making the pills harder to crush into powder for snorting or injecting.13,14 States such as Florida, Ohio, Minnesota, and Utah have seen patients turn to heroin after crackdown on prescription opioid availability.11,14

The New England Journal of Medicine warned us of what would be a two-fold increase in heroin use after the reformulation of Oxycontin.15 In the 2010 ODLL report, the United States DEA also attempted to warn health care organizations that Oxycontin users might switch to heroin.16,17 The first paper we know of to report this warning was published 3 years later in 2013.16 This paper, a qualitative study of the transition of opioid pill users to heroin users, provides insight into the economic and convenience factors associated with the switch. The researchers interviewed a small sample of heroin users, forty-one in all. All but one of the 19 heroin users aged 20–29 started with pills and progressed to heroin – “termed pill initiates.”16

Numerous popular news reports directly implicate decreased opioid pill availability in the rise of heroin abuse and overdose.16 However, very little discussion of this phenomenon has entered the emergency medicine literature.

The drug cartels have capitalized on the United States opioid appetite and now decreased supply of pills. The route from Mexico to Detroit, then south through Ohio, ends up in northern and central Kentucky. The Kentucky State Police recovered 433 samples of heroin in 2010. In 2012 the number was 1349.13 In Lexington, KY, the eight total heroin arrests in 2011 exploded into 160 in the first 6 months of 2013.18,19Undercover narcotics officers in Lexington find it easier to buy heroin than marijuana.

Heroin-related overdoses in Kentucky increased from 22 cases in 2011 to 143 cases in 2012, and 170 in the first 9 months of 2013.8,20,21 Kentucky’s percentage of overdose deaths involving heroin went from 3.2 in 2011 to 19.5 in 2012 and up to 26 in 2013.8,21 This phenomenon has occurred in Florida, California, Massachusetts, New York, Oregon, Washington and Ohio.11,22–24

The emergency medicine literature has minimal recent discussion of heroin overdose management in the ED; nor have we discussed secondary prevention. Supportive therapy suffices in the ED, with liberal naloxone use and airway protection. State and federal actions to curb heroin deaths can be effective. Good Samaritan laws, present in only one third of states, protect from prosecution those lay individuals attempting to help themselves or companions in overdose situations.

Also present in only one third of states are laws to expand community access to reversal agents such as naloxone. Twenty-two states have laws requiring or recommending education for opioid prescribers. Medicaid expansion to cover substance abuse treatment has occurred thus far in less than half (24) of states.1

As more states enact measures intended to reduce total opioid prescriptions, legislators and healthcare providers alike must be aware of the predictable and devastating rise in heroin sales, abuse, and overdose. Funding for this legislation should include monies allocated toward substance abuse treatment programs and availability of naloxone. Similarly, pill mill bills could universally be coupled with Good Samaritan laws in anticipation of the increase in parenteral opioid overdoses. Funds could be allocated to lay population education via public service announcements. Stricter punishments for drug traffickers could accompany such legislative changes. Many of these measures have been presented as interventions to combat prescription opioid abuse and can now be applied to the subsequent heroin abuse and overdose dilemma.9

At the first line of medical care, emergency physicians must be involved in efforts to minimize collateral damage in this long-term process of curing America’s addiction to opioid drugs and their horrible consequences.


Full text available through open access at

Address for Correspondence: Martin Huecker, MD, University of Louisville Hospital, 530 S. Jackson Street, Louisville, KY 40202. Email: 7 / 2014; 15:561 – 563

Submission history: Revision received February 18, 2014; Submitted March 3, 2014; Accepted March 29, 2014

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.


1. Lang A, Segal L. Prescription Drug Abuse: Strategies to Stop the Epidemic. Trust for America’s Health Website. Available at: Accessed January 5, 2014.

2. Kentucky Board of Medical Licensure. 201 KAR 9:260 Summary. Kentucky Board of Medical Licensure Website. Available at:,d.aWc. Accessed January 5, 2014.

3. Beshear S. Gov. Beshear Signs HB 217, Makes Common SenseImprovements to Landmark Prescription Drug Abuse Bill March 05, 2013. Website. Available at: Accessed January 5, 2014.

4. Gugelman HM, Perrone J. Can prescription drug monitoring programs help limit opioid abuse. JAMA. 2011;306:2258-2259.

5. Cantrill SV, Brown MD, Carlisle RJ, et al. Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012; 60:499-525.

6. Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and death rates from drug overdose. Pain Med. 2011; 12:747-754.

7. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010; 56:19-23.e1–3

8. behaviors. Ann Emerg Med. 2010;56:19-23.e1-3.

9. Van Ingram, executive director of the Kentucky Office of Drug Control Policy. Personal Interview. 2013.

10. Chakravarthy B, Shah S, Lotfipour S. Prescription Drug Monitoring Programs and Other Interventions to Combat Prescription Opioid Abuse. West J Emerg Med. 2012;13:422-425.

11. Florida doctors no longer among the top oxcodone purchasers in the United States. DEA Website. Available at: Accessed January 5, 2014.

12. Blackwell B. The heroin epidemic: death toll from drug continues to soar in Cuyahoga County. Cleveland state website. Available at: Accessed January 5, 2014.

13. Castillo T. Does cracking down on prescription opiates lead to more heroin use?. Huffington Post website August 13, 2013. Available at: Accessed January 5, 2014.

14. Musgrave B. Heroin replacing pain pills as drug of choice in some parts of Kentucky. Kentucky state website January 25, 2013. Available at: Accessed January 5, 2014.

15. Moyer CS. Opioid abuse crackdown puts heroin back in style. American Medical News. 2013.

16. Cicero TJ, Ellis MS, Surratt HL. Effect of abuse-deterrent formulation of OxyContin. N Engl J Med. 2012;12;367:187-189.

17. Mars SG, Bourgois P, Karandinos G “Every ‘Never’ I Ever Said Came True”: Transitions from opioid pills to heroin injecting. Int J Drug Policy. 2013. Accessed January 5, 2014.

18. Office of Diversion Control Liaison and Policy Section Liaison Unit (ODLL), Drug Enforcement Administration (2010) Information bulletin regarding a change in formulation of OxyContin tablets.

19. Spears V Senator to revisit bill to crack down on heroin dealers, provide treatment for addicts. Kentucky state website October 13, 2013. Available at: Accessed January 5, 2014.

20. Spears V, Harrison T Heroin Task Force announces response to sharp rise in overdose deaths. Kentucky state website July 12, 2013. Available at: Accessed January 5, 2014.

21. Cheves J. Kentucky drug deaths decline slightly in 2012, but heroin deaths up sharply. Kentucky state website July 26, 2013.

22. Moore M. Kentucky heroin overdose deaths on the rise. Central Kentucky News website October 9, 2013.  Avaialble at: Accessed January 5, 2014.

23. Koebler J. Study: Heroin abuse may be due to prescription painkiller crackdown. US News website June 12, 2013. Available at: Accessed January 5, 2014.

24. Seville L, Rappleye H. Crackdown on painkiller abuse fuels new wave of heroin addiction. NBC News website June 7, 2012. Available at: Accessed January 5, 2014.

25. Daly E, Montgomery M, Ching C. With rise in young painkiller abusers, officials see more heroin overdoses. California Watch Website. Available at Accessed January 5, 2014.