Mary first took oxycodone after a minor surgery and found she liked it. Returning to her surgeon a month later with vague ongoing pain, she received another prescription. Her primary care provider took over from there — until one day that physician checked a urine drug screen and a prescription monitoring program (PMP) report, only to find that she was obtaining various opioids from several providers. The physician cut her off and reported her to the PMP just as crackdowns on opioid prescribers arose. The prescriptions dried up. She tried buying pills from illicit sources but found that at roughly a dollar a milligram, the street price of prescription opioids can rapidly exceed a generous mortgage every month. A friend offered her heroin to stave off the shivering, vomitous withdrawals, and she accepted. She is now hooked on heroin.
The patient is not real, but her story is a true-to-life composite of dozens of patients who have recounted the same well-beaten pathway to heroin in my medication-assisted treatment (MAT) practice. These patients fall victim to the pull of narcotics on an opioid-adjusted brain, but they also fall prey to the invisible hand of inviolable market principles. For people stuck on these substances, prescription opioids are a product of “price inelasticity” — the economic principle that posits that the demand for some products stays steady no matter how steep the price. Many people will not be able to quit opioids simply because Medicaid stops paying the copays — but they will drift to the cheapest source of a substance that will fit tight into the opioid receptor and satisfy the withdrawals for another day or at least another hour. And if the price of that source rises, they will either pay it or find another product that will do the job.
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