The latest analysis of U.S. heroin trends can be summed up in one discouraging word: more. More heroin use, more populations using heroin, more use of other drugs alongside heroin, and more people — many more — dying.
The report, a joint effort of the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA), paints a sobering picture of the national toll from 2002 to 2013 as heroin use soared. It also confirms the link between prescription opioid painkiller use and heroin, also an opioid. In fact, the study found that abuse or dependence on opioid painkillers was the strongest risk factor for heroin addiction.
But along with the bleak look back, the report also looks forward, outlining ways that everyone from state leaders to the medical community to individuals can play a part in bringing the crisis to a close.
Findings of the Study
Heroin use and diversity of use are up:
- Heroin use was once largely limited to young, low-income males in urban areas. They are still the top users, but heroin use has increased across almost all demographic groups — and some of the increases are dramatic. Over the past decade, use among women doubled, for example, and it more than doubled among non-Hispanic whites.
- In total numbers, roughly 379,000 people reported past year heroin use from 2002 to 2004. By 2011 to 2013, past year use averaged 663,000 — an almost 75 percent increase.
“The groups who have historically been at risk and using heroin are still at risk and using heroin, and we have more groups who are now using heroin or using it at higher rates than they have historically,” says Christopher M. Jones, PharmD, MPH, the first author of the study and senior adviser in the FDA’s Office of Public Health and Strategy and Analysis. Tellingly, the populations using heroin now more closely mirror the populations with high rates of prescription opioid abuse.
Heroin and Other Drugs
Other drugs are almost always part of the heroin-use picture:
- Nearly all — 96 percent — who reported past-year heroin use also used at least one other drug in the past year, and 61 percent used at least three. Data from the last few years of the study show 45 percent of heroin users met abuse or dependence criteria for prescription opioids, 36 percent for alcohol, 25 percent for cocaine, and 24 percent for marijuana. Use of multiple substances increases the overdose risk.
- Those who abuse or are addicted to prescription opioids were 40 times more likely to abuse heroin or become dependent on it.
The statistics are proof that drug use is “rarely done in isolation,” Dr. Jones says, and they also offer more evidence of the strong link between prescription opioid painkiller use and heroin.
More People Dying of Heroin Overdose
Important statistics about heroin and drug-overdose deaths include:
- As use has increased, so have deaths. From 2002 through 2013, the rate of heroin-related overdose deaths nearly quadrupled.
- More than 8,200 people died from heroin overdose in 2013, the most recent study year. Of those, 60 percent involved at least one other drug that was a contributing factor. Cocaine was the most common co-involved substance among the deaths.
While the numbers are dramatic, Jones noted that heroin is still a smaller issue than many other substance use problems. Slightly more than 500,000 people are estimated to be addicted to heroin, for example, compared to 2 million estimated to be addicted to prescription opioids. “The real concern,” Jones says, “is the proportion of deaths to use is very high — and much higher than you see for other substances.” Statistics suggest, in fact, that 1 in 50 who become addicted to heroin will die from it.
What’s Behind the Increases?
So what’s driving the growing heroin epidemic? The study points to two main factors: the increased number of people addicted to prescription opioids and an increase in heroin supply and a decrease in its cost.
The link to prescription opioids, however, may have been misunderstood, the researchers noted. The assumption has been that policies put into place in recent years to limit the epidemic of prescription opioid overuse — things such as prescription tracking programs — have led those who can no longer get prescription opioids as easily to shift to heroin use. In some instances, this is indeed the case, Jones says, “but it’s not this single straight-line trajectory that you stop using prescription opioids and then you start using heroin and you never use prescription opioids again.”
Rather, prescription opioid use appears to be “priming” people for heroin addiction, says Tom Frieden, MD, MPH, director of the CDC, in a press briefing on the new statistics. “In general, what we’re finding is that the higher the rate of the prescription opiate use, the higher the rate of heroin use.” It’s a “one-two punch” of need and economics, he says. People who are addicted to prescription opioids are primed for heroin addiction because the chemicals are essentially the same and act on the brain in the same way, and heroin is easier to come by and roughly five times cheaper than prescription opioids on the street.
Use then becomes more about what’s available and what’s affordable in the moment, rather than representing a progression from one drug to another. Understanding this, Dr. Frieden says, helps set a future course toward prevention and also helps clarity that policies surrounding opioid prescribing should be seen as part of the solution, “not part of the cause of the heroin problem.”
What to Do About Heroin Use From Here
While the report offers plenty that discourages, it also helps point the way toward change. Among the recommendations:
Better opioid prescribing. This should include:
- Better education for doctors and patients on when it’s appropriate to use prescription opioids, which are so strongly linked to heroin use. “For chronic non-cancer pain, you really have to look at the risks and the benefits,” Frieden says, “and the risks are very, very clear. A few pills and you can get addicted. A few pills too many, and you can die.” He says that the federal government is helping in this effort by compiling chronic pain-prescribing guidelines for medical workers that should be available next year. Patients should also get involved by questioning their doctor whenever opioids are prescribed and by making sure he or she understands their medical history. Mental health issues and a past history of substance abuse can boost the chance that opioids will be a problem, for example.
- Prescription drug monitoring programs that limit inappropriate prescribing and also help identify those for whom opioids may become a problem. States can help ensure compliance by setting up systems that provide up-to-date information and are easy for medical workers to use.
- Alternatives to opioids for pain relief. Many options already exist, such as physical therapy, nonsteroidal medications and anti-inflammatories, and more should be explored and developed. Jones noted that the FDA has worked with the drug industry to incentivize development of non-opioid pain medication, and that several such medications have been approved in the past few years that may prove helpful for chronic low back pain or other types of musculoskeletal pain.
Better addiction treatment. Those dealing with dependence on heroin or other opioids need access to and insurance coverage for evidence-based substance abuse treatment. And that treatment must include medication-assisted therapy, which has been shown to be effective in reducing opioid use and related deaths. Perhaps most crucially, society must work to overcome the stigma that keeps those with addiction issues from seeking help. “I think as we start to normalize both in the medical community as well as in the community at large that addiction is a chronic disease like any other disease and there are treatments for it, I think that will really go a long way in helping to reverse the current trends that we’re seeing,” Jones says.
Expanded use of naloxone. This drug can reverse opioid-related overdose and should be available for first-responders, caregivers, family members and others in the community so that more lives can be saved.
Better law enforcement. By tracking communities where heroin use is increasing and then working to limit the supply, heroin will become less available, less affordable and a less-appealing option.
The recommendations require collaboration across all levels of government and society, and heroin’s broad reach may well help in that effort. “I think people are recognizing that this issue touches all of our communities,” Jones says. “This isn’t what people always perceived drug addiction being. It’s your friends, your neighbors, your family, and that is really galvanizing people to respond.” With the roadmap that the study data provides, “I think we know what we need to do. Now it’s just moving forward and doing it.”