As previous UPDATES articles warned, there has been a growing resurgence of “smack” (ie, heroin) raging across the United States, due largely to restrictions on pain reliever prescribing and abuse-deterrent formulations of those drugs. According to a recent report in USA Today, heroin is spreading like a cancer into even the most upscale suburban areas throughout the country.
The report by Donna Leinwand Leger [here] in the April 15, 2013 edition of the newspaper notes that heroin was once an urban problem that is now finding a new home in affluent suburbs and small towns throughout America. Fueling the revitalized tsunami of addiction, overdose, and deaths is the fact that opioid medication prescribing is being more closely scrutinized and regulated, and newer formulations of those analgesics deter abuse. So, drug abusers and addicts are turning to more dangerous heroin, which also feeds crime wherever it appears.
Leger observes that, to stem the tide of people abusing prescription opioids, authorities began cracking down on pain clinics, and drug companies began creating pill formulations that made them harder to crush and snort for a quick high. Consequently, opioid addicts found it more difficult, and expensive, to get their fix: an 80 mg OxyContin costs $60 to $100 per pill; whereas, heroin costs about $45 to $60 for a multidose supply.
Leger writes, “As addicts move from legitimate prescriptions to the black market of pure, precisely measured narcotic pain pills to the dirty world of dealers, needles and kitchen table chemists, health officials and police are noting sharp increases in overdoses, crime and other public health problems.” Large cities and small towns across the U.S. are reporting surges in heroin use. In Illinois, the state crime commission last month called heroin an epidemic, noting that the Chicago metro area ranks first in the nation for emergency department admissions due to heroin use.
Here are some further observations from around the country in Leger’s article:
- In Charlotte, North Carolina, dealers deliver heroin right to the suburbs and run specials to attract young, professional, upper-income customers. Robert Martin, director of substance abuse services at Carolinas Medical Center, said, “Our heroin patients come from the five best neighborhoods.” He notes that many addicts started out as legitimate pain patients, but turned to cheap, easy-to-access heroin after their opioid prescriptions were discontinued and the black market supply became too costly.
- Last September, there was a spike in heroin overdoses in Maine, New Hampshire, and Vermont. “When you switch to heroin, you don't know what's in there from batch to batch,” observed Karen Simone, director of the Northern New England Poison Center. “It's a big jump to go to heroin. It may be strong; it may be weak. They don't know what they are getting. Suddenly, the whole game changes.”
- In Portland, Maine, a dramatic change was seen 6-to-8 months ago at the Mercy Hospital Recovery Center. Drug abusers who once typically favored oxycodone were reporting intravenous (IV) heroin as their opiate of choice. IV heroin is particularly dangerous because addicts often share needles, exposing themselves to blood-borne diseases such as HIV and hepatitis, and they can easily overdose when injecting heroin. According to Ronni Katz, substance abuse prevention program coordinator for Portland, they had expected an increase in heroin abuse and are dealing with the fallout of overdoses. “One substance will go down, but another will go up. And unfortunately, I think [heroin abuse] is going to grow,” he said.
- In Minnesota, 1 in 5 persons seeking treatment is addicted to opiates, according to Carol Falkowski, the former drug abuse strategy officer for Minnesota. “Heroin is huge. We've never had anything like it in this state,” she says. “It's very affordable. It's very high purity. Most people did not believe that heroin would happen here in Lake Woebegone, but it really has a grip, not only in the Twin Cities, but all around the state.”
- In Elizabethtown, Pennsylvania, a borough of 12,000 people, Police Chief Jack Mentzer noted prescription pill addicts have gradually turned to heroin during the past 18 months. “Folks are looking for that better high,” he said, and, with the rise in street drugs came increasing crime wave.
- In Delaware, heroin investigations have soared over the past 2 years, commented Sgt. Paul Shavack, spokesman for the State Police. In 2011, there were 578 heroin investigations, which more than doubled to 1,163 last year. This year, heroin continues as the top street drug because it is cheap and easy to get — and, along with that, thefts and burglaries to garner quick cash for drugs have spiked.
- In San Diego, California, DEA Special Agent Amy Roderick observes that, when prescription drugs are too expensive, cheaper heroin is always available. Many of the heroin users and dealers whom federal agents arrest in San Diego are younger than 30, and some are as young as 17, she said. “They're telling us as we're arresting them, ‘We can't find the Oxy. We can't find the Vicodin.’ [Heroin is] a very dangerous drug. Once you're addicted, it takes over your life.”
Leger notes in the USA Today article that, once tighter restrictions on prescription analgesics were in place, abuse of those medications declined, particularly among young adults 18 to 25. At the same time, however, the number of heroin abusers rose sharply.
According to the U.S. National Survey on Drug Use and Health (NSDUH [PDF here]), the number of prescription-opioid abusers dropped from 5,093,000 in 2010 to 4,471,000 in 2011. Among young adults, the number dropped from a high of 1.62 million in 2006 to 1.22 million in 2011.
In contrast, the NSDUH survey estimated that 281,000 people 12 and older were current heroin users in 2011 (at the time of the survey), up more than 100% from a decade low of 119,000 in 2003. The survey further reported that the number of people who were past-year heroin users in 2011 (620,000) was much higher than the number in 2007 (373,000). In 2011, there were 178,000 persons aged 12 or older who used heroin for the first time, up from 90,000 to 108,000 per year during 2005 to 2007.
Another study, which assesses the number of people seeking treatment for heroin, found increases in 30 of 39 states reporting data in 2011 to the Substance Abuse and Mental Health Services Administration. In 2011, 238,184 persons sought treatment for heroin addiction, up from 224,198 previously.
COMMENTARY: The USA Today article tells a terrible tale, which should come as no surprise to followers of our UPDATES. Last July [here] and November [here], 2012, we warned that the crackdown on opioid-analgesic prescribing in the United States, combined with abuse-deterrent formulations of certain opioid medications, ironically appeared to be fueling a resurgence of deadly heroin abuse and addiction.
Much earlier, in 2011, we had reported [here] that new opioid-analgesic prescribing policies being imposed in Washington State were spawning a new generation of heroin users, who were turning to illicit drugs as legitimate medications for treating chronic pain were becoming scarce. Unfortunately, neither data tracked in government reports nor commentary in the USA Today article provide estimates of just how many patients with chronic pain resort to heroin after their opioid analgesic prescriptions are decreased or discontinued.
We also have previously observed [eg, here] that the U.S. unquestionably faces serious substance abuse problems, as do most other countries worldwide. At the same time, well-meaning efforts to curtail the prescribing and distribution of opioid analgesics — to stem an alleged “epidemic” of prescription opioid abuse, addiction, overdose, and deaths — may be headed in the wrong direction by fostering several unintended consequences:
- Foremost, is the upsurge in heroin abuse and addiction, which seems strongly driven by tightened controls on prescription opioids.
- Along with that, we may expect to see increases in heroin-associated morbidity — eg, HIV/AIDS, hepatitis, tuberculosis, other infections — with attendant mortality. This will not only have a devastating impact on individuals, but on families, communities, and society overall.
- New and restrictive rules governing pain management with opioid analgesics — such as those in Washington State and elsewhere — are limiting access to these essential medications for legitimate patients with chronic pain who benefit from long-term analgesic therapy.
- Left with few or no alternatives, some of those patients with undertreated or untreated chronic pain may be among a new generation of heroin abusers; although, the numbers of such persons are still undetermined.
Another irony is that abuse-deterrent versions of certain opioid medications — eg, controlled-release oxycodone (OxyContin®) and extended-release oxymorphone (Opana®) — appear to have been successful in stemming abuse of those drugs, but not in reducing opioid abuse and addiction overall, and possibly spurring rises in heroin use [as described in UPDATE here]. So, those formulations seem to have solved one problem, but have done little to diminish drug abuse and addiction overall in the population. And, just recently — on April 16, 2013, as the original patent for OxyContin expired — the U.S. Food and Drug Administration [here] declared that future generic versions of long-acting oxycodone also must have abuse-deterrent properties.
Essentially, what we have here is a “balloon effect”: squeeze a balloon in one place and it will expand somewhere else. Curtail the availability or appeal of prescription opioids and heroin expands to make up the difference, and the illicit-drug dealers seem glad to be of service in helping this along.
While this is not a justification for recklessly liberalizing opioid-analgesic prescribing, it is a compelling reminder that societal problems of substance abuse and addiction are complex and multifaceted. Simplistic solutions seeking only to restrict drug supply have never succeeded in reducing drug demand. However, in the case of prescription-opioid restrictions, many millions of legitimate and innocent patients end up paying a price in pain and suffering due to the misbehaviors of a relatively small minority of the population who persist in their pursuit of substances to abuse — including heroin.
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