Amid documented reports that fatal heroin overdoses are increasing as fatal prescription opioid overdoses are leveling off or decreasing, we checked in with federal officials and experts in the field to try to get an answer to these two questions: (1) Are people switching from prescription opioid addiction to heroin addiction? and (2) If so, what is being done to address this phenomenon?
It is clear that heroin use and overdoses are going up, but it is not clear that this is due to the restrictions on prescription opioids imposed by prescription drug monitoring programs, prescriber education or other supply-side initiatives, according to federal experts, who also stressed that the sheer numbers of prescription opioid dependence and overdoses outweigh those of heroin by far. Still, the best intervention to prevent heroin initiation and overdoses is treatment for people who are addicted to any opioids, prescription or heroin, our sources agreed, citing medication-assisted treatment as the best approach for opioid use disorders.
“Certainly it is clear that there has been a major increase in heroin overdose deaths through 2013 nationwide,” said Leonard J. Paulozzi, M.D., of the federal Centers for Disease Control and Prevention (CDC), in an interview with ADAW last week. A medical epidemiologist with the CDC’s Division of Unintentional Injury Prevention, Paulozzi is the lead federal expert on drug overdoses, especially prescription drug overdoses. Opioid prescription overdose deaths have flattened out, with 16,900 in 2011, 16,000 in 2012 and up to 16,235 in 2013, he said.
When the CDC looked at the relationship between heroin and prescription opioid deaths in 28 states from 2010–2012, the findings were that as prescription deaths went up, so did heroin deaths, said Paulozzi (see ADAW, October 20, 2014). However, switching from prescription opioids to heroin “is a topic of interest” to the CDC, said Paulozzi. “But there are a lot of things going on here,” said Paulozzi, making it hard to draw conclusions about the reasons for the increase in heroin overdoses. An increase in heroin supply and a slight decrease in heroin costs, as well as changing opioid-prescribing practices by physicians, could all play a role, he said.
Asked whether there is any data to back up widespread anecdotal reports from local law enforcement that people with opioid dependence are switching from prescription opioids to heroin because the prescriptions are now less available and more expensive than heroin, Paulozzi said that this may be only a local phenomenon. “It may be very clear in some communities that there’s been a decline in prescribing opioid analgesics, but nationwide there has been only a small decline overall in prescribing,” he said.
“I know that it is a concern that we expand treatment, especially medication-assisted treatment, for people addicted to heroin and/or prescription opioids,” said Paulozzi. “There’s interest in trying to expand buprenorphine, having more doctors get the waiver.”
In Florida, a successful crackdown on pill mills has not quelled the opioid addiction epidemic but has led to a reduction in overdose deaths, said James Hall, Ph.D., epidemiologist with the Center for Applied Research on Substance Use and Health Disparities at Nova Southeastern University. “I am not too sure if we are seeing that much of a reduction in prescription opioid nonmedical misuse,” he told ADAW. “What we are seeing, at least here in Florida, is a reduction in deaths related to that abuse.” Hall added that Florida’s increasing heroin use should not be attributed to the crackdown on pill mills and high levels of doctor shopping, which has been deterred by the prescription drug monitoring program. “Without these supply-side strategies, heroin use would have likely increased even more, because prescription opioid abusers constitute the breeding ground for the nation’s heroin epidemic in the 21st century,” he said. “However, Florida’s failure was in not expanding treatment and prevention resources while enforcing prescription diversion control.” Prevention includes providing access to medication-assisted treatment, said Hall.
SAMHSA and the CBHSQ
The Substance Abuse and Mental Health Services Administration (SAMHSA) found an association between the nonmedical use of prescription opioids and the initiation of heroin in 2013: heroin use was 19 times higher in people who had used prescription opioids, said Peter J. Delany, Ph.D., director of SAMHSA’s Center for Behavioral Health Statistics and Quality. “But the caveat is that the heroin numbers are very small overall,” he said. “The vast majority of people who have used prescription pain relievers have not progressed to heroin use. People see ’19 times’ and think it’s huge, but we’re talking about small numbers.” (For the data review, go to www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.pdf.)
Still, the number of regular heroin users has doubled since 2002, according to the National Survey on Drug Use and Health (NSDUH). “That is a pretty sharp increase, and it is a public health concern,” Delany told ADAW.
But still, the numbers are low, he stressed. Current NSDUH data show that 689,000 people used heroin in the past year — that is .2 percent of all drug users. There are 289,000 regular users of heroin. “The take-home is that although these numbers are small, it is of concern because they are going up,” said Delany.
Delany said the reasons for initiating heroin use are not covered in the NSDUH. “They may not have stopped using prescription opioids; they may have added heroin — maybe the heroin is easier to get,” Delany said. “I don’t know.”
When the federal Department of Health and Human Services issued its approach to the opioid overdose epidemic in March (see ADAW, March 30), it listed three initiatives: prescriber education, access to naloxone and improved access to medication-assisted treatment. We asked Delany how SAMHSA, as the lead HHS agency for treatment, planned to address this. “Treatment is the province of each state, and each state makes adjustments based on their available resources,” he responded. “I think what HHS is saying is they want to encourage states to expand their MAT, not necessarily that they’re going to expand it for them.”
“Recent data show that overdoses from prescription opioids appear to be leveling off, but there was a dramatic 39 percent increase in heroin overdoses from 2012 to 2013,” said Samuel Schumach, press secretary with the Office of National Drug Control Policy (ONDCP). Overall, there are still many more overdose deaths due to prescription opioids than heroin, however. And only 4 percent of people who use prescription opioids move on to heroin over a five-year period, Schumach added, citing the same data review referred to by Delany.
The ONDCP stressed the importance of treatment with medications. “It is critical for our medical system to identify and treat people who misuse prescription opioids early to prevent them from ever starting to inject drugs or use heroin,” he said. “Failure to intervene can have dire medical consequences. To achieve this, we must expand access to both naloxone and treatment, especially medication-assisted treatment, to help people stay in recovery.” Schumach added, “MAT, when combined with other supports, has been shown to be the best course of treatment for opioid use disorders.”
Changing prescribing practices
The solution to reducing heroin use, to the extent that it starts with prescription opioid use, is to reduce the initiation of prescription opioids, according to the National Institute on Drug Abuse (NIDA). “The relationship between prescription opioids and heroin abuse is complex and needs further study,” said Jack Stein, Ph.D., director of NIDA’s Office of Science Policy and Communications. “However, interviews with some people with heroin use disorder suggest that when faced with the increasing difficulty in accessing and/or affording prescription opioids to maintain the dependence they developed on these medications, they transitioned to heroin, which is cheaper and in some communities easier to obtain.” He added, “This suggests that preventing the initiation of prescription opioid misuse is a crucial component of efforts to prevent heroin use.”
“It may be some years before efforts to try to change prescribing practices take hold,” said the CDC’s Paulozzi. Acknowledging that prescribing of opioids rose dramatically over the past 15 years, Paulozzi said “that doesn’t mean we can’t change things now, and try to reap the benefits.”
But for many people, it’s too late — they are dependent and need treatment, said Paulozzi. “If you have a large cohort of people who are already physiologically dependent on heroin or prescription opioids, those people aren’t going to go away,” he said. “They’re going to seek drugs, and they will need to get into treatment. But if we can stop feeding that pool now, it will help.”
The best way to reduce heroin overdoses is to increase treatment with medications for opioid addiction, whether to prescription opioids or heroin, federal leaders tell ADAW.