The National Survey on Drug Use and Health (NSDUH) released September 24 by the Substance Abuse and Mental Health Services Administration (SAMHSA) found that prescription drug use is down but heroin use is increasing. The results fell short of confirming that there is a relationship between the two — that opioid-dependent people are turning to heroin as the supply of prescription drugs is cut off by initiatives like drug take-backs and prescription drug monitoring programs (PDMPs).

The survey found that past-year heroin use almost doubled between 2007 and 2010, from 373,000 to 620,000. For people with heroin dependence or abuse, the number also nearly doubled, from 214,000 in 2007 to 426,000 in 2011.

Causation?

There is a correlation between a decrease in prescription opioid abuse and an increase in heroin use confirmed by the NSDUH data, but not causation, said H. Westley Clark, M.D., director of SAMHSA’s Center for Substance Abuse Treatment (CSAT). “The NSDUH data does not explain cause and effect,” Clark told ADAW. “There has been an uptick in heroin use — that’s correlation. And there’s been an increased demand for treatment based on both prescription drugs and heroin. So it’s not far-fetched to conclude that one thing may be linked to the other.”

While the NSDUH is not designed to reveal whether there is a definitive connection, said Clark, it does contribute to understanding the problem. People who are dependent on prescription opioids and can’t get them anymore — whether because their physician, afraid of consequences, has stopped writing prescriptions or because the street supply has dried up — have three choices, said Clark. They can quit, they can go to treatment or they can turn to heroin.

Several years ago, when Florida began its crackdown on pill mills, the state opened additional methadone slots, recognizing that there would be a need for treatment. But in many states there is no coordination between the enforcement against overprescribing of opioids and the need for treatment for people who are dependent and can’t quit. In fact, the trend is for states to cap buprenorphine treatment at one year, and the difficulty of opening or expanding methadone treatment programs is a major barrier to care. And there is still a pervasive attitude against agonist medications like methadone and buprenorphine, even among many in the substance abuse treatment community.

The unintended consequence of the successes in reducing prescription drug abuse may well be an increase in heroin use, said Clark, noting that medication-assisted treatment has resulted in reducing HIV and hepatitis by reducing needle sharing.

The NSDUH questioned people about the “nonmedical” use of these prescription drugs. Nonmedical use is defined as use without a prescription of the individual’s own, or using “for the experience or feeling the drugs caused.”

The summary report used two additional studies — the Treatment Episode Data Set (TEDS) and the Drug Abuse Warning Network (DAWN) — to analyze prescription opioid and heroin data. SAMHSA’s TEDS compiles data on admissions to publicly funded treatment centers. SAMHSA uses DAWN to monitor emergency department visits related to drug use, abuse and misuse.

It also looked at the Monitoring the Future (MTF) study conducted by the National Institute on Drug Abuse (NIDA) to find out what drugs school-age children are using. The MTF data on 8th and 10th graders are combined to give the age range that approximates 12 to 17 years, the youth age group used for the NSDUH.

The heroin connection

Prescription opioid abuse declined from 3.2 percent in 2002 to 2.3 percent in 2011 among youths; among young adults, it declined from 4.4 percent in 2010 to 3.6 percent in 2011.

MTF’s definition of prescription drug misuse differs from the NSDUH definition: MTF defines it as use “not under a doctor’s orders.” MTF doesn’t ask general prescription drug misuse questions but does ask about “narcotics other than heroin,” which is similar to the NSDUH pain reliever category.

The 2011 NSDUH data show higher numbers of heroin users and new heroin users. “These findings seem to support anecdotal reports that have suggested increasing use of heroin among young people,” according to the NSDUH report. “For example, news media reports have linked the increase in heroin use to nonmedical use of prescription pain relievers among young people, suggesting that some prescription pain reliever abusers have shifted to heroin. It is not possible in this summary report of the 2011 NSDUH findings to fully explore the potential association between pain reliever misuse and heroin use.”

The NSDUH also underestimates heroin use, because household samples mean there is likely to be undercoverage of heroin users. “Nevertheless, despite the underestimation that is believed to be present, NSDUH's consistent methodology over time permits assessment of trends, providing an important baseline and descriptive background for studying the recent heroin problem.”

The estimated number of new users of heroin increased from 109,000 per year during 2002–2005 to 169,000 per year during 2009–2011, according to the report. This increase in initiation occurred particularly in older age groups: it went down from 28,000 per year in 2002–2005 to 27,000 per year in 2009–2011 for youths, but up from 53,000 per year to 89,000 per year for young adults, and up from 28,000 per year to 54,000 per year for older adults.

Unintended consequences

Of course, the consequences are “unintended,” but that doesn’t mean they couldn’t have been foreseen. “It was never the intention to force people to take heroin,” said Clark. “But if you shut down treatment, and there is an increase in heroin, there will be an increase in HIV, increase in hepatitis, increase in crime, increase in complications associated with using and an increase in international criminal activity.” There will also be an increase in overdoses, which is painfully ironic given that the main reason prescription opioids have had so much attention is the overdoses.

“You can predict the dosages that will cause overdoses with prescription medication,” said Clark. “But with heroin, you’re moving to a market where not only can you not predict the dosage, but you can’t predict the quality — you can’t predict anything — and the risks really start to climb. Treatment is the logical alternative to that chaos.”

Progress has been made on the prescription opioid front, said Clark. “But with that progress we’ve had some other consequences. If it’s a correlation, it’s an unintended consequence. But if it’s a causation, we need to do something about this. Once you become dependent, you need a public health or a medical alternative. It should not be the intent of any authority to drive people from pain relievers to heroin.”

For the report, go to http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.pdf.