News from the New York Times and other media outlets yesterday that actor Philip Seymour Hoffman had been found dead of an apparent overdose puts a familiar face on an ongoing epidemic of opioid abuse in the United States. To provide some background on the recent resurgence of heroin abuse in the United States, we’ve reposted a JAMA Medical News and Perspectives article that appeared in October that details the US heroin resurgence.
SAMHSA: Pain Medication Abuse a Common Path to Heroin, Likely Driving Heroin Resurgence
Bridget M. Kuehn, MSJ
“I swore I would never use a needle,” is a common refrain that physician Marc Fishman, MD, hears from young patients in treatment for opioid addiction.
But many of his patients who began their drug use with prescription pain medications do indeed surprise themselves by resorting to injection heroin use. The switch often comes when they are struggling with withdrawal and requiring higher doses to ease their symptoms and can no longer afford to purchase pain medications, which have a far higher price on the illegal drug market.
“It becomes much cheaper and easier to sustain a habit with heroin,” said Fishman, who is the medical director of the Maryland Treatment Centers and an assistant professor at Johns Hopkins University, in an interview.
It’s a sad story physicians at opioid treatment facilities have been telling for years. Now, data from the Substance Abuse and Mental Health Services Administration (SAMHSA) suggest these anecdotes are indeed signs of a national trend, which may be a driving factor in the resurgence of heroin use in the United States.
Heroin use has increased substantially in the United States, from about 373 000 in 2007 to 620 000 in 2011. This trend mirrors rising use and abuse of prescription pain medications.
Using data collected from 2002 to 2011 for the National Survey on Drug Use and Health, an annual anonymous survey of a nationally representative sample of 70 000 US individuals, scientists found that the incidence of heroin use is 19 times higher among individuals who have abused prescription pain medications than among those who have not. Although the overall incidence of heroin use in the population is low, there was a substantial difference in heroin use rates between the groups, with 0.39% of those with a history of pain medication abuse reporting heroin use compared with 0.02% of those who reported that they had never used prescription opioid medications for nonmedical purposes.
A staggering 79.5% of the individuals who reported that they began using heroin in the past year had previously abused prescription pain medications. But only 3.6% of individuals who reported they recently began using pain medication for nonmedical purposes reported using heroin in the 5 years preceding their abuse of the prescription pain drug.
Fishman noted that given the high numbers of individuals using prescription pain drugs nonmedically—SAMHSA estimates that 1.9 million initiated such use in 2011—even a nearly 4% conversion rate to heroin use is a public health crisis. He noted that heroin users face high mortality rates, and they are at risk of lifelong complications, such as contracting hepatitis C.
“It’s a catastrophic risk,” Fishman said.
He urged clinicians to intervene aggressively with individuals who are abusing prescription pain medications, especially young people, who are particularly vulnerable to substance abuse. He said physicians should alert such patients to the risk of progression to illicit drugs and the risks associated with them.
“If there is any use, we ought to be jumping all over it and using it as an opportunity for intervention,” he said.
Heroin Use Increasing
A substantial increase in the number of new heroin users (those who first used the drug in the past year) between 2007 and 2011, estimated to be from 106 000 to 178 000, has driven considerable concern among public health authorities. The total number of individuals who have used heroin in the past year has increased from 373 000 to 620 000 over the same period.
Anecdotal evidence such as that reported by Fishman and others in the addiction treatment arena, as well as smaller studies of drug-using populations, have suggested that prescription opioid abuse was a major contributor to the initiation of heroin use. The new data from SAMHSA provide stronger evidence for substantial spillover into heroin use.
Elinore F. McCance-Katz, MD, PhD, the chief medical officer of SAMHSA and an addiction treatment specialist, explained in an interview that both prescription opioids and heroin affect the same brain receptors and produce physical dependence. She noted that drug dealers may steer drug seekers who cannot afford prescription medications to heroin, which may be snorted initially or injected to deliver a higher dose faster and more cheaply.
She said the new findings should encourage physicians to be more judicious in their use of pain medications. “Just because someone has pain doesn’t mean they need an opioid,” she said.
Physicians should consider alternatives to opioid medications and, if they are necessary, have a clear plan for measuring successful treatment and stopping the treatment if it is not working, she said. They should also assess whether individuals are at elevated risk for substance abuse because of a history of addiction and consult state prescription monitoring databases to determine whether the patient is receiving opioid medications from another physician. Additionally, she recommended drawing up a treatment agreement with all opioid patients to spell out the risks, benefits, goals of treatment, and patient responsibilities.
She noted that physicians should also be aware that there are effective treatment options available for individuals addicted to heroin or prescription pain medications. Two medications—naltrexone, an opioid antagonist, and buprenorphine-naloxone, which requires that the physician have a waiver from the Drug Enforcement Administration—can be prescribed by primary care physicians or psychiatrists in their offices. Methadone maintenance therapy is also available at federally licensed clinics. Physicians should lay out these options for patients with an opioid addiction and help them choose the course that best suits their needs, she said.
Preventing opioid addiction should be a priority for all physicians.
“There is really not a lot of difference between prescription pain medication and heroin in terms of effects on the brain and body,” McCance-Katz said. “It’s very important to be judicious in prescribing these medicines.”