The face of heroin use in the United States is changing. A study published in JAMA Psychiatry this week found that compared with previous generations of heroin users, newer initiates are more likely to be older, to be white, to live in nonurban areas, and to have previously abused prescription painkillers.
Anecdotal reports from law enforcement and substance abuse treatment professionals have long suggested that many individuals who become addicted to prescription painkillers eventually move on to heroin when it becomes too difficult or expensive to access prescription opioids. Recent data from the Substance Abuse and Mental Health Services Administration support this anecdotal evidence.
The latest study provides evidence of major shifts in the demographics of heroin users, and bolsters the case that prescription opioid abuse is fueling a rise in heroin use. Using survey data from a national sample of 2797 patients entering substance abuse treatment, the researchers found that although individuals who began using heroin in the 1960s were mostly young men in their mid-teens whose first opioid drug was heroin, more recent initiates have a very different profile. Most were in their mid-20s and predominantly white (90%), lived in suburban or rural areas, and began abusing prescription drugs before trying heroin. In addition, men and women were equally represented among newer users. Prior to the 1980s, heroin users were roughly equally divided between white and minority groups, the authors note.
“Heroin is now out in mainstream America,” said Theodore J Cicero, PhD, lead author and professor of psychiatry at Washington University in St Louis. Cicero discussed his findings with news@JAMA:
JAMA: Why did you decide to do this study?
Dr Cicero: We have been surveying people entering treatment for many years. Until 3 to 4 years ago, individuals rarely indicated they had used heroin during the past month. We started looking in a systematic fashion at what was driving people from prescription opioids to heroin.
JAMA: What do your findings tell you about the current demographics of heroin users?
Dr Cicero: The typical heroin user in our population is a white, middle-class male or female. Historically, females were a minority of heroin users. Most are in their mid-20s and fairly well educated. It’s not who you would picture a heroin addict to be.
JAMA: What do you think has driven this change in the demographics of heroin users?
Dr Cicero: In the ’60s and ’70s, there was less prescribing of opioid medications. In the ’90s, physicians were urged to increase use of analgesics. As a result there was some leakage from therapeutic to nontherapeutic use. These prescription opioids weren’t very accessible in inner-city communities but they were readily available in suburban and rural areas. Once individuals got hooked, they started seeking out other drugs that are cheaper or that are more accessible to get the high they want.
JAMA: Could the availability of treatment have influenced your results?
Dr Cicero: There is that limitation in data. We tried to balance treatment areas around the country. In many cases, there is very little publicly funded treatment in the inner city. I don’t think we are seeing a sharp decrease in heroin use in the inner city. What’s growing is rural and suburban use. Overall, the number of users is increasing.
JAMA: Why did your survey respondents say they switched from prescription opioids to heroin?
Dr Cicero: Most indicated that the high was better with heroin, but the primary driver was expense or availability. It was a very practical decision. They were concerned about the danger of heroin. Most express surprise at themselves but say, “I was almost forced [to take heroin]. I need to take it to not get sick.”
JAMA: What do you think physicians and the public need to know about this data?
Dr Cicero: Physicians have to recognize that middle-class, white patients may be taking heroin and [patients] need to be aware of the health risks that go with that, including HIV/AIDS, hepatitis, and overdose.