COMMENTARY

Heroin: The Epidemic That Knows No Boundaries

Tom Frieden, MD, MPH

Disclosures

July 27, 2015

Editorial Collaboration

Medscape &

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As a physician, I am alarmed by our latest research on heroin trends.

Between 2002 and 2013, heroin use increased by more than 60%. Tragically, the heroin death rate also increased by nearly 300%.

Heroin abuse is highest among males, non-Hispanic whites, people with low incomes, people without insurance and not enrolled in Medicaid, and those living in large urban areas. However, researchers found big increases among groups who have had historically low rates of heroin use: women, people with higher incomes, and people with private insurance.

Nearly all heroin users report using another drug in addition to heroin in the past year. Two out of three used at least three drugs. Cocaine continues to be commonly used alongside heroin, but we also found a startling increase—130%—in the percentage of people using heroin and prescription opioids without a medical reason.

Our data show that people who are abusing or are dependent on prescription opioids are 40 times more likely to be abusing or dependent on heroin.

There has been speculation that the decrease in inappropriate opioid prescribing is driving people from abusing these drugs more to heroin. For some individuals, this may have happened, but the data strongly suggest that that is not the primary driver of the heroin increase.

Heroin is cheaper, more potent, and more available than it has been in the past. Just like alcohol and cigarettes, when heroin is cheap and readily available, people are more likely to use it.

Clinicians have an important role in reversing this troubling trend in heroin abuse. We need to talk with our patients about the serious risks of taking prescription opioids. These risks include addiction, overdose, and death. We need to remind them of other pain treatment options that may be more appropriate for their conditions and less likely to lead them down a terrible path.

Prescription opioids are powerful and highly addictive. It's critical that providers follow best practices for prescribing, and providers should use their state's prescription drug monitoring program to identify patients who might be misusing prescription drugs.

If a patient hasn't previously received an opiate, consider all options before prescribing one. Even for severe pain, physical therapy, nonsteroidal medications, acetaminophen, local measures such as warmth and ice, and realistic expectations about time to recovery can make a big difference. Giving a patient an opiate medication for the first time is a momentous decision. Other than for patients with intractable, terminal pain from conditions such as advanced cancer, opioids should be prescribed only if other options fail.

For patients already struggling with heroin addiction, it's imperative that they have access to effective, medication-assisted treatment. This includes methadone, buprenorphine, or naltrexone, with counseling and behavioral therapies.[1] Medication-assisted treatment has been shown to improve social functioning and reduce risky behaviors that transmit infectious diseases such as HIV and hepatitis C.[2]

Heroin use is increasing across nearly all populations, and there is a connection to prescription opioid abuse. The bottom line is that it's our job to prescribe prescription opiates responsibly, identify patients who might be misusing them, and support those who are addicted to prescription opioids or heroin with medication-assisted treatment.

Web Resource

Vital Signs: Today's Heroin Epidemic

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