National data is released frustratingly slowly, but recent reports out of Washington state, New York City and Maryland suggest that, over the next several years as national data trickles out, heroin deaths will be up across the board.
“The local trends are what feeds into the national data and what we’ve seen are increasing heroin indicators such as overdoses, arrests and deaths,” says Wilson Compton, deputy director of the National Institute on Drug Abuse. “We’re seeing a shift in the heroin epidemic system to areas that previously weren’t involved in it. In rural and suburban areas.
Opioids – the class of drug that both heroin and many prescription painkillers are a part of – all bind to the same part of the brain to induce euphoria and relieve pain. Though there are often differences in how a drug user takes an opioid (painkillers are generally swallowed, though they can also be crushed up and injected whereas heroin is snorted or injected), once they’re in the body, they often feel essentially the same to a drug user. Compton notes that in blind studies, drug users often can’t tell the difference between types of opioids. That’s an important part to the puzzle, because it makes heroin a good substitute for painkillers, and vice versa.
“When heroin users weren’t able to obtain heroin, they’d use pills as a secondary substance,” Compton says. “They’d say it wasn’t their favorite, but sometimes they liked it just as much. But what has been emerging is the trajectory from pill to heroin use.”
That data hasn’t shown up in national studies yet, but one report in Maryland saw a 41 percent increase in heroin deaths between 2011 and 2012, following four years of decline. Meanwhile, prescription opioid overdoses decreased by 15 percent over the same time frame. In Washington, the number of criminal suspects who tested positive for heroin jumped from 842 in 2007 to 2,251 in 2012, a 167 percent increase.
Starting in the last several years, states such as Florida, West Virginia, Kentucky, New York and Maine have enacted laws making it more difficult to obtain prescription painkillers. Some of the laws require better patient identification, prohibit “doctor shopping” – a process where patients (or addicts) will go from doctor to doctor, collecting prescriptions, set prescription limits and make it harder to use fake prescriptions to obtain drugs.
The result? Street prices of prescription opioids have increased and supply has plummeted. Once someone is already addicted to opioids, heroin becomes an alternative.
“The similarities [between heroin users and prescription drug abusers] are becoming closer and more similar over time,” says Leonard Paulozzi, an epidemiologist at the Centers for Disease Control and Prevention. “A lot of new heroin users in the past few years were originally prescription opioid users, and they’re usually the ones who were using heavily on a daily basis.”
Paulozzi says that, anecdotally, new heroin users are likely to be older than the stereotypical young junkie and was likely introduced to opioids through a prescription.
“You’ve seen increases in the white population, in women, there’s been more penetration of heroin into rural areas,” he says. “Heroin used to be primarily urban, but opioids changed that because of the fact that everyone lives near a pharmacy. Perhaps current heroin sellers are taking advantage of prescription users in areas of all sizes.”
There’s law enforcement data to back up the theory. The Drug Enforcement Administration seized four times the amount of heroin along the U.S.-Mexico border in 2012 as it did in 2008.
Politicians are stumped about what to do: Maine Governor Paul LePage said Tuesday in his State of the State address that heroin overdose deaths increased fourfold between 2011 and 2012 and called on lawmakers to provide greater resources to the state’s DEA and law enforcement in order to fight the trend.
But better law enforcement probably isn’t the answer, according to some research. Despite the increase in seizures, heroin is now more plentiful than ever, according to a report by the University of British Columbia’s Urban Health Research Initiative released in the British Medical Journal last year. Worldwide, the average purity of heroin increased by 60 percent between 1990 and 2010, the study said. The street price of heroin was cut in half.
“Cocaine or heroin can be cut at a number of stages in the process, but the supply is so great that there’s no need to do that anymore,” Evan Wood, lead author of that study, said.Wood said even if seizures continued to increase, the overall amount of seizures at the border are ultimately a drop in the bucket.
“All the drugs needed to supply the U.S. for a year could fit into 60 semi trucks,” he said. “At Laredo, there’s 5.5 million trucks crossing the border every year. It gives you a sense of how difficult this task is.”
In Vermont, Gov. Peter Shumlin, Democrat, noted similar increases as Maine’s LePage, a Republican, but suggested a legal crackdown should be secondary to expanded treatment.
“In every corner of our state, heroin and opiate drug addiction threatens us,” he said, in his own State of the State delivered Jan. 8. “What started as an OxyContin and prescription drug addiction problem in Vermont has now grown into a full-blown heroin crisis.”
Instead, Shumlin said he’d increase the number of treatment centers and work on preventing addiction altogether.
While there’s no magic pill to prevent addiction or make the problem go away, there is, essentially, a magic pill that can prevent an overdose. Called naloxone, the drug binds to the brain’s opioid receptors but has none of the effects of heroin or oxycodone. NIDA’s Compton says the drug essentially knocks another opioid off the receptor and prevents it from having any effect.
“When people are breathing in a shallow manner, halfway dead, you can give it to them and it has remarkable effects within a few minutes,” he says.
It is routinely given in hospitals and, in other countries, is often available over the counter. In the United States, it’s a controlled substance only available with a prescription.
There are ongoing studies that would look at whether naloxone should be “in every first responders’ bag,” Compton says, and whether it might be safe enough to be given over the counter to addicts and their families.
Last year, Maine’s LePage vetoed a bill that would have expanded the availability of naloxone.
“We’re working on ways to reduce this horrific epidemic, and we’re working with the federal government on ways to increase its availability,” Compton says. “Researchers are looking at what should be the limits of access.”