Americans are becoming "primed" for heroin addiction through the growing use and abuse of prescribed opioid painkillers, the Centers for Disease Control and Prevention reported Tuesday.
CDC Director Dr. Thomas Frieden said there's an incorrect perception that reducing opioid-painkiller prescriptions leads to a rise in heroin addiction. Both drugs are “essentially the same chemical” and have the same effect on the brain, but the street price of heroin has been about five times less than the price of opioids.
“It's heartbreaking,” Frieden said of the resurgence of injected drugs.
The CDC issued a Vital Signs report Tuesday that compares heroin trends from 2002 through 2013.
There were 8,257 heroin overdose deaths in 2013, nearly four times the rate in 2006. It remained relatively flat at 0.7 per 100,000 deaths between 2002 and 2006, but rose to 1.4 in 2011 and then 2.7 in 2013.
The use of heroin among males ages 12 and older has increased 50% from 2.4 per 1,000 people between 2002 and 2004 to 3.6 between 2011 and 2013. Use of among females increased 100% between those periods, rising to 1.6 per 1,000.
There are about 500,000 heroin addicts in the U.S., according to the CDC, and the number of overdose deaths in 2013 means about 1 in 50 of them are dying, which Frieden called a “remarkably high proportion.”
Ninety percent of heroin abusers use at least one other drug, and Food and Drug Administration Senior Adviser Christopher Jones said that at least one other drug contributed significantly to 59% of the heroin overdose deaths in 2013.
The CDC reported that people who abuse or are dependent on opioid painkillers are 40 times more likely to also abuse or be dependent on heroin. For other drugs, the correlation was much smaller. Cocaine addicts and abusers were 15 times more likely to abuse or be dependent on heroin. For marijuana, it was three times more likely. And, for alcohol, it was two times more likely.
The good news, Frieden said, is that treatment works—but it requires a society-wide effort.
States need to improve prevention and treatment, and make overdose intervention drugs such as Narcan (or naloxone) more widely available. In New Jersey, several hospitals provide free Narcan to police departments so officers have the drug when they encounter someone suffering an overdose.
Healthcare providers, the CDC said, should follow best practices for opioid prescribing. This includes asking patients about past drug and alcohol abuse prior to opioid prescribing, and prescribing at the lowest-effective dose with the minimum quantity needed.
Frieden said the consequences of inappropriate prescribing and addiction are “quite palpable,” but stressed that improving prescribing is part of the solution and not a root cause of the increase in heroin use. There also needs to be increased use of electronic prescription monitoring, he said, and law enforcement needs to make heroin less available, which would drive up the price.
Prescription drug abusers attempt to bypass the opioid pills' time-release mechanisms by crushing the pills and then injecting or inhaling what's left. Manufacturers have stepped up efforts to make this more difficult. But Frieden noted that abuse-deterrent mechanisms in the drugs do not make them non-addictive.
In response to a question about why these products are still on the market, Frieden said that healthcare providers have been trying to get the risk-benefit balance right for 100 years as the pendulum between over- and under-prescribing has swung back and forth.
Patients with terminal cancer pain or acute pain from a car accident need to have access, Frieden said. But he said other methods such as heat, ice, “localized measures,” or physical therapy should be tried first for chronic, non-cancer-related pain. Jones said opioids should be considered if those methods are not effective, not tolerated or not adequate.
Writing an opioid prescription, rather than addressing the root causes of pain, is often the “path of least resistance” for providers, Frieden said.