Study Finds Most Heroin Users Start with Painkillers

Study Finds Most Heroin Users Start with Painkillers

The demographics of heroin users have changed significantly in the past 50 years, with many young people attracted to the drug not only for the “high” it brings but because it is less expensive and easier to get than prescription painkillers.

“In the past, heroin was a drug that introduced people to narcotics. But what we’re seeing now is that most people using heroin begin with prescription painkillers such as OxyContin, Percocet or Vicodin, and only switch to heroin when their prescription drug habits get too expensive,” said Theodore J. Cicero, PhD, a professor of neuropharmacology in psychiatry at Washington University School of Medicine in St. Louis.

Image courtesy of Washington University School of Medicine

Image courtesy of Washington University School of Medicine

Cicero and his colleagues analyzed data gathered from more than 150 drug treatment centers across the United States. More than 9,000 patients dependent on narcotic painkillers, or opioids, completed the surveys from 2010 to 2013. Of those, almost 2,800 reported heroin as their primary drug of abuse.

“Our surveys have shown a marked shift in the demographics of heroin users seeking treatment over the past several decades,” said Cicero.

Respondents who began using heroin in the 1960s were predominantly young men in their teens living in urban areas, whose first opioid use was heroin (80%). Recent users are more likely to be white, older (average age almost 23 years) men and women living in suburban or rural areas. Three out of four were first introduced to opioids through prescription painkillers.

To get more detail about their use of heroin, the researchers zeroed in on 54 patients who participated in unstructured interviews.

Most got high with prescription opioid drugs that were acquired illegally Heroin became their drug of choice because it was cheaper than painkillers and more readily accessible. The introduction of “tamper resistant” opioid formulations, which make the drugs harder for abusers to crush or liquefy, was also a factor in their use of heroin.

“If you make abuse-deterrent formulations of these drugs and make it harder to get high, these people aren’t just going to stop using drugs,” said Cicero. “As we made it more difficult to use one drug, people simply migrated to another. Policymakers weren’t ready for that, and we certainly didn’t anticipate a shift to heroin.”

A recent study by the Substance Abuse and Mental Health Services Administration found that use of heroin nearly doubled in United States after a reformulated version of OxyContin was introduced in 2010.

“The price on the street for prescription painkillers, like OxyContin, got very expensive. It has sold for up to a dollar per milligram, so an 80 milligram tablet would cost $80. Meanwhile, they can get heroin for $10,” said Cicero.

Previous studies of heroin users in the 1960s and 1970s found that over 80% were young male minorities who lived in inner cities. Many began using the drug at about age 16.

“Our earlier studies showed that people taking prescription painkillers thought of themselves as different from those who used heroin,” Cicero said. “We heard over and over again, ‘At least I’m not taking heroin.’ Obviously, that’s changed.”

“The overdose deaths and hospitalizations are symptoms of a problem that we really need to deal with,” he said. “You can’t effectively treat people or prevent addiction unless you know why they are taking drugs, and we don’t really have a handle on that yet. Unfortunately, the problem with heroin is it’s the most powerful opiate ever created, and even if people think they are being careful, it can kill.”

Authored by: Pat Anson, Editor

There are 13 comments for this article
  1. James Connell (Ga.) at 12:15 pm

    Why can’t those Idiots in the D.E.A use Lie Detector test on the pain patients they think are taking meds for fun, INSTEAD OF CALLING US LIARS! They are stupid I know but how stupid can u get. Thereare ways to control drug abuse but collage educated fools just can’t figure out how to do nothing rright! Ask the friends & neighbors that see and talk to the patients, if they are abusing pain meds they will know! Its not that hard. Dr.s are MONEY ADDICTS ANYWAY!

  2. James Connell (Ga.) at 12:07 pm

    This country has gone Hyper Paranoid over Prescription Drug Abuse and blaming it on Dr.’s who are trying to help patients. Now you can’t get pain meds unless you’re 90 like my mom. Dr.s overprescribe some and UNDER PRESCRIBE OTHERS ( younger people 40 – 60 ). You people in your 30’s & 40’s…froget about it, ur screwed! Drug Abuse hurts the Drug Abusers…the Drug War….HURTS THE INNOCENT. THE DRUG WAR IS THE DUMBEST ENDEVER, EVER! Its INSANE to continue it. If you’re young, get out of America, there are far better countries to grow old in. They treat older people w/respect! AMERICA SUCKS FOR THE CRONIC PAIN PATIENT. GET OUT NOW, DON’T WAIT!

  3. Dennis Kinch at 8:16 pm

    See how it works?! Even if the article said “Heroin found to be not at all linked to opioids!” Most would read it as: “Heroin is just like those scum who take legal opioids.”

    Until the media covers the legit patients and the good things we do thanks to opioids, and gives it a lot of attention, this will be the way things go.
    So everyone can miss the point. How about an article about what true addiction is? Think that would be newsworthy? Or a study of how much more legit patients taking the correct drugs get done than they would otherwise? Is that newsworthy?

    You are seeing the frustration we all feel, not only as we read these reports, but also when our meds are cut in half by some fearfful “patriots” trying to save us from ourselves. Think of all the work I do with people in pain that they “saved’ me from!

  4. Myron Shank, M.D., Ph.D. at 5:54 pm

    @Wendy: I have read your comment several times, trying to make sure that I understand you. If I misunderstand you, please correct me.

    Your complaint seems to be a perception that National Pain Report is promoting hysteria about the “crisis” of opioid abuse. I can understand how you might get that impression from a few of the articles, if taken in isolation. However, while I often take issue with National Pain Report (see below, for example), I do not believe that the point of this report was the extent of opioid abuse. Rather, it is about a medical paper concerning the changing patterns of that abuse.

    From the paper ( The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years.Cicero Theodore J., Ellis Matthew S., Surratt Hilary L., Kurtz Steven P. JAMA Psychiatry. 2014:366 http://archpsyc.jamanetwork.com/article.aspx?articleid=1874575), the study only dealt with those who had “a primary (DSM-IV) diagnosis of heroin use/dependence.” In other words, this was NOT a study of the abuse of prescription-type opioids, nor even of their abusers.

    A strength of the paper was that approximately 85% of those who were approached agreed to participate in the study–an excellent sampling. Three-fourths of those who participated were from small urban or non-urban areas, almost half were women, and four out of five described themselves as white. All of these are very different from the classic patterns of heroin abuse in this country. Factors that favored use of heroin, as compared to prescription-type opioids: 98% considered the “high” from heroin better, 94% said that prescription-type opioids were far more expensive and harder to obtain, and 32% also mentioned heroin’s greater ease of injection or inhalation. As an example, one participant said: “Heroin is cheaper and stronger than the prescription drugs listed, and the supply is typically pretty consistent. It is also much easier to use intravenously than pills and other prescriptions, which often take more complex methods to break down [into an injectable form].”

    Scientifically, the paper is not strong (but at least it is better than what I have come to expect from the JAMA family of journals). In this study, the authors did not address the sources for prescription-type opioids, nor whether or not their abusers had ever had their own prescriptions, much less whether or not abuse had started with prescriptions for opioid analgesics.

    Unlike much of its news coverage, the article did NOT go beyond its evidence to suggest that therapeutic use of opioid analgesics leads to heroin abuse (As an example: “…overprescribing can lead to harm and abuse.” Geoffrey Lamb, as quoted in: Fauber John. Opioids leading to new class of heroin abusers, study finds. Milwaukee Wisconsin Journal-Sentinel, May 28, 2014. http://www.jsonline.com/news/health/opioids-leading-to-new-class-of-heroin-abusers-study-finds-b99278535z1-260996001.html).

    Although the lead author has previously been quoted as saying that about half of abusers had “started taking these drugs because they had difficulty controlling pain” (Dryden Jim. Among prescription painkillers, drug abusers prefer oxycodone. Washington University in St. Louis Newsroom. November 25, 2013 http://news.wustl.edu/news/Pages/26204.aspx), an even earlier news report cites him as saying that we need to work on ending demand for opioids, rather than on stemming the supply (Storrs Carina. ‘Abuse-Resistant’ Oxycontin May Be Driving Addicts to Heroin. HealthDay News, July 11, 2012. http://www.medicinenet.com/script/main/art.asp?articlekey=160178).

    I am critical of the lead author of the paper’s naivete for being surprised that addicts would substitute a cheaper and more readily available drug when a safer and more predictable drug becomes scarcer and less desirable. However, at least he is honest enough to say that the effect of “abuse-deterent” formulations is to favor the abuse of other drugs.

    I fully agree with you about National Pain Report’s sensational and misleading headline for this article. I also agree with you about the disproportionate preoccupation with opioids, over the much greater health costs of a legal drug, alcohol (and, I would add, tobacco). One might also point to the experience with “prohibition” of alcohol and the counter-experience with “maintenance” therapies for opioids to argue that the social costs of addictive drugs are greatly amplified by an illegal status.

  5. Wendy at 10:50 pm

    You think the editor of this rag could address this “issue” with some balance or education?? Apparently not. Imagine discovering opiate abusers at a drug rehab facility! Tell me something I don’t know!

    Unfortunately, some folks will only read the headline. So give us one on the fiction of the opiate crisis! Maybe more people will read beyond the headline. And you do know the stats are skewed. Just take a look at how many people died from alcohol related causes last year, for instance.

  6. Christina at 5:41 am

    National Pain Report you think you could do a piece on all the dieases there are? Or injuries that impact a persons life? Or nerve blocks and surgeries that have failed patients that leave them in pain? Nobody talks about that stuff only drug abuse and over dose and using out of dated information. They don’t seperate the over doses with everything that was in their body only opioids. Cancer is not the only thing that calls for opioids or when your on the death bed. The world needs to be educated on all of these things that effect patients health. Not just the side of abuse..

  7. Kurt at 5:53 pm

    Lies my government told me…

    They used to say marijuana was the “gateway” drug to heroin. Now the new bogie man is opiate pain medication. Times change, right?

    Remember when LSD caused psychotic “flashbacks” and “chromosome damage”?

    The fact is that there is a political faction in America that has a vested interest in maintaining the economics of the War on Drugs. They’ve been busy trying to will the battle for hearts and minds lately on the prescription opiate front, because the in their minds, the nation has gone bonkers on the subject medical marijuana.

    My problem when the politico/regulatory/antidrug lobby pressures pain doctors into treating their chronic pain patients like suspects that need to be monitored for “abuse” and misuse with so-called opiate contracts.

    When these doctors “fire” a patient for and are fired with the first infraction, which could simply be their PCP treating a sprain with a Vicodan Rx, these patients often have no where to go and end up in health threatening situations due to opiate withdrawal and neglect.

    Opiate withdrawal is enough to make any law abiding citizen look for a solution where he can find it.

    How about if we practice medicine instead of controlled substance regulation?

  8. Dennis Kinch at 1:49 pm

    In studying addiction there is plenty of evidence that addicts come from the truest gateway drug…themselves. There is a lot of confusion with the terms “addiction, withdrawal, tolerance, need want, etc.” Too bad the media doesn’t do its job and flood us with real education, like I had in 6 months of pain classes.
    A series on the myths and urban legends surrounding drugs would be a great idea and wake people up, but it would have to be covered like the flashy, exciting stories. It has to be covered everywhere, like TV shows about it, and songs written about it, and free commercials about it, and cereals with pain patient’s pictures on it; a complete saturation. Got any money?

  9. Bob Twillman at 6:28 am

    I suspect the headline is just a tad misleading. I think it’s likely that most heroin users didn’t “start” with prescription opioids, but instead, started with nicotine, alcohol, and/or marijuana. I also suspect that was true before there was a prescription opioid abuse problem, and the real change is that prescription opioids have been inserted into the chain between those semi-legal drugs and heroin.

  10. Dennis Kinch at 4:52 am

    See how this works? To the drug treatment centers, heroin and painkillers and all the abuses of the laws and the rules around prescription drugs are a huge problem. They dissect and analyze all the data. They take surveys and interview the patients and from this they infer many things, because this is their focus. The abuse of drugs is in their radar. Their world is surrounded by the epidemic of painkiller misuse and for some reason they feel the need to let the public in on their world and their paranoia…and still we get blamed.

    Is it any wonder that my family and friends think I must be addicted to morphine? Is it any wonder that they think my life went down the tubes because of the drug use and not the disease? Is this why my own doctor saw me as an addict who “found a great way to get free Vicodin” instead of looking at his own bone scan results recommending further tests for a bone marrow disease? Does he even realize that this caused me 5 years of needless suffering, advanced disease and the loss of my job and insurance and eventually, MY KIDS!

    Can you see why this story gets all the attention, all the media, all the free commercials showing kids raiding the medicine cabinets? What a shame the problems legal patients experience as they try to fill legal prescriptions doesn’t get the attention. Do we always have to link the minority of people with real addictions with the legitimate patients? The people in this survey have real problems but their “disease” is addiction. Their reason for trying to get these drugs is to satisfy the addiction and get high.

    Pain patients, making up a huge majority of people, like 50 MILLION! – are using the drugs to help with disease and to lessen some of their pain. Every step we take in the process is legitimate and overseen, with doctors, nurses, and pharmacists, and based on legitimate blood tests, MRI’s, bone scans, et al, all so we can find some small amount of peace in an otherwise chaotic life of suffering. It says right in my records, “There is no cure or treatment for this disease at this time. All we can do for the patient is try to make his days as comfortable as possible.”

    Is it for the numbers, do you think? I mean, the number of patients under a doctor’s care and guidance is far larger than the number of abusers. If you don’t have good numbers with the addicted abusers alone, why not bring in some unsuspecting patients to fill the quotas? Why not put fear in the hearts and minds of the public and create some exciting headlines filled with all the scary buzz words like, drugs, heroin, addicts, abuse, illegal, DEA, on and on.

    I guess the story isn’t the same when the headline reads, “Millions of patients with painful diseases find solace and productivity with prescription painkillers!” Or, “ We surveyed 10’s of thousands of pain clinics who prescribe opioids to their patients and no one did anything illegal” ; “The doctor / prescription system works great and has helped most patients find a higher quality of life and a happy, productive existence as they look towards the end of their lives, one of constant pain.” Just not an exciting story is it?

    Not the kind of thing that sells newspapers or looks good in an internet headline,huh, and yet, every time I read these headlines, I get very excited. I guess my focus is in a different area…the legal user in pain.

  11. Steve M at 10:59 pm

    They started by abusing prescription opioids, not taking them as directed. I’m so sick of misleading titles like this one. People read that and believe it. Opioids aren’t the problem, the addicts are.

  12. Myron Shank, M.D., Ph.D. at 6:27 pm

    It is public policy malfeasance to target comparatively safe opioid preparations that have known potency (such as oxycodone) and pretend that it will not promote switching by addicts to far more dangerous and completely unstandardized opioids (such as heroin). The authors of the referenced study are not to blame for those policies; in fact, they should be commended for being among the few to speak out. However, it is hard to fathom their expectation that addicts would not to simply substitute a much cheaper and more readily available opioid for one that had become scarcer and less desirable. Such naivete from “policy makers” who regularly demonstrate their ignorance would be bad enough, but we ought to be able to expect more from “a professor of neuropharmacology in psychiatry.”

    Furthermore, a very clear distinction needs to be made between unprescribed (illegally obtained) opioid drugs and “prescription opioid drugs.” Drugs “acquired illegally” are not “prescription opioid drugs.” One can accurately speak of the nonprescription use of “prescription-type” opioids, to describe legitimate drugs that become diverted into illegitimate use, if one wishes to distinguish them from those that never were legitimate. On the other hand, it is not appropriate to call drugs “prescription” that were not prescribed to their users. It is past time for the rest of us to stop using dishonest terms invented and promulgated by those who have propaganda agendas against the medical use of opioid analgesics.

  13. Pharmaciststeve at 1:41 pm

    One thing that they seldom- if ever – incorporate in these studies is how many of these people abusing some substance.. are multipak a day smoker and are at least border line alcoholics… As a society, we continue to deny that alcohol and Nicotine can be “gateway drugs”.. other than the 51 million a year in taxes they generate.. it is hard to explain the rational of ignoring this fact.