CDC Reports Significant Increase in Heroin Use and Overdose Deaths, Positive Correlation with Prescription Opioid Use

[Arch-MaesterPhilip]

OMG, Philip, I'm so very sorry. Did she overcome it? :(

Yeah, she is clean for three years and a half years. I'm so proud of her.

[karaddin]

OK I know I'm going against the prevailing direction of most voices on this subject, but I find excessive response to opiates very concerning - these drugs are an important tool and doctors need to have access to use them when appropriate. There is an awful lot of concern around opiate addiction, but I question how many of these people would simply have killed themselves in years where these drugs were not available. Chronic pain is a huge issue in the US today, and rather than simply cutting off pain relief for these people you need to examine the issues that are causing the chronic pain and address those, and continue to provide relief for those that need it. As I said in my previous post cannabis would definitely be an effective approach for many of these people. I could speculate that at least some of these issues come from things like extended life expectancy, coupled with increasing retirement ages, less healthy lifestyles and insufficient time off work (both generally, and specifically insufficient medical leave).

When you look at the current medications used for pain treatment, you have 4 broad categories (excluding cannabis as so much of the world is still being stupid on this) - simple analgesics (paracetamol/acetaminophen, ibuprofen etc), opioids, benzodiazapines and adjunctive therapies. Simple analgesics are of very limited use for anyone with moderate or greater pain and sustained use carries a high risk of health complications, liver damage, stomach damage etc. Adjunctivee therapies includes anticonvulsants and antidepressants and are primarily useful in treating nerve damage, and are not actually more effective than opioids however they do not have as many issues with tolerance. They frequently have much higher issues of adverse effects, and I'll come back to this later. Opioids are obviously what is under discussion in this thread, I'll just note that the adverse effects for them are dependency, development of tolerance leading to the need for higher doses, opioid induced hyperalgesia (increased pain response) and risk of overdose, lesser adverse effects include constipation. Benzodiapines include valium, treat anxiety, can be a muscle relaxant and other effects, but also carry the risk of dependency - they are used in conjunction with opioids. A study from March this year found that the the harm from the different methods of pain management (taking into account the overdoses etc) was highest for simple analgesics, followed by adjunctive therapies, with a substantial gap to opioids on their own and the lowest harm was from the combination of benzos and opioids. Obviously if you overdose and die that harm is greater than side effects, however that's on the individual level and overall harm measures the impact of all the different side effects and their impact on health and quality of life. The same study also stated what should have been obvious, that seeking pain relief when you are suffering chronic pain, is completely rational and not an indication of a desire to abuse the drugs and that patients presenting with these issues shouldn't be treated with suspicion. A consequence of excessive concern around opioids (which tends to extend to benzos as well in my personal experience) pushes people that need these drugs onto the other categories of drugs and results in greater levels of harm on average.

My personal experience was to be pushed towards several drugs - amitriptyline, pregbalin and duloxetine primarily, with a trial of the anticonvulsant gabapentin tacked on the end which may also help with migraines. The first drug did nothing to help me, but made me drowsy. The second I started taking at a dose 1/12 the strength needed to actually work, the idea being that you titrate up to that dose, I was on it for 3 weeks and I have basically no memory from that entire 3 weeks and was a complete zombie to the point of falling asleep even while performing post surgical maintenance work that was very painful, it was impossible to have any quality of life on this drug and I wasn't even able to attempt to increase the dose to try get to the point it would help, so obviously it didn't help. The third one I refused to try, I already suffer from vertigo from my migraines and duloxetine has a 20% rate of causing balance issues, it also has a high incidence of causing sexual dysfunction. As the surgery I just had was sex reassignment surgery, anything which messes with sexual function like that risks causing me lasting issues with my new sex organ and for both these reasons I considered it a no go. That was before I heard from two separate sources that on top of these issues, it is also extremely dependence inducing with withdrawal worse than opioid withdrawal, yet not once in many times this drug was pushed to me was that mentioned by a doctor - it can't get you high, so this dependency is not seen as the issue that it is from drugs that can get you high. Gabapentin isn't causing any excessive issues, however it is in the category of drug that you aren't supposed to stop taking suddenly, so it's still something I need to be aware of and be careful around.

By contrast the slow release oxycodone provided the pain relief that I needed, with minimal side effects. I am highly tolerant so the dosages I needed were very very high, however I was still somewhat functional even on the highest doses I was on, and I have been able to wean my dosage down to the point where my next step is stopping completely without any drama so far. I didn't want to take the drug, I just wanted to be in pain less, so I had no reluctance to wean, and I dropped doses as soon as I could tell it was possible. As I said earlier, I'd be on heroin or dead without it, yet I had to jump through hoops to get it and keep access to it, and had to justify it being the appropriate drug. I'm lucky I'm educated enough and articulate enough to argue my case to doctors, many people are not so lucky and will be shunted off onto the other drugs, possibly forced cold turkey (which is even more likely to push them to illegal sources - and once you are going black market, you might as well go the more effective cheaper option of heroin). So I get passionate about this subject.

[DanteGabriel]

Regarding the early question on why heroin use is increasing -- one factor is that it's just much cheaper than it used to be, and often easier to get than prescription pills.

[eyenon15]

Could it be that heroin trading has less legal penalty than trading prescription pills?

I'm pretty sure both are felonies in most places, the laws for selling prescriptions have gotten really stiff recently.

[Fez]

Street value of a bottle of Oxy (or similar opiate painkiller) is around $80-$90, street value of a similar amount of heroin is $7-$10.

People start on the pills, eventually lose their legal access or get re-prescribed to a tamper-resistant formula, find the cost of diverted pills is too expensive and switch to heroin. This isn't breaking news.

[Michael Seswatha Jordan]

Well I'm from the Hillbilly Heroin capital of the USA, West by god Virginia. I can tell you the most likely reasons. Heroin is rampant in our area. Matter of fact the FED's just handed out 41 indictments in a Heroin drug ring stretching 5 states. Its in the papers everyday, either a bust or a overdose. Its a epidemic.

First off, it usually starts as a pill habit (hillbilly heroin). What causes people to go to heroin is not a lack of pills. Its $$$$$$$$$$$$$. After a while your body builds a tolerance to pills and when paying 1$ per mg (street value), well that becomes a very expensive habit. Then they are introduced to heroin. Where for 20$ you'll get higher than you've ever been in your life. Then from there, as they say, your chasing the dragon.

Couple this with virtually no assistance to help addicts get off the junk, well, you have a shit ton of dope heads. And, its sad. You see family and friends you'd never would have thought, with their life in the gutters. And, trust me, they'd rather put you in jail than help you get yourself together. Its a problem, a huge one at that.

I never touched heroin, and I thank god everyday I wasn't dumb enough to do it. I did have a bit of a pill problem. I kicked it when I had my first born. Unfortunately, many aren't so lucky. I know that a majority of people have dabbled in the pills around here. Its a huge problem in the school systems. I have a few friends who are teachers, and they say it rampant. So, yea, it needs to be addressed. But, all you ever see being done is cops in the paper with stacks of money and bags of oxycotin, smiling ear to ear. Not a single rehab facility in the town. Have to go out of state to get treatment. So, that's the cycle. And, I don't see a damn thing being done about it.

[Guy Kilmore]

Stuff that was informative and totally agree with

Using medication to treat pain is a valid tool and should be available. I went through an awful car accident, had to learn to walk again, all that fun stuff. My pain medication made it possible for me to do this.

With that said, there are two concerns in the medical system that I have seen and experienced with my case load. Many Medical Doctors are ignorant on issues surrounding addiction and they will prescribe highly addicting medications to individuals who are still in recovery. That is....dangerous and could kill the person. (Being off an opiate and then going back to an opiate, relapsing and trying to go right back to the level you were abusing can be lethal.) The other issue that I run into is that alternate ways of treating pain are not supported within the health insurance frame work appropriately, so medication becomes the only real tool that can be used. So we have a situation where a Hammer gets used for everything and that isn't viable.

[Guy Kilmore]

W/r/t methadone I was just talking about withdrawal, in terms of effects it is much different - methadone has euphoric effects similar to other opiates, Suboxone does not (hence the higher functioning you mention). In the linked article they mention tapering down off of Suboxone, which I'm sure is the Suboxone manufacturer's company line. What they don't mention is that even if you taper down to next to nothing, the withdrawal will be quite intense, and if you re on subs for any length of time, it will be very long. Like I said above, it works if you use it for really short time periods, or if you plan to stay on it forever. But there is not much profit in short term prescriptions, and people would opt not to take it if they knew they'd be on it forever, so they act as if tapering is going to be easy. And doctors don't question this, because why would they? It's what they've been told, they have no first-hand experience with withdrawal that would make them question it, and they make more money with longer prescriptions. So they're probably not all lying deliberately, but patients are definitely being misinformed. I'm inclined to be less than charitable b/c several friends have had experiences where all Suboxone related doctor visits were cash only.

I definitely think it is an effective treatment that should be used often, but people should know what they're getting into.

While I'm not doubting your experiences. I'm having a hard time with the word "definite". I have worked with too many clients who were on Suboxone and have successfully tapered off to say that the medical community is trying to milk it for as much as they can. While I have heard stories, just never seen it. When it doesn't happen it appears to me to be a client driven choice and not misdirection from the doctor. This could be a regional thing (I work in Minnesota).

Like Trisk, I would love to see some research on it.

[aceluby]

Is the strength of illicit opiates higher now than in the past? That could be a reason why people who become addicted, perhaps through prescriptions, end up ODing.

No, what's happening is that the stuff on the street isn't actually heroin, it's a concoction being sold as such. What happens is that it gets cut enough so that it still passes as heroin, but then there's another drug that gets added to the large quantity of cut stuff. Like a teaspoon to a vat of the stuff. If one uses and gets ONE GRAIN of this stuff while they ingest will cause a very euphoric feeling that's much stronger than heroin. Three grains of it an it's OD time. I saw some exposes on it after Phillip Semore Hoffman's death.

[jet199]

A good article on drug addiction but it is unfourtunately written by Johann Hari.

Addiction from medical usage is actually very rare considering the thousands of opiates that are given as pain relief every day.

[karaddin]

Using medication to treat pain is a valid tool and should be available. I went through an awful car accident, had to learn to walk again, all that fun stuff. My pain medication made it possible for me to do this.

With that said, there are two concerns in the medical system that I have seen and experienced with my case load. Many Medical Doctors are ignorant on issues surrounding addiction and they will prescribe highly addicting medications to individuals who are still in recovery. That is....dangerous and could kill the person. (Being off an opiate and then going back to an opiate, relapsing and trying to go right back to the level you were abusing can be lethal.) The other issue that I run into is that alternate ways of treating pain are not supported within the health insurance frame work appropriately, so medication becomes the only real tool that can be used. So we have a situation where a Hammer gets used for everything and that isn't viable.

No arguments on either of those points, lack of understanding of these drugs (actually just drugs in general) on the part of doctors and the public is a big part of the problem.

Part of the reason that I push back so hard on this is because the popular narrative around the dependence (and terminology is important here, physically needing the drug or you get withdrawal is dependence, addiction is a psychological issue - aimed at others in the thread as I'm sure Guy is aware of the distinction) causing properties of these drugs actually makes the situation worse. People respond to drugs in part due to the way they are primed to respond, if you tell someone that a drug is horribly bad for dependence they are more likely to become dependent. If you tell someone the drug carries a risk of dependence, but is still safe to use for strictly medical needs and they stick to that (also important here, the ritualistic element of using it as medicine plays a role here) they are more likely to either avoid dependence or safely wean off after its needed. Recreational abuse is more likely to lead to problems both physically and psychologically, so people that do that are in a different bucket. Basically the mass hysteria on the subject is a feedback loop that makes the problem worse, and I wouldn't be surprised if it also encourages more to abuse the drug as well.

The problem in your health care system is a separate and very large problem.

[Michael Seswatha Jordan]

A good article on drug addiction but it is unfourtunately written by Johann Hari.

Addiction from medical usage is actually very rare considering the thousands of opiates that are given as pain relief every day.

Ha, that's funny. Though, actually true. What you see around here is the person being given the prescription, takes only what's necessary to keep levels up to pass urines test, and sells the rest.

[Centrist Simon Steele]

One big issue recently is the DEA along with some other government goons forced pain killers into a higher class of restriction (last year I think). I know because I can't take triptans for migraines as I suffer too many side effects, so my neurologist prescribed hydrocodone to me. He would do thirty pills at a time, and I would call in a refill when I needed it, and I would see him every 6 months. This was doable on my teacher salary, and the way we worked it, I felt like it kept me from getting carried away as I really do have an addictive personality, and I do like the medicine. I never had much laying around, and I knew I couldn't call him often or too soon, so I had to use it when I needed it.

When the law changed last year, I now have to go see him for every prescription, and my copay being 50 bucks, I can't reasonably afford that. Especially when I go through the bad cycles of excessive migraines. So guys like me, who aren't addicts, basically just got screwed out of pain treatment. I deal with the migraines as they come. The addicts who don't want to see a doctor every time to get the written script because this supposedly makes it harder (I guess? More expensive?), they just go get the heroine now I suppose. Thanks DEA!

Anyway, I'm probably better off without them. He offers to fill a 30 pill supply on my six month visit but I don't take it. Midrin came back on the market, and the topomax we tried at about the same time this all happened, and my migraines have been better since then.

I'm just not sure how the restrictions help people. I can imagine people in excessive pain having to get out and see doctors a lot more not being the best for them.

[karaddin]

Having just discovered zolmitriptan (the only good thing to come out of this process was I talked about migraines to the pain doctor and he suggested it) I feel for you, as for me it seems a miracle drug for me... Although at $35 for 4 pills it's not a cheap miracle.

We really need to get a better handle on the cause of migraines rather than treating the pain, but until then I'll take the pain killers when I don't have another alternative.

[Guest]

A good article on drug addiction but it is unfourtunately written by Johann Hari.

Addiction from medical usage is actually very rare considering the thousands of opiates that are given as pain relief every day.

I have seen several articles and interviews with Hari since this book came out. I have not read the book beyond the exerts available.

Hari makes one of the same points in virtually every interview about people going to the hospital post-injury and being given tons of morphine in a medical setting and yet not emerging from the hospital addicted. He is undoubtedly right that this is the case, and one of his points here is that the idea that the drug just instantly hooks your brain/body therefore the solution is to eradicate the substances themselves is BS. That said, the folks that do get hooked, however it happens, get hooked to substances just the same, so while I largely agree with Hari's point, I don't see it as an iron-clad or all-encompassing point.

Hari would tell you that the real cause of addiction is people lacking connections or feeling like they cannot bear to be present in their lives. Again, I think there's something to this, but I resist any catch-all explanation for addiction as I strongly suspect that it is multi-factorial (and importantly, a different cocktail of factors for each individual). For example, while I think most "addicts" are really struggling with existence as Hari suggests, there are also examples of people who were doing just fine until they encountered opiates or booze or what-have-you and only then struggled with existence. A classic chicken-or-egg conundrum.

Back more specifically to the topic: does anyone know to what extent heroine is cheaper today relative to previous eras? Because if it's not, then I would think it would be safe to more-directly finger the opiate Rx drugs as the real culprit here, but I wouldn't jump to that conclusion without knowing if the price of heroin has changed dramatically or not over the years. If heroine is way cheaper than it used to be, that's really interesting. But if heroine is just way cheaper than the newly-prominent Rx drugs, I think you're on the trail.

[kuenjato]

Back more specifically to the topic: does anyone know to what extent heroine is cheaper today relative to previous eras? Because if it's not, then I would think it would be safe to more-directly finger the opiate Rx drugs as the real culprit here, but I wouldn't jump to that conclusion without knowing if the price of heroin has changed dramatically or not over the years. If heroine is way cheaper than it used to be, that's really interesting. But if heroine is just way cheaper than the newly-prominent Rx drugs, I think you're on the trail.

I read a book released earlier this year, Dreamland: The True Tale of America's Opiate Epidemic, which answers this question. It's overlong but quite interesting. The author traces the history of how Big Pharma developed Oxycontin and then aggressively marketed it using bogus statistics, essentially that most patients given opiates as treatment did not become addicted -- the source being a letter a doctor had written in a random medical journal in the late 1970's based on a controlled test from a small sample. This letter was then picked up and used as scientific proof by drug reps, particularly at 'professional training' conferences doctors were required to attend starting in the mid 1980's. The solution proposed? Give 'em pill$, lots of pill$, they aren't addictive, the science says so.

In tandem, he also covers the development of cheap heroin manufacture in a small, forgotten region of Mexico called Xalisco. The native residents in the hills grew poppies and the opium was processed as 'black tar,' which was then smuggled into the USA and distributed through small cells operating in large cities in the west (early-mid 1990's). Because the distributors all came from the same small town, they avoided conflict, became 'friendly competitive' and streamlined the marketing of the product, using a delivery service where junkies called a number and promptly had doses delivered to them. The heroin was always pure--not 'stepped on'--making it very attractive to users. As more cells moved in, prices dropped and the Mexican distributors gave special deals and discounts to retain customers -- the book compares this trafficking and sales model to fast food. As more and more poor Mexican boys moved in, established dealers expanded to other regions in the USA, blending into established immigrant communities in midwest cities like Indianapolis, Nashville, Chattanooga, etc. while avoiding places like Baltimore and New York, which was cartel/mafia territory. During this time the government began to notice the big upswing in prescription medication abuse (around the mid-late 2000's) and started to regulate it heavier. Given the market model above, black tar heroin was cheaper, more powerful and eventually easier to obtain than Oxycontin et al., making it a booming business. As MSJ wrote above, it's become a huge problem in Appalachia, the Rust Belt, etc. The book also describes how heroin became chic among upper-middle class whites during this period, but how the shame involved--particularly when well-to-do teenagers would overdose -- lent a closed-community approach to the growing problem.

http://www.amazon.com/Dreamland-True-Americas-Opiate-Epidemic/dp/1620402505