Uptick in Heroin Use Linked to Prescription Opioid Abuse

FP Expert Offers Practical Advice on Detection, Intervention

July 23, 2015 01:57 pm Cindy Borgmeyer

Ready to gauge how much you know about heroin use in the United States? Here's a short quiz.

[Substance abuse and man/woman shooting up with heroin syringe]

Which of the following statements is true?

A. According to the latest data, people who abuse or are dependent on opioid analgesics are 40 times more likely than non-users to abuse or be dependent on heroin.
B. Although men remain more likely than women to abuse or be dependent on heroin overall, growth in the prevalence of heroin use among women between 2002 and 2013 far outstripped that seen among men over the same period.
C. During the past decade, most people who used heroin also used at least three other drugs.
D. A and C only.
E. All of the above.
F. None of the above.

Sadly, the correct answer is E. And the gloomy statistics don't stop there.

According to new CDC data,(www.cdc.gov) the number of people who use heroin -- and the number of overdose deaths attributed to the drug -- have skyrocketed in the past decade. In fact, the rate of heroin overdose deaths quadrupled between 2002 and 2013.

Story Highlights
  • According to new CDC data, the number of people who use heroin -- and the number of overdose deaths -- have skyrocketed in the past decade.
  • It's a trend that can be tied directly to the nation's prescription opioid epidemic, says CDC Director Tom Frieden, M.D., M.P.H.
  • Family physician Robert "Chuck" Rich, M.D., outlines steps to work with patients who use opioid analgesics to prevent them from becoming addicted to the drugs or to intervene if they do.

What's behind the dismal numbers? CDC Director Tom Frieden, M.D., M.P.H., chalks it up to two complementary factors.

"Heroin use is increasing at an alarming rate in many parts of society, driven by both the prescription opioid epidemic and cheaper, more available heroin," he said in a statement on the CDC website.(www.cdc.gov)

In a July 7 telebriefing,(www.cdc.gov) Frieden spoke in greater detail about the problem, noting that the latest information puts the number of people in the United States who are addicted to heroin at about 500,000. In 2013 alone, he pointed out, more than 8,200 people overdosed on the drug. A break-down of those numbers would suggest that about one in every 50 people who are addicted to heroin may die from using the drug in any given year.

"That's a remarkably high proportion and reflection of how dangerous it is to have a heroin addiction, to have heroin supply from sources where the purity may change rapidly, and to use it by an intravenous route," Frieden observed.

The solution he envisions is fourfold:

  • improve opioid prescribing practices to prevent addiction,
  • expand treatment access to those who are addicted,
  • boost naloxone use to reverse overdoses and
  • facilitate law enforcement agencies' efforts to reduce the supply of heroin.

"We need an urgent, all-of-society response to improve prescribing, help those who are addicted (find) treatment, and work with law enforcement at all levels to reduce heroin supply," said Frieden. "Everyone has a role to play."

What the Research Shows

Recognizing that both heroin abuse and dependence and heroin-related deaths have risen significantly in recent years, researchers from the CDC and the FDA teamed up to assess the demographic and substance abuse characteristics of today's users, hoping to inform prevention efforts. Their findings were published(www.cdc.gov) July 10 in the CDC's Morbidity and Mortality Weekly Report (MMWR).

Using data collected from 2002 to 2013 as part of the Substance Abuse and Mental Health Services Administration's annual National Survey on Drug Use and Health, the researchers were able to formulate national and state-level estimates of illicit drug use, including nonmedical use of certain prescription medications, along with alcohol and tobacco use estimates. They then examined cause-of-death data from the National Vital Statistics System for the same period to identify heroin-related overdose deaths.

The researchers highlighted a number of key findings:

  • The annual average rate of past-year heroin use among people ages 12 and older rose from 1.6 per 1,000 individuals to 2.6 per 1,000 individuals over the study period.
  • The prevalence of past-year heroin abuse or dependence was strongly correlated with heroin-related overdose deaths in the United States, with overdose deaths increasing by 286 percent between 2002 and 2013.
  • Prevalence of past-year heroin use was consistently higher among men than women over the life of the study, wrapping up at 3.6 per 1,000 men compared to 1.6 per 1,000 women.
  • Heroin use among people ages 18-25 saw the biggest increase (108.6 percent) over the duration of the study.
  • Overall, 96 percent of past-year heroin users reported using at least one other drug during the year, and 61 percent said they used three or more other drugs.

The MMWR report found that past-year use of heroin showed the greatest increases in two groups that historically have had the lowest rates, doubling among women and more than doubling among non-Hispanic whites.

The Family Physician's Role

Those last statistics come as no real surprise to one family physician expert. Robert "Chuck" Rich, M.D., of Bladenboro, N.C., chair of the AAFP Commission on Health of the Public and Science and former chair of the commission's workgroup on opioid abuse and pain management, observed that given the well-documented increase in substance abuse in the general population overall, "it is not surprising to see increases by populations not previously in the higher use demographics."

"With heroin's increasing availability and drop in price -- particularly versus the increasing street price of opioid pain relievers reflecting, partially, the drop in supply from the effect of stepped-up enforcement efforts -- I would expect to see increased use of heroin by all demographics," Rich explained.

Moreover, because it's a trend Rich expects to continue, he recommends heightened vigilance for all signs of abuse.

"As we continue to focus on the abuse of opioid pain relievers, I remind all providers that we must not forget previous drugs of abuse such as heroin and cocaine, as well new emerging drugs of abuse, and be willing to intervene for patients," Rich said.

As for how family physicians can intervene, Rich offered plenty of practical advice, starting with acknowledging that patients who use opioids are at increased risk for abusing a wide range of other substances, including heroin.

"After acknowledging that the problem exists, family medicine physicians have a responsibility to then periodically screen both their existing patients on opioid pain relievers and patients new to opioid pain relievers for the possibility of substance abuse," Rich said.

He suggested that FPs use validated patient screening protocols and tools such as Screening, Brief Intervention, and Referral to Treatment(www.integration.samhsa.gov) (SBIRT) or the Drug Abuse Screening Test.(www.bu.edu)  (An overview of Medicare and Medicaid coverage for SBIRT screening and related topics is available from CMS.(www.cms.gov))

A comprehensive approach to screening for substance abuse may include use of various urine and blood toxicology screens, as well as accessing information contained in the prescription drug monitoring programs now available in most states, Rich added.

If abuse is detected, he said, it is the physician's responsibility to work with the patient to ensure that he or she takes the next step to obtain treatment.

"While many family medicine providers may choose to refer their patients for substance abuse treatment to other providers, as family medicine physicians, we need to work to make sure that our patients receive the treatment needed and to advocate for coverage of that treatment by governmental and private insurers."

For those who choose to provide these services themselves, Rich has this message: "Kudos to you, and as a reminder to the rest of our membership, there are training courses readily available, including online courses for medication-assisted treatment."

Finally, he advised, "In working with patients tapering off opioids, providers must remind themselves that the process can be difficult for the patient, often requiring weeks to months to accomplish and associated with the potential for relapse."

It's critical that physicians be patient, supportive and understanding during this time, Rich said. In instances in which a patient is receiving treatment outside the practice, the physician's role is primarily supportive and focused on ensuring the patient adheres to treatment.

"To assist in that process, our members can ensure that these patients receive counseling and referral to support groups, with more frequent visits to our offices to ensure that treatment is ongoing," he said.