A review article published in this Thursday's New England Journal of Medicine cites several studies to counteract the oft-stated theory that government crackdowns on access to prescription opioids caused a spike in heroin use and overdose.
Co-authored by leaders at the National Institute on Drug Abuse (NIDA), the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC), the article suggests that while non-medical use of prescription opioids remains a strong risk factor for heroin use, research findings paint a very different relationship from what is often depicted at public forums attended by addiction professionals.
The review concludes that:
- Heroin use among users of prescription opioids is relatively rare;
- Upward trends in heroin use surfaced well before the mainly state-level policies to combat prescription drug misuse were enacted; and
- Market factors around access and price are primarily responsible for the heroin surge.
The article states that “there is no consistent evidence of an association between the implementation of policies related to prescription opioids and increases in the rates of heroin use or deaths, although the data are relatively sparse.”
NIDA deputy director Wilson M. Compton, MD, is the review article's lead author; the article states that while several federal colleagues provided input into the content, the views expressed are those of Compton and his two co-authors and do not necessarily reflect those of their respective federal agencies.
Amid an atmosphere in which federal leaders have aggressively resisted embracing the notion of a link between government actions on prescription drugs and patterns of heroin use, it remains to be seen whether this review article will alter the dialogue among many treatment professionals who appear convinced that a strong link exists.
Question of timing
Much of the journal article's emphasis centers on when patterns of increased heroin use and consequences began to emerge, and how that might relate to trends in prescription drug misuse. The article cites national surveillance data and information collected by poison control centers that show increases in heroin use starting in the 2006-2007 period.
“It appears that the shift toward heroin use among some nonmedical users of prescription opioids was occurring before the recent policy focus on prescription-opioid abuse took hold,” the article states. State-level actions such as implementation of state prescription drug monitoring programs (PDMPs) and enforcement actions against blatantly inappropriate prescribing patterns largely began to take hold after 2010.
Moreover, the article states that a data review published in 2013 found that only 3.6% of nonmedical users of prescription opioids initiated heroin use within five years of starting to misuse prescription drugs. These and similar findings led authors of the latest review article to state that nonmedical use of prescription opioids “is neither necessary nor sufficient for the initiation of heroin use and that other factors are contributing to the increase in the rate of heroin use and related mortality.”
Issues of economics
Chief among those other factors, according to the authors of the latest article, are cost and availability. The authors say that thoughout the period from the late 1990s to 2013, these ranked as the key considerations that users of prescription opioids cited for initiating heroin use.
The authors did add, “Some interviewees made reference to doctors generally being less willing to prescribe opioids as well as to increased attention to the issue by law enforcement, which may have affected the available supply of opioids locally.”
Yet the article also cited five studies—one a multi-state analysis and the other examining trends in North Carolina, Wisconsin, Florida and New York—that suggest that state policies did not directly lead to increases in heroin use. The study in Florida, which in 2010 and 2011 instituted a major crackdown on prescription opioid supply by targeting “pill mill” operations, found that while prescription opioid overdose deaths dropped by 27% in the aftermath of these actions, the declines were accompanied by a scant increase of 60 in deaths related to heroin.
The journal article concludes with a call for a unified approach to combating prescription opioid and heroin addiction, with recommended strategies that include universal family-based prevention, expanded access to naloxone to reverse overdose, and greater access to medication-assisted treatment of an adequate duration.