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Mismanaging the Heroin Crisis

David W. Murray & John P. Walters

What is driving the staggering rise in heroin use rates, addiction, and overdose deaths—all up sharply since 2008, and accelerating?

The standard answer, repeated by both the media and even some government officials, is that an earlier epidemic of addiction to prescription opiate medication led to a “cross-over” from pills to heroin following a crackdown on improper prescribing and pill mills. According to this assertion, the medical community and law enforcement unintentionally worked together to create a heroin epidemic, the former by over-prescribing opioids and the latter by acting against the problem.

Why does it seem plausible? First, heroin is cheaper, and unaccountably more potent and abundant than prescription opiates (according to this account), leading those addicted to their medication to abandon the quest for pills and turn to heroin. Annual overdose deaths attributed to painkillers (16,000) have leveled over the past five years, while heroin deaths (over 8,000) are still soaring, with a near 40-percent one-year increase in deaths between 2012 and 2013.

Further, some studies show that as many as 80 percent of recent heroin initiates report previous use of prescription opiates.

However, a careful look at the data reveals that this narrative has been vastly oversold.

No responsible person defends the over-prescription of opiates. That is a real problem, as are the misuse of opiate pills and the subsequent deaths by overdose. Nonetheless, wrongly attributing the rising heroin epidemic to the misuse of opioid medications obscures the true causes of the heroin threat and, most of all, the measures needed to counter it.

It is true, as Dr. Andrew Kolodny, Chief Medical Officer of the major treatment provider Phoenix House, puts it, that “Because of the epidemic of opioid addiction, you now have markets for heroin that you didn’t have in the past.” But that fact is not sufficient to drive the current tragedy. In fact, there are two epidemics. It is the supply of heroin that drives the heroin crisis.

The preferred cross-over narrative is actually composed of more than one subplot and several supposed villains. Each dimension has some truth, but none is sufficient to explain what we face. Some story lines lay the blame on pharmaceutical companies, such as Oxycontin maker Perdue, for pushing extravagant over-prescribing.

Somewhat surprisingly, Dr. Tom Frieden, Director of the Centers for Disease Control (CDC), shifted the blame to physicians. As he told the Economist, “This is a doctor-caused epidemic.” To bolster the claim, the Economist notes that “in states with higher prescription rate of opioid painkillers, such as Michigan, Ohio and Indiana, the number of heroin addicts is higher too.”

This statement, however, is only partially true. As the CDC itself analyzed it, ten of the highest opiate prescribing states are in the South, which has the lowest regional heroin use, while heroin use is highest in the Northeast and Illinois.

Further, doctors shouldn’t take all of the blame for the over-prescription of opiates. The Food and Drug Administration (FDA) is also complicit, since they were slow to intervene in prescription abuse (which peaked in 2006, according to national surveys). More recently, the FDA even approved a new and powerful opiate formulary, Zohydro, against the recommendation of its own advisory panel.

Finally, and revealingly, a popular version of this story puts the blame on the Drug Enforcement Administration (DEA) for its “war on drugs” approach to attacking drug supply. According to this narrative (echoed by California Democrat Judy Chu during a House hearing on heroin abuse), it was the DEA’s crackdown on overprescribing that drove addicts into heroin’s embrace. As a US News headline put it, “Heroin Abuse Increase May Be Due to Prescription Pain Killer Crackdown.”

Such accounts nearly always end by supporting “harm reduction” approaches to “managing” the heroin crisis. They cite the familiar “balloon effect” critique of supply reduction efforts: that reducing one part of the problem just makes another part bigger, supposedly rendering all such efforts inherently futile.

These narratives all support the drug control policy of the Obama Administration, which includes rejecting supply control strategies, responding to the increase in deaths by expanding the delivery of overdose antidotes (which does not solve the underlying problem), and, critically, ignoring responsibility for the mismanagement of international programs intended to curtail heroin production and the flow across our borders.

How did the media and the Administration get it so wrong? Mostly by over-simplifying the data and ignoring multiple caveats, many from the CDC itself.

Yes, a majority of new heroin users started with prescription pills. But those making the familiar “gateway” argument must acknowledge that the vast majority of prescription users do not move on to heroin. An even larger proportion of current heroin users first used marijuana, but again, most marijuana users do not so progress.

Even though over-prescription is a problem, the misuse of opiates is not truly “doctor-caused.” Abuse of prescription drugs and marijuana use are risk factors, not causes, of heroin use.

Moreover, heroin users are overwhelmingly poly-drug users. They do not so much “cross-over” from pills to heroin as add another drug to their use profile. As the CDC notes, the majority of heroin users abuse no fewer than three other drugs along with it. Fully 96 percent of people who reported using heroin also reported using at least one other drug within the past year.

Finally, most overdose deaths from opiates involve a variety of substances, including alcohol and benzodiazepines. And although it accounts for only 2 percent of all opiate prescriptions, 30 percent of opiate deaths involve methadone (notwithstanding this fact, the Administration is aggressively seeking to expand its use in opiate treatment therapy).

The same holds true for the small subset of prescription opiate users who begin to misuse pain pills: They commonly have a history of using multiple illicit substances, to which they add prescription misuse. The prescription pill recipient without a history of substance use problems who suddenly falls victim to heroin addiction is simply not typical.

A more careful appraisal of the data reveals the true relationship of prescription pill use to heroin use.

First, with regards to overprescribing: Doctors reported issuing 259 million opiate prescriptions in 2012. In a country of roughly 250 million people, that’s enough to provide every American older than 18 with 75 pain pills per year.

Yet reports from Health and Human Services show important qualifiers. Only 4.3 million people reported misusing prescription opiates within the past month in a 2014 survey. Of these misusers, only 3.6 percent (that is, 155,000) initiated heroin use within 5 years, which works out to about 4 percent of an estimated 914,000 past-year heroin users (2014 data) as possible cross-over users in that year. That is, 96 percent of all heroin users came to heroin in some other manner than direct “cross-over.”

The cross-over argument is stronger if we examine only new heroin initiates, of which there were 178,000 in 2011 (the most recent year available). These data suggest that 20 percent of new heroin initiates in that year could have previously been prescription users. But again, it appears that these people do not so much “cross-over” to heroin as begin to use both heroin and prescription pills at around the same time.

As the CDC writes,

Although it has been postulated that efforts to curb opioid prescribing, resulting in restricted prescription opioid access, have fueled heroin use and overdose, a recent analysis of 2010–2012 drug overdose deaths in 28 states found that decreases in prescription opioid death rates within a state were not associated with increases in heroin death rates; in fact, increases in heroin overdose death rates were associated with increases in prescription opioid overdose death rates…. Thus, the changing patterns of heroin use and overdose deaths are most likely the result of multiple, and possibly interacting, factors.

Next, and crucially, the heroin use crisis was already in motion prior to whatever pill “crackdown” has been implemented. According to the CDC, “In 2013, an estimated 517,000 persons reported past-year heroin abuse or dependence, a nearly 150% increase since 2007.” (The figure for past-year use has risen, as we have seen, in 2014.) In other words, the persistent rise in heroin use and overdoses, starting in 2007 and sharply accelerating in 2010, predates the prescription crackdown, which began in 2011.1

As Dr. Kolodny points out, “there is strong evidence that heroin use was increasing before any significant federal or state interventions on prescription opioids were implemented. The idea that efforts to curb prescription drug misuse have led to a spike in heroin use or overdose has become a common media narrative, but the facts don’t support it.”

The Obama Administration did preside over a raft of initiatives against over-prescription: the DEA’s crackdown on pill mills distributing massive amounts of opiates; state-level prescription-monitoring programs cutting down on doctor-shopping; the up-scheduling of the most widely used opiates, hydrocodones, to the more restrictive Schedule II (taking effect in October, 2014); and the development of an abuse-resistant version of Oxycontin. All of these produced an impact well after the heroin use and overdose epidemic was fully upon us.

Importantly, the crackdown appears to have affected Oxycontin most sharply, and other opiate pills very little. This suggests that abusers had already moved on to drugs such as Opana, Dilaudid, Fentanyl, and hydrocodones, to which heroin gets added.2

As the New England Journal of Medicine found, after the new formulary Oxycontin was introduced that, use decreased, but “… for other opioids, including high-potency fentanyl and hydromorphone, selection rose markedly… it appears that [Oxycontin users] simply shifted their drug of choice … [leading to] a replacement of the abuse-deterrent formulation with alternative opioid medications and heroin.”

Despite the unwillingness of the White House to face the reality of the heroin crisis, and the preference politically for the “cross-over” narrative, the facts concerning heroin point to another factor, one that is still growing rapidly.

The heroin epidemic now underway reflects the sharp increase in heroin availability in recent years. Measurements of the consequences of drug use—of which addiction and overdose deaths are only two—are lagging indicators of changes in the supply of heroin.

Thus it is chilling to note that in 2012, the most recent year for which data on Mexican heroin production is available, the White House posted 26 Metric Tons of potential pure heroin. That is the supply driving the indicators we are seeing today. Though the production estimate for 2014 is supposed to be finished, as yet there has been no White House release, or comment, on just how bad things have gotten among the now-dominant cartels.

Perhaps there are “technical issues” surrounding the release of the data, which could certainly prove discomfiting to White House international policy, if recent reports in the New York Times hold true. The Times, referring to Mexican heroin for 2014 (no one yet knows the state of 2015 activity), reports no less than a 50-percent increase over the previous year, according to unnamed Mexican and U.S. officials.

Moreover, the Mexican government has already announced a stark increase in eradication of opium poppy (from 15,000 hectares to 21,000 hectares) in 2014. Historically, the poppy that Mexico claims to eradicate is often about the same amount that subsequently becomes heroin.

An increase of 50 percent in production would yield nearly 40 metric tons of pure heroin from Mexico alone, a staggering amount considering that past estimates of total U.S. consumption, from all global sources, were between 18–20 metric tons. And it is possible that Mexican production may exceed 40 metric tons.

The 2014 production, already being sold on U.S. streets (though the consequences are not yet recorded in official data sets), may take us well past today’s tragic toll in addiction and death. All eyes should be on the upcoming White House release of this Mexican heroin production data; they will likely portend great damage.

And looming on the horizon is Afghan heroin. For 2014, the United Nations reported that the Afghan crop (measured in poppy cultivation and in opium, rather than heroin) was at a record 224,000 hectares, with 6,400 metric tons of opium (which could generate approximately 600–800 metric tons of pure heroin). It dominates all other sources of heroin for most of the rest of the world.

Were Afghan heroin—already entering Canada—to reach the lucrative U.S. market, the flow would turn into an unprecedented flood of the deadly drug.

The Obama Administration’s misunderstanding of the central role of the increasing heroin supply and failure to make controlling that supply a priority now puts us at risk of a public health disaster.

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