The fact that more Americans are using heroin now than they were 15 years ago has been extensivelycovered. But who are all these new users, and why are they using? How many of them develop heroin use disorders—that is, shooting up daily and behaving in ways that hurt themselves and their families? Science has been slow to answer these questions with hard data. But now, a new, large-scale study focused on heroin use offers some answers on how America’s opioid epidemic developed, and what’s changed over the past decade.
“What we saw is that heroin use and heroin use disorder increased significantly among the American general population, particularly among whites,” says Silvia Martins, an epidemiologist at Columbia University who worked on the study. She and a team of public-health researchers from Columbia and the National Institutes of Health analyzed the results of two nationally representative surveys, conducted in 2001–02 and 2012–13. Together, the surveys included more than 79,000 American adults.
Between 2001 and 2013, the share of Americans who had ever used heroin increased almost five-fold, from 0.33 percent to 1.6 percent, Martins and her co-authors found. The proportion who struggled with a heroin use disorder more than tripled in that time, to about 0.7 percent. Whites are now nearly twice as likely to use heroin as non-whites, and users tend to be white, poor, unmarried men who haven’t gone to college. That’s worrisome because low-income folks aren’t likely to have many resources to help them overcome an addiction.
Martins’ numbers also reveal a little about the culture that gave rise to a more-than-480 percent increase in heroin use in the United States since the turn of the century. More than half of heroin users in 2013 reported that they started with prescription painkillers, compared to about one-third who reported the same in 2001. (The study can’t tell whether those pills were legally or illegally obtained.) That statistic supports the idea that painkillers now often lead people to use heroin, which scientists still debate. “I think there is a strong link,” Martins says, “but, in the scientific community, there are several researchers that don’t agree.”
In addition, heroin users are actually less likely now to be addicted than they were in 2001. Back then, about one in three people who had ever tried heroin had also eventually became addicted; in 2013, the fraction fell to one in five. But because so many more Americans now try heroin, the total number of people with addictions has grown. The new study suggests that, in 2013, about 1.6 million American adults had a past or current heroin use disorder — a number that’s likely an underestimate because the surveys didn’t include people who are homeless or incarcerated.
Martins offers two hypotheses to explain the drop in addiction rates between 2001 and 2013. One possibility: Many of the 2013 heroin users were new to the drug. Perhaps some will become addicted in the future, driving the percentages up to what they were in the past. Another possibility is that heroin has become more socially acceptable, so a wider swath of Americans are willing to try it.
“Because prescription opioid misuse is so normalized in American society, it might also be normalizing heroin,” Martins says. It used to be that Americans often didn’t try heroin unless they were already using other drugs, and were perhaps at a higher risk for developing a substance use disorder. Now there’s a small number of people who report that heroin was the very first drug they tried. Some of these folks may not be at high risk for addiction. But even if someone never develops a heroin use disorder, there are many dangers to shooting up “socially,” including contracting blood-borne diseases from shared needles and overdosing, especially if the heroin is cut with stronger substances, such as fentanyl.
The solutions Martins wants to see sound a lot like what many advocates have, for years, been calling for: Better access to addiction treatment and to naloxone, an overdose-reversing medicine. She also wants to see “educational campaigns to let people know that it’s not a normative behavior.” Even if addiction isn’t guaranteed — Martins’ study suggests that around one in five adult heroin users in America now develop a disorder — the drug still poses many dangers.