There are times when crime-fighting and public health policy can resemble giant games of Whac-A-Mole. Increase police patrols and bright streetlamps to fight street crime in one neighborhood, and that crime might just migrate to the next neighborhood over. Shut down a restaurant for health code violations, and it might just open up in the same spot, registered under a new name. Or, crack down on the abuse of prescription painkillers, and that might just spark an uptick in heroin abuse, as users are forced to find new ways to satisfy their growing addictions.
Prescription painkillers, which go by names like Vicodin, OxyContin, or Percocet, are powerful drugs, and powerfully addictive. Overdoses of these drugs are responsible for 100 deaths a day in the United States, according to the Centers for Disease Control and Prevention; this rate has tripled since 1990. McGill University researchers found that the United States and Canada rank first and second in the world, respectively, for deaths due to prescription painkiller abuse—deaths that now also outnumber the deaths from heroin and cocaine combined.
These drugs are being over-abused because they’re being over-prescribed. The CDC found that, in 2012, clinicians wrote 82.5 prescriptions for opioid painkillers for every 100 Americans. In the highest-prescribing states (Tennessee and Alabama), there were 143 prescriptions per 100 people.
"The incidence of heroin use is 19 times higher among individuals who have abused prescription pain medications than among those who have not."
To address this epidemic, health officials and law enforcement are increasingly cracking down. The Drug Enforcement Agency announced new restrictions last month on how these hydrocodone-based drugs can be prescribed, and for how long. States’ strategies differ, but many state officials are beginning to take the problem seriously. In Florida, for instance, after a massive policing effort and set of new laws starting in 2009, prescription drug overdose deaths dropped significantly by 2012.
But there are side effects. At the same time that prescription drug overdoses were dropping in Florida, heroin overdose deaths were rising. Opioid pills and heroin affect the same brain receptors, and so they produce the same high. Heroin is more potent, though, and so as addicts’ tolerance increases, many find themselves making the switch.
Marc Fishman, the medical director of the Maryland Treatment Centers, told the Journal of the American Medical Association last year that the heroin addicts he treated often said to him, “I swore I would never use a needle.” As Dr. Bridget Keuhn wrote in JAMA, “the incidence of heroin use is 19 times higher among individuals who have abused prescription pain medications than among those who have not,” and “a staggering 79.5 percent of the individuals who reported that they began using heroin in the past year had previously abused prescription pain medications.” And the numbers of new heroin users has increased sharply since 2007.
Last year New York became the first state to reclassify and control hydrocodone in the same way that the federal government did just last month. Since then, Capital reported last week, the state has seen a drop in the number of painkiller prescriptions being filled. Overdoses from these drugs are still increasing, but they are increasing at a smaller rate—giving health officials hope that there were fewer people who were becoming new addicts.
Just a few days before that report, though, there was another from the New York City Department of Health and Mental Hygiene that showed that the city is experiencing a heroin overdose crisis, “with more people in the city dying in overdoses from the drug than in any year since 2003,” as theNew York Times reported. “The death toll from heroin has more than doubled over the last three years,” even as overdoses from prescription painkillers has leveled off during that time. The article noted the fear among treatment experts that the younger generation of prescription painkiller users will switch to heroin as increased regulations and monitoring make prescriptions harder and harder to come by.
New York was the first state to reclassify hydrocodone; will other states across the country see these same side effects? This discussion is certainly ongoing elsewhere. In Minneapolis, prosecutors, doctors, law enforcement officers, and treatment experts all convened at a statewide “heroin summit” last Thursday to try and address what they are calling a “public health epidemic” in Minnesota. The Star-Tribune reported that “medical professionals talked about how addiction to prescription painkillers continues to drive the increase in heroin use. The pills are often stolen from medicine cabinets at home and lead to stronger drugs like heroin.”
All of this is not to say that law enforcement and policymakers shouldn’t crack down on prescription drugs, despite the risk that pill addicts will spill over into the heroin market. Putting a stop to rogue prescribers, shutting down “pill mills,” and educating well-meaning but out-of-touch doctors about the need for stricter controls, can all help to decrease the number of new addicts. And even without new regulations on prescriptions, current addicts have other reasons to make the switch to the harder stuff. For one thing, heroin is much cheaper than prescription pills. “Opiate pain medications cost the uninsured about $1 per milligram; so a 60-milligram pill will cost $60,” according to CNN. “You can obtain the equivalent amount of heroin for about one-tenth the price.”
In another JAMA article this July, Bridget Kuehn interviewed Theodore Cicero, a psychiatry professor at Washington University who had been studying the changing demographics of heroin users in America. (Compared with previous generations of users, new heroin users “are more likely to be older, to be white, to live in nonurban areas, and to have previously abused prescription painkillers.”) Kuehn asked Cicero about why the people in his study said they made the switch from prescription drugs to heroin. “Most indicated that the high was better with heroin, but the primary driver was expense or availability,” he said. “It was a very practical decision.”