As children growing up in rural parts of a Midwestern farming community in the 1950s and 1960s, my friends and I thought of drugs and addiction, and especially heroin addiction, as things that happened far away, only in big cities, mostly among people who were very different from me. To this day, ask some people what they think the average heroin user may look like, or who they are, and one answer you here will be something about a street person, maybe living under bridge, probably an older guy, maybe an ethnic minority, someone so into the drug that they never take time to look after themselves, clean up or dress up, or engage in the normal work-a-day world. Maybe someone on the street who had to steal money or things to sell in order to meet the financial demands of a full-time heroin use. The idea of the homeless bum on the street, a poor, unkempt, middle aged ethnic minority is a stereotype many people carry about substance abusers, and heroin users in particular, that was never really accurate, and is even less so now. In 1960, heroin users were overwhelmingly male (80%). While ethnic minorities were overrepresented, a slight majority were young white males, and the average age of first using the drug was only 16 years old. It was, in those days, mainly a problem in major urban centers, and more than 80% of first time users started with street heroin.
A recent study in the AMA Journal ‘Psychiatry’ by Theodore J. Cicero, PhD., details just how much all that has changed, and sparked a flurry of review blogs and articles in Forbers, the Washington Post, Business Insider, and others. Cicero’s findings: More than 50% of heroin users are now women. More than 90% are white. First time users are now mostly in their 20s. In the 1960s, most opioid users started on heroin. Today, a majority, over 60%, begin not with the street drug, but with prescription opioids – pills like OxyContin, hydrocodone, fentanyl, codeine, morphine, and tramadol – switching to heroin only after the pill habit grows out of control and too expensive to maintain.
That was Mary’s story. She never saw it coming. She never believed she could become a heroin addict. Injured in an accident in 2001, her doctor prescribed multiple drugs to contain her pain, including high doses of OxyContin, a prescription opioid. Over time, her dose was lowered, but by then she was already hooked. Addictions Nurse Katie Bell states: “At a certain point, the physiologic dependence is guaranteed. Then patients begin to develop a tolerance, a need for more. People start taking more than prescribed, getting from others, eventually buying it on the street.” Mary had discovered exactly that – she couldn’t do without the higher doses of the drug without experiencing the painful and uncomfortable symptoms of withdrawal. As the brain adjusts to prescribed doses of opioids, come people find a terrible thing happening- t hey need more and more of the drug to experience the basic relief that required only a few, moderate doses of the med before. To supplement her lowering prescription, Mary turned to the internet and to the street s, where black-market OxyContin pills were selling at a steep $80 per pill. Unable to afford the spiraling costs of eight pills a day, she quickly learned t hat she could sell her pills and use the money she got to buy less expensive heroin, whose price on the street has dropped enormously in the last 20 years.
The sudden resurgence of opioids as a drug of abuse and addiction can be traced to the interactions of social, political, policy, supply, and user dynamics. Legal opioid abuse (mostly prescription painkillers) has been driven by the medical and pharmacological efforts to ease the burden of chronic physical pain. These pain medicines in turn become available to young users through family members who have prescriptions, or through friends who have similar access through family members. These same pills in turn appear on the black market, as some people sell them to make money, either to supplement incomes or raise funds for a cheaper habit, like heroin. The expansion of the heroin trade can likewise be traced to changes in production, including a shift from Asia to Mexico as a primary source for American street heroin. As Americans move to legalize marijuana in more and more states, traditional growers of this crop in the Mexican Sierra Madre mountains have in turn switched to opium poppies as a new cash crop to replace lost sales of marijuana to people in states like Colorado, Washington, and California, where pot is becoming an increasingly profitable agricultural product for budding entrepreneur pot farmers. Also changing are local delivery systems: dealers are no longer all hard core criminal types in central cities, and sometimes include elderly neighbors who have extra pills they will sell to increase their meager retirement incomes. Nurse Bell, formerly of the VA, now works in community medicine in a small mountain community in the Western United States: “Part of what we have to do is reform the economic issues that create the problem of the ‘pill ladies’ that are now a part of small communities like this.”
We have learned the hard way that this isn’t true. In 1999, as opioid prescribing became an entrenched feature of chronic pain care, overdose deaths attributable to such drugs were 4,000 per year. By 2008, such deaths had almost quadrupled, topping 15,000 that year according to the CDC Mortality and Morbidity Weekly Report. During this same time period, concern over safety and ease of overdose escalated in regulatory agencies, and strategies were devised to make prescription drugs less easily abused. In 2012, Dr. Russell Portenoy, MD, the same researcher who had so avidly supported in expansion of prescription opioid treatment for pain in the 1980s and 1990s, published an oped in the Wall Street Journal acknowledging that the risk of addiction is indeed higher than had been thought – nearly 40% of moderate to long-term users of opioid pain killers are at risk for ongoing addiction. The same year – 2012 – four out of ten fatal drug overdoses in America (over 16,000) involved prescription opioid painkillers, more than 40 people every day.
While the average age of opioid users has risen, many people still start young. One study suggests that 1 out of every 60 young people will start abusing prescription opioids every year, usually at or around 16 years of age. Many people will start by getting or stealing pills from family or friends. Surveys indicate that half of all children have access to their parents medicine at home, and significant numbers of families ‘stockpile’ prescription pain killers ‘in case’ somebody else in the family ‘needs’ them. In the clinical setting I’ve often had people tell me they started with pills they’d somehow gotten from parents or grandparents. Prescription opioids have also fostered an entirely new class of drug dealers in many neighborhoods, especially rural areas. As noted above, some elders have found that getting a prescription opioid they don’t need, and selling these pills at street value is an excellent way to supplement inadequate retirement income. These “pill ladies” supplement the flow of prescription opioids to the streets, alongside those noted above who sell their prescribed pills to obtain cheaper, injectable heroin.
The number of annual heroin users was only 370,000 in 2007; this has grown to 680,000 in 2013. Along with this change in demand has come changes in the supply chain that gets raw heroin to the US street corners. As noted above, the decreased cost and increased availability of marijuana in the United States over all, and the decriminalizing/legalizing states in particular, has had an impact on economy of marijuana supplier. Traditionally, apart from those who’ve grown their own or who’ve cultivated as a collective, American pot on the street has been a product of multitudes of small farmers from the Mexican Sierra Madre Occidental, under the direction cartels of suppliers who bundled and shipped it the US border and on. As pot demand and prices plummeted, the movement of pot from this mountainside network of pot farms dried up in response, and the farmers (and their cartel directors) moved toward the production of opium poppies, the raw ingredient from which all opioids are manufactured. This has been facilitated by policy changes in the US, in which the DEA and their Mexican counterparts shifted their attention away from the Sierra production landscape and into high-drug-crime and smuggling hotspots like Ciudad Juarez and Tijuana along the US/Mexico Border, allowing the increase in opium production in the mountains to go unnoticed, or at best, unaddressed. As a result, Mexico is now the 3rd largest supplier of opium products to the United States, after Afghanistan, and Myanmar. Proximity to the US makes for very low transportation costs compared to heroin from Asia or South America, and smugglers are getting savvier and more daring. Once upon a time, confiscating even 5 kg was a big take down for the DEA. Now it is not uncommon to find 20 kgs in a single shipment, if it is found and confiscated at all.
Along with change in how people use opioids, how they first become addicted, and where their supply chain comes from, have come changes in addiction recovery, as well as ongoing recovery support and intensive rehab treatment strategies. As cultural perceptions of the typical user change, so also do attitudes about treatment and rehabilitation. With opioid abuse on the uptick, more of us are likely to know someone, perhaps even a family member, who suffers with the disease of addiction. This is itself one of the changing attitudes – addiction is being seen in medical and psychological terms more and more as a disease, a very bio-physical-psychological disease, rather than as an over-simplified, individual social and moral problem. Goals of treatment and rehab are also changing. We want to provide adequate medical support for t he complex biophysical process of withdrawal from heroin and other opioids, a process than can be months in unfolding, as a body begins to adjust to adapt to the challenges of living with the pains and aches, as well as the emotional wounds and traumas, that drug abuse has been used to mask. We also want to support those in recovery
in learning new skills both to take the place of the soothing aspect of the drugs they have been using to cover up pain, as well as skills to maintain their ongoing emotional health. We also return again and again to basic family models, and seek to incorporate family and community support in the recovery process, as well as greater access to support medications that reduce cravings and increase the chance of those in recovery to avoid relapse and other setbacks. If you know someone who suffers from this disease, now may be the time to step and support their movement to treatment and healing.
Fred Erwin, Ph.D.
REFERENCES AND ADDITIONAL READING:
Theodore J. Cicero, PhD. JAMA Psychiatry, May, 2014. Demographics of Heroin Users Change in Past 5O Years.
Nick Miroff, Washington Post: Tracing the U.S. heroin surge back south of the border as Mexican cannabis output falls
Jason Millman, Washington Post: the dramatic shift in heroin use in the past 5O years.
Jeanette Y. Wick, Pharmacy Times: Legal Opioids: An octopus of a problem.