Opioid Rx Linked to Heroin Use Later

Heroin-related deaths have jumped 39% in just one year, from 2012 to 2013, and looking over the course of the last decade, from 2002 to 2013, the rate of heroin-related overdose deaths nearly quadrupled, the Centers for Disease Control and Prevention reports.

Notably, 75% of heroin addicts today say that they used prescription opioids before turning to the drug.

And according to the CDC, 45% of people who have used heroin in the last four years were simultaneously addicted to prescription painkillers. These survey results help illuminate the disturbing trend that many modern-day heroin users are arriving at that addiction from prescription pain pill addiction.  The CDC states that the prescription opioid-dependent are 40 times more likely to abuse heroin.

In fact, a new study published in Pediatrics confirms the trend among young people. The objective of the study was to estimate the risk of future opioid misuse among adolescents who have not yet graduated from high school.

The researchers looked at asked over 6,000 high school seniors to complete questionnaires about drug use. The subjects were then followed until age 23. Overall, healthcare provider-recommended prescription opioid use by grade 12 was independently associated with a 33% increase in risk for opioid misuse later.

Counterintuitively, the association was the most pronounced among participants without a history of drug misuse at baseline—and even among those who strongly disapproved of marijuana use.

“Legitimate” opioid use by 12th grade is therefore a strong predictor of opioid misuse after high school. The fact that this association is concentrated among adolescents who are least expected to misuse opioids should both alarm us and shed a slim ray of light on how to best combat the problem.

The study authors note, “For these drug-naïve individuals, an opioid prescription is likely to be their initial experience with an addictive substance. Most likely the initial experience of pain relief is pleasurable, and a safe initial experience with opioids may reduce perceived risk. A pleasurable and safe initial experience with a psychotropic drug is a central factor in theories of who goes on to misuse drugs.” (Emphasis added.)

For clinical practice, the results suggest an unrecognized risk of opioid prescribing. This risk should be incorporated into prescribing decisions and patient counseling. Until recently, the short-term use of opioids to treat pain was thought to carry a negligible risk for precipitating future misuse. The current study associates short-term prescriptions with misuse for some youth.

Education and prevention efforts have substantial potential to reduce future opioid misuse among this particularly high-risk subset of young people—who after all begin opioid use with strong attitudes against illegal drug use.

The CDC also reported over the summer that “significant increases in heroin use were found in groups with historically low rates of heroin use, including women and people with private insurance and higher incomes. The gaps between men and women, low and higher incomes, and people with Medicaid and private insurance have narrowed in the past decade.”

As opium production dramatically increases in Mexico and Afghanistan—by 50% and 36% respectively, according to the United Nations’ annual World Drug Report—the necessity of combatting the surge in heroin use becomes more and more urgent.

Parents should strongly consider opting for nonopioid options for their children as the initial treatment of minor painful conditions. In yet another study, researchers recently looked at patterns of schedule II opioid prescribing and found that a “broad swath” of physicians were prescribing them, much more than previously thought. It had been the conventional wisdom that opioid prescriptions were concentrated among the top 1% of Medicare schedule II opioid prescribers. These so-called “high volume” prescribers, it turns out, accounted for only 18% of opioid prescriptions in 2013, the study finds.

For comparison, California Workers' Compensation data showed that the top 1% accounted for a full third, 33%, of all claims. While specialties in pain management, anesthesiology and physical rehabilitation had the highest rates of opioid claims, family and general medicine had the most claims by volume.

The authors of the study, published as a research letter in JAMA Internal Medicine, conclude: "Efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective."

Pediatrics, 2015, Vol. 136, No. 5, http://pediatrics.aappublications.org/content/136/5/e1169

The New York Times, Oct. 30, 2015, The Numbers Behind America’s Heroin Epidemic, http://nyti.ms/1LH7yPP 

JAMA Intern. Med., Published online December 14, 2015, http://archinte.jamanetwork.com/article.aspx?articleid=2474400

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