President Obama stands ready to sign the Comprehensive Addiction and Recovery Act (CARA). This bill will make available more treatments for opioid addiction and is intended to deter inappropriate prescribing of prescription opioids. As a recent Washington Post article points out, critics of CARA fear that this legislation could “cause prescription opioid users to switch to heroin, thereby feeding a second opioid epidemic.”

The Heroin Epidemic

I am also concerned about the heroin epidemic. But it’s important that we understand the actual reasons for the increase in heroin use. The Post article cited above, “The Real Reason That So Many More Americans Are Using Heroin” by Keith Humphreys, clarified some of the myths surrounding this issue.

In his article, Humphreys says, “Wilson Compton of the National Institute on Drug Abuse…discovered that the timing of the prescription opioid and heroin epidemics is not consistent with the simple narrative that increased controls on the former instigated use of the latter. Heroin use and heroin-related emergency-room visits and hospitalizations were rising for years before the 2009-2011 period in which controls of prescription opioids expanded.”

The article points out, “Compton and colleagues noted that fatal heroin overdoses began rising in 2007 — prior to the initiation of tighter opioid prescribing practices — and have not showed any consistent relationship with prescription opioid overdoses since.” In fact, the number of unique opioid prescriptions written annually has actually been dropping since 2012, while the use of heroin has been rising.

Some would contend that, as opioid prescriptions have declined, some patients have moved to heroin. Of course, there may be other reasons to explain the surge in heroin use. The increase in heroin use is likely multifactorial.

Major Reason Does NOT Appear To Be Prior Opioid Exposure 

The major reason does not appear to be prior prescription opioid exposure. Additionally, not all people who use heroin do so because they are seeking a high. The reasons why people use drugs (including heroin, and other legal and illegal drugs) are quite variable. And, in fact, the reasons why people use heroin have changed over time.

The graph you’ll see here shows a shift in the origin of heroin use. In the 1960’s, most people in treatment for opioid addiction started their drug use with heroin. In the past 20 years, heroin users have shifted to first-use prescription opioids before moving to heroin. But this does not mean that prescription opioids are the gateway to heroin, as is commonly promoted in the media and even government sources.

Heroin use is rising, though, and it is important to understand why.

Possible Factors Behind Increased Heroin Use 

Change in CDC Guidelines: One factor behind the increase in heroin use is possibly the CDC Guidelines that were published in March of 2016. The day after the CDC released those guidelines Reason published an article called, “CDC Prescription Guidelines Will Leave More Patients in Pain and Drive More Addicts to Heroin.” The article’s point is that “…the overall message sent by the guidelines and several of the CDC’s specific recommendations inevitably will impede access to narcotic painkillers by legitimate patients who would benefit from them.” That, according to the article, will “drive more addicts to heroin.” If the CDC guidelines do drive pain patients to heroin, then we’ll see the use of heroin escalate even further.

Cheaper, More Potent Product: Another explanation for the increase in heroin use offered by Compton and his colleagues is that the establishment of heroin markets expanded access to a cheaper, more potent opioid. The opioid they developed appealed to people addicted to prescription painkillers who needed a more affordable alternative.

Opioid Addiction or Less Access To Pain Meds? This certainly could be a reason why some people moved to heroin. However, it is less clear what percentage of the heroin epidemic is due to an existing prescription opioid addiction, and how much of the heroin epidemic is due to a lack of access to pain medication by people seeking medication to relieve their pain.

Most current heroin users started their drug use with prescription opioids, but the reverse — progression to heroin following exposure to prescription opioids — is very uncommon and is rarely reported.

Heroin Addiction: More Analysis Needed

That’s particularly unfortunate, since heroin overdoses are commonly blamed on the overprescribing of opioids. Of course, this leads to blaming patients, physicians, and Pharma for the heroin epidemic rather than acknowledging that the problem of heroin addiction is very complicated, and requires a more critical analysis of the root causes to the problem.

Purchase my book The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us (available on Amazon) or read a free excerpt here.

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Copyright 2016, Lynn Webster, MD