Pubdate: Mon, 02 May 2016
Source: Boston Globe (MA)
Copyright: 2016 Globe Newspaper Company
Author: Evan Horowitz


The Massachusetts heroin epidemic is unlike any other in the United 
States. The overdose rate in the state is more than twice the 
national average. And deaths from prescription opioids like OxyContin 
are only slightly less harrowing.

Unusual, too, is the degree to which these two scourges are feeding 
off each other. A substantial and spiking number of overdoses in 
Massachusetts involves both heroin and prescription drugs, something 
you rarely find elsewhere in the United States.

Until now, it's been hard to see how, exactly, heroin and 
prescription opioids were interacting, since almost all available 
data lump them together under the heading of "opioids." But a Globe 
examination of the information in death certificates from 1999 to 
2014 reveals the increasingly toxic interplay between the drugs, both 
at the state level and in individual counties.

Here's what those death certificates tell us:

Half of all opioid deaths in Massachusetts in 2014 involved heroin. 
This is a very new development. As recently as 2010, heroin was 
implicated in less than 20 percent of opioid deaths.

The umbrella term "opioids" hides the fact that Americans are 
actually dying from separate scourges.

Prescription opioid overdoses seem to be soaring again after a brief 
plateau. Between 2013 and 2014, they increased by over 90 percent.

Massachusetts isn't like other states. Elsewhere in the country, 
heroin and prescription opioids tend to kill people of different ages 
- - heroin strikes the young, prescription drugs the middle-aged. Not 
so in Massachusetts, where 25- to 34-year-olds increasingly bear the 
brunt of both.

County by county, there are some big variations. In the Berkshires, 
and outside the big cities, heroin is the dominant killer. Across the 
southeast portion of the state, however, it hasn't made the same inroads.

Heroin vs. prescription drugs

Initially, the big problem was prescription opioids like OxyContin 
and Vicadin. Between 1999 and 2010, Massachusetts saw a six-fold 
increase in deaths from such prescription opioids - a rapid change, 
to be sure, but consistent with what other states were experiencing.

That changed in 2010, when heroin was added to the mix and 
Massachusetts diverged from the national pattern. Heroin deaths 
across the Bay State rose faster than prescription drug overdoses 
ever did, far outpacing national numbers.

Ominously for Massachusetts, the rise of heroin seems to have 
reenergized demand for prescription opioids. Two features of this 
return to prescription opioids make it especially concerning.

First, a growing number of users seem to be overdosing on a 
combination of heroin and prescription opioids. That's both new and 
rare. In 2013, death certificates record only 36 such examples. In 
2014, that jumped to 179, easily among the highest levels in the 
country. One possible culprit is Fentanyl, a prescription opioid 
increasingly being used as a heroin additive, boosting potency and 
virulence (another explanation would be a regulatory shift affecting 
death certificates, but the Massachusetts Department of Public Health 
said it was unclear whether that was a factor.)

Second, the victims are getting younger. In the past - and all across 
the country - prescription opioids tended to kill older people, 
particularly those ages 45 to 54. But in 2014, the bulk of 
prescription opioid deaths in Massachusetts involved people ages 25 
to 34 - the very same age group disproportionately affected by heroin.

Put these together and it really does seem that the heroin and 
prescription opioid epidemics are joined in Massachusetts in a way 
that they simply aren't elsewhere. And that their combination is 
helping to drive the state's surging opioid crisis.

County by county

The mix of heroin and prescription opioids varies quite a bit within the state.

Heroin deaths are concentrated in the central and eastern part of the 
state - and nowhere are they higher than in northeast Essex County.

But the shift from prescription drugs to heroin is happening all 
over. In the areas around Boston, Worcester, and Springfield - and 
again in Berkshire County to the west - heroin now plays a role in 
well over 50 percent of opioid-related deaths. In Hampden County, 
surrounding Springfield, it's over 70 percent, a sign of the deep 
penetration of heroin in the Interstate 91 corridor.

Only Bristol County, in the southeast, has resisted the incursion.

There, prescription opioids remain the dominant killer, though it's 
not clear whether that's because this area is somehow less 
susceptible to heroin, or if it's merely a matter of time.

The state and its neighbors

Only four states have a higher heroin death rate than Massachusetts, 
and two of those states are here in New England. In fact, 
Connecticut, New Hamphsire, Rhode Island, and Vermont all join 
Massachusetts as five of the 10 worst-hit states in the nation.

There are a couple of possible explanations for why heroin has become 
endemic to New England. It could be cultural transmission; users 
share their experience and expertise with neighbors, who pick up the 
habit and share with their own friends and peers.

However, the New England addiction also reflects the geography of 
drug smuggling and dealing. Once heroin traffickers establish an 
effective trade route, they have a strong incentive to expand their 
local business, leveraging their networks to move more drugs.

Most heroin comes to New England from Mexico, stopping for processing 
in New York before traveling up major highways, including I-91 and 
Interstate 95. From there, every exit becomes an untapped market, a 
way for dealers to reach new users and spread the disease.

What the future holds

As revealing as the death certificate data are, the information only 
goes through 2014, which leaves us 16 months behind a fast-evolving 
epidemic. And every few weeks seems to reveal a cluster of new 
opioid-related deaths, including recent reports of over 20 deaths in 
Middlesex County.

Since taking office in 2015, Governor Charlie Baker has pressed for 
greater state action, spearheading initiatives to improve treatment, 
to increase the use of overdose-prevention drugs like Narcan, and to 
limit the availability of prescription opioids.

It's unclear, however, whether these efforts can curb the 
accelerating appeal of heroin or stem the tide of opioid deaths.

One fundamental challenge is that we don't know what's causing the 
problem in the first place.

Economic hardship doesn't seem to be the driving factor, since the 
rise of heroin has accelerated even amid a growing economy. And while 
it's tempting to think in terms of a chain of addiction - the rise of 
prescription opioids drew users, who then switched to heroin - this 
too seems inadequate. Many other states saw a similar rise in 
prescription opioids, without a subsequent heroin spike.

Absent a single solution, the multipronged approach seems to make the 
most sense, including a combination of heightened anti-trafficking 
efforts, better treatment, and ongoing public education.

And given that opioids have become a marked problem for our region as 
a whole, state policy alone may not suffice. This Massachusetts 
crisis may require a New England solution.
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MAP posted-by: Jay Bergstrom