Pubdate: Thu, 21 Jul 2016
Source: Boston Globe (MA)
Copyright: 2016 Globe Newspaper Company
Contact: http://services.bostonglobe.com/news/opeds/letter.aspx?id=6340
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Details: http://www.mapinc.org/media/52
Author: Keith Humphreys, Washington Post

ANALYSIS: THE REAL REASON THAT SO MANY MORE AMERICANS ARE USING HEROIN

President Obama has committed to sign the Comprehensive Addiction and 
Recovery Act, which includes among its provisions new policies to 
reduce inappropriate prescribing of prescription opioids such as 
Oxycontin and Vicodin. Given the ongoing epidemic of addiction and 
death caused by opioid painkillers, this seems like sensible 
public-health policy, but some critics charge that tighter 
prescribing rules simply cause prescription opioid users to switch to 
heroin, thereby feeding a second opioid epidemic.

The New England Journal of Medicine recently published the first 
systematic analysis of this terrifying possibility.

Wilson Compton of the National Institute on Drug Abuse, who led the 
analysis, 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 - for example, by 
strengthening of state prescription-monitoring programs, crackdowns 
on pill mills, and the introduction of an abuse-deterrent formulation 
of Oxycontin.

Compton and colleagues also 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.

Heroin deaths rose from 2011 to 2012, when prescription opioid deaths 
had their only year-on-year drop, but they kept rising the next year, 
when prescription deaths were flat and have kept increasing since the 
time that prescription opioid deaths began rising again.

If controls on prescription opioids are not driving the heroin 
epidemic, what caused this drug to reemerge?

Compton and colleagues point to the establishment of heroin markets 
that expanded access to a cheaper, more potent opioid that appealed 
to people addicted to prescription painkillers. This is highly 
plausible, given evidence that Mexican heroin traffickers made 
special efforts to expand into communities with established 
prescription opioid problems.

Compton also points out that "addiction to pharmaceutical opioids 
drives many people to seek new sources whether there are any controls 
in place or not." As users become tolerant to the effects of opioids, 
they often consume an increasing amount of the drug until they simply 
cannot afford to purchase the dozens of pills they want each day from 
legal or illegal sources.

Heroin, which once may have seemed unthinkable, becomes attractive 
because of its affordability.

Compton does not deny that some people, particularly those who are 
already using some heroin in addition to pharmaceutical opioids, 
might increase their heroin use if their doctors cut them off their 
prescription, and indeed studies of people being treated for heroin 
addiction document that such patients exist.

By the same token, studies of the select sample of people being 
treated for established heroin addiction by definition will never 
capture data on the far larger number of people who responded to 
reduced access to pharmaceutical opioids by ceasing use of those 
drugs. Nor will such studies make apparent an even more important 
group of beneficiaries of more careful opioid prescribing rules: the 
individuals in the future who will not be inappropriately prescribed 
opioids in the first place.
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MAP posted-by: Jay Bergstrom