The Myth of Increased Recreational Opioid Use
The popular myth we have been led to believe is that of Johnny, a typical teenager, who is rooting around in grandma’s medicine cabinet and finds her pain pills. He tries one and becomes instantly addicted. When he runs out of pain pills, his new brain disease sends him foaming at the mouth out onto the street in search of heroin where he dies of an overdose with a needle in his arm.
Heroin has become the new marijuana – with one difference: it is one hundred percent deadly. There is just one problem with the above scenario: almost every particular in it is contradicted by the research data.
First, let us establish some basic facts we can all agree on. The number of prescription opioid painkiller prescriptions in the U.S. has roughly doubled from 1999 to the present, with the number of prescriptions peaking in 2011 at 219,000,000 prescriptions for the year. This subsequently dropped in 2012 and 2013, very likely due to prescriber education programs and Prescription Monitoring Programs. This data is summarized in Figure 1.
Along with the increase in opioid painkiller prescribing has come an increase in opioid overdose deaths. According to data from the CDC, from 1999 to the present the number of opioid overdose deaths (either painkillers or heroin) per capita has nearly quadrupled, going from 21 deaths per million in 1999 to 77 deaths per million in 2013, as can be seen in Figure 2. In terms of actual deaths, there were 5,990 deaths in 1999 as compared to 24,492 in 2013. These numbers are also very likely a major underestimate of the actual numbers because many death certificates for poisoning do not specify what the poison was, and the number of deaths from unspecified poisons has also increased dramatically between 1999 and 2013. The number of deaths by opioid poisoning alone is now approaching the number of traffic fatalities, which, according to the CDC, was 33,783 deaths (rate of 108 per million) in 2013. (Note: if we look at the data from all poisonings, not just opioid poisonings, these exceeded the number of deaths from traffic accidents several years ago: the total of all poisoning deaths for 2013 is 43,982.)
Many people have assumed that there has been a corresponding increase in non-medical opioid users and individuals with Opioid Abuse or Dependence to go along with these increases in prescribing and in overdoses; however, data from the National Survey on Drug Use and Health (NSDUH) do not bear this assumption out.
Figure 3 shows us the percentage of the U.S. population over the age of 12 engaged in non-medical painkiller use or heroin use from 2002 to 2013. It is quite surprising that there has been no increase in the number of non-medical users of painkillers given that the number of prescriptions roughly doubled during this period and the number overdose deaths has roughly quadrupled. We do, however, see increases in heroin use starting around 2009, with the number of heroin users roughly doubling between 2003 and 2013.
Figure 4 shows the percentage of the U.S. population over age 12 with a Painkiller Use Disorder (DSM IV Use or Dependence) and the percentage with Heroin Use Disorder (DSM IV Use or Dependence). Again, there has been little increase in Painkiller Use Disorder although we see increases in Heroin Use Disorder from around 2009. It is likely that this increase in heroin use and Heroin Use Disorder is due at least in part to increased Prescription Drug Monitoring Programs, but a detailed exploration of this topic is beyond the scope of this article.
I would like to put forth the following hypotheses as possible explanations for the above facts:
- Medical users of painkillers may be mixing their painkillers with other drugs or alcohol more frequently than before.
- Non-medical users of painkillers may be mixing their painkillers with other drugs or alcohol more frequently than before.
- Non-medical users may be using larger quantities of painkillers and/or more frequently than before.
- 2 & 3 combined
Drug mixing is probably the cause of over 90 percent of drug poisonings in the U.S. Since the CDC compiles its mortality statistics from death certificates, and since death certificates often fail to note the presence of drug mixing, it is not possible to determine the frequency with which drug mixing is involved in overdose deaths via the CDC data alone, although the CDC estimates that this number is large (CDC 2014).
More than a quarter of overdose deaths in New York City involve mixing three drugs together, with the most common combination being heroin, cocaine, and alcohol.-Kenneth Anderson
The fact that laws and customs vary from state to state is a major factor in limiting the quality of national data. However, the New York City Department of Health has conducted precise scrutiny of the overdose deaths occurring in the city and has found that in 2012 the percentage of drug overdose deaths involving drug mixing was 97 percent and in 2013 it was 94 percent. More than a quarter of overdose deaths in New York City involve mixing three drugs together, with the most common combination being heroin, cocaine, and alcohol. Figure 5 shows the most common lethal drug combinations found with non-medical painkiller use for the year 2011 in New York City. Since any number of drugs can be involved in a death, these percentages add up to far more than 100 percent.
The increasing use of heroin in the U.S., particularly among whites and in the suburbs, has led some alarmist voices to make claims such as “heroin is the new marijuana.” But is there any justification for such alarmist cries? Although use rates for heroin have roughly doubled between 2002 and 2013, heroin remains a highly stigmatized drug shunned by the vast majority of drug users. Figure 6 shows the comparative percentages of the U.S. population over age 12 who were past year users of marijuana, opioid painkillers, and heroin from 2002 to 2013. In 2013 there are only about two heroin users for every one hundred marijuana users.
However, we do not wish to trivialize or minimize the role of heroin in overdose deaths in the United States. Although heroin only accounted for about 6 percent of non-medical opioid use in the U.S. in 2013, it accounted for around 34 percent of opioid overdose deaths; in other words heroin users were 6 times more likely to suffer overdose death than the users of other opioids. This is illustrated in Figures 7 and 8.
For the sake of completeness we must also discuss how addictive opioids are. As we can see from Figure 9, rates of Substance Use Disorder for non-medical painkiller use are roughly on par with those for cannabis use; they are only slightly higher than those associated with alcohol use. Rates for Heroin Use Disorder are many-fold higher; whereas only about one sixth of non-medical painkiller users have Painkiller Use Disorder, between half and two thirds of heroin users have Heroin Use Disorder. The reasons that rates of Heroin Use Disorder are so much higher than those of Painkiller Use Disorder have far more to do with sociological and cultural factors than pharmacological properties; however, a discussion of this topic is beyond the scope of this article.
Given all this data, what can we conclude to be the appropriate actions to take in response to the current overdose epidemic?
It is only sensible to use great caution in issuing new opioid prescriptions to people for long-term chronic pain who have never had such prescriptions before. Since the research shows that opioids are not usually the best choice for fighting chronic, as opposed to acute, pain, such prescriptions should be issued only as a last resort. However, it is clearly detrimental to abruptly cut off those people who have been using opioid painkillers on a regular basis.
We need to meet drug users where they are at and accept their right to use drugs if we ever wish to have any success in reversing the current opioid overdose crisis.-Kenneth Anderson
The sensible thing to do in this case is to offer opioid maintenance to all regular opioid users with their opioid of choice. This includes heroin maintenance for heroin users, Oxycontin maintenance for Oxycontin users, and so on. Unfortunately, we have done the exact opposite and encouraged doctors to cut off opioid users abruptly and treat them as criminals if they are caught “doctor shopping” or “engaging in drug seeking behavior.” This has pushed many people to switch to heroin and has simply continued to fuel the overdose crisis and lead to ever increasing numbers of overdose deaths.
Because of the fact that almost all opioid overdoses involve drug mixing, it is of utmost importance to offer all regular opioid users education on safe opioid use. It is essential that we do this without shaming people or attempting to force them to quit using if we wish this educational program to be effective. We need to meet drug users where they are at and accept their right to use drugs if we ever wish to have any success in reversing the current opioid overdose crisis.
Image Credits: streetroots.org, Kenneth Anderson