The Heroin Upsurge

Last updated on November 4th, 2019

Why has heroin use made a comeback over the last decade, and what can we do about it?

Every illicit drug has its own myths that public information campaigns need to fight. “Marijuana isn’t addictive.” “Cocaine is a rich person’s party drug.”

Until recently, heroin’s reputation was so awful that there wasn’t anything worth fighting. Heroin has always been “the hardest drug,” with a social stigma even among problem users of other drugs. In fact, heroin was often the ultimate fear factor in anti-drug propaganda; every recreational drug has at some point been alleged to “lead to heroin use.”

“About as many people start dabbling in prescription opiate abuse each year as take up marijuana, and a small but significant number of them will eventually turn to heroin.”-Mark KleimanThings have changed. Even though heroin is still very rare compared with cocaine or methamphetamine, its use has increased. That’s probably the result of the prescription-opiate problem (mostly hydrocodone [Vicodin] and oxycodone [Percodan, Percocet, and Oxycontin]) that exploded between 1994 and 2002 and has not dropped off much since. About as many people start dabbling in prescription opiate abuse each year as take up marijuana, and a small but significant number of them will eventually turn to heroin. Easier access to potent prescription opiates has allowed people to develop a heroin-strength habit before they even try the drug.


Also Read: How to Avoid ‘Dumb’ Marijuana Legalization

Abuse of opiate painkillers is nothing new, but the problem worsened when high potency, time-release formulations were developed. The idea was good: time-release opiates are less addictive if used properly because they control pain for long periods of time without causing a rush of euphoria.

Unfortunately, drug abusers eager to get high quickly found that crushing and snorting or injecting the pills would send the drug straight to the bloodstream, where it hits much like heroin. This misuse of these stronger pills creates heroin-scale habituation and dependence in people who might never have ventured into the dark world of street drugs had an apparently safer – and less stigmatized – path not been available.

“This misuse of these stronger pills creates heroin-scale habituation and dependence in people who might never have ventured into the dark world of street drugs had an apparently safer – and less stigmatized – path not been available.”-Mark Kleiman

The transition from pills to heroin is relatively rare, but some amount of it is utterly predictable. Heroin is cheaper; prices have fallen 80 percent in the past 30 years, and on a potency-equivalent basis, it’s now about a quarter the price of the prescription versions. It’s stronger, and dealers use prescription fentanyl as an even-cheaper booster drug, with often deadly results.

Enforcement efforts to shut down “prescription mills” can have the perverse effect of opening up new markets for heroin dealers. To make matters worse, electronic communication and home delivery makes drug-dealing more convenient and less frightening than venturing out to buy on the street. Even the stigma of “heroin” can’t deter a desperate addict whose source has dried up or who cannot afford to continue buying pills. And there you have it: a heroin addict who went straight from medication to the hardest drug.

What are we to do about this? There is no “cure” for the problem, but there are a few things that we should do right now.

  • Doctors need to be smarter about prescribing, and about ways of dealing with chronic pain other than piling on the opiates. (That’s easier said than done, and no sensible person wants to go back to the bad not-so-old days when cancer patients died in preventable agony due to “opio-phobic” doctors afraid of over-aggressive regulators.)
  • All prescriptions should come with clear instructions about the importance of safeguarding the pills from those who might abuse them.
  • Doctors should also be more aggressive in detecting and treating substance abuse. The Affordable Care Act will make substance abuse treatment possible for more patients, which may help doctors stop viewing substance abuse as anything other than an illness. Screening, brief intervention, and referral to treatment – SBIRT – should become the standard of care so that skipping it is a recipe for a malpractice suit, akin to omitting a prostate exam or a mammogram.
  • Substitution – methadone and buprenorphine (Suboxone) – should be recognized legally and in policy terms for what it is scientifically: the standard of care for most opiate dependency. That means, for example, telling drug court judges and the people who run drug-diversion programs that they can’t substitute their prejudices for clinical judgment by forbidding their clients from making use of substitution therapies.
  • Naloxone, which as the nasal spray Narcan, can interrupt a fatal overdose in progress, should be made widely available not only to first responders but to opiate abusers and household members who might discover an overdose.
  • Users and the friends who bring them to emergency rooms should be freed of the fear of arrest.

Like the poor, drug addiction will always be with us, but our inability to eradicate it is no excuse to stop trying. For now, we should make it harder for people, especially young people, to get opiates, diagnose and treat those who have started, and stop being squeamish about treating heroin addiction.

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