The life of a heroin addict is not the same as it was 20 years ago, and the biggest reason is what some doctors call “heroin lite”: prescription opiates. These medications are more available than ever, and reliably whet an appetite that, once formed, never entirely fades.
The actor, who quit heroin more than 20 years ago, reportedly struggled to break a prescription painkiller habit last year. Experts in addiction say that the use of medications like Vicodin, OxyContin and oxycodone — all opiates like heroin — has altered the landscape of addiction and relapse, in ways that affect both current users and former ones.
“The old-school user, pre-1990s, mostly used just heroin, and if there was none around, went through withdrawal,” said Stephen E. Lankenau, a sociologist at Drexel University who has surveyed young addicts. Today, he said, “users switch back and forth, to pills then back to heroin when it’s available, and back again. The two have become integrated.”
Rates of prescription opiate abuse have risen steadily over the last decade, while the number of people reporting that they used heroin in the past 12 months has nearly doubled since 2007 to 620,000, according to government statistics. That’s no coincidence, researchers argue: more people than ever now get a taste of opiates at a young age, and recovering addicts live in a world with far more temptations than there were a generation ago.
“You can get the pills from so many sources,” said Traci Rieckmann, an addiction researcher at Oregon Health & Science University. “There’s no paraphernalia, no smell. It’s the perfect drug, for many people.”
Millions of people use these drugs safely, and doctors generally prescribe them conscientiously. But for some patients, prescription painkillers can act as an introduction — or a reintroduction — to an opiate high. The pills set off heroin craving in recovering addicts, doctors say, every bit as well as they soothe withdrawal in current users.
Dr. Jason Jerry, an addiction specialist at the Cleveland Clinic’s Alcohol and Drug Recovery Center, estimates that half of the 200 or so heroin addicts the clinic sees every month started on prescription opiates.
“Often it’s a legitimate prescription, but next thing they know, they’re obtaining the pills illicitly,” Dr. Jerry said.
In many parts of the country, heroin is much cheaper than prescription opiates. “So people eventually say, ‘Why am I paying $1 per milligram for oxy when for a tenth of the price I can get an equivalent dose of heroin?’ ” Dr. Jerry said.
Investigators do not yet know whether Mr. Hoffman was taking prescription opiates at the time of his death. Toxicology tests are pending, and the purity and content of the heroin found in his apartment will certainly be a focus.
While the deluge of prescription painkillers is new, other risk factors for overdose have not changed in decades.
“These are common danger zones,” said Dr. Nicholas L. Gideonse, the medical director of O.H.S.U. Richmond Community Health Center in Portland.
Even a change in where a person uses his or her drug of choice can increase the likelihood of an overdose, studies suggest. “If you habitually use in your car, for example, the body prepares itself to receive the drug when it’s in that environment,” Dr. Rieckmann said. “It’s called conditioned tolerance. When people using are in an unfamiliar places, the body is less physically prepared.”
The risk of dying from an overdose is higher when people are using alone. “Another person, sober or not, can notice when someone nods off, or just say, ‘Hey man, slow down,’ ” Dr. Lankenau said. “And users act as a gauge for each other of when they’re doing something dangerous.”
Many needle exchange programs and clinics now have overdose prevention courses, teaching users to notice danger signs and administer the drug naloxone, an opiate blocker that E.M.T.s use to revive addicts who have overdosed.
None of which might have spared Mr. Hoffman. One thing that has not changed for heroin addicts over the past 20 years is the certainty that this next shot will not be deadly.
“You have to understand that addicts inject three or four times a day for years and years on end,” Dr. Gideonse said. “They don’t perceive any one shot to be dangerous or potentially deadly, because in their experience, there’s no reason to.”
The deadliest drug problem in America is not heroin or cocaine or even crack cocaine. It’s the abuse of perfectly legal prescription pain medications — familiar names such as Vicodin and Lortab and generic hydrocodone.
Last month, federal regulators finally got around to recommending stronger restrictions on access to these medications by limiting refills and mandating more frequent visits to doctors to obtain prescriptions. Now doctors, who helped create the problem, need to do their share to control it.
Fourteen years have passed since Ronald Dougherty, a doctor and addiction specialist, noticed something odd at his clinic in suburban Syracuse, N.Y.: More patients were addicted to legal drugs than to illegal narcotics. He petitioned the federal government to treat these drugs as the growing danger they were.
Dougherty, it turned out, was as prescient as the federal government was sluggish. Since 1999, overdose deaths from narcotic painkillers in the U.S. have quadrupled. Every day, they kill 45 people and send 1,370 to emergency rooms. By contrast, cocaine kills 12 people a day and heroin kills eight.
One addictive painkiller, hydrocodone, is the most prescribed medication in America — 4 billion prescriptions a year at last count. Dr. Tom Frieden, director of the Centers for Disease Control and Prevention, said “doctors caused” this epidemic. “We’re prescribing massive amounts of opiates,” he told us last week, “and patients are getting hooked.”
Dealing with the problem has been tricky. That’s because these medications are indispensable for some people with extreme, chronic pain — particularly from terminal illness that renders addiction meaningless. And because easy access has powerful support from patient groups, drug chains, drug makers and many physicians. These lobbies have impeded the most promising responses.
One of the best solutions is state prescription monitoring programs designed to prevent addicts from doctor-shopping. Some physicians, unaware that a patient is getting multiple prescriptions from several sources, become unwitting accomplices to addiction. Others get rich running pill mills.
Databases to monitor prescriptions and prevent overlap are finally running in almost every state. Pharmacists can record when they fill certain prescriptions, and doctors can check patient histories. But most doctors don’t use these registries — a failure both mystifying and outrageous. Doctors should be in the forefront of combating abuse.
To deal with this, a few states — Kentucky, New York and Tennessee, with more in the works — require doctors to query the database. New York’s database used to get, on average, 10,000 queries a month. In the two months since the mandate, there have been 2.7 million requests.
The Food and Drug Administration’s recommendation can do the same. Patients can only receive three, 30-day prescriptions at a time. They must see a doctor every 90 days to get new prescriptions.
The strict limits could make it harder for some rural or homebound patients to get necessary relief, suggesting a need for some narrow exemptions. But that shouldn’t be used as an excuse for further delay in dealing with such a deadly public health problem.
National Prescription Drug Take Back Day – Saturday, October 26, 2013 –
The National Prescription Drug Take-Back Day aims to provide a safe, convenient, and responsible means of disposing of prescription drugs, while also educating the general public about the potential for abuse of medications.
In a period of nine months, a tiny Kentucky county of fewer than 12,000 people sees a 53-year-old mother, her 35-year-old son, and seven others die by overdosing on pain medications obtained from pain clinics in Florida.1 In Utah, a 13-year-old fatally overdoses on oxycodone pills taken from a friend’s grandmother.2 A 20-year-old Boston man dies from an overdose of methadone, only a year after his friend also died from a prescription drug overdose.3
These are not isolated events. Drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs.4
100 people die from drug overdoses every day in the United States.4
What Do We Know?
The role of prescription painkillers
Although many types of prescription drugs are abused, there is currently a growing, deadly epidemic of prescription painkiller abuse. Nearly three out of four prescription drug overdoses are caused by prescription painkillers—also called opioid pain relievers. The unprecedented rise in overdose deaths in the US parallels a 300% increase since 1999 in the sale of these strong painkillers.4 These drugs were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined.4
The misuse and abuse of prescription painkillers was responsible for more than 475,000 emergency department visits in 2009, a number that nearly doubled in just five years.6
More than 12 million people reported using prescription painkillers nonmedically in 2010, that is, using them without a prescription or for the feeling they cause.7
The role of alcohol and other drugs
About one-half of prescription painkiller deaths involve at least one other drug, including benzodiazepines, cocaine, and heroin. Alcohol is also involved in many overdose deaths.8
In 2008, there were 14,800 prescription painkiller deaths.4
How Prescription Painkiller Deaths Occur
Prescription painkillers work by binding to receptors in the brain to decrease the perception of pain. These powerful drugs can create a feeling of euphoria, cause physical dependence, and, in some people, lead to addiction. Prescription painkillers also cause sedation and slow down a person’s breathing.
A person who is abusing prescription painkillers might take larger doses to achieve a euphoric effect and reduce withdrawal symptoms. These larger doses can cause breathing to slow down so much that breathing stops, resulting in a fatal overdose.
In 2010, 2 million people reported using prescription painkillers nonmedically for the first time within the last year—nearly 5,500 a day.7
Where the drugs come from
Almost all prescription drugs involved in overdoses come from prescriptions originally; very few come from pharmacy theft. However, once they are prescribed and dispensed, prescription drugs are frequently diverted to people using them without prescriptions. More than three out of four people who misuse prescription painkillers use drugs prescribed to someone else.7
Most prescription painkillers are prescribed by primary care and internal medicine doctors and dentists, not specialists.10 Roughly 20% of prescribers prescribe 80% of all prescription painkillers.11,12,13
Who is most at risk
Understanding the groups at highest risk for overdose can help states target interventions. Research shows that some groups are particularly vulnerable to prescription drug overdose:
People who obtain multiple controlled substance prescriptions from multiple providers—a practice known as “doctor shopping.”14,15
People who take high daily dosages of prescription painkillers and those who misuse multiple abuse-prone prescription drugs.15,16,17,18,19
Low-income people and those living in rural areas.
People on Medicaid are prescribed painkillers at twice the rate of non-Medicaid patients and are at six times the risk of prescription painkillers overdose.20,21 One Washington State study found that 45% of people who died from prescription painkiller overdoses were Medicaid enrollees.20
People with mental illness and those with a history of substance abuse.19
Where overdose deaths are the highest
The drug overdose epidemic is most severe in the Southwest and Appalachian region, and rates vary substantially between states. The highest drug overdose death rates in 2008 were found in New Mexico and West Virginia, which had rates nearly five times that of the state with the lowest rate, Nebraska.4
There are many different points of intervention to prevent prescription drug overdoses. States play a central role in protecting the public health and regulating health care and the practice of the health professions. As such, states are especially critical to reversing the prescription drug overdose epidemic.
The following state policies show promise in reducing prescription drug abuse while ensuring patients have access to safe, effective pain treatment.
Prescription Drug Monitoring Programs
Thirty-six states have operational Prescription Drug Monitoring Programs.22
Prescription Drug Monitoring Programs (PDMPs) are state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients. They are designed to monitor this information for suspected abuse or diversion—that is, the channeling of the drug into an illegal use—and can give a prescriber or pharmacist critical information regarding a patient’s controlled substance prescription history. This information can help prescribers and pharmacists identify high-risk patients who would benefit from early interventions.
CDC recommends that PDMPs focus their resources on
patients at highest risk in terms of prescription painkiller dosage, numbers of controlled substance prescriptions, and numbers of prescribers; and
prescribers who clearly deviate from accepted medical practice in terms of prescription painkiller dosage, numbers of prescriptions for controlled substances, and proportion of doctor shoppers among their patients.
CDC also recommends that PDMPs link to electronic health records systems so that PDMP information is better integrated into health care providers’ day-to-day practices.
Patient review and restriction programs
State benefits programs (like Medicaid) and workers’ compensation programs should consider monitoring prescription claims information and PDMP data (where applicable) for signs of inappropriate use of controlled prescription drugs. For patients whose use of multiple providers cannot be justified on medical grounds, such programs should consider reimbursing claims for controlled prescription drugs from a single designated physician and a single designated pharmacy. This can improve the coordination of care and use of medical services, as well as ensure appropriate access, for patients who are at high risk for overdose.
Health care provider accountability
States should ensure that providers follow evidence-based guidelines for the safe and effective use of prescription painkillers. Swift regulatory action taken against health care providers acting outside the limits of accepted medical practice can decrease provider behaviors that contribute to prescription painkiller abuse, diversion, and overdose.
Laws to prevent prescription drug abuse and diversion
States can enact and enforce laws to prevent doctor shopping, the operation of rogue pain clinics or “pill mills,” and other laws to reduce prescription painkiller diversion and abuse while safeguarding legitimate access to pain management services. These laws should also be rigorously evaluated for their effectiveness. View your state’s prescription drug laws.
Better access to substance abuse treatment
Effective, accessible substance abuse treatment programs could reduce overdose among people struggling with dependence and addiction. States should increase access to these important programs.
These recommendations are based on promising interventions and expert opinion. Additional research is needed to understand the impact of these interventions on reducing prescription drug overdose deaths.
The amount of prescription painkillers sold in states varies.4
The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999. Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for one month.
Nearly 15,000 people die every year of overdoses involving prescription painkillers. In 2010, 1 in 20 people in the US (age 12 or older) reported using prescription painkillers for nonmedical reasons in the past year. Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month.