Factors Behind Growing Heroin Epidemic; 120 Die Per Day From Overdose

According to a July 7, 2015 CDC Release, heroin use has increased across the United States among men and women, most age groups, and all income levels. The greatest increases have occurred in groups with historically lower rates of heroin use, including women and people with private insurance and higher incomes. In addition, nearly all people who use heroin also use multiple other substances, according to a new report from the CDC and the FDA. The report also finds the strongest risk factor for heroin use is a prescription opioid use disorder.


As heroin use increases, more people are dying from heroin overdoses. Heroin-involved overdose deaths nearly doubled between 2011 and 2013; more than 8,200 people died in 2013 alone.


“Heroin use is increasing at an alarming rate in many parts of society, driven by both the prescription opioid epidemic and cheaper, more available heroin,” said CDC Director Tom Frieden, M.D., M.P.H. “To reverse this trend we need an all-of-society response – to improve opioid prescribing practices to prevent addiction, expand access to effective treatment for those who are addicted, increase use of naloxone to reverse overdoses, and work with law enforcement partners like DEA to reduce the supply of heroin.”


The people most at-risk of heroin abuse or dependence include non-Hispanic whites, men, 18-to-25 year-olds, people with an annual household income less than $20,000, Medicaid recipients, and the uninsured. The gaps between men and women, low and higher incomes, and people with Medicaid and private insurance have narrowed in the past decade.


Nearly all (96 percent) people who reported heroin use also reported using at least one other drug in the past year with more than half (61 percent) using at least three other drugs. People who abuse or who are dependent on prescription opioid painkillers were 40 times more likely to have heroin abuse or dependence. People who abuse or who are dependent on cocaine are 15 times more likely to abuse or be dependent on heroin.


As heroin abuse or dependence has increased so has heroin-related overdose deaths. From 2002 through 2013, the rate of heroin-related overdose deaths nearly quadrupled.


“Approximately 120 people die each day in the United States of a drug overdose,” said DEA Acting Administrator Chuck Rosenberg. “We will continue to target the criminal gangs that supply heroin, and we will work to educate folks about the dangers and to reduce demand. In this way, we hope to complement the crucial efforts of the CDC and our nation’s public health agencies.”


The report’s findings highlight the need for a comprehensive response that addresses the growing number of demographic groups using heroin along with multiple other drugs and should be considered in the development and implementation of prevention policies.


Heroin is an illegal, highly addictive opioid drug. A heroin overdose can cause slow and shallow breathing, coma, and death. People often use heroin along with other drugs or alcohol. This practice is especially dangerous because it increases the risk of overdose. According to Dr. Frieden, “heroin costs roughly five times less than prescription opiates on the street. The opioid epidemic cuts across the life span. In addition to abuse, overdose and death, we're seeing rising rates of neonatal abstinence syndrome. That's a series of issues for newborns exposed to drugs in the womb with tragic consequences. We're also seeing drunk driving and opioid-related falls among senior citizens.”


Heroin is typically injected but is also smoked or snorted. When people inject heroin, they are at risk of serious, long-term viral infections such as HIV, Hepatitis C, and Hepatitis B, as well as bacterial infections of the skin, bloodstream, and heart.


Dr. Frieden said, “We're seeing now the need to really get it right in terms of risks and benefit. If someone has severe terminal pain from cancer, you absolutely want to provide all palliation. If someone has excruciating pain from a surgical procedure or a car crash, you absolutely want to provide pain relief. For chronic non-cancer pain, you really have to look at the risks and the benefits and the risks are very, very clear. A few pills and you can get addicted. A few pills too many, and you can die. The benefits are far less clear because of acclimation to the drug and the way the liver metabolizes these drugs, people need higher and higher doses which come closer and closer to lethal doses. Now, getting that risk/benefit ratio right is a challenge. Even with severe pain we look for alternative ways to get treated because we recognize that these are dangerous drugs. Those can include nonsteroidal medications, anti-inflammatories of various types, physical therapy, the use of ice, heat, or local measure, movement and modification of some of the ways that you can trigger or avoid pain, realistic sense of how long it will take for a pain syndrome to resolve, encouragement if you see that resolving gradually. There are a whole host of things that can be done to support patients in a way that's both safe and effective.”


States play a central role in addressing and helping to reverse the heroin epidemic; states can:


  • Address the strongest risk factor for heroin abuse or dependence: abuse or dependence on prescription opioid painkillers.
  • Make prescription drug monitoring programs (electronic databases that track the dispensing of certain drugs) timely and easy to use. Providers can analyze patient prescription-drug history and make informed decisions before prescribing opioid painkillers.
  • Look at the data and practices of state Medicaid and worker’s compensation programs to identify and reduce inappropriate prescribing.
  • Increase access to substance abuse treatment services, including medication-assisted treatment (MAT) for opioid abuse or dependence.
  • Work with Medicaid and other insurance companies to provide coverage for MAT.
  • Support adoption of MAT in community settings.
  • Expand access to and training for administering naloxone to reduce opioid overdose deaths.
  • Ensure that people have access to integrated prevention services, including access to sterile injection equipment from reliable sources, as allowed by local policy.
  • Help local jurisdictions to put these effective practices to work in communities where drug abuse or dependence is common.


There is some speculation about whether opioids come from a doctor’s prescription or from grandmother’s medicine cabinet, but according to Dr. Chris Jones at the CDC, “The vast majority of prescription opioids used for nonmedical purposes originate from a prescription.”


According to Dr. Frieden, “The use of prescription drug monitoring programs can identify providers who may have outlier patterns of prescribing opiates and may need either information and education or enforcement action if they're serving essentially as pill mills. Often the path of least resistance is to write a prescription rather than spend the time to address some of the root causes of the patient's pain and it may be that the individual doctor doesn't see the long-term consequences for that individual of addiction, overdose, death, and the social and medical impacts that it can cause.”


See the CDC Announcement


See the CDC Report


See the CDC Teleconference Transcript


See also Medical Law Perspectives, January 2014 Report: Prescription Painkillers: Risks for Patients, Pharmacists, and Physicians


See also Medical Law Perspectives, May 2013 Report: Drugs, Dosage, and Damage: Physician Liability for Prescribing or Administering Medication


See the Medical Law Perspectives February 16, 2015, Blog: Pharmacy Owes Duty To Patient Not To Fill Excessive Prescriptions for Opioids 


See the Medical Law Perspectives October 8, 2014, Blog: Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double