Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double

Nationally, death rates from prescription opioid pain reliever (OPR) overdoses quadrupled during 1999 to 2010, whereas rates from heroin overdoses increased by less than 50%. Individual states and cities have reported substantial increases in deaths from heroin overdose since 2010. The CDC analyzed recent mortality data from 28 states to determine the scope of the heroin overdose death increase and to determine whether increases were associated with changes in OPR overdose death rates since 2010.


The CDC published a report that summarizes the results of that analysis, which found that, from 2010 to 2012, the death rate from heroin overdose for the 28 states increased from 1.0 to 2.1 per 100,000, whereas the death rate from OPR overdose declined from 6.0 per 100,000 in 2010 to 5.6 per 100,000 in 2012. Heroin overdose death rates increased significantly for both men and women, all age groups, all census regions, and all racial/ethnic groups other than American Indians/Alaska Natives. OPR overdose mortality declined significantly among males, people under 45 years old, persons in the South, and non-Hispanic whites.


Combined mortality data from 28 states, encompassing 56% of the U.S. population, indicate an increasing problem with fatal overdoses from heroin from 2010 to 2012. Death rates from OPR declined overall but remained more than twice as high as heroin overdose death rates. Changes in heroin death rates were positively correlated with changes in OPR death rates. Mortality from overdoses of any type of drug rose slightly.


The findings indicate a need for intensified prevention efforts aimed at reducing overdose deaths from all types of opioids while recognizing the demographic differences between the heroin and OPR-using populations. Efforts to prevent expansion of the number of OPR users who might use heroin when it is available should continue. Some persons using prescription OPRs non-medically have reported switching to or also using heroin.


Timely national, regional, and state surveillance data are necessary to target prevention efforts in the face of rapid changes in drug use patterns that vary across the country. Prevention, treatment, and response strategies that help reduce both heroin and OPR overdose deaths are indicated. Clinical interventions that focus on opioid prescribing, such as screening for substance abuse history and urine testing for drug use, can prevent opioid misuse, particularly for those at high risk for abuse.


The study began in February 2014, when the CDC invited state health departments to submit data from their mortality files for the period 2008 to 2012 if they judged those files to be substantially complete and if the causes of death had been coded by the International Classification of Diseases, 10th Revision. Participating states had the option of submitting resident deaths or deaths that occurred in the state. States submitted annual counts of deaths with an underlying cause of drug overdose of any intent. They also submitted counts of subsets of the overdose deaths, those involving heroin and those involving OPR. States also provided the demographic distributions of these types of overdoses.


Because examination of state rates revealed pronounced increases in heroin death rates for most states in the study after 2010, the CDC calculated changes in rates by demographic characteristics for the period of increasing rates only from 2010 to 2012. The correlation of change in state heroin overdose death rates with change in state OPR overdose death rates was examined both overall and for specific demographic subgroups.


The death rate from heroin overdose doubled in the 28 states from 2010 to 2012, increasing from 1.0 to 2.1 per 100,000 population, reflecting an increase in the number of deaths from 1,779 to 3,635. Comparing the same years, the death rate from OPR overdose declined 6.6%, from 6.0 to 5.6 per 100,000, a decline from 10,427 to 9,869 deaths. The overall drug overdose death rate increased 4.3%, from 13.0 to 13.6.


Heroin death rates increased after 2010 in every subgroup examined. Heroin death rates doubled for males and females, whereas OPR death rates declined 12.4% in males and were unchanged in females. Heroin death rates increased for all age groups, whereas OPR death rates declined for people under 45 years of age. OPR death rates increased for people between the ages of 55 and 64. Heroin death rates doubled in non-Hispanic whites and Hispanic whites, and nearly doubled in blacks. OPR death rates decreased 8% in non-Hispanic whites and remained level in all other races/ethnicities. The Northeast and South had much larger heroin overdose death increases (211.2% and 180.9%, respectively), than the Midwest and West (62.1% and 90.7%, respectively). OPR death rates declined only in the South.


Comparing 2010 to 2012, trends in heroin and OPR overdose death rates varied widely by state. Of the 28 states, five states had increases in OPR death rates, seven states had decreases, and 16 states had no change in the OPR death rate. Of the 18 states with heroin overdose death rates based on at least 20 deaths, none had a decline. Increases in heroin overdose death rates were significantly associated with increases in OPR death rates. Similar patterns in the death rates for males and non-Hispanic whites, the two populations with the largest numbers of heroin deaths, also were observed, but the associations were not significant.


In 2012, the age group with the highest heroin overdose death rate was between 25 and 34 years old, and the age group with the highest OPR overdose death rate was between 45 and 54 years old. The racial/ethnic population with the highest death rate for both heroin and OPR was non-Hispanic whites. The death rate for heroin among males in 2012 was almost four times that among females, whereas the death rate for OPR among males was 1.4 times that among females.


The increase in heroin deaths parallels increases seen in individual states reported previously. Kentucky reported a 279% increase in heroin deaths from 2010 to 2012. In Ohio, the number of heroin deaths increased approximately 300% from 2007 to 2012, with men between the ages of 25 and 34 at highest risk for fatal heroin overdoses. Mortality data for the United States show a 45% increase in heroin deaths from 2010 to 2011, the largest annual percentage increase since 1999. The increasing death rate from heroin is also consistent with the 74% increase in the number of current heroin users among people 12 years old and older in the United States during 2009 to 2012. Nationally, OPR death rates from 2010 to 2011 were stable (5.4 per 100,000), although there was a slight increase in the number of OPR deaths.


The rapid rise in heroin overdose deaths follows nearly two decades of increasing drug overdose deaths in the United States, primarily driven by OPR drug overdoses. The number of persons using OPR non-medically on a frequent basis also has grown. From 2002–2004 to 2008–2010, past year heroin use increased among persons reporting frequent nonmedical use of OPR, from 62.0 to 94.7 per 1,000. Moreover, the only increases in past year heroin use were observed among persons who reported past year nonmedical use of OPR.


In a sample of heroin users in a treatment program, 75% of those who began opioid abuse after 2000 reported that their first regular opioid was a prescription drug. In contrast, among those who began use in the 1960s, more than 80% indicated that they initiated their abuse with heroin. Persons who initiated heroin use after 2000 have reported that heroin often is more readily accessible, less expensive, and offers a more potent high than prescription opioids.


Although some persons might be discontinuing prescription opioids and initiating heroin use as a replacement, results from this study indicate that recent heroin death rate increases were not significantly associated with decreases in OPR overdose mortality. Numerous risk factors contribute to drug-specific use and overdose death rates. For example, an increase in overall heroin supply and greater availability of heroin in some parts of the country might contribute to the trend and variation observed in heroin mortality.


The findings in this report indicate a growing problem with heroin overdoses superimposed on a continuing problem with OPR overdoses. Increasing use of heroin is especially concerning because it might represent increasing injection drug use. The small decline in OPR overdose mortality is encouraging given its steep increase during 1999 to 2010, but efforts to address opioid abuse need to continue to further reduce overdose mortality and avoid further enlarging the number of OPR users who might use heroin when it is available.


Clinical interventions that might address abuse of both OPR and heroin include screening for substance abuse, urine testing for drug use, and referral to substance abuse treatment. The use of prescription drug monitoring programs can address inappropriate opioid prescribing and further prevent OPR abuse. State policies that increase access to naloxone, a drug that can reverse potentially fatal respiratory depression in persons who have overdosed from either OPRs or heroin, or policies that reduce or eliminate penalties when someone reports an overdose, are potentially useful strategies. Given the rapid changes in drug overdose epidemiology, timely, drug-specific fatal and nonfatal surveillance data at the local, state, and regional level will be necessary to target prevention efforts.


See the CDC Report


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 also Medical Law Perspectives, March 2012 Report: Off-Label Use of Prescriptions: When is this Medical Malpractice? Is the Pharmaceutical Company Liable for Overpromotion?