Heroin

Heroin Users Are Less Likely to Be Dependent But More Likely to Die

A new study highlights the gap between rising heroin use and rising heroin deaths.

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JAMA Psychiatry

Survey data reported last week in JAMA Psychiatry indicate that the share of Americans who have ever used heroin nearly quintupled between 2001-02 and 2012-13, from 0.33 percent to 1.61 percent. During the same period, according to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the share of Americans who have ever experienced a heroin-related "substance use disorder" (which includes "abuse" and "dependence") only tripled, from 0.21 percent to 0.69 percent. In other words, the prevalence of substance use disorders among heroin users fell—by about a third, from 63 percent to 43 percent.

That decrease is counterintuitive, since heroin users are three times more likely to die as a result of their habits today than they were in 2002. Evidently there is a difference between the factors that contribute to heroin-related fatalities and the criteria for a diagnosis of abuse or dependence. Some of those criteria, such as "physically hazardous use," taking larger amounts than intended, and "use persistence despite physical health problems due to heroin," seem relevant to the risk of death. So does frequency of use, which is not one of the explicit criteria but is logically related to them. Yet the percentage of heroin users who have ever used the drug on a daily basis also declined during the study period, from 36 percent to 30 percent. Other factors must be making heroin use more lethal, possibly including an increase in drug mixing (the primary cause of so-called heroin overdoses), greater variability in potency (perhaps related to increased use of powerful adulterants such as fentanyl), or an influx of novice heroin users who are unaccustomed to the unpredictable purity of black-market drugs.

Consistent with that last explanation, the NESARC numbers provide further evidence that many of the newer heroin users switched from prescription opioids. Although prior nonmedical prescription opioid (NMPO) use was not more common in the 2012-13 survey among all heroin users, it was more common among white heroin users. Columbia University epidemiologist Silvia Martins and the other authors of the JAMA Psychiatry study note that "increases in heroin use and related disorders were particularly prominent among white individuals, leading to a significant race gap in lifetime heroin use by 2012-2013." In the second survey, the prevalence of lifetime heroin use among non-Hispanic whites was 1.9 percent, compared to 1.05 percent among the other respondents. "Heroin use appears to have become more socially acceptable among suburban and rural white individuals," Martins et al. say, "perhaps because its effects seem so similar to those of widely available [prescription opioids]."

Still, the prevalence of lifetime heroin use also rose among blacks and Hispanics, even though fewer of them reported prior NMPO use in the second survey. Martins and her colleagues also note that when subjects are divided according to the extent of their NMPO use, increases in heroin use can be seen in every group, "suggesting that factors other than increasingly frequent NMPO use contributed to the increase in heroin use."

The NESARC data confirm that heroin use, despite the dramatic increase in heroin-related deaths (which sextupled between 2002 and 2015, according to the CDC), remains rare in the general population. According to the second survey, 1.61 percent of Americans had ever used heroin, and 14 percent of that group—i.e., 0.23 percent of the general population—had used heroin in the previous year. The rarity of heroin use is the main reason Martins et al. decided to focus on lifetime use rather than past-year or past-month use. "We focused on associations with lifetime use, lifetime disorder, and patterns of lifetime disorder across time, which are important population parameters, particularly for very rare conditions such as heroin outcomes in the general population," they explain. "For very rare conditions (eg, any heroin outcome in the general population), examining lifetime cases may be the only way to determine demographic and clinical correlates and patterns of use during the life course, which simply cannot be estimated from small numbers of survey participants with current heroin use or use disorders."

One point that is apparent in those patterns of use will come as a surprise to anyone who believes heroin addiction is irresistible and inescapable: The vast majority of the heroin users identified by NESARC—91 percent in the 2001-02 survey and 86 percent in the 2012-13 survey—had not used the drug in the previous year. That is similar to the breakdown in the National Survey on Drug Use and Health, which in 2015 found that 84 percent of lifetime heroin users had not used the drug in the previous year, while 95 percent had not used it in the previous month.

The fact that someone is not a current heroin user, of course, does not mean the drug never caused him problems. Recall that the second NESARC survey found 43 percent of lifetime heroin users qualified for the "abuse" or "dependence" label at some point. But at the time of the survey, only 7 percent did.

Martins et al. note that NESARC "excluded homeless and incarcerated individuals," and "including these populations would likely increase the overall prevalence of heroin use and use disorder." The same problem afflicts other surveys as well. But surveys such as NESARC and NSDUH still should be useful in estimating trends, assuming that the percentage of users they miss remains about the same over time. Both surveys indicate that past-year heroin use has increased since 2002, but not nearly as dramatically as heroin-related deaths. In fact, NSDUH measured a drop in heroin use between 2014 and 2015, even as heroin-related deaths continued to rise. That divergence is where efforts to reduce the harm associated with heroin use should be focused.

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  1. ‘Efforts to reduce the harm’ should include DARE asking kids in school auditoriums to raise their hands if they’ve seen a heroine needle and then hold those kids back after the assembly is dismissed to cleverly encourage children to ruin their own families by snitching on them.

    Then, after the home is raided and emptied of the addicted the despairing child who lost a family member (or members) to prison gets to walk to and from school for months in front of the same smiling cops who park at the curb searching for speeders while ogling teenagers in yoga pants.

    Small towns hold terrible secrets.

    1. Is this, finally, the gritty origin story of Agile Cyborg?

      1. Nothing special, bro.

        Houses boarded and strangely wistful, alert weeds, cats with limps, cheap paint always coating thinly, bloody knuckles, sunsets on sirens, zero TV, old stolen beer, graffiti garages and coughers, musty basement walls damp and lined with old boards gingerly holding canned beans, beets, and assorted meats, torn shoes shuffling gravel under muted bored tones in alleys, hollow streets perpetually whistling the mundane scrawls of claustrophobic survival, small gardens with bright green hallelujahs bursting from city soil unaware and blissful, run-of-the-mill citified origins under the street lamp of beat-up shadows.

        1. That was beautiful.

          1. Thank you, kind sir.

            1. It was beautiful, Agile. Like a China Mieville prologue.

              1. I would like to read something by him but I can’t get past the no-shit Communism.

                1. His communism usually comes through in his books as oppressed people fighting against assholes in power. Something to which libertarians can usually relate. There is not a whole lot, if any, Marxist economics nonsense.

                  1. His communism usually comes through in his books as oppressed people fighting against assholes in power.

                    So… projection?

          2. I was into Canned Beans, Beets, and Assorted Meats before they made it big.

            1. Assorted Meats was my nickname in college.

              1. BS. Your nickname was “Beets Meats”.

        2. Houses boarded and strangely wistful, alert weeds, cats with limps, cheap paint always coating thinly, bloody knuckles, sunsets on sirens, zero TV, old stolen beer, graffiti garages and coughers, musty basement walls damp and lined with old boards gingerly holding canned beans, beets, and assorted meats, torn shoes shuffling gravel under muted bored tones in alleys, hollow streets perpetually whistling the mundane scrawls of claustrophobic survival, small gardens with bright green hallelujahs bursting from city soil unaware and blissful, run-of-the-mill citified origins under the street lamp of beat-up shadows.

          Samesies.

      2. Netflix better get on this shit pronto.

    2. I still think they should replace the entire DARE program with a mandatory screening of Requiem for a Dream for all 4th graders. It would be a lot more effective at making them never want to do drugs.

  2. Great, now i’ve got Neil Young stuck in my head.

  3. Lost somebody in my extended family last year to a heroin OD . He was an on-again, off-again user who had been to rehab several times. He got some expectantly pure heroin after not using for a while and killed himself.

    1. That’s sad, sorry to hear it. Fortunately, none of my dumb ass friends who went down that road have died.

      And another OD that probably wouldn’t happen without the war on drugs.

      1. Probably not but who knows. He started hooked on prescription stuff then moved on. A chick in his rehab actually introduced him to the H.

        But he had lots of chances to clean up and declined them all. His original injury had long since healed. Before the end my sister wouldn’t let him in her house or near her kids – unpredictable behavior and thievery even of family stuff.

        I guess without the war on drugs he could have gone through life drinking Laudanum or whatever.

        1. I guess without the war on drugs he could have gone through life drinking Laudanum or whatever.

          That’s what I was getting at. There will always be the possibility of people doing dumb shit and OD’ing. But if you can reliably control the dose and know what you can handle, opioids are reasonably safe. Most ODs happen because of unknown potency or adulteration with things like fentanyl.

          1. I agree. I’m still skeptical that he would have been a functional member of society in that condition. I do not know enough about his circumstances and the drugs to predict if he would have been able to hold a job, be any kind of a father to his child, etc… or if he would have been using welfare and theft to buy his laudanum – albeit at lower prices, far higher quality and predictable concentrations.

        2. A chick in his rehab actually introduced him to the H.

          Rehab and N/A meetings don’t always work as planned.

          1. Junkies are good at creating more junkies.

            1. Very true, especially when they are forced to hangout with other junkies.

  4. Read a factoid that said that drug addicts are 77% of the population of ‘frequent users’ (10+ visits per year) of emergency rooms.

    I’m not opposed to them killing themselves. Indeed, that is rather salutary. But could they please do so quickly and without incurring a burden on others?

    1. How many of those visits are ODs or injuries and how many are attempts to get some painkillers?

      1. idk – data is from an industry publication – http://bit.ly/2oJ0Tym

        1. “data is from an industry publication ”

          An industry that sprung from the ethos of empathy. Keep that in mind, friend.

    2. Though I’d bet that a significant number of them are also homeless and only go to the ER that often because they are arrested for being homeless and the jails are full of hardened homeless terrorists on that night.

    3. It is not unusual for the police to take people to the hospital against their will. I’m sure that they claim to do it for the person’s good, but I suspect it’s so they can add a monstrous hospital bill to whatever other injury they inflict on the person.

    4. I’m not opposed to them killing themselves. Indeed, that is rather salutary. But could they please do so quickly and without incurring a burden on others?

      Amen to that.

      1. Y U HAT POOR WIHT PPL SPRAKY

        1. BECUZ THERE TEH DUMBZ!

      2. Sparky is okay with the extermination of poor whites? Big surprise.

        1. No, no, I’m just an elitist poser.

  5. The new hotness in our area is couples heroin. Buy, then shot up in the car in the Hardee’s parking lot while the kids in the back seat watch.

    The latest story is a young mom who ODed and was taken to the hospital. So her husband went to get her, but of course he shot up in the bathroom (through his toes!) before he went to get her. It was a family outing!

  6. “Heroin use appears to have become more socially acceptable among suburban and rural white individuals”

    Not everything is about Medicaid, but some things are.

    This article is tying increased opioid use in rural America to the expansion of Medicaid.

    “The expansion of Medicaid through the Affordable Care Act increased the percentage of Clay County residents with Medicaid and gave more of them access to free prescription drugs, including pain pills.

    Though Clay County’s opioid problem long preceded the act, the improved legal access helped bring a long standing problem out from the shadows. Statistics show residents are swallowing the preferred prescription opioid more.”

    —-Kaiser Health News

    http://tinyurl.com/j3awum3

    Some of the statistics in that article are pretty compelling.

    “Clay’s residents filled prescriptions for 2.2 million doses of hydrocodone and about 617,000 doses of oxycodone in the 12-month period ending last September ? that’s about 150 doses for every man, woman and child. About half as many doses of each drug were reported in Allen County (population 20,640), on the Tennessee border 160 miles southwest. Even smaller quantities were used in Breckenridge (population 20,018), another central Kentucky county.”

    Those sound like small towns to most people, but those towns they’re comparing it to are probably fairly large compared to the more rural county.

  7. The same people who don’t care if heroine users die (90% of the poulation) are very concerned that they be allowed to do heroin in the first place. Because sinning must be illegal and all sinners must be punished.

    1. people who don’t care if heroine users die (90% of the poulation)

      Well, heroin users that they don’t know.

  8. Heroine use has become socially acceptable ? Really ? The author is on something.

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