The Changing Face of Heroin Use in the United States

Abstract

IMPORTANCE Over the past several years, there have been a number of mainstream media reports that the abuse of heroin has migrated from low-income urban areas with large minority populations to more affluent suburban and rural areas with primarily white populations.OBJECTIVE To examine the veracity of these anecdotal reports and define the relationship between the abuse of prescription opioids and the abuse of heroin.DESIGN, SETTING, AND PARTICIPANTS Using a mixed-methods approach, we analyzed (1) data from an ongoing study that uses structured, self-administered surveys to gather retrospective data on past drug use patterns among patients entering substance abuse treatment programs across the country who received a primary (DSM-IV) diagnosis of heroin use/dependence (n = 2797) and ( 2) data from unstructured qualitative interviews with a subset of patients (n = 54) who completed the structured interview. MAIN OUTCOMES AND MEASURESIn addition to data on population demographics and current residential location, we used cross-tabulations to assess prevalence rates as a function of the decade of the initiation of abuse for (1) first opioid used (prescription opioid or heroin), (2) sex, (3) race/ethnicity, and (4) age at first use. Respondents indicated in an open-ended format why they chose heroin as their primary drug and the interrelationship between their use of heroin and their use of prescription opioids.RESULTS Approximately 85% of treatment-seeking patients approached to complete the Survey of Key Informants' Patients Program did so. Respondents who began using heroin in the 1960s were predominantly young men (82.8%; mean age, 16.5 years) whose first opioid of abuse was heroin (80%). However, more recent users were older (mean age, 22.9 years) men and women living in less urban areas (75.2%) who were introduced to opioids through prescription drugs (75.0%). Whites and nonwhites were equally represented in those initiating use prior to the 1980s, but nearly 90% of respondents who began use in the last decade were white. Although the "high" produced by heroin was described as a significant factor in its selection, it was often used because it was more readily accessible and much less expensive than prescription opioids. CONCLUSION AND RELEVANCEOur data show that the demographic composition of heroin users entering treatment has shifted over the last 50 years such that heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas.

Vital Signs: Trends in HIV Diagnoses, Risk Behaviors, and Prevention Among Persons Who Inject Drugs — United States

“…Fewer blacks are injecting drugs now than before (10) Black PWID currently account for <20% of new PWID. This decrease might be partially explained by changes in social norms regarding drug injection in black communities (10), as well as increases in injection drug use among whites (11).…”

“…Although HIV diagnoses among white PWID have decreased since 2008, recent trends suggest heroin use and injection drug use among whites are increasing (10,11) and, coupled with high rates of syringe sharing, might challenge the decades of progress in HIV prevention among PWID. For the first time, in 2014, a larger number of white PWID received an HIV Further, although white PWID in 22 cities reported increases in receipt of sterile syringes from SSPs similar to increases reported among blacks and Hispanics, they were least likely to receive all their syringes from sterile sources and most likely to have shared syringes.…”

“…For those who do inject, provision of sterile syringes and services through SSPs can decrease risk for HIV transmission and other negative health outcomes. A need to address injection drug use and associated risk behaviors exists because of several factors, including recent increases in heroin addiction and overdose (6); the HIV outbreak in Scott County, Indiana, which saw an increase in diagnoses from five in 5 years to 181 in 1 year (14); and the recent 364% increase of HCV transmission in rural areas (16), largely fueled by the current U.S. opioid epidemic (11). The window of opportunity for implementing SSPs that provide comprehensive services to prevent, rather than respond to, HIV outbreaks might be closing.…”

Between a rock and a hard place: Prescription opioid restrictions in the time of fentanyl and other street drug adulterants

“…Individuals who cannot acquire POs due to limited availability or cannot use POs via their preferred route of administration due to abuse deterrent formulations may resort to a substitute drug; indeed, research findings link PO supply reduction measures in the United States with transitions from POs to street drugs such as heroin among some at-risk groups. 6,7 In an era of increasing adulteration of street drugs with fentanyl, related analogues and new synthetic chemicals, these risks are particularly concerning. Although POs are only effective for treating certain types of pain, 8 the issue of pain management is entwined with NMPOU,…”

Addressing the growing opioid and heroin abuse epidemic: a call for medical school curricula

“…One factor that may account for the sharp increase in the number of heroin users is the potential association between prescription opioid misuse and heroin use [7], as roughly 80% of heroin users report first abusing prescription opioids [8]. Possible reasons for this association include the increased availability and lower cost of heroin, making it easier to obtain [7, 9–12]. Similar to increased rates of heroin overdose, rates of overdoses from synthetic opioids (excluding methadone) increased by 88% between 2013 and 2016 [2].…”