Just like they did in the 80s, Americans are increasingly going straight to heroin, skipping prescription opioids. Too bad US policy doesn't reflect that.
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Jeremy Lesser is one of the faces of America's increasingly mainstream opioid crisis. Now in recovery for two years, he's 27, white, and comes from a middle-class family in New Jersey. But he didn't start using opioids with pills from a doctor—or even pills from a friend or the family medicine cabinet. Instead, his first opioid was heroin.
By now, many Americans have heard sad stories that begin with a white teen innocently ingesting a prescription obtained from a pharma-influenced doctor. Often, these tales end with the degradation of heroin—a good kid accidentally addicted, driven to crime, and maybe even dead.
But if legitimate prescriptions were ever the chief pathway to heroin—and strong evidence has long existed that they might not be—new research and stories like Lesser's suggest the pathway for people who get addicted to opioids is changing. Just like I did in the 1980s, heroin users in America appear to be increasingly going straight to the street drug, skipping the flirtation with pharmaceuticals.
Not that the people making drug policy seems to be noticing.
Although a Washington Post-60 Minutes exposé finally derailed the troubling nomination of Tom Marino as drug czar on Tuesday, its key finding—that pharma lobbying helped curtail the DEA's power to cut the prescription drug supply—fails to account for the fact that doing so without offering medication treatment might have just sped up the heroin and fentanyl crisis.
This tunnel vision focus on prescription drugs as the key factor in America's opioid crisis is shared widely throughout the government. At a recent congressional hearing on the issue, FDA commissioner Scott Gottlieb testified that "most people become addicted after receiving the drugs for a medical condition," according to USA Today. The CDC, even before Donald Trump became president, has long highlighted the fact that the vast majority of today's heroin users previously took prescription opioids. And a bipartisan group of state attorney generals earlier this month released a letter claiming that people "often develop opioid addiction through prescribed medical usage, with no intent by the patient to engage in abusive behavior, simply because of the addictive properties of opioid drugs."
Except this is an overly simplified picture. The fact is that the government's own statistics show most people start misusing prescription pills that are not prescribed to them. And the myth of innocent white addiction has led to policy that relentlessly focuses on reducing medical access, regardless of harm to pain patients. With President Trump set to finally declare the opioid crisis an official national emergency next week, now is as good a time as any to take stock of what America's prescription crackdown gets wrong—and how we can do better.
New research is increasingly finding that cutting the supply of prescription opioids isn't even stopping opioid initiation—just changing which drug people try first. A study released this year of nearly 6,000 people treated for opioid-use disorder across the US over a ten-year period found that in 2005, only 9 percent of new users reported losing their opioid virginity to heroin. By 2015, however, this number had more than tripled, to just more than a third. Although most users still get their first taste from one of several prescription pills, heroin is now the single most common individual opioid taken by people first trying this class of drugs, the study found.
"Supply-side efforts are beginning to show their effectiveness in bending the curve of prescription opioid use, which is both commendable and necessary," study co-author Matthew Ellis, an epidemiologist at Washington University in St. Louis, told me. "However, using the balloon analogy, when you squeeze one side, another side expands."
"It makes complete sense that in a context of suppressed prescription drug supplies, people are starting on alternative sources of opioids," added Leo Beletsky, associate professor of law and health sciences at Northeastern University in Boston, who noted that without addressing factors that really drive demand like inequality, unemployment, mental illness and despair, substitution is hardly surprising.
In other words, cracking down on prescription drugs has not stopped people from starting opioid use. In fact, it may just be sending more first-time experimenters to the most dangerous stuff on the black market.
Another recent study published in Health Affairs found that while the number of hospital admissions related to prescription overdose fell by around 5 percent annually between 2010 and 2014, the number of admissions for heroin increased by 31 percent each year between 2008 and 2014. Similarly, CDC statistics show that while opioid prescribing rates peaked in 2010 and fell about 5 percent per year between 2012 and 2016, heroin overdose rates have quadrupled since 2010 and overdoses linked to synthetic opioids like fentanyl increased 72 percent between 2014 and 2015 alone.
The vast majority of opioid misusers don't simply jump into the drug pool at the deep end: by the time they get to opioids, even those who do start by misusing a legitimate prescription have typically more than just experimented with recreational use of alcohol, cigarettes, weed, and often psychedelics and cocaine. Going hard or exclusively after prescription drugs is not going to disrupt that.
In another recently published paper, Ellis and his colleagues found that even among those whose opioid addiction apparently began with medical exposure, 95 percent had previously taken other drugs recreationally. "Even when discounting alcohol, tobacco and marijuana, 70.1 percent still had prior experience with other substances," he told me—a rate far higher than that seen in the general population. In 2016, for example, just 21 percent of high school seniors and 36 percent of young adults had ever even tried an illicit drug other than pot.
Lesser, who is now studying for a degree in counseling psychology, recalled being anti-drug until he was around 17, having simply accepted that "drugs are bad," as his parents and teachers claimed. In college, however, he began to question his hardline stance. "I had friends going to Ivy League schools, and all these smart, cool kids were doing these drugs," he told me.
He smoked weed for several months without any disaster, and likewise enjoyed MDMA, cocaine, and mushrooms. "None of the bad stuff society told me would happen, happened," Lesser said. And so, in 2009, when a kid he texted said he didn't have weed, but did have heroin, he was game to try it.
Chloe*, also 27 and who preferred to remain anonymous to discuss her addiction, came to heroin via a similar route: What her parents and the government said about drugs like weed didn't seem to square with reality. She had begun smoking regularly during her sophomore year of college and later learned that some of her friends were using heroin, too. "At the time, it sounded a little crazy, but so did smoking pot [at first]," she said. "My reasoning was, 'Oh, they were lying to me about weed, why not?'"
She added of heroin, "It was just this calm rushing over you and feeling peaceful and less anxious and able to turn everything off."
Lesser, who had always struggled with social anxiety, said that in his case, the first time using heroin was "underwhelming"—and definitely didn't live up to the hype he'd seen in films like Trainspotting. But that gave him a false sense of security, and when he did it a few more times, he began to understand what the fuss was about.
"I felt like I never really had a handle on my emotions," he told me. "I let them dominate me." But with heroin, he added, "I really liked that feeling of social and emotional control. The euphoria was cool, but it was definitely not the hooking point for me."
Lesser's experience of medicating symptoms like anxiety and poor emotional control seems to be the rule, rather than the exception among people who develop opioid problems. "Psychiatric issues are very common," Ellis explained. "Roughly two-thirds of our sample indicate they have been diagnosed and treated for a psychiatric disorder, primarily depression and anxiety." In yet another study with the same sample, Ellis's group found that a similar proportion "indicated they used prescription opioids to self-treat psychological issues, and 80 percent indicated they did so to 'escape' from daily stressors, past trauma, [or other] issues going in their lives," he recalled.
It's not just Ellis's work, either. Fellow researchers' data has long suggested that early life stress, trauma, and mental illness—not the first drug someone happens to try—are the real gateways to addiction. And overhyping the dangers of certain substances clearly also runs the risk of doing more harm than good.
Whether the sequence of use goes "alcohol, marijuana, cocaine, then heroin" or "alcohol, marijuana, methamphetamine, prescription opioids, then heroin," or some other way, the result is the same. If America doesn't address why people find opioid escape so compelling right now, cutting the supply of medical drugs with known strength and purity may just push users to more dangerous and unpredictable street substitutes like fentanyl.
Humans have always used chemicals as ways to change their moods. To prevent overdose death and help people avoid damaging addiction, we need to offer alternatives—and to be creative when addressing supply so that the inevitable substitution leads to less harm, not more.
*Not her real name.
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