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What Can We Do About the Heroin Overdose Epidemic?

June 24, 2014

A striking new dimension of our nation’s ongoing opioid epidemic is the escalating number of deaths from heroin overdose. According to data from the Centers for Disease Control and Prevention (CDC), 4,102 people died as an unintended consequence of heroin overdoses in 2011 (the most recent year for which data are available), compared to 2,789 deaths in 2010—a 47 percent increase in a single year. Heroin overdose deaths had risen somewhat over most of the preceding years (except for 2009-2010, when they actually declined), but the general upward trend had been more gradual, so these numbers come as a wake-up call.

For a few years, NIDA and other Federal partners have been sounding the alarm over the rise in heroin use, particularly among people with addictions to prescription opioids who switch to heroin because it is cheaper and easier to obtain. Half a million Americans are now addicted to heroin, and four out of five recent heroin initiates had previously used prescription opioids non-medically. Public light on this problem was shed earlier this year by the heroin-overdose death of Phillip Seymour Hoffman, who had reportedly begun using heroin after having developed a prescription drug addiction. But the scope and impact of the problem in our society is revealed in CDC’s population-wide numbers, which I discussed last week at a White House Summit on the opioid epidemic. In 2011, 11 Americans died every day from heroin overdose—nearly one person every 2 hours. (The same year, 14,091 people died from accidental overdoses of prescription opioids, also a figure that continues to rise steadily; see below.)

NIDA has actively pushed research on an easy-to-use intranasal formulation of naloxone, a drug that can save lives in the event of opioid overdose. We have also taken various measures to improve the education of clinicians in pain treatment and opioid prescribing and created resources (NIDAMED) to guide doctors in detecting and addressing prescription opioid abuse in their patients. But we and other government agencies must do much more to address one of the major drivers of the overdose epidemic: underlying opioid use disorders. Particularly, we must push for wider adoption and implementation of existing medication-assisted treatments (MATs) for opioid addiction.

Last month I coauthored a “Perspective” in the New England Journal of Medicine on the severe underutilization of these treatments, along with CDC Director Thomas R. Frieden, Pamela S. Hyde, Administrator of the Substance Abuse and Mental Health Services Administration, and Stephen S. Cha of the Center for Medicare & Medicaid Services. The opioid antagonist naltrexone and maintenance therapies using the agonists buprenorphine or methadone have proven effective at helping patients recover from opioid addiction and at reducing overdoses.  Moreover, all three treatments have been shown to improve social functioning, reduce criminal activity, and lessen the risk of transmitting infectious diseases like HIV. They are also cost-effective. But less than half of private-sector treatment programs have adopted MATs, and even in programs that offer them, only 34.4% of patients receive medications. Policy-related hindrances and limitations in the area of insurance coverage are among the barriers to wider MAT adoption, as is a shortage of physicians trained and qualified to deliver these medications. But another major barrier is attitudinal—namely, lingering beliefs (even among some staff and managers at opioid treatment clinics) that maintenance treatments simply replace one addiction with another. When maintenance treatment is offered, it is often at an insufficient dose or duration, leading to treatment failure and reinforcing the erroneous belief that medication is a poor approach.

Implementation of the Affordable Care Act (ACA) will help with some of the insurance coverage issues, but only by transcending old prejudices and misconceptions about opioid treatment (often rooted in stigma) can we ensure they are used and used effectively. We will not reduce the unacceptable numbers of overdose deaths from prescription opioids and, increasingly, heroin, without realizing that addiction—and failure to treat it—lies at the heart of the problem.

Trends in overdose deaths 1999-2011, of significance from 2006 to 2011, opiod deaths up 28%, cocaine deaths down 35%, heroin deaths up 119%

Source:  National Center for Health Statistics/CDC, National Vital Statistics Report, Final death data for each calendar year (June 2014). * includes opium

This page was last updated June 2014

Comments

Heroin

Dr. Volkow, I am currently putting together an educational Power Point on Heroin and I would really appreciate the latest statistics and known physical damage that is caused to the body by the drug,
Thank You
Jesse M. Crosby

Drug-Abuse

As one who believes in fighting the problem BEFORE it becomes a problem, it is imperative for our society to get their heads out of the sand and place more importance on the EDUCATION on the dangers of drugs! As I've said for years now and continue to say, such education should be implemented into the school system for students as young as 7 years to students who reach the high school level!

It is totally cost-effective to implement such education in that teachers are already being paid to teach and it could be implemented immediately! Only after such education is implemented can society realize unprecedented declines in the abuse of drugs, (which include heroine), as soon as a decade after implementation! There is no other way outside of repetitive education on the dangers of drugs, to effectively seek actual declines of its abuse!

Though it is a good thing and necessary to treat those who are addicted and waging personal battles against their own drug-abuse, there should be an honest effort to effectively fight a war on drugs and that is, as I've said, to invoke a repetitive system of education on the dangers of drugs, to ALL students who attend school in the United States!

MAT Procedures

I applaud current efforts to address the opioid epidemic in this country. I believe awareness and education are the greatest tools to prevent and treat this alarming trend. As a recovering addict myself, I understand how difficult this battle can be. I'm currently participating in a Drug Court program in Cuyahoga County where heroin has become incredibly pervasive in the city at its suburbs. Every week I hear of yet another overdose due to opioid abuse, many of which I've come to consider friends.

My views on (agonist) MATs are mixed. (I would like to state that I am not a trained addiction specialist or behavioral scientist. However, as a recovering addict and psychology student, I have a broad understanding of this disease. I regularly read scientific journals, NIDA-advocated Web-sites, blogs and other related materials.) I agree with the sentiment that using drugs like buprenorphine and methadone (both incredibly powerful opioids) are simply replacing one addiction for another. As an addict, particularly of the opiate variety, it's difficult to arrest addictive behaviors. Many addicts I know participating in MAT programs sell their medications to raise money to purchase heroin and/or other illicitly obtained prescription opiates/opioids. Also, medication abuse is common among patients. Comprehensive treatment when utilizing MATs is paramount. Intensive residential and community-based programs ought to be prescribed in tandem with the medications to increase the likelihood of positive outcomes. Even then, I believe (agonist) MATs should be used sparingly, and for relatively short periods of time; six to twelve months at most. Additionally, strict medical supervision should be employed. The reality is, heroin addicts are crafty, cunning, and sneaky individuals. We often find ways to manipulate and exploit opportunities.

My personal situation involves the use of Naltrexone; a complete opioid antagonist. I participated in a 90 day residential program, and continue to attend an outpatient program and regular 12-step meetings. I frequent treatment facilities to constantly remind me of the outcome should I return to active use, that is, if I'm lucky enough to make it out alive and back into treatment. I reside at a sober-living house and have much support from my peers. Random drug screenings and frequent interactions with the court and its agents keeps me accountable. The Drug Court program is lengthy and intensive, and much support is offered. My treatment program is comprehensive to say the least, and for an addict like me necessary!

Conversely speaking, I can understand the desire to advocate for long-term use of MATs. Considering the increasing opioid-related deaths, criminal activities, and general negative social impacts, MATs have their benefits. When used in the more desperate of circumstances, and under close supervision, application of these drugs is a much better option than the alternatives. With continued research and observation, and greater understanding of the brain and its related disorders, hopefully responsible and effective dispensing and use of MATs will help to abate this epidemic.

Despite evidence that (agonist) MATs are effective at combating opiate/opioid addiction, I remain firm in my belief that medications merely treat the symptoms of the disease, rather than the cause, and that talk-therapies and peer-related programs offer the best prognosis for recovering from addiction. I believe that it is too early to determine whether or not [MAT] therapies will have any sustainable benefits upon the general opiate-dependent population, and that further observation is necessary to determine their effectiveness in the long-term.

Are MAT's Treating the Problem or the Symptoms?

I am one of those struggling opiate addicts that believes MAT's treat the symptoms of a much deeper problem. Addiction in my opinion is centered in my thinking but manifests in my behaviors. Medications although helpful for some have never worked for me for an extended period of time. If I'm to stay clean I need to change my thinking and that only happens with therapy and 12 step meetings. This is just my experience,

Heroin

Hi, I am the mother of a 19 year old heroin addict. I am a mortgage processor with a local mortgage company. I am not a doctor, counselor, or psychologist. But I will tell you that I seem to understand how this drug works more than the counselors, or treatment facilities that are currently in place here in MN. I do not understand what is being done, and I would like to help and I have many good ideas that can be implemented in these programs for opiate or heroin addicts. Things need to change dramatically. A 50 year old alcoholic with a wife and 3 kids is completely different that a 19 year old heroin addict. My son alone has racked up over 100,000 grand in bills for treatment this year alone. Why are we shuffling these kids around without looking in to what center they are being put into? These addicts have no money, phone, car, anything by the time they have reached treatment. And most of them cant get in for weeks because "heroin withdraw doesnt kill you". I think more one on one interaction and several activities need to be done during the small amount of time that is given.

to help my son

My son has been a drug addict since he was fifteen,,,hooked on oxytocin, a long road is now ,thirty nine,has been on the drug,,,,can't remember the name now, any way it's hard to get unless you have money and can go to the Doctor,,,,,I was told if he can go seven days with out any drug at all there is an ejection he can get that last a month,,,,,,and what does he do in that seven days,,,fall apart, I know this he won't make it,,,,,Please help, any information, signed muther

Very sorry to hear about your

Very sorry to hear about your son’s addiction. There are several medications that can be effective for treating opioid addiction, but no matter what, it is a difficult problem, often requiring support from family and friends and other sorts of treatment to help a person regain their life. From your inquiry, it sounds like you are referring to a medication called vivitrol, which is given by injection once a month, and is an opioid blocker (it keeps drugs like oxycontin from having any effect). In a person who is addicted to opioids or taking methadone or buprenorphine, it is important that they are drug free before getting this injection, so that they do not experience severe withdrawal symptoms in response to it. If that is what you and your son decide is the best approach to take, then your son should be under medical care if he is going to be withdrawn from his current medication. What is most important is that your son can get to a treatment provider who is experienced in working with people who suffer from opioid addiction so that you can learn about the various options. The Substance Abuse and Mental Health Services administration has a site that provides information about treatment programs by location --including those that provide methadone and buprenorphine as well as vivitrol. NIDA also has a brief publication that explains some of the different medications used to treat opioid addiction. Please don’t give up—people do recover even from the most difficult addictions.

Addiction

My daughter started smoking at 14. Alcohol was next, then pot, then experimenting with nearly everything out there. We were able to help her through college and thought we were on the way to wholeness. Wrong! Shortly after graduation and starting a great job she reconnected with a past boy friend who was a heroin addict and it didn't take long for her to join him. Now, 21 years later, we have spent thousands on treatment, been defrauded and had the theft of thousands more. We have endured many overdoses, HepC, weeks visiting the hospital, many nights looking for her, days not knowing where she was and if she was alive. We spent hours in courtrooms, months of visits at jail, letters from prison, joined NAMI, participated in "family" drug education and suffered more heartache and stress related illnesses than I knew existed.
I knew something wasn't right from birth, she was awake the entire time in the hospital and slept very little the first years of life. If she was awake she was crying, which was most of the time since she slept very little. Before she was 2 I knew she was hyperactive, but the doctors did not believe me. She was a danger to herself and others I had to watch her like a hawk to keep her alive.
She had her first mental breakdown at 11 and was diagnosed with mental illness a few years later. At 14 she was anorexic, a cutter, had endured being raped and suffered great depression. While in college she was diagnosed as bi-polar, severe anxiety disordered and of course ADHD which we already knew.
Heroin use has made the mental illness much worse. The only program that ever made a difference was a dual-diagnoses rehab which was $3,000.00 for 30 days of treatment. I believe if she had been able to stay longer she would have been able to make it.
A sad commentary of our society is - if you have money you can get good health, if you are rich there are many options, if you are middle class you only going to get what is affordable - it's not much!
A bright, intelligent, talented, beautiful life being wasted. My heart stays perpetually broken. My prayer is for her to outlive us!

Very sorry about the

Very sorry about the devastating times your family has had to endure. We hope that you and your daughter will not give up—although it is terribly difficult, there are treatments and services geared for people with dual diagnoses that can be effective. But as you point out adequate and long term treatment must be available for people of all incomes, and this is something that we hope will improve as the Affordable Care Act and the Mental Health Parity and Addiction Equity Act are implemented.

Methadone maintenance

I am currently on methadone maintenance and would like to share some of the ways the program is still stigmatized. Even thought the program is sanctioned by the state and monitored by I believe the DEA, the local police of the town where my clinic is located, put up a road block coming out of the clinic about 4 months ago . They proceeded to threaten us with DUI's. While only one person received a DUI, I believe they did this to make sure we knew we werent welcome. There was some protest among the residents in town concerning the clinic; the belief was that it would bring drugs into their town. I found this to be particularly funny since I used to go to their town when I was actively using because it is peopled with addicts. People think everything is okay as long as its not right in front of their face. Anyway, I dont think law enforcement is made aware of the effects of methadone. Contrary to popular belief, methadone does not make one feel "high". All it does is block the way for heroin into our dopamine receptors. If a persons dose is too high, it might make them overly tired. This is monitored prodigiously by clinic staff. I think all physicians and law enforcement should be made aware of effects of the drugs most used by people. I find it hard to believe that the doctors prescribing pain medication are unaware of the affects of what they are prescribing. Almost every addict I know, including myself, started off using pain medications. I would also like to state that our penal system does not offer any MAT's in jails or prisons. Wouldent one think this is where is would be most useful?

Suboxone

My son is a polysubstance abuser/heroin addict so using maintenance doesn't help with the other drugs. He abused suboxone and injected it. His doctor gave him too much and he was like a zombie. I suspect he was also selling it. One needs to be vey stable and well monitored with counseling for MAT to work and it has side effects just like other opiods. As a family member, I think you need to be careful before calling for mass use of this harm reduction. It is not a silver bullet. That is why many treatment centers I talked to did not use it except for detox. It may help some people but not people like my son. Also, the withdrawal is said to be worse and longer than heroin. The addiction treatment protocols for doctors involve long term monitoring and no opiod replacement because doctors have to be clear thinking and the opiods cloud thinking. What about vivitrol which is naltrexone? It can be given in injections in early recovery which stops the problem of not taking it and can also be used as a patch.

There are now several options

There are now several options for patients addicted to opioids including methadone, buprenorphine (Suboxone, Subutex), and depot naltrexone (Vivitrol). Patients and families should work with their health care professional to determine what treatment is most effective for individual patients--including the value of non-medication approaches, such as behavioral therapies and support services.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.orgExternal link, please review our disclaimer.. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

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