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Most heroin users also use prescription painkillers, Wash U. researchers find

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It’s commonly understood that prescription painkillers are a gateway drug to heroin—both drugs are in the opiate family and provide similar highs. But new research from Washington University School of Medicine is redefining what that means.

Rather than switching from prescription painkillers to heroin, the Washington University researchers have found that many people who try heroin also continue to abuse prescription opiates.

“There’s been an assumption that took place that heroin had replaced opiates,” said lead researcher Ted Cicero, a psychiatry professor at Washington University who specializes in the brain chemistry of substance abuse. “We found that really they were being used interchangeably.”

Using a national survey of more than 15,000 people receiving treatment for opiate addiction, Cicero and his research team found that almost 42 percent of those surveyed in 2014 had used both prescription painkillers and heroin in the past month. That number has risen steadily since 2008, when people who used both drugs represented about 23 percent of opiate addicts.

According to Cicero, who has been surveying people who abuse opiates since the late 1990s, prescription painkillers used to be seen as a “socially acceptable means to get high once in a while” while maintaining that “at least I’m not a dirty junkie.”

But over time the street price of prescription painkillers such as OxyContin and Hydrocodone went up due to demand and became less accessible due to a government crackdown on pill mills and script doctors. That left addicts with the looming threat of painful withdrawal.  

“Heroin dealers recognizing a market moved in very effectively, undercut the prices and sold very inexpensive heroin, which was a lot more pure than it was previously,” said Cicero. “Their drug habit can be up to $100 a day or more. Heroin is a much cheaper alternative. And the social stigma once associated with heroin is now fairly much dissipated, which is a scary trend.”

Cicero said the choice between heroin and a prescription painkiller is often made based on cost and availability, with some who choose heroin because they think the high is better.

“So we see this shifting between the drug of choice perhaps being a prescription drug and heroin," he explained. 

The number of people in the Northeast and West who use both heroin and prescription painkillers has now surpassed the number of people who abuse prescription painkillers alone, according to the Washington University survey. The Midwest is also trending in that direction, with about 40 percent of people using both drugs in 2014.

The shift is especially dramatic in the Northeast, where 70 percent of opiate addicts exclusively used prescription painkillers in 2008. As of 2014, 60 percent of Northeasterners surveyed used both prescription painkillers and heroin.

Cicero attributed the quicker conversion to concurrent use in the Northeast to a larger drug-using population.

“The sheer volume of prescription drug abuse in the Northeast and the West Coast was really, really staggering. And the Midwest was close behind. Interestingly the Deep South showed the fewest patterns in this regard. It’s not quite clear to us why,” Cicero said.

The South also is the slowest to see an increase in concurrent use of prescription painkillers and heroin. Asked whether the South could have a stronger stigma to heroin, Cicero said that was possible.

There still seems to be a recognition that heroin is a dangerous thing to do. So they only use it when they really have to use it. - Dr. Ted Cicero

“That certainly is a factor. In The Bible Belt part of the country there still is this disdain for many of these behaviors that might not exist elsewhere,” Cicero said.

“We’re going to see more and more people transitioning I fear to heroin,” he added. “As we restrict the supply of prescription opioids we have to recognize on a national level that we’re going to see increases in heroin and (we need to) begin to tackle this problem before it gets out of hand.”

While the number of opiate addicts surveyed who use heroin grew substantially between 2008 and 2014, the number of those who exclusively use heroin has only increased incrementally. It continues to hover at about 10 percent nationwide.

“There still seems to be a recognition that heroin is a dangerous thing to do,” Cicero said. “So they only use it when they really have to use it.

“They’re intelligent enough, well-educated enough to understand that in the long-term this is not going to be a good thing for them, and that injecting drugs that are not sterile into your veins you have all kinds of issues.”

More people die of prescription opiate overdose deaths than from heroin, but Cicero said that a person who uses heroin is more likely to die than a person who uses prescription drugs.  The larger overall prescription drug death number is due to a larger population of people using prescription painkillers.

According to the National Survey on Drug Use and Health, 4.3 million Americans abused prescription painkillers in 2014, while 0.4 million Americans abused heroin.

Follow Camille Phillips on Twitter: @cmpcamille.