Opioid abuse crackdown puts heroin back in style

Emergency physician Christina E. Hantsch, MD, sees several patients each month who have overdosed and are barely breathing. Their skin is blue-tinged and their pupils are like pinpoints.

“These are people near death,” said Dr. Hantsch, who works in the emergency department at Loyola University Hospital in Maywood, Ill. “We have to resuscitate them rapidly.”

The overdose source for an increasing number of such patients is heroin — signaling a slight shift from the predominantly prescription opioid overdoses seen at the hospital in the past, she said.

In recent years, federal and state officials have taken steps to prevent misuse of prescription opioids, including shuttering pill mills and launching prescription drug monitoring programs. Such increased scrutiny about opioid misuse has prompted some physicians to be cautious about prescribing pain medicine to patients.

An unintended consequence of the closer watch on pain medication is an uptick in heroin use among people who no longer can access legal opioids, say pain and addiction specialists.

In Florida, for example, heroin-related deaths have surged in recent years, said James Hall, PhD, a drug abuse epidemiologist at Nova Southeastern University in Fort Lauderdale, Fla. The rise in fatal heroin overdoses has become so alarming in Minneapolis that some prosecutors there request third-degree murder charges for the drug dealer in the deadly incidents, according to news reports. The idea is to discourage illicit drug sales in the city.

Salt Lake City pain medicine specialist Lynn Webster, MD, has seen a growing number of patients turn to heroin after their prescription pain drugs were reformulated and made more difficult to crush. Crushing extended-release analgesic opioids causes the active ingredient to take full effect almost immediately after ingestion.

“In order to get a comparable effect and because of the [high] cost” of prescription opioids, people often turn to heroin, said Dr. Webster, president of the American Academy of Pain Medicine. “Heroin is readily available and a fraction of the cost.”

In addition to being more affordable and accessible than prescription opioids, heroin has the same neurochemical affect as commonly prescribed pain medications, said Nicholas Kardaras, PhD, an addiction specialist in East Hampton, N.Y.

“It's the same high, but you don't need to go through certain gatekeepers to get it,” said Kardaras, clinical director of the Dunes, an addiction recovery center in East Hampton.

Trouble in the Sunshine State

Florida is among the states where the recent upswing in heroin use and overdoses has been most noticeable, although the numbers are still small.

Medical experts say the uptick isn't surprising considering that Florida also was one of the states hardest hit by the nation's pain medication epidemic.

“Florida had a much bigger problem with pill mills than [most other states] … so it would be more likely to notice a dramatic change if there was more of a crackdown” on prescription drug abuse, Dr. Hantsch said.

Up until recently, the state housed hundreds of pill mills, and there was limited oversight of physician dispensing habits, said the Office of the Attorney General of Florida.

Much of that has changed. Florida has shut down pill mill operations. In 2011, the state implemented a prescription drug monitoring program, among other preventive measures, Hall said.

The effects of those efforts are already visible, experts say. For instance, in 2013 there have been no Florida doctors on the Drug Enforcement Administration's list of the nation's top oxycodone-purchasing physicians. In 2010, 90 of the nation's top 100 oxycodone-purchasing physicians were in Florida, according to the DEA. Those doctors sold the pain medication directly to patients rather than writing a prescription and letting the pharmacy distribute the substance.

Hall said Florida still hasn't properly addressed the need for treatment among residents who are addicted to pain medications that they no longer can access. These people “are switching to heroin.”

Florida had 33 heroin-related deaths from January to June 2012, according to the latest data from the Florida Medical Examiners Commission. That is up from 19 such deaths during the same period in 2011. There were 759 oxycodone-related deaths in Florida between January and June 2012, according to the Florida Dept. of Law Enforcement.

Heroin-related criminal charges also have increased slightly, according to law enforcement officials. There were 1,343 such charges between January and April, up from 1,008 during the same period in 2012.

The increased street price of prescription opioids, “and the fact that opioid addicts also develop tolerance and therefore need more of the drug, has made heroin a cheaper and more available substitute than prescription opioids,” Hall said.

Research has linked decreasing prescription drug abuse and increasing heroin use.

For instance, 47.4% of people used OxyContin to get high in the past 30 days before a crush-resistant form was available compared with 30% after the reformulated product was on the market, said a study of 103 patients entering U.S. treatment programs between July 2009 and March 2012. During that same period, however, heroin use nearly doubled, said the study in the July 12, 2012, issue of The New England Journal of Medicine.

The authors wrote: “These changes appear to be causally linked, as typified by one [study participant's] response: 'Most people that I know don't use OxyContin to get high anymore. They have moved on to heroin [because] it is easier to use, much cheaper and easily available.' ”

Internist Joanna L. Starrels, MD, said there have been a handful of similar studies in recent years that raise serious concerns that the nation's crackdown on prescription opioids will lead to an increase in heroin-related problems.

“I'm very concerned about it,” said Dr. Starrels, assistant professor in the Dept. of Medicine at Albert Einstein College of Medicine of Yeshiva University in New York.

Heroin's health risks

Most alarming for some physicians are the serious health and public health implications of an upswing in heroin use. For people injecting the drug, the health risks include contracting infectious diseases, such as hepatitis C and HIV, from sharing needles, physicians say. Injecting the drug also can cause skin abscesses and bacteremia, which can lead to potentially fatal endocarditis, Dr. Starrels said. Because heroin is illegal, it's unclear what potentially toxic ingredients the drug has been cut with, and there's no dosage information, she said.

Critical to tackling the problem is educating physicians on how to manage pain properly. That includes understanding that prescription opioids are not intended to remove all discomfort, said David Kloth, MD, a pain management specialist in Danbury, Conn. The purpose of such medications is to take the edge off pain and help the person function to a certain degree until the problem can be fixed.

“There are instances when you can't cure the pain, but that decision has to be made by a pain medicine specialist,” Dr. Kloth said.

Such physician education is becoming more common thanks to a Food and Drug Administration mandate that manufacturers of extended-release and long-acting opioids fund continuing education programs for doctors and others on how to prescribe the drugs. The training sessions, which began in March, are voluntary for health professionals. Some sessions are offered online.

When physicians discontinue medication because of suspicion that a patient is abusing or misusing it, they should ensure that the individual gets linked to the proper treatment, Dr. Starrels said. Knowing the types of addiction specialists and pain experts who practice in the area and their philosophies can help physicians make good recommendations for patients who need specialized care, Dr. Kloth said.

Dr. Hantsch encourages physicians to speak briefly with patients who use prescription opioids (and their parents if they are minors) about the recent increase in heroin use. Such discussions could include information about the drug's addictiveness and health risks, she said.

“I see patients who didn't know what they were getting themselves into” when they used heroin for the first time, Dr. Hantsch said. “Some people try it once and can't walk away from it.”