A Slippery Slope: Prescription Painkillers to Heroin

Concerns about so-called “gateway drugs” – substances that, for a variety of reasons, may make it easier or more likely for an individual to progress from the use of one substance to a more addictive or deadly one – abound in the substance abuse treatment field.

And while prescription painkillers can be quite dangerous and even deadly on their own, disturbing patterns have recently been discovered linking non-medical prescription opiate use to heroin experimentation and dependence.

The latest study, published in the journal Drug and Alcohol Dependence (See full study here) this winter, reports that non-medical use of prescription opioids (pain-killers) such as Vicodin, Percocet, and OxyContin has become increasingly problematic in recent years with increases nation-wide in overdoses, hospital treatment admissions, and deaths – but also appears to be contributing to heroin initiation.

One of the first nationally representative studies in the U.S. to examine the linkages between nonmedical use of opioids and heroin in high school seniors, the research specifically showed that almost a quarter (23.2%) of students who reported using opioids more than 40 times also reported lifetime heroin use.

This latest research is alarming in more ways than one. First, it directly builds on findings from earlier studies which all illustrated the dramatic increases since the early 2000’s in the widespread availability, and resulting negative consequences from use of, prescription opiates.

Research from 2005 to 2012 has consistently cited a steady rise in the rate of prescriptions for pain relief and management over the last 25 years and has simultaneously tracked a notable increase in rates of abuse and addiction.

The number of prescriptions for opioids (like hydrocodone and oxycodone products) has escalated from around 76 million in 1991 to nearly 207 million in 2013, with the United States emerging as their biggest consumer globally.

The estimated number of emergency department visits involving nonmedical use of opioid analgesics increased from 144,600 in 2004 to 305,900 in 2008; treatment admissions for primary abuse of opiates other than heroin increased from one percent of all admissions in 1997 to five percent in 2007; and overdose deaths due to prescription opioid pain relievers have more than tripled in the past 20 years, escalating to 16,651 deaths in the United States in 2010.

What’s more, this latest research study of high school seniors underscores a progression to, or perhaps a drug “swapping” pattern involving, prescribed opiates and heroin.

In 2010, researchers at the University of Buffalo found that 31 out of 75 patients hospitalized for opioid detoxification “first became addicted to legally prescribed painkillers.” And studies from 2011-2013, including the National Institute on Drug Abuse’s (NIDA) Epidemiologic Trends in Drug Abuse, have found that nearly half of the young people who end up injecting heroin reported abusing prescription opioids before starting to use heroin.

Some individuals reported switching to heroin because it is cheaper and easier to obtain than prescription opioids. The latest study released puts a finer point on things – showing that the connection between prescription painkillers and heroin is not only real – but that it begins for many in high school and continues into their adult lives.

The implications of the collection of data on the subject seem to be two-fold. First, as NIDA has noted, it seems that drastic increases in the number of prescriptions written, a greater social acceptability for using medications for different purposes, and aggressive marketing by pharmaceutical companies have helped to foster a broad “environmental availability” of prescription medications in general and opioid analgesics in particular. These pills are around and relatively easy to come by…and as a result, people are using and abusing opiates like never before.

Second, and perhaps more importantly, many individuals incorrectly correlate “medically prescribed” with “safe.” Prescription drugs seem to be more abused and lead young people down the road to other opiates like heroin, because their legality (when prescribed by a doctor for a legitimate ailment) and the strict approvals and purity that allow them to be marketed as pharmaceutical products may cause some young people to falsely conclude that they are less harmful to use.

Not so. The key consideration is why and how the drug is used. Any drug when used in excess and for recreational purposes is incredibly dangerous. Prescription medications are, now more than ever, found in many people’s medical cabinets and are increasingly taken without consideration for side effects and appropriate dosages.

Their effects – sedating, stimulating, pain-relieving – can mimic the effects of narcotics and other controlled substances, and if a patient meets enough risk factors, there is a feasible possibility that the misuse of prescription medication can lead to experimentation with more dangerous substances.

All of these considerations make non-medical use of prescription drugs in the current climate of increased opioid abuse a call for heightened awareness and targeted education. Dr. Joseph J. Palamar, who published the latest study of high school seniors, urges “Teens experimenting with pills need to look at all of these people around them becoming addicted to – and dying from heroin. Most of these people started on pills and felt they had no choice but to move onto heroin. Targeting this group may prevent future heroin initiation, and decrease the troubling trend nation-wide in opiate-related deaths.”

For a summary of findings from Dr. Palamar’s study, click here .