Heroin: A Deadly Resurgence

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Dr. David Hammond
Dr. David Hammond

Philip Seymour Hoffman was yet another talented young man whose battle with addiction ended his life all too soon.  Whenever a public figure or celebrity dies in a public way from addiction, the media turns its attention to the subject of substance abuse.  Articles are written, reports are filed, and everyone collectively pauses for a moment to reflect on the sadness and loss of another promising future that will never be realized.  Then, the moment passes, other things grab our attention, and the plague continues.  Surprisingly, the substances killing our young people today are not very different from the drugs that took our brothers and sisters forty years ago.  The cycle continues unabated.

 

Recently, the Drug Enforcement Administration released a statement identifying prescription medications as the biggest drug problem in the United States.  With the ever-expanding prescribed drug problem being in the forefront of discussions, some attention has been diverted from illegal drug use.  Chief among these is heroin; one of the oldest known and most dangerous drugs available.  Once a tolerance is acquired to the pills, a more direct route of administration is sought.  The more direct the administration, the more dangerous the drug becomes.

 

The Centers for Disease Control and the National Survey on Drug Use and Health in 2012 released the following statistics regarding heroin use in the United States:

• 3.8 million people report having used heroin at least once in their lives;
• 560,000 people used heroin in the last year;
• 338,000 people used heroin in the last month;
• the incidence of heroin use in people incarcerated is almost 25%.

These numbers reveal an increase in the incidence of heroin use in our youth population.  Compared to the survey in 2005, the incidence of heroin use by people ages 18 to 25 increased by 0.2%.  A small percentage increase that reflects a large number of people.  With the direct IV administration of the drug, the dangers of overdose are quite significant.

 

With the increase in exposure to IV narcotics, there is a subsequent increase in emergency room visits, hospital admissions, and overdose-related deaths.  The CDC reported that, in 2002, the number of emergency room visits related to heroin use was 93,519.  In 2008, that number had more than doubled, to 201,000. Subsequently, the number of heroin related deaths increased to an average of 2,000 per year.  The most common deaths were:

1. Overdose (21.6%)
2. Homicide, Suicide, Accidents (19%)
3. Liver Disease (15.2%)
4. Cardiovascular Events (11%)
5. Cancer (11%)

 

The statistics for 2014 are sure to be even more startling.  The increase in the use of oxycontin by prescription has introduced an entirely new cohort of people to the use of opiates.  Recently, the street value of oxycontin actually significantly exceeded that of heroin.  In short, once someone becomes opiate dependent, it is cheaper to substitute heroin than to continue to buy oxycontin.  The problem then becomes expansive.  What is the person buying? Is it really heroin? What has been added to it?  How potent is it?  All of these questions relate directly to the most concerning question—how much of this is too much?

 

Recently, there has been a new problem introduced.  The northeast has seen a significant increase in the number of overdoses and deaths from a combination of heroin and fentanyl.  CNN reported that, in Western Pennsylvania, six counties reported 22 deaths in a single week in January.  Pittsburgh, during the same week, reported 15 deaths alone.  All deaths were from overdose of the deadly combination.  The mixture, referred to on the street as “Theraflu” or “Bud Ice”, resembles an old heroin mixture known as “China White”.  The problem is that the mixture is often up to 50% fentanyl instead of heroin.  Fentanyl, gram for gram, is 10 times more potent than heroin, or its breakdown product, morphine.  Fentanyl is used in hospitals, and is usually dosed in micrograms due to its potency and respiratory suppression effects.  It’s easy to understand how an overdose occurs.  If the person injecting the suspected heroin does not adjust the dose by one tenth, severe respiratory suppression and subsequent death occurs easily.

 

Law enforcement and the CDC have started publishing warnings in the most highly affected areas, naming the compounds to be wary of on the street.  The difficulty is that, many times, the dealers will change the name of their product in order to keep selling it.  Also, the dealers themselves are often unsure of the product’s components.  Victims in the middle of a severe opiate detox will use the product, even knowing it may be mixed with fentanyl, and attempt to adjust the dose accordingly.  Given the very small amounts of fentanyl necessary for respiratory suppression, the ability to adjust safely while using IV drugs is difficult, if not impossible.

 

With the growing prescription drug problem leading to more opiate addictions and the subsequent increase in the use of IV narcotics including heroin, the number of overdoses and deaths will continue to rise.  Add to this the use of fentanyl in combination with heroin, and the number of young people who fatally overdose will continue to increase for the foreseeable future.  While celebrity deaths continue to captivate our collective consciousness, were those 22 non-celebrity deaths in six counties in Pennsylvania in one week in January alone any less tragic?

 

The general population has become increasingly excited about the legalization of cannabis.  Subsequently, media attention is being paid to states that have recently made drug use a socially acceptable recreation.  While the virtues of recreational cannabis use are being argued, the bigger questions are being ignored.  As a society, what can be done to address the growing addiction problem facing our young people?  With the increasing prescription drug problem, how many more opiate addicts will turn to heroin?  Of those that use heroin, how many will overdose?  How many more will die from an old school drug now made new again?