How to Slow Heroin’s Comeback
At first glance, the death of Philip Seymour Hoffman, who was found with a syringe in his arm and surrounded by dozens of packets of heroin, tells us little about the wider opiate problem in the U.S.: Money and freedom from 9-to-5 schedules make successful entertainers frequent victims of addiction, but they’re far from typical.
Yet the attention generated by Hoffman’s death is a reminder that heroin use is making something of a comeback nationwide, even though its use is still very rare compared with cocaine or methamphetamine. And ferocious enforcement hasn’t kept heroin prices from falling 80 percent over the past 30 years, with no prospect that even-more-ferocious enforcement would matter much.
Fentanyl, a pure synthetic, now competes with -– or, sometimes, is mixed with -– heroin. Milligram for milligram, fentanyl is perhaps 20 times as potent as heroin, and even cheaper, though reportedly not as euphoric. That tempts heroin dealers to mix fentanyl with heroin or substitute it entirely. But street fentanyl, precisely because of its potency, is even more dangerous than heroin. When the dose required to get high is a fraction of a milligram, “a little more than a little is by much too much.” The deaths by overdose of 22 users over a two-week period last month in Pittsburgh seem to have resulted from fentanyl-heroin mixtures, though apparently Hoffman’s didn’t.
The spread of heroin appears to be an indirect result of the prescription-opiate problem, which exploded from 1994 to about 2002 and has remained at high levels since; about as many people start dabbling in non-medical opiate use each year as take up marijuana.
Perversely, heroin use can be a side effect both of illicit trafficking in oxycodone and hydrocodone and of enforcement efforts against that traffic. Pills are more attractive than heroin to new users. Swallowing a pill of known dosage and purity is much safer than injecting heroin of unknown composition. And pills don’t carry the same social stigma as heroin. For users who haven’t yet developed a high tolerance, the pills are reasonably affordable: a few dollars for a pleasantly dreamy afternoon.
But opiate habits can build very rapidly, and as they do, heroin’s overwhelming cheapness gets to be more and more important: The pills cost more than twice as much dose for dose. Dependent users can also economize by snorting or injecting rather than swallowing, and heroin powder is convenient for those purposes.
So a wave of prescription-opiate abuse is almost certain to be followed by a smaller wave of heroin use. And enforcement efforts to shut down “prescription mills” -- where doctors who don’t even bother to pretend they’re treating pain simply charge for prescriptions based on the number of pills prescribed -- can have the perverse effect of attracting heroin dealers to fill the unmet demand: preventing future addiction at the cost of moving current addicts from pills to heroin.
This is where I’m supposed to start saying, “and here’s what to do about it.” But I’m mostly stumped. As mobile phones and home delivery replace street markets and drug houses, the illicit drug business gets more efficient, less scary to users and harder for law enforcement to detect.
Persuading people not to use pills is easier said than done, and some pill-dependent users are sure to move on to heroin. More aggressive screening for drug use by primary-care physicians, especially those who see adolescents, would be a partial roadblock on a path to addiction, but that’s a conversation most doctors would rather avoid. Screening, brief intervention, and referral to treatment -– SBIRT -– needs to become part of the required standard of care.
The new legal requirement that substance abuse treatment get parity with other diseases in insurance coverage, plus expanded insurance coverage under Obamacare, will make treatment more available. Substitution therapies (methadone and buprenorphine) for opiate addiction are valuable tools, but only if the treatment system and the criminal justice system are willing to follow the evidence rather than “just say no” prejudices.
A nasal spray containing the opiate antagonist naloxone (Narcan) makes it possible for a layperson to rescue someone from what would otherwise be a fatal overdose, but we still need to get rid of barriers to its availability based on fears about “sending the wrong message,” and protect those who try to help overdose victims from criminal charges.
Would any of that have saved Philip Seymour Hoffman? Probably not. Could all of it together solve the country’s opiate problem? No. But we could save some lives.
(Mark A.R. Kleiman is professor of public policy at the Luskin School of Public Affairs at the University of California at Los Angeles and co-author of “Drugs and Drug Policy: What Everyone Needs to Know.” Lowry Heussler is general counsel of BOTEC Analysis Corporation, a consulting group specializing in crime and drug policy.)
To contact the writer of this article: Mark A.R. Kleiman at firstname.lastname@example.org.
To contact the editor responsible for this article: Katy Roberts email@example.com.