The death last Sunday of Oscar-winning actor Philip Seymour Hoffman at age 46 focused media attention on the nationwide surge in heroin use and overdoses. But the very real heroin epidemic is framed by an even more dramatic increase since the beginning of the century in overdoses from pharmaceutical drugs known as opioids.
These are, in effect, tandem epidemics — an addiction crisis driven by the powerful effects on the human brain of drugs derived from morphine.
Prescription opioids are killing Americans at more than five times the rate that heroin is, according to the most recent numbers from the Centers for Disease Control and Prevention. These drugs are sold under such familiar brand names as OxyContin, Vicodin and Percocet and can be found in medicine cabinets in every precinct of American society. They’re also sold illicitly on the street or crushed and laced into heroin.
There have been numerous efforts by law enforcement agencies to crack down on “pill mills” that dispense massive amounts of the pharmaceuticals, as well as regulations aimed at preventing users from “doctor shopping” to find someone who will write a prescription.
Those efforts have had the unintended effect, officials say, of driving some people to heroin in recent years as their pill supply dries up.
The latest government survey of drug abuse shows a drop since 2010 in first-time users of illegally obtained OxyContin. But heroin use is up. It’s akin to pushing on a beanbag chair. Health officials in Maryland, for example, reported that in the first seven months of 2012, a 15 percent drop in pharmaceutical opioid overdoses was accompanied by a 41 percent increase in heroin overdoses.
Market forces play a role in this drug substitution, as do the brutal realities of addiction and the need for a fix. Street heroin is much cheaper than a pharmaceutical — typically $10 a packet for heroin, compared with perhaps $80 on the street for an 80 milligram OxyContin, public health officials say.
The stigma and lethality of street heroin — long viewed much more negatively than drugs such as cocaine, according to government surveys — are no deterrent to someone facing the agony of withdrawal from an opioid.
“In the storm of narcotic withdrawal, any opiate port will do,” said Jim Hall, an epidemiologist at Nova Southeastern University in Florida who studies addiction.
Prescription painkillers may also grease a slippery slope toward a relapse for former heroin addicts. Hoffman appears to be a case in point. He was found with a needle in his arm and dozens of heroin packets in his Manhattan apartment. The autopsy and initial toxicology tests were inconclusive, and so the precise cause of Hoffman’s death — whether he overdosed on heroin alone, for example, or in combination with one or more other drugs — is pending further investigation.
But the actor revealed last year that, after being clean for two decades, he suffered a relapse into heroin use after first taking prescription pills.
“The main driver of overdoses right now in our country is from opioid medications, more than from heroin,” said Nora Volkow, director of the National Institute on Drug Abuse.
In 2010, according to the CDC, 3,036 people died in the United States from heroin overdoses, up from 1,960 in 1999.
But 22,134 people died in 2010 from unintentional pharmaceutical drug overdoses, nearly triple the 7,523 deaths reported in 1999, according to the CDC. About three out of four of those overdoses — 16,652 — were from opioids. Most of the rest of the overdoses came from such drugs as Xanax, Valium and Ativan, which are used for anxiety or sleeplessness and are categorized scientifically as benzodiazepines.
Most people who abuse pills don’t have legal prescriptions for them. They get them from family and friends, and sometimes from drug dealers. Young people may view them as safer than street drugs such as heroin because they are manufactured as medicine and originate with doctors.
“We have tried to shatter the myth that these are safe,” Volkow said.
Young people are often the victims of chemical combinations they don’t understand, said Karen Hacker, director of Pennsylvania’s Allegheny County Health Department, which includes the city of Pittsburgh. They combine pills with alcohol and other drugs. They may feel that snorting or smoking certain drugs is safer than injecting them. And they may not realize that slow-release opioid painkillers have long-lasting effects.
“We had people going to sleep kind of drunk and literally not waking up in the morning,” Hacker said.
Her county had a rash of 16 deaths between Jan. 17 and Jan. 30 from heroin laced with the opioid painkiller fentanyl, which is many times stronger than heroin. The chief medical examiner, Karl Williams, said that in the 1980s and 1990s, Allegheny County would typically have about 100 overdoses annually. But in the late ’90s, he said, the numbers began steadily rising, and now there are about 250 overdoses each year.
Even that huge rate of overdoses didn’t prepare the coroner for what he saw on Friday, Jan. 17, when three bodies were brought in with signs of heroin overdoses. The next day, Saturday, he saw four more cases, and then Sunday brought three more — 10 deaths in three days. Laboratory tests showed that all had taken a lethal 50-50 mixture of heroin and fentanyl.
The overdoses from the fentanyl-laced heroin apparently have stopped, Williams and Hacker said — presumably because word got to users that they were in grave peril from heroin sold in plastic envelopes stamped “Theraflu” and “Bud Ice.”
“One of the challenges, of course, with this is that there are people who hear that there is some particularly strong heroin, and they would like some of it,” Hacker said. But, she added, “most users don’t want to die. They’re not looking to overdose. They’re not looking to commit suicide. They’re looking to get high.”
Gil Kerlikowske, a former Seattle police chief who is director of the White House Office of National Drug Control Policy, said he is concerned that many young people simply don’t grasp how addictive heroin can be.
“We see it in suburbs, among high school kids, and again it goes back to high school kids not being aware how dangerous it is. They think if they snort it or smoke it, they won’t become addicted — and within weeks they’ve become an injecting drug user,” Kerlikowske said.
“This is really among the most debilitating of drug addictions that we historically know of,” said Hall, the Florida epidemiologist. “The heroin or opioid becomes the whole focus of the person’s life. Everything is centered on how are they going to take care of their need to have the opiate in their brain in the next 24 hours and what are they going to do to get that.”
The White House is pushing more cities to follow the model of Quincy, Mass., where officers on patrol carry an anti-overdose medication called naloxone, which is sold under brand names such as Narcan. Lt. Patrick Glynn, commander of the Quincy police narcotics unit, said the program began after the city and neighboring jurisdictions had 99 overdose deaths in just 18 months in 2008 and 2009.
“We realized we could not arrest our way out of this epidemic. Young people, middle-aged people were dropping on the street, overdosing on heroin,” Glynn said.
In a recent three-year period, Glynn said, police administered 227 doses of nasal-spray Narcan and were able to reverse 216 of the overdoses.