From the Journals

Rate of heroin use in U.S. soars, especially among white individuals

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Altered prescribing practices needed

Opioid misuse can be prevented by the medical community with a change in prescribing practices aimed at limiting the supply of prescription opioids, Bertha K. Madras, PhD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Mar 29. doi: 10.1001/jamapsychiatry.2017.0163). Also, medical training “should include awareness of the risks posed by high opioid doses, immediate-release formulations, use combined with alcohol and/or benzodiazepines, history of overdoses, and other factors,” she wrote.

The United States has more than 14,000 drug treatment programs, but many are staffed with clinicians who are not licensed. One way to foster comprehensive services would be to develop an integrated medical and behavioral treatment system that would be supervised by a physician and substance abuse specialist. “Resources, training, and workforce issues are a concern, but the benefits of integrated health care and behavioral treatment conceivably outweigh the risks of maintaining the status quo,” she wrote.

Dr. Madras is affiliated with the department of psychiatry at Harvard Medical School in Boston, and McLean Hospital in Belmont, Mass. She also serves on the scientific advisory board of RiverMend Health and consults for Guidepoint.



Rates of heroin use and heroin use disorder rose dramatically between 2001-2002 and 2012-2013, and the trend was greatest among the white population. The rise among white individuals could be tied to the opioid epidemic, because nonmedical opioid also rose disproportionately in that group, according to research published online March 29.

The findings come from an analysis of 43,093 people who responded to the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), and 36,309 respondents to the 2012-2013 NESARC-III.

Photo of heroin, and hypodermic needle, and a spoon PaulPaladin/thinkstock
Overall prevalence of lifetime heroin use increased from 0.33% in 2001-2002 to 1.61% in 2012-2013, as did the rate of lifetime heroin use disorder (0.21% vs. 0.69%), reported Silvia S. Martins, MD, PhD, of the department of epidemiology at Columbia University, New York, and her associates. While the rates of heroin use among white and nonwhite individuals were comparable in 2001-2002 (0.34% vs. 0.32%), the rates had increased substantially more among white individuals by 2012-2013 (1.90% vs. 1.05% among nonwhites; P less than .001) (JAMA Psychiatry. 2017 Mar 29. doi: 10.1001/jamapsychiatry.2017.0113).

In addition, Dr. Martins and her associates found a significant rise in the number of white heroin users who had started nonmedical prescription opioid (NMPO) use before heroin (35.83% to 52.83%; P =.01). In contrast, the percentage of nonwhite individuals who started off with NMPO use dropped from 44.12% to 26.20% (P = .04).

The increase in heroin use was larger among individuals at less than 100% of the poverty level (0.44% to 2.42%; P less than .001), as well as among people with education levels of less than high school (heroin use, 0.41% to 2.01%; P = .03; heroin use disorder, 0.24% to 0.87%; P = .08) and among those with no more than high school education (heroin use, 0.39% to 2.15%; P =.003; heroin use disorder, 0.29% to 1.11%; P = .003). The absolute values of the findings may be inexact, because the methods of the two surveys differed slightly. In addition, the investigators did not include homeless and incarcerated individuals.

Based on their analysis, Dr. Martins and her associates offered strategies aimed at addressing the crisis. “To curb the heroin epidemic, particularly among younger adults, collective prevention and intervention efforts may be most effective,” they wrote. “Promising examples include expansion of access to medication-assisted treatment (including methadone hydrochloride, buprenorphine hydrochloride, or injectable naltrexone hydrochloride), educational programs in schools and community settings, overdose prevention training in concert with comprehensive naloxone hydrochloride distribution programs, and consistent use of prescription drug–monitoring programs that implement best practices by prescribers.”

NESARC and NESARC-III were funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. The authors received funding from several sources, including the National Institute on Drug Abuse, the New York State Psychiatric Institute, and the J. William Fulbright and the Colciencias doctoral scholarships. One of the study authors, Deborah S. Hasin, PhD, was a principal investigator on a study that was funded by InVentiv Health Consulting, which pool funds from nine pharmaceutical companies.

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