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Premature Closure? CDC Report Concerning the "Link" between Prescription Pills and Heroin Overdose Deaths Misreported by Reuters
(Paula Bronstein/Getty Images)

Premature Closure? CDC Report Concerning the "Link" between Prescription Pills and Heroin Overdose Deaths Misreported by Reuters

David W. Murray

There is widespread (and not unreasonable) concern among Americans that those who misuse prescription opiate pain killers might switch over to heroin use if their access to the pills is constrained. Yet this potential “link” between the use of these drugs has been largely a worrying conjecture, without a great deal of empirical support.

Until now, that is. At least, if a Reuters news story is to be believed (“US heroin deaths double in link to prescription painkillers, says CDC,” October 3, 2014.)

Misuse of prescription opiates rose at the turn of the millennium, peaking in 2005 before flattening out and perhaps beginning a welcome decline over the past couple of years.

This rise in misuse has been correlated with an enormous expansion in the number of prescriptions written for these substances (reaching 200 million for opiates per year), leading many medical authorities to warn of “overprescribing” and leading law enforcement to crack down on illegal “pill mills” flooding vulnerable markets, such as Appalachia, with opiates.

The rise in the misuse of these drugs, familiar under such names as Vicodin, Methadone, and Oxycontin, has further driven an increase in overall opiate death rates, historically a function of street heroin, and not medical prescribing.

In fact, according to recent data, opiates account for almost 17,000 “drug induced” deaths per year, a stunning number made possible by the wider availability of these medical pain killers, and not by major changes in heroin deaths.

That appears now to have changed. The Centers for Disease Control (CDC) reports that the death rate from strictly heroin overdoses has doubled between 2010 and 2012 (now at 2.1 deaths per 100,000 population). Further, the death rate from prescription overdoses experienced a small decline over that same time period.

As the CDC reports, “The rapid rise in heroin overdose deaths follows nearly two decades of increasing drug overdose deaths,” while the overall death rate from all opiates was “primarily driven by OPR (prescription pain killer) drug overdoses.”

Is there a compelling link between these two trends? Here is where the Reuters reporting gets it wrong, in a manner that could mislead drug control policy. Reuters posits that the doubling in heroin deaths is “linked” to the prescription pain killers, arguing that the “over-prescribing of pain killers is fueling … (the) rise in heroin use.”

Further, they attributed that conclusion to the CDC’s recent report (“Increases in Heroin Overdose Deaths – 28 States, 2010-2012” MMWR, October 3, 2014). As Reuters concludes, “The switch from prescription pain killers to heroin poses a public health concern.”

After all, there is a study of opiate treatment subjects, and of those who started heroin use since 2000, some 75 percent, notes the CDC, reports that “their first regular opiate use was a prescription drug.”

However, a crossover is not what the CDC actually concludes. The posited “switchover” from pills to heroin is still not established. As the CDC puts it, “Although some persons might be discontinuing prescription opioids and initiating heroin use as a replacement, results from this study indicate that recent heroin death rates increases were not significantly associated with decreases in OPR overdose mortality.”

In actuality, the CDC report notes that “changes in state heroin overdose rates were associated with increases rather than decreases in state OPR overdose death rates.” That is, Reuters has mistaken what “might” be with what the actual study established.

The risk of a switch over is real, and monitoring the overprescribing of opiate pain killers, while continuing policies to prevent their diversion and misuse, are clear imperatives, regardless of whether or not such measures might be linked to heroin use and subsequent overdoses.

Misuse of such medicines is dangerous in its own right, and we need to be on guard.

But there is another risk we run from this premature conclusion involving a posited “cross-over” between the two drug types. Heroin use and heroin overdose deaths are rising on their own, independent of the pain killer link, likely because the supply of heroin is driving its own epidemic of deaths.

Indeed, the new impact of heroin itself on overdose deaths reflects an increase in heroin use in the US, which has risen fully 74 percent between 2009 and 2012 among past month users 12 and older. This increase in use has been underpinned by a stunning increase of the supply of heroin flooding into the US in recent years. In fact, seizures of heroin at the Southwest Border region with Mexico have roughly quadrupled since 2008.

As the CDC itself notes, “Numerous factors contributed to drug-specific use and overdose death rates… an increase in overall heroin supply and greater availability of heroin in some parts of the country might contribute to the trend and variation observed in heroin mortality.”

The lesson for policy makers is that we need a comprehensive strategy that addresses both the supply of misused prescription opiates as well as soaring heroin supply. That is, we must integrate effective reduction in the demand and availability of medicines that are misused with effective international interventions (primarily in Mexico, a current principle source of US heroin, but with a striking threat from Afghanistan heroin looming) and stronger efforts against drug traffickers.

What is urgently needed is a drug control strategy combining drug demand and drug supply programs. We must reassert effective measures to control the movement of drugs across our borders, and reestablish pressures against the transnational cartels operating too freely abroad, as well as increasingly at home in the US.

The current movement pushing for the legalization of drugs is dragging us in the wrong direction. Prescription drugs are “legal,” yet when misused are a source of national tragedy. That realization should make us face a hard fact: simply “legalizing” drugs does not reduce their dangers.

Finally, a broader epidemiological point: we know there is a distinct risk factor for initiating heroin use besides the previous misuse of opiate pills. As the British journal Lancet recently (September 9, 2014) re-confirmed, the heavy use of marijuana, especially in adolescence, increases by a factor of 8 the likelihood of subsequent use of drugs such as heroin, compared to non-marijuana users.

Simply put, we cannot expect to expand the pool of marijuana users exposed to the new, highly potent cannabis such as found in Colorado, and believe that the risks end there. Rather, by increasing marijuana prevalence, we will inexorably have expanded the risk pool even wider for the use of other drugs, including heroin. Legalization portends consequences beyond the immediate damage from marijuana alone.

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