Unintended consequences: Why painkiller addicts turn to heroin

Watch Sanjay Gupta, MD on CNN at 4:30 p.m. ET on Saturdays and 7:30 a.m. ET on Sundays.

The face of heroin abuse in America is changing.

Back in the 1960s, heroin users were usually young men, who started using around an average age of 16. They were most likely from low-income neighborhoods, and when they turned to opiates, heroin was their first choice.

Now, more than 50 years later, a study from JAMA paints a very different picture.

Today’s typical heroin addict starts using at 23, is more likely to live in the affluent suburbs and was likely unwittingly led to heroin through painkillers prescribed by his or her doctor.

While heroin is illicit and opioid pills such as oxycontin are FDA-approved, each is derived from the poppy plant. Their chemical structures are highly similar and they bind to the same group of receptors in the brain. (A few opioids, like fentanyl, are totally synthetic but designed to bind with those same receptors).

In any case, the various drugs produce the same result: an increase in pain tolerance and a sense of euphoria, along with drowsiness, occasional nausea and, at higher doses, a slowing of the user’s breathing.

All these drugs trigger “tolerance” – the need to take higher doses for the same effect – and a craving for the drug in its absence.

It is precisely because there are so many similarities that pain pill addicts frequently turn to heroin when pills are no longer available to them.

Heroin is usually cheaper than prescription drugs. Opiate pain medications cost the uninsured about $1 per milligram; so a 60-milligram pill will cost $60. You can obtain the equivalent amount of heroin for about one-tenth the price.

This may be news to you, but it’s likely not to some of your neighbors, friends and family members.

Last year, the Carolinas Medical Center in Charlotte spent time trying to better understand the patients who were coming into detox for heroin. What they found were cops, lawyers, nurses and ministers who came from some of the best neighborhoods in the area.

Most of them shared a common story: “We used to take pills, but now we inject heroin.”

For years, we have been railing about the flagrant abuse of pain pills in the United States. Former President Bill Clinton called me a couple years ago after he lost two friends to accidental prescription drug overdose. As we dug into the issue together, we were stunned to learn 80% of the world’s pain pills are consumed in the United States, which has just 5% of the world’s population.

As a result, drug overdose is the leading causes of unintentional death for Americans. Someone dies in this manner every 19 minutes. That is more deaths than from car accidents.

The response to these tragic statistics has been gratifying and effective, but somewhat shortsighted.

Doctors have been less willing to prescribe medications, especially in states like Florida, formerly known for its pill mills, where tighter restrictions on prescribers led to a 23% drop in overdose deaths between 2010 and 2012.

The drugs themselves have been tweaked as well. In August 2010, an abuse deterrent version of Oxycontin was released to great fanfare. It was reformulated so it could not as easily be crushed or solubilized so abusers would have a difficult time injecting or snorting it. Within two years, the choice of oxycontin as a drug of abuse went from 35.6% to 12.8%.

That was the good news. The bad news is that the same study showed heroin use nearly doubled.

It became apparent that drug abusers weren’t going to stop as a result of government crackdowns or new technologies. They were simply morphing into people who abused other drugs.

Oxycontin used to be called the hillbilly heroin. Society and technology helped fix that problem. But addicts started turning back to real heroin instead.

A spokeswoman with the National Institute on Drug Abuse told us recently that nearly half of young people who inject heroin say they abused prescription opioids before turning to the illegal drug.

The headlines are horrifying and for good reason. The abuse of opiate pills and heroin are both taking a tremendous toll on the United States.

They are leading to increased crime, decreased productivity and they’re stealing the lives of too many people. While it is nearly impossible to pit one evil against another, it is important to remember that heroin, as a street drug, is unregulated, often impure and usually injected.

As a result, heroin users suffer from collapsed veins, abscesses, infections of the heart lining and valves, and rheumatological diseases. From sharing needles, they are more likely to suffer from HIV, Hepatitis and other blood diseases.

And just like their pill popping counterparts, they die of overdose in shocking numbers.

Some countries are more willing than the United States to pursue a strategy of harm reduction – that is, to steer addicts away from the most dangerous types of behavior. A number of countries have implemented programs that actually provide heroin to addicts; some studies (PDF) show that doing so improves addicts’ health and reduces their use of other illicit drugs.

Marijuana laws may reduce painkiller deaths

Yet in general, the U.S. strategy has not been harm reduction, but to target users and doctors.

While all of this was unexpected, it was likely also predictable. Medication or drugs aren’t the problem; it’s the intrinsic behavior of human beings. We don’t need to treat the drugs we are taking; we need to treat the drug addiction we are suffering.

Like the people who take the pills in the first place, society wanted a quick fix. Instead of treating the core cause of drug addiction, we implemented blanket policies to restrict the medications, alter them and place them increasingly out of reach. Yet human beings are smart, and it was easy to reach for something on a lower shelf, more easily accessible.

Make no mistake, the crackdown on opiates was a good thing, but there have been unintended consequences.

On one side, patients with legitimate pain have been caught in the crossfire, easily dismissed as malingerers and unable to get relief. On the other side, abusers have become more creative, turning to heroin to feed their addiction.

We must work to make sure treatment for drug addiction is a pillar of drug policy in the United States. We already know that it can work at levels similar to the effects of treatment of other chronic diseases, such as diabetes, hypertension and asthma.

Good doctors don’t focus on the symptoms of a disease; they want to ultimately treat the disease itself. If we do the same here, we can rid America of this awful drug habit, and save many lives in the process.

Editor’s Note: An earlier version of this article mistakenly stated prescription drug overdoses were the leading cause of acute preventable death in America. It should have stated drug overdoses are the leading cause of unintentional death.