This document summarizes research on the intertwined opioid and heroin epidemics in the United States. It discusses trends showing rising overdose rates for both opioids and heroin since the 1990s. Qualitative interviews suggest many individuals transition from misusing prescription opioids to heroin. The epidemics are intertwined as the at-risk populations overlap and many initiate heroin use after developing dependency from prescription opioids. However, the heroin epidemic also involves a "heroin pull" from increased heroin availability and new forms of heroin being supplied. Ongoing challenges include addressing excessive opioid prescribing, improving surveillance of heroin products and use patterns, expanding treatment programs, and implementing harm reduction strategies.

1. Dan Ciccarone, MD, MPH
Professor, Family and Community Medicine
University of California, San Francisco
Sarah Mars, PhD
University of California, San Francisco
Jay Unick, PhD
University of Maryland
Intertwined Epidemics: Opioid And
Heroin- Related Overdose

2. HEROIN IN TRANSITION (“HIT”) STUDY
NIH: National Institute of Drug Abuse
• DA037820
• Multi-methodological study: quantitative and qualitative
aims
• Emerging patterns in consequences of use
• Heroin supply flows
• New heroin source-forms and how they are perceived and
used

3. OBJECTIVES
EPIDEMIOLOGY
• Compare and contrast prescription opioid- and heroin-
related overdose
• Trends
• Demographics
• Regional differences
• Opioid “push” vs heroin “pull” forces
QUALITATIVE
• Relate stories of heroin use

4. NIS: Opioid OD
hospitalizations:
1993-2013
Apogee reached?

5. Unfortunately:
• Heroin use and
consequences are up
• Rise is concurrent with the
later stages of the opioid
misuse epidemic
TRENDS IN HEROIN USE AND
CONSEQUENCES

6. NIS: Heroin Overdose
Admissions,
1993-2013:
- Sharp rise, doubling
since 2005

7. ARE THESE THE SAME EPIDEMICS?
• Intertwined epidemics:
• Intertwining of population at risk1
• Stories of heroin initiation: “Every never…”2
1UNICK, ET AL. INTERTWINED EPIDEMICS: NATIONAL DEMOGRAPHIC TRENDS IN
HOSPITALIZATIONS FOR HEROIN- AND OPIOID-RELATED OVERDOSES. PLOS ONE 2012
2MARS, ET AL. “EVERY ‘NEVER’ I EVER SAID CAME TRUE”: TRANSITIONS FROM OPIOID PILLS
TO HEROIN INJECTING. IJDP 2013

8. HEROIN’S RELIABLE AVAILABILITY EASES
TRANSITION
… like a lot of people, you start on the pills, and then the doctor
gives you some and some more, and then you get cut off by the
doctor… [so] every morning we would go to the [dealer’s house] and
they had both things, but …they never were out of heroin…[but]
three times a week…they didn’t have the pills. So I’d have to
scramble around, and then I finally had enough and said, fuck. The
hell with this, give me a bag, and was off to the races.
- 51 year old using heroin 5-6 years,
originally prescribed Percocet for knee injury

9. Heroin patients in
treatment: first opiate
of abuse
• 75% of the 2000 cohort
of heroin tx pts started
with an prescription
opioid
Cicero TJ, Ellis MS; Surratt HL; Kurtz SP. The Changing Face of Heroin Use in the United States: A
Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. Published online May 28, 2014.

10. Google trends: interest
in OxyContin vs heroin
vs _________
• US
• Health category
• Jan. 2006 to Nov.
2014
Data Source: Google Trends (www.google.com/trends)
Search: D Ciccarone, 11.3.14
Analysis: J Unick

11. ARE THESE THE SAME EPIDEMICS?
• Intertwined epidemics:
• Intertwining of population at risk1
• Stories of initiation: “Every never…”2
• How does the heroin epidemic differ from the
earlier opioid misuse epidemic?
• Comparisons by age, ethnicity, gender and region
1UNICK, ET AL. INTERTWINED EPIDEMICS: NATIONAL DEMOGRAPHIC TRENDS IN
HOSPITALIZATIONS FOR HEROIN- AND OPIOID-RELATED OVERDOSES. PLOS ONE 2012
2MARS, ET AL. “EVERY ‘NEVER’ I EVER SAID CAME TRUE”: TRANSITIONS FROM OPIOID PILLS
TO HEROIN INJECTING. IJDP 2013

13. NIS: OVERDOSE RATES (1993-2013)
BY ETHNICITY:
HOD: White and
African American
OPOD: White and Native
American

14. NIS: OVERDOSE RATES (1993-2012)
BY AGE GROUP:
HOD: 20-34 y.o. OPOD: 45-59 y.o.

15. CONVERGENCE IN HOD/OPOD RATES:
20-34 YEAR OLDS

16. AGE AND GENDER DISPARITIES
Opioid at-
risk
Heroin at-risk

17. NIS: OVERDOSE RATES (1993-2012)
BY GEOGRAPHIC REGION:
HOD: Northeast and
Midwest!!
OPOD: Even – South
Good News: West

18. • Timing of opioid and heroin curves: +/-
• Surveys of recent heroin initiates report
prior opioid dependency
• Key convergences by ethnicity
• Symmetrical converging curves in 20-34
yo age groups
• Demographic differences can be
explained by risker sub-population
• Exception: Midwest
Summary:
Opioid “Push”

20. Heroin Seizures,
Southwest Border:
2000-2013
• SW heroin seizures up
4-fold
Source: National Seizure System. Reported in the 2014 National Drug
Threat Assessment Summary; DOJ, DEA, 2014

21. HEROIN OF UNKNOWN SOURCE
Source: Domestic Monitoring Program. Reported in the 2015 National Drug Threat
Assessment Summary; DOJ, DEA, 2015

22. NFLIS: Fentanyl
• Testing seized drugs
• Highest rise in rates in
NE and MW
• However: recent
relative to earlier rises in
heroin overdose
NATIONAL FORENSIC LABORATORY INFORMATION SYSTEM.
Special Report: Opiates and Related Drugs Reported in NFLIS, 2009–2014. Office
of Diversion Control, DOJ, DEA. 2015

23. • The novel entry of
Colombian-sourced
heroin increased HOD
rates; 1993-1999
• More dangerous heroin:
• New form of Mexican-
sourced heroin
• Fentanyl(+) adulteration
• Wider distribution models
• Intertwined with opioid pill
epidemic
HEROIN IN EVOLUTION: “HEROIN PULL”

24. CHALLENGES: OPIOID PRESCRIBING
226% increase
122% increase

25. CHALLENGES: DATA
Rx Opioid hospitalizations RX Opioid deaths

26. CHALLENGES: OPIOID RESTRICTION
• Opioid to heroin transitions

27. • Heroin as initial drug
of choice
CHALLENGES: HEROIN

28. FINAL THOUGHTS: CHALLENGES
• Opioid to heroin transitions:
• High dependency
• Opioid restrictions?
• Heroin as initial drug of choice:
• New England, Mid-Atlantic and Midwest: New market
strategies; expanded supply;
• New products that we don’t understand
• Fentanyl but it cant explain everything as it hits later
than the rises seen in heroin OD
• Testing bias?

29. FINAL THOUGHTS: CHALLENGES
• Better surveillance:
• Public health forensics: “contaminated lettuce”
• Heroin and fentanyl products
• Synthetics are the new reality eg NPS, cannabinoids
• Use patterns and consequences
• Harm reduction responses:
• Naloxone: 2 decades of community peer use
• Technological and policy innovations
• Supervised injection facilities
• Expanding MAT:
• Only 3% of DEA registered physicians are buprenorphine prescribers

30. BALTIMORE: “SCRAMBLE”

31. FUTURE RESEARCH
• Opioid “push”
• How did excess supply in opiates lead to opioid misuse and
dependency
• Do restrictions in opioid prescribing, ie curtailing supply, lead to heroin
initiation, dependency and consequences?
• Heroin “pull”
• How did heroin supply changes lead to heroin initiation

32. THE BOONDOCKS © 2002 Aaron McGruder. Dist. By UNIVERSAL UCLICK.
Reprinted with permission. All rights reserved.

33. ACKNOWLEDGEMENTS
 Heroin in Transition study:
 Jay Unick, PhD, University of Maryland
 Sarah Mars, PhD, UCSF
 Jeff Ondoscin
 NIH/NIDA funding: R01DA037820
 Jon E. Zibbell, PhD, CDC
 Baltimore City Health Dept.
 Mishka Terplan
 Derrick Hunt, Jeffrey Long and NEP staff
 NDEWS: Erin, Kathy and Marwa. - Eric Wish
 Maryland Department of Health and Mental Hygiene
 Michael Baier
 Philippe Bourgois, PhD
 Drug Enforcement Administration
 Photo credits: Fernando Castillo,
Dan Ciccarone

34. BALTIMORE

35. BALTIMORE: HEROIN
• Estimated number of injection drug users: ~19,000
• Doubling of heroin overdose deaths 2010-2014
• Dramatic rise in fentanyl-related deaths late 2013 to
2014
Source: Drug and Alcohol-Related Intoxication Deaths in Maryland, 2014.
Maryland Department of Health and Mental Hygiene. May 2015

36. BALTIMORE: “HEROIN” (FIELD WORK 11/15, 3/16)
• High quality:
“The best stuff I've ever used is the stuff I’m using now“
- 28 yo from Ohio, using heroin x 8 years
• Chemical feel/”taste”
Q: How does the heroin you are using now feel?
A: “Its kinda like [heroin]. It gets me well. But it is also tastes chemically”
- 60+ yo using over 30 years
• Fentanyl contamination: likely; other synthetics possible
• Sometimes sold as is; sometimes desired; however effect short-
lasting and users know this
• Some fear/concern; some old-timers are doing “tester shots” which
is unusual

37. BALTIMORE: “SCRAMBLE”
• Old term but a new form
• White powder heroin – unique
• Mixed locally;
• contains multiple powders; mixing problem!
• in contrast to “raw” heroin: not as powerful but better “rush”
• Highly variable:
• Wide range in price, volume
• Color changes: white to concrete grey, colored speckles or white
sparkles
• In solution: clear to ice-tea colored
• Effect: good rush, duration of effect 0.5 – 12 hours
• Unpredictable!
• Growing in popularity and market share

38. CLEAR HEROIN SOLUTION: UNUSUAL

39. “WE MUST STOP KILLING EACH OTHER”