Heroin and Opioid Policy

SUMMARY

Record numbers of Americans are becoming addicted to both heroin and legal opioids. Opioid overdoses have reached record highs. We must combine a number of interventions to prevent opioid addiction, bring more users into treatment, and reduce overdose, infection and other harmful consequences of opioid use. We can prevent opioid addiction by reducing painkiller prescription. To expand treatment, we must increase funding for and acceptance of medication-assisted treatment. To reduce overdose deaths, we need Good Samaritan and naloxone access laws. To reduce disease transmission, we need to expand needle exchange programs. Above all, we need to reach the most marginalized individuals, who are often homeless, lack health care, have given up on treatment, and show up in emergency rooms for overdose and infection. We can most effectively reach this population by establishing supervised injection facilities, which protect these users from death and disease while bringing them into contact with medical and treatment professionals.

INTRODUCTION TO OPIOIDS

Opioids are medically useful but dangerously addictive drugs. Also referred to as opiates or narcotics, they are derived from the resin of the Asian poppy seed pod. They include heroin, morphine and opium as well as common prescription drugs: OxyContin, Vicodin, Codeine and Percocet. These drugs are particularly useful for acute post-trauma and chronic pain treatment, but they are also highly addictive. While prescription opioids are normally consumed in pill form, opioids can also be snorted, inhaled or injected. The latter methods release the drug into the bloodstream more rapidly, causing more intense euphoria, respiratory depression and nausea. If consumed in excess, they can shut down respiration and cause overdose death. Dependent users who quit taking opioids suffer a few days of flu-like withdrawal symptoms, often followed by years of intense cravings.

While heroin is chemically similar to other opioids, its illegal status reduces our legal control over it. Since it has no accepted medical uses, it is classified as a Schedule I Drug, meaning that the manufacture, distribution or possession of heroin for any purpose is a serious crime. Other opioids are manufactured by pharmaceutical companies and carefully monitored by the government. Demand for heroin is filled exclusively by illegal operations—for the U.S., primarily Mexican and Colombian cartels. As a result, the government cannot control the quality of heroin, license the distributors, or monitor the users.

THE OPIOID EPIDEMIC

Americans are becoming addicted to both heroin and legal opioids in increasing numbers. Today, an estimated 2.1 million people struggle with opioid addiction, and an estimated 467,000 are addicted to heroin.[1] From 2002 to 2013, heroin use increased 63 percent.[2] In 2010, 16,235 Americans died of prescription opioid overdose, and in 2013, heroin overdose killed another 8,257.[3] Between 2002 and 2013, the rate of heroin overdose deaths has nearly quadrupled.[4]

The increase stems from doctors overprescribing prescription opioids. Due to a new medical focus on treating pain in the 1990s as well as false advertising by pharmaceutical companies, opioid painkiller prescriptions exploded from 76 million in 1991 to 219 million in 2011, almost one for every American adult.[5] Around 2007, authorities began responding to growing addiction and overdose by cracking down on prescription excess and fraudulent "pill mills." Many patients, upon finding themselves addicted when their prescriptions ran out, began buying their pills on the street. Since the government crackdown reduced the supply of pills, the street price skyrocketed. Dealers convinced many patients to switch from $50 Oxycontin pills to the cheaper, more accessible alternative—$10 doses of heroin. An estimated 80% of new heroin users began using the drug after becoming addicted to prescription opioids.[6]

POLICY SOLUTIONS

As we reduce painkiller prescriptions, we can expect the increase in illegal pill and heroin use to continue. Despite the government crackdown, painkiller prescriptions have barely declined since their peak in 2011; this year, doctors still wrote almost one prescription for every adult in America.[7] New research shows that while the crackdown targeted “pill mills”—facilities overprescribing painkillers for profit—the wider problem is overprescription by well-intentioned doctors.[8] The small decline in prescriptions has already pushed hundreds of thousands of patients to buy opioids on the street. As more doctors cut prescriptions, more patients will turn to the street market, and many of them to heroin.

We can stop the pipeline from prescriptions to heroin by changing how doctors handle opioid-dependent patients. Currently, when doctors suspect a patient has become dependent, they treat the patient as a criminal. They immediately cut off the prescription, ask accusatory questions, require drug tests and threaten criminal proceedings. Instead of providing help, doctors force the patient to quit a notoriously addictive drug in silence. Many patients begin to buy pills on the street, where dealers introduce them to heroin. To stop the pipeline, doctors must continue to approach patients as patients, not suddenly treat them as criminals. Addiction experts recognize that dependent users need to transition off of opioids gradually, instead of trying to quit “cold turkey.” In many cases, the greatest obstacle to connecting a patient to treatment is the patient’s own doctor, who considers addiction a simple matter of willpower. In other cases, the doctor fears that supplying pills to a dependent patient will expose them to criminal charges. The Drug Enforcement Administration (DEA) needs to ensure that doctors can treat patients’ addictions responsibly without fearing prosecution.

For the millions of people who have become addicted to opioids, we need to expand a number of underused interventions proven to avoid overdose, stop dependency, and prevent the most damaging consequences of opioid abuse. These include: (1) Naloxone Access and Good Samaritan Laws, (2) Medication-Assisted Treatment, and (3) Safe-Injection Facilities.

Naloxone Access and Good Samaritan Laws

We need to make sure that patients survive their opioid addictions. Many are surprised to learn that heroin overdose deaths are entirely preventable. Naloxone (brand name Narcan), which is administered by injection or nasal spray, reverses overdose within seconds by dislodging the drug from the brain's opioid receptor sites.[9] Naloxone is available in hospitals and carried by paramedics and some police officers. In a small number of cities, community-based overdose programs train users, family and friends to administer naloxone.

If we can stop heroin overdoses, why do they still claim the lives of twenty Americans a day? Users of illicitly purchased opioids tend to use alone and in hiding, where they are likely to die in case of an overdose. Any heroin user who attempted to ensure his or her safety by injecting in a hospital or near a policeman would be arrested. Even when users overdose around others, fellow users often hesitate to call 911. In 29 states, if a user calls 911 to save a friend from overdose, police can arrest those at the scene for drug possession. In these states, users often abandon those who overdose to avoid arrest.

These obstacles can be removed through Naloxone Access and Good Samaritan Laws.[10] Since naloxone cannot be abused, it should be distributed to anyone likely to witness an overdose, including users and their friends and families. All states need to allow pharmacies to dispense naloxone over the counter to anyone who cares to carry it, as California has done.[11] Local governments and nonprofits should train those likely to witness an overdose to administer naloxone. Similarly, Good Samaritan Laws protect users from prosecution for calling 9-11 or administering naloxone to save a friend’s life.[12] From 1996 through June 2014, these laws have empowered Americans to reverse an estimated 26,000 overdoses.[13] We could save thousands of lives every year by expanding these laws to all 50 states.

Medication-Assisted Treatment

Opioid addiction cannot be cured, but it can be managed. Successful treatment programs help individuals get through withdrawal, cope with cravings, and manage personal issues that lead to addictive behaviors through both pharmacological and behavioral interventions.

The most effective treatment method, Medication-Assisted Treatment (MAT), lacks availability and funding. MAT patients receive regular oral doses of opioids, usually methadone or buprenorphine (brand name Suboxone). When properly dosed, these opioids stop cravings without causing a “high,” allowing patients to function normally. Patients continue to take these opioids for months or years, until they are ready to quit. Traditional abstinence-only treatment advocates criticize MAT for “simply replacing one opioid with another.” However, anyone familiar with MAT knows the difference between “nodding” on illegal, uncontrolled heroin and using Suboxone to banish cravings while functioning normally. These replacement opioids allow MAT patients to take safe, controlled levels of medication, rebuild their lives, and fully quit when they are ready.[14] As a result, MAT programs have far lower relapse rates than abstinence-based programs, which force users to quit immediately. Still, these criticisms have limited MAT funding.[15] 

In addition to being underfunded, MAT is blocked by our medical and criminal justice systems. Concerned about doctors dealing drugs, the federal government requires doctors to get specially certified for MAT and caps their allowed number of Suboxone patients.[16] In rural areas, many patients cannot find an open MAT slot.[17] MAT patients also suffer in the criminal justice system. If arrested, most jails refuse to allow patients to continue their Suboxone treatment, sending them into withdrawal. Many drug courts, which are designed to divert drug users out of the criminal justice system, require patients to quit MAT. Fortunately, the Obama administration has threatened to cut off funding for drug courts hostile to MAT. Access to MAT programs needs to be expanded, particularly in rural areas and within the criminal justice system.

Supervised Injection Facilities

What can be done to help the most marginalized and depressed heroin users, who are not seeking treatment? Many of these people are homeless, unemployed, suffering from disease and chronic skin infections, cut off from family and friends, and branded with a criminal record. Heroin is their solution to this situation.[18] They need a place where they can avoid overdose and disease. In order to successfully quit their painkiller, they need comprehensive support to tackle their housing, employment, medical, criminal and personal problems.

In 92 locations across Europe, Canada, and Australia, injection drug users bring their own drugs into supervised injection facilities (SIFs) and inject in the presence of medical staff. SIF staff provide sterile injection equipment, medical advice and treatment referrals, and they intervene in case of overdose. All 92 SIFs have demonstrated a track record of success—millions of injections and tens of thousands of overdoses have not killed a single person.[19] The difference is stark. A year ago in Pittsburgh, a batch of heroin mixed with fentanyl killed 22 people.[20] Nine months later in Vancouver, a similar batch caused 32 people to overdose. Thirty-one of them overdosed at Insite, the city's SIF, where the medical staff saved their lives. The 32nd, a woman in her 20s, was found dead in a downtown hostel.[21]

SIFs also save millions of dollars by reducing disease transmission. Since users can be arrested for possessing needles, many share syringes with other drug users, spreading blood-borne diseases. As a result, when compared to the general U.S. population, people who inject drugs are 35 times more likely to have Hepatitis C and 23 times more likely to be HIV positive.[22] A single new infection carries lifetime costs of $68,000 for Hepatitis C and $408,000 for HIV/AIDS.[23] Researchers estimate that over the past decade alone, the Vancouver SIF has saved millions of dollars and dozens of lives for the local population.[24]

SIFs have a number of other benefits. Medical staff spot skin infections early on and intervene before they develop into expensive, life-threatening conditions.[25] Studies show that SIFs also reduce syringe littering and the frequency of drug use in public places.[26]

Critics warn that SIFs will encourage more heroin use, but in fact they reduce use. SIF medical staff build relationships with depressed, outcast users and help them turn their lives around. Studies show that SIFs increase the percentage of users entering treatment.[27] They also show that SIFs do not attract new users, which makes sense--who takes up an activity because a medical facility treats it as a disease?[28]

Given that SIFs have been so effective against heroin overdose crises in other countries, why don't we embrace them here? Public officials are reluctant to support SIFs because they fear their constituents' reactions: "Why spend taxpayer money to enable drug use?" The answer: SIFs save taxpayer money by preventing death and disease. They don't enable drug use, they support drug users in seeking medical help and bring more drug users into treatment.

OPIOIDS and CJPF

We must treat individuals suffering from opioid addiction with dignity and respect during all stages of their drug use and recovery.  We must admit that threatening and punishing drug users has failed to stop drug use, while ruining millions of lives. Over 80 percent of Americans agree that the war on drugs has failed.[29] Around the nation, policy makers are adopting elements of an effective opioid policy, starting with smarter prescription drug controls, Naloxone Access and Good Samaritan Laws, increased funding for and access to Medication-Assisted Treatment. Another intervention, supervised injection facilities, has been called for by the Mayor of Ithaca, NY.

CJPF has long advocated for the safe and humane treatment of all individuals who struggle with addiction. Recently, in 2015, Executive Director Eric E. Sterling testified before the Maryland Heroin and Opioid Emergency Task Force. Chief of Staff Amos Irwin wrote an article on heroin overdose and supervised injection facilities for the Huffington Post.[30] Amos Irwin for CJPF has prepared cost-benefit analyses to estimate how much money would be saved by establishing SIFs in specific American cities (In press).

SOURCES

[1] Volkow, Nora. (2014). “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.” National Institute on Drug Abuse, May 14. Accessed 15 Dec 2015 at http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/americas-addiction-to-opioids-heroin-prescription-drug-abuse#_ftn2

Volkow, Nora. (2014). “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.” National Institute on Drug Abuse, May 14. Accessed 15 Dec 2015 at http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/americas-addiction-to-opioids-heroin-prescription-drug-abuse#_ftn2

[2] Jones, Christopher; Logan, Joseph; Gladden, Matthew; Bohm, Michele. (2015). “Vital Signs: Demographic and Substance Use Trends Among Heroin Users—United States, 2002-2013.” Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR). Jul 10. Accessed 10 Dec 2015 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm?s_cid=mm6426a3_w 

[3] Davidson, Peter; Gilbert, Michael; Jones, Stephen; Wheeler, Eliza. (2015). “Opioid Overdose Prevention Programs Providing Naloxone to Laypersons—United States, 2014.” Center for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR). Jun 19. Accessed 15 Dec 2015 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

Chen, Li-Hui; Hedegaard, Holly; Warner, Margaret. (2015). “Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013.” Centers for Disease Control and Prevention NCHS Data Brief. Accessed on 15 Dec 2015 at http://www.cdc.gov/nchs/data/databriefs/db190.pdf

[4] Bernstein, Lenny. (2015). “Heroin Deaths Have Quadrupled in the Past Decade.” The Washington Post, Jul 7. Accessed 15 Dec 2015 at https://www.washingtonpost.com/news/to-your-health/wp/2015/07/07/heroin-deaths-have-quadrupled-in-the-past-decade/

[5] Meier, Barry. (2007). “In Guilty Plea, OxyContin Maker to Pay $600 Million.” New York Times, May 10. Accessed 23 Dec 2015 at http://www.nytimes.com/2007/05/10/business/11drug-web.html?_r=0

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[6] Kuehn, Bridget. (2013). “SAMHSA: Pain Medication Abuse a Common Path to Heroin Experts Say This Pattern Likely Driving Heroin Resurgence.” Journal of the American Medical Association, Oct 9. Accessed 10 Dec 2015 at http://jama.jamanetwork.com/article.aspx?articleID=1750124

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[7] Volkow, Nora. (2014). “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.” National Institute on Drug Abuse, May 14. Accessed 15 Dec 2015 at http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/americas-addiction-to-opioids-heroin-prescription-drug-abuse

[8] Diep, Francie. (2015). “How Family Doctors Contributed to America’s Opioid Problem.” Pacific Standard Magazine, 15 Dec. Accessed 23 Dec 2015 at http://www.psmag.com/health-and-behavior/family-doctors-america-opioids

[9] Irwin, Amos. (2015). “Why Heroin Overdoses Are Rising and How We Can Prevent Them.” Huffington Post, Mar 10. Accessed 10 Dec 2015 at http://www.huffingtonpost.com/amos-irwin/why-heroin-overdoses-are-_b_6831632.html

[10] Davis, Corey. (2015). “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws.” The Network for Public Health Law. Accessed on 15 Dec 2015 at https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf

[11] DPA. (2014). “Governor Jerry Brown Signs Overdose Law Expanding Naloxone Access in California Pharmacies.” Drug Policy Alliance website, Sept 16. Accessed 23 Dec 2015 at http://www.drugpolicy.org/news/2014/09/governor-jerry-brown-signs-overdose-law-expanding-naloxone-access-california-pharmacies

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[12] Davis, Corey. (2015). “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws.” The Network for Public Health Law. Accessed on 15 Dec 2015 at https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf

[13] Davidson, Peter; Gilbert, Michael; Jones, Stephen; Wheeler, Eliza. (2015). “Opioid Overdose Prevention Programs Providing Naloxone to Laypersons—United States, 2014.” Center for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR). Jun 19. Accessed 15 Dec 2015 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

[14] U.S. Department of Health and Human Services. (2009). “Medication-Assisted Treatment for Opioid Addiction.” Substance Abuse and Mental Health Services Administration (SAMHSA). Accessed 15 Dec 2015 at https://store.samhsa.gov/shin/content/SMA09-4443/SMA09-4443.pdf

[15] National Institutes of Health (2009). “Effective Medical Treatment of Opiate Addiction.” National Institutes of Health Consensus Development Statement. Nov 17. Accessed 15 Dec 2015 at https://consensus.nih.gov/1997/1998treatopiateaddiction108html.htm

[16] National Institutes of Health (2009). “Effective Medical Treatment of Opiate Addiction.” National Institutes of Health Consensus Development Statement. Nov 17. Accessed 15 Dec 2015 at https://consensus.nih.gov/1997/1998treatopiateaddiction108html.htm

[17] Cherkis, Jason. (2015). “Dying to be Free.” Huffington Post, Jan 28. Accessed 23 Dec 2015 at http://projects.huffingtonpost.com/dying-to-be-free-heroin-treatment

[18] Spencer, Ruth; Popovich, Nadja. (2014). “The Mind of a Heroin Addict: The Struggle to Get Clean and Stay Sober.” The Guardian, Feb 11. Accessed 10 Dec 2015 at http://www.theguardian.com/society/interactive/2014/feb/11/heroin-addiction-recovery-readers-response-interactive

[19] Beletsky, L., Davis, C. S., Anderson, E., & Burris, S. (2008). The law (and politics) of safe injection facilities in the United States. American Journal of Public Health, 98(2), 231–237.

[20] Ferrigno, Lorenzo and Kevin Conlon. (2014). “Cancer painkiller mixed with heroin blamed for 22 Pennsylvania deaths.” CNN, Jan 28. Accessed 23 Dec 2015 at http://www.cnn.com/2014/01/27/health/pennsylvania-drug-deaths/

[21] Luba, Frank. (2014). “Potent heroin blamed for Vancouver woman’s death in hostel, 31 overdoses at InSite injection facility.” National Post, Oct 14. Accessed 23 Dec 2015 at http://news.nationalpost.com/2014/10/14/one-dead-after-21-overdose-at-vancouvers-supervised-drug-injection-facility-potent-heroin-blamed/

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[27] DeBeck, K., Kerr, T., Bird, L., Zhang, R. et al. (2011). Injection drug use cessation and use of North America’s first medically supervised safer injecting facility, Drug and Alcohol Dependence, 113, pp. 172–176.

[28] Wood, Evan, M Tyndall, C Lai, J Montaner, and T Kerr. (2006). “Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime.” Substance Abuse Treatment. Prevention, and Policy 13.

[29] Rasmussen Reports (2013). “82% Say U.S. Not Winning War on Drugs.” Rasmussen Reports, Aug 18. Accessed 15 Dec 2015 at http://www.rasmussenreports.com/public_content/politics/general_politics/august_2013/82_say_u_s_not_winning_war_on_drugs

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[30] Irwin, Amos. (2015). “Why Heroin Overdoses Are Rising and How We Can Prevent Them.” Huffington Post, Mar 10. Accessed 10 Dec 2015 at http://www.huffingtonpost.com/amos-irwin/why-heroin-overdoses-are-_b_6831632.html