This article first appeared in the St. Louis Beacon, July 20, 2012 - For the past several years, St. Louis County has seen an unprecedented number of deaths from heroin and prescription drug overdoses. While the number of overdose deaths has dropped by 25 percent in the first part of 2012, said Dan Duncan, director of community services for the St. Louis office of the National Council on Alcoholism and Drug Abuse, the problem is far from over.
Last year, 92 people in St. Louis County died from heroin and prescription drug overdoses -- almost a 50 percent increase from the 62 who died in 2010, according to Duncan.
Most of the people whom Duncan sees using heroin are in their late teens and early 20s. They “didn’t know that much about heroin because it hadn’t been a mainstream issue,” he said. “It’s been around forever but it was always relegated to highly urban, low socio-economic, real skid-row type locations.”
Now the problem has moved to the suburbs. Duncan and others believe the growth in heroin usage stems from the popularity of abusing prescription drugs.
“The bulk of them didn’t start using heroin, they started with prescription pain killers,” Duncan said.
Since about 2007, law enforcement officials and drug treatment centers have been seeing an upsurge in heroin usage in the St. Louis area — one that is mirrored across the country. Then in 2010, Duncan said the problem exploded. This increase was no coincidence.
In 2010, Purdue Pharma introduced a new formula for the prescription drug OxyContin to discourage its recreational use. Now a study from researchers at the Washington University School of Medicine suggests that this change may have inadvertently contributed to the rise in heroin usage.
‘I switched to heroin’
Originally developed as a drug to ameliorate pain in end-stage cancer patients, OxyContin, a generic form of oxycodone, was designed to release large amounts of the drug slowly over time. The drug’s long onset led people to believe it would have a low potential for abuse. No one realized how easy it would be to crush the tablets, releasing the oxycodone in a powder that could be snorted or made soluble and injected.
“OxyContin became the leading drug preferred by about 45 percent of the drug-using population. So the company decided to come out with an abuse-deterrent formulation that would be much harder to crush, much harder to solubilize, and that’s the product that’s currently on the market,” Theodore Cicero, principal investigator of the Washington University study, said.
Cicero’s report appeared as a letter to the editor in the July 12 issue of the New England Journal of Medicine. Researchers are still analyzing data, but Cicero feels that the data they’ve found so far are important.
The study began in 2008. Investigators tracked about 26,000 people dependent on opiate medications and entered treatment facilities across the country. Since researchers started gathering data, the number of users who selected OxyContin as their primary drug of abuse has decreased from 35.6 percent before the abuse-deterrent formula to 12.8 percent now.
“What occurred as a corollary, which was not expected, was there was a shift in preference from OxyContin. In other words, users didn’t stop using, they simply went to a different drug, and most of those turned out to be much more potent,” Cicero said.
A significant percentage switched to heroin, Cicero said. In addition to the many surveys conducted, more than 125 subjects agreed to interviews for Cicero’s study, and when investigators asked about what drug the individuals currently used, “most said something like: ‘Because of the decreased availability of OxyContin, I switched to heroin,’” Cicero said in a press release.
“Heroin is very similar to OxyContin in terms of its effects. You get the rush and the immediate surge of drug into your brain,” Cicero said. “So heroin became the choice of a lot of people because they could continue to use it in the manner they’d always used it.”
Cicero compared drug abuse to a balloon. If you press one spot on a balloon, he said, that doesn’t decrease the volume of the balloon. Instead, something else pops out on the other side. This is what happened with the increase in heroin usage.
He emphasized that Purde Pharma can’t be blamed for this increase. “The intent at the beginning was just to reduce the abuse of their own drug, and arguably they’ve been very successful at that,” he said.
Duncan agreed, saying that he believes addicts would switch eventually to heroin even without the change in OxyContin. Not only is heroin cheaper than prescription painkillers, but it is stronger chemically and produces a more effective high, according to Duncan.
“Even if that addict previously had the mindset that ‘I’m not going to touch the heroin,’ ... by virtue of becoming addicted and being at the desperation level … they will make that shift, and it happens all the time,” he said.
No matter who’s at fault, the effects of the drug’s change in formulation carry weighty consequences.
“People now don’t know what dose [of heroin] to use. They’re accustomed to OxyContin, which had a tablet size and had markings on it,” Cicero said. “With heroin, this certainty is gone. You’re not quite sure what you’re getting … and that’s a perfect formula for overdoses.”
National and local agencies are fighting back against what many have called the heroin epidemic. With a drop in overdose-related deaths so far this year, Duncan said the awareness campaigns seem to be helping.
The St. Louis office of NCADA, along with the Missouri Division of Alcohol and Drug Abuse, the St. Louis County Children’s Service Fund, and the St. Louis County Police Department launched the Curiosity + Heroin: Not Even Once campaign to spread awareness of the heroin problem to families in the region. The campaign uses everything from town hall forums to advertisements in movie theaters and on bus stops.
Kate Tansey, executive director of the St. Louis County Children’s Service Fund, said that while marijuana and alcohol are considered common, heroin creates a longer-term problem.
“An opiate addiction is so much more difficult to treat and get off. Recovery is possible but it often takes many episodes of treatment, it’s very costly, it’s very costly to a family emotionally, spiritually, every which way,” she said.
The Children’s Service Fund runs three different types of programs: prevention, intervention, and treatment. Tansey said one of her main goals is to educate kids early on about the dangers of drugs.
“The longer we can keep our kids off drugs and they choose not to use, the less likely they will become addicts,” she said. “When they start early, the chances of them becoming addicts increases.”
Duncan, the director of community services for the St. Louis NCADA, says he sees families blind-sided by heroin usage every day.
“When I meet parents who have lost their child, it’s heartbreaking. … These families were good families and these kids were good kids,” he said.
He feels the problem leads back to prescription drugs.
“We’re going to have to take this issue to the pharmaceutical companies and the medical community and say ‘We have to be more discerning. You have to be more discerning about who you prescribe these synthetic opioids to and why,’” he said.
A prescription drug-monitoring database would help reduce unnecessary prescriptions, he said. Missouri is now the only state that does not have a prescription drug-monitoring program—a fact Duncan called “shameful.”
With a database in place, doctors would be able to check whether a patient has multiple refills for a drug, when the patient last got a refill, and how many doctors' patients have asked for prescriptions.
“That would give them [doctors] a much better idea as they’re prescribing drugs if the person is truly a patient or is someone trying to misuse the system,” Cicero said.
Tansey also expressed frustration over Missouri’s lack of a monitoring program. For now though, she says much of the onus is on parents and communities.
“We really have to stay focused and pay attention to what those trends are and what our kids are doing. Not talk to kids about drugs but to talk about drugs with them,” Tansey said. “It can happen to anybody ... and we’re in it together.”