Do Efforts to Crack Down on Prescription Drug Abuse Drive Users to Heroin?

By Tessie Castillo 02/18/14

Nearly 80% of recent heroin initiates started by misusing prescriptions. What are we doing about it?

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Let’s face it. Our country has a pill problem. Some blame our prescription addiction on an aging population of baby boomers with pain needs. Others point to the frantic pace of work and home obligations that make it easier to pop a capsule than to embrace lifestyle changes. The pharmaceutical industry’s aggressive marketing efforts to doctors and patients likely play a role. But however our affair with pills developed, the relationship has turned deadly. Prescription painkiller use has skyrocketed 300% over the past decade, and currently more than 12 million Americans take pain relievers simply to get high. Equally disturbing, the dramatic growth in the availability of prescription opiates has mirrored a surge in heroin use. Nearly 80% of recent heroin initiates now start by misusing prescriptions. 

In response to the prescription crisis, the government has launched a formidable campaign to crack down on pill diversion and abuse. Efforts include ramping up law enforcement operations targeted at “pill mills,” or illegitimate pain clinics, state implementation of prescription monitoring programs, reformulation of some pain relievers into tamper-resistant capsules, and medication take-back programs. While many of these methods may reduce the availability of abusable prescriptions, there is a growing concern that supply-based interventions don’t decrease addiction, but merely divert it. 

Case in point, in 2010 Purdue Pharma reformulated OxyContin in a tamper-resistant capsule to make it more difficult to crush for snorting or injecting. Follow up research among residents of drug treatment programs nationwide revealed that while preference for OxyContin dropped 64%, reports of heroin use nearly doubled. 

Dr. Caleb Banta-Green, a research scientist at the Alcohol and Drug Abuse Institute at the University of Washington, explains, “Reformulation helped dry up the market for diverted Oxy pills, but it likely pushed some people who were already addicted toward other opiates. In the old days when the main opiate was heroin, there were hurdles, such as difficulty with access, illegality, and stigma that kept a lot of people from starting to use. Now with the phenomenal increase in prescription opiates and the misconception that they are ‘safe,’ whatever natural percentage of the population that is predisposed towards opiate addiction has much greater chance of developing problems.”

With a deadly cocktail of pills available in most medicine cabinets, addictive substances are increasingly accessible, but Uncle Sam has wasted no time choking off the supply through a scramble to implement state prescription monitoring programs (PMPs). PMPs are designed to track patient utilization of medications, physician prescription practices, and pharmacy dispensing in order to flag suspicious behavior. The alerts might result in disciplinary action against a prescriber or pharmacy that gives out too many pills or a patient who appears to be seeking medication from multiple sources. While some hail PMPs as a critical tool to reduce prescription abuse, others raise concerns about the system wrongly flagging people with chronic pain needs, invasion of patient privacy, and the lack of treatment options for addicted patients once they are cut from their drug source.  

Dr. Sharon Stancliff, Medical Director at the Harm Reduction Coalition in New York City, works with addicted patients and has used PMP data in her practice, though she has yet to change her treatment plan based on the results. “PMPs are new in most states, so we haven’t had a chance to see the effects,” she says. “I suspect they will prevent some drug abuse, but we don’t know how many patients will turn from prescriptions to heroin. When you get rid of one source of opiates, you don’t get rid of addiction. To combat that, we need to make treatment as easy to get as heroin.” 

If there is a cause and effect relationship between crackdowns on prescription opiates and an increase in heroin use, it’s imperative that efforts to reduce drug abuse include prevention and treatment options, as well as new laws and programs designed to prevent accidental deaths from overdose. Fortunately, overdose prevention laws are already gaining momentum. Fourteen states have recently implemented laws that make it easier for people to call 911 in an overdose situation without fear of police reprisal. Additionally, seventeen states have passed legislation to increase public access to naloxone, an antidote that reverses the effects of opiate overdose. Naloxone is safe and effective enough to be administered by nonmedical personnel, such as friends or family of an overdose victim, via intramuscular injection or a nasal spray. Nationwide, community programs have distributed over 53,000 naloxone kits to people at risk for overdose and recorded over 10,000 reversals. Even new programs, such as the Overdose Prevention Project in North Carolina, launched in August of 2013, report one successful reversal for every six distributed kits. 

Dr. Banta-Green believes that in addition to controls on opiate prescribing, greater drug treatment access, and efforts to reduce accidental death from overdose, a national discussion is necessary on why we use drugs, licit and illicit, and how to promote wellness in other ways. Given that the drug overdose deaths have now surpassed car accidents as the leading cause of accidental fatalities, one might say that a national discussion on the prescription drug crisis is not only necessary, but overdue.

Tessie Castillo is the Advocacy and Communications Coordinator at the North Carolina Harm Reduction Coalition, a leading public health and drug policy reform agency in the South. She writes a regular column for The Huffington Post on overdose prevention, drugs, sex work, HIV/AIDS, law enforcement safety and health.

For more information on overdose prevention, visit, the Harm Reduction Coalition and the North Carolina Harm Reduction Coalition website.

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Tessie Castillo is a writer and drug policy advocate in Raleigh, North Carolina. Her articles explore topics such as criminal justice reform, drug policy, and harm reduction. Castillo previously served as the Advocacy and Communications Coordinator for the North Carolina Harm Reduction Coalition (NCHRC), a statewide nonprofit that advances drug policy and criminal justice reform. During that time, she played a pivotal role in helping to legalize syringe exchange programs and expand access to naloxone, a medicine that reverses opioid overdose. Find Tessie at her website or on Facebook, TwitterInstagram, and LinkedIn.