Here's How We Solve the Heroin Epidemic

June 10th 2015

Heroin hasn't been far from the public eye over the past few months—from Hillary Clinton’s promise to address America’s opiate addiction crisis, to last month's large heroin bust in bust in New York City, and now, a bill that could make recovery more accessible for chronic users. 

The increased media attention and political activity, including the Recovery Enhancement for Addiction Treatment Act (TREAT Act), a Senate bill backed by Sen. Edward Markey (D-Mass.) and Sen. Rand Paul (R-Ky.), is indicative of a gradual societal awakening to this burgeoning epidemic drug. A dramatic increase in overdoses by prescription pain relievers and heroin are now causing more deaths annually in the U.S. than car accidents, according to the press release announcing the TREAT Act. Journalist Sam Quinones reported in “Dreamland: The True Tale of America’s Opiate Epidemic,” that from 2007 to 2012, reported heroin usage rose from 373,000 people to 620,000.

What is heroin?

Heroin belongs to a class of drugs known as opioids (the term “opiate” is also frequently used) that are derived from the opium poppy plant. Heroin and other opioids, including many prescription painkillers like OxyContin, contain variations of the morphine molecule. 

ATTN: asked Dr. Andrew Coop, Chair of Pharmaceutical Sciences at the University of Maryland and a source for "Dreamland," to explain how heroin works.

"Heroin (and all other opioids such as morphine and oxycodone) activate mu opioid receptors in the central nervous system (the term is that they are full agonists),” Coop explained via email.  

According to the National Institute of Drug Abuse, heroin can be sniffed, smoked or injected into a vein initiating a rush, or pleasurable sensation, within seconds, then dry mouth. The needles used by heroin addicts present a set of health risks separate from those presented by heroin itself, which include nausea, vomiting and withdrawal symptoms after a matter of hours. Users typically get addicted to heroin as the drug use delivers the drug to the brain quickly, contributing to a user's high risk for addiction.  Addicts who manage to get clean, and then relapse, are at high risk of fatally overdosing because of their drastically lowered tolerance. 

Why is heroin addictive? 

“One result of the activation of mu opioid receptors is the release of dopamine, a neurotransmitter that is central to our reward system, and thus euphoria is experienced by the individual. This is the reason why taking heroin gives its high. However, it is the continued, sustained use that causes adaptations to the biological systems resulting in ‘addiction’,” Coop said. 

“That is, the body responds to the presence of the drug so that the presence of the drug is required for normal functioning. If the drug is no longer present, the person undergoes withdrawal as normal functioning requires the drug to be present. Eventually the body regains its balance, and this physical dependence wanes. However, the emotional and psychological components remain.” 

Because the rush from heroin lasts only a few hours, addicts need multiple fixes per day. This leads many to deal themselves, or to steal in order to support their habit. 

“All addiction is very self-centered, but these opiate drugs are the worst in that regard,” Sam Quinones told me during a previous interview last month. “They create people that have no relationship to anything else. The morphine molecule is a very jealous mistress. Everything else that you enjoyed doing at one point, you stop doing. It’s all about satisfying your need, and it is an intensely individualizing drug.“

Quinones recently wrote on his blog that Hillary Clinton’s health-policy advisor was reading "Dreamland" and called him to ask for policy advice. “This epidemic is neither a red nor a blue issue. Thus I hope candidates from both parties will respond as well,” wrote Quinones. “I’d hope, moreover, they would focus not only on heroin, but on the broader problem of overprescribing of opiate painkillers, which so often provide the gateway to heroin. Pain pills have their legitimate role in medicine, but too often are massively and unnecessarily prescribed.” 

What is buprenorphine? 

Many heroin users (80 percent, according to "Dreamland") first became addicted to prescription painkillers, which were rampantly overprescribed and aggressively marketed by pharmaceutical companies in the 1990s and early 2000s. This legacy of painkiller over-prescription and abuse, and the popularity of “abstinence-only” substance abuse treatment in the U.S., have left many addicts struggling to legally obtain buprenorphine (sold as Suboxone), the medicine that has been used to treat heroin addicts for the last 10 years. 

Currently, doctors are allowed to treat only 30 patients with buprenorphine in the first year after they have been certified to prescribe this medicine, and 100 patients annually each subsequent year. The TREAT Act proposes raising the initial cap for buprenorphine prescriptions from 30 to 100 patients. The bill also proposes that nurse practitioners and physicians assistants who meet certain criteria be allowed to treat up to 100 patients annually, and recommends that doctors (provided they are either substance abuse specialists or have completed training) have the option to request removal of the cap after one year. 

Insistence on abstinence-only treatment in recovery centers often leads to high rates of dropouts, the Huffington Post reported in January, and in Kentucky, the dropout rates reach as high as 75 percent. These dropouts are at high risk for relapses and fatal overdoses. 

“As buprenorphine is a partial agonist, meaning there is a ceiling to its effects. Respiratory depression (the major reason for overdose death to opioids) does not reach critical levels with buprenorphine,” Coop told ATTN:. “Thus, a patient taking buprenorphine is far less likely to overdose than a patient taking heroin or a prescription full agonist (morphine, oxycodone). As such, I have always been in favor of buprenorphine as a safe treatment agent.” 

Other attempted solutions

Other countries and cities have adopted more radical policies to address drug addiction and overdose. Portugal, which once has the highest rate of heroin usage in the European Union after England and Wales, decriminalized low-level drug possession and now has among the lowest rates of drug usage in the EU. 

Vancouver, Canada, piloted the first legal supervised injection site in North America, which reported 376,149 visits to the site by 9,259 unique individuals in 2012. A study that evaluated the success of this program reported identifying “a number of risk behaviours — difficulty getting sterile needles, needle sharing and reuse, injection of drugs in public and injecting alone (one of the main contributing causes of overdose) — that may be alleviated by the establishment of supervised safer injecting rooms.” 

In a video published by Democracy Now! in March, British journalist and author of  "Chasing the Scream: The First and Last Days of the War on Drugs" Johann Hari talked about the success of Vancouver’s safe injecting sites and emphasized the importance of human connection in fighting addiction—an idea that echoed the conclusion in “Dreamland.”

“It seems to me that the way to combat [the self-centered nature of addiction] is through community,” Quinones told me. “The areas that were first lambasted by this problem were areas that had had their community destroyed—Rust Belt, Appalachian areas—and it spread into areas where people had lots more money, but they didn’t seem to have more community.”

He highlighted the town of Portsmouth, Ohio, as a place ravaged by addiction and working its way towards healing by focusing on strengthening community infrastructure.  

"The town of Portsmouth has been in this longer than anybody," said Quinones. "They were our canary. If we’d watched what happened in Portsmouth, and really paid attention, and really ratcheted back [on over-prescribing painkillers], we’d have had a running start on this problem years ago. But we ignored it. Portsmouth was one of the towns to lead us into this whole thing, and it also seems to me to be leading us out of it, in really important ways."

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