Exploration of the Complex Interrelationship Between Nonmedical Use of Prescription Opioids and Heroin Use

There is concern that changes in opioid prescribing practices have contributed to increases in heroin use in the United States. In this extensive review of the literature, federal representatives explore the relationship between nonmedical use of prescription opioids, policy changes regarding opioid prescribing, and the development of heroin use and its associated morbidity and mortality. Their primary findings include:

• Although both prescription opioids and heroin produce their action through similar neurobiological circuits, these substances have different properties; individual variation exists regarding how one perceives their rewarding effects.
• Available epidemiological data suggest a clear link between nonmedical use of prescription opioids and heroin use, especially among young people with frequent nonmedical use and those meeting criteria for a prescription opioid use disorder.
• Only a small proportion of individuals with nonmedical use of prescription opioids go on to use heroin. Shifts in the demographics of individuals seeking treatment for heroin use to white, non-urban populations seem to mirror the demographic of the prescription opioid epidemic. Recent increases in heroin use appear to be due to its lower cost relative to prescription opioids and increases in purity rather than there being a direct causal link between prescription opioid use and subsequent heroin use.
• Studies suggest that a shift from prescription opioid use to heroin use was occurring before policies were enacted to address inappropriate opioid prescribing by practitioners.

Comments:

Although nonmedical use of prescription opioids is a risk factor for heroin initiation, the transition seems to occur at a low rate and among certain subpopulations with frequent nonmedical use, or among those who already meet criteria for opioid use disorder. This article highlights the public health threat that both prescription opioids and heroin pose and suggests the need for a multipronged approach to addressing the epidemic.

Jeanette M. Tetrault, MD