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Christopher M. Bohm , MPH 3 Author affiliations at end of text. Background: Heroin use and overdose deaths have increased significantly in the United States. Assessing trends in heroin use among demographic and particular substance-using groups can inform prevention efforts. Trends in heroin use among demographic and substance using groups were compared for —, —, —, and — A multivariable logistic regression model was used to identify characteristics associated with heroin abuse or dependence. Results: Annual average rates of past-year heroin use increased from 1. Rates of heroin abuse or dependence were strongly positively correlated with rates of heroin-related overdose deaths over time. For the combined data years —, the odds of past-year heroin abuse or dependence were highest among those with past-year cocaine or opioid pain reliever abuse or dependence. Conclusions: Heroin use has increased significantly across most demographic groups. The increase in heroin abuse or dependence parallels the increase in heroin-related overdose deaths. Heroin use is occurring in the context of broader poly-substance use. Implications for Public Health Practice: Further implementation of a comprehensive response that targets the wider range of demographic groups using heroin and addresses the key risk factors for heroin abuse and dependence is needed. Specific response needs include reducing inappropriate prescribing and use of opioids through early identification of persons demonstrating problematic use, stronger prescription drug monitoring programs, and other clinical measures; improving access to, and insurance coverage for, evidence-based substance abuse treatment, including medication-assisted treatment for opioid use disorders; and expanding overdose recognition and response training and access to naloxone to treat opioid pain reliever and heroin overdoses. During —, heroin overdose death rates nearly quadrupled in the United States, from 0. However, during this period heroin initiation rates generally increased across most demographic subgroups 3. Most heroin users have a history of nonmedical use of prescription opioid pain relievers 3 — 5 , and an increase in the rate of heroin overdose deaths has occurred concurrently with an epidemic of prescription opioid overdoses. Although it has been postulated that efforts to curb opioid prescribing, resulting in restricted prescription opioid access, have fueled heroin use and overdose, a recent analysis of — drug overdose deaths in 28 states found that decreases in prescription opioid death rates within a state were not associated with increases in heroin death rates; in fact, increases in heroin overdose death rates were associated with increases in prescription opioid overdose death rates 6. In addition, a study examining trends in opioid pain reliever overdose hospitalizations and heroin overdose hospitalizations between and found that increases in opioid pain reliever hospitalizations predicted an increase in heroin overdose hospitalizations in subsequent years 7. Thus, the changing patterns of heroin use and overdose deaths are most likely the result of multiple, and possibly interacting, factors. Moreover, there is a lack of research examining recent trends in the prevalence of other substance use among persons using heroin, especially among the high-risk population of heroin users who meet diagnostic criteria for heroin abuse or dependence. To improve understanding of current heroin use, abuse, and dependence trends and to identify individual-level risk factors that could help tailor prevention efforts, the Food and Drug Administration FDA and CDC examined demographic and substance use, abuse, and dependence trends among heroin users in the United States during — NSDUH employs a state-based design with an independent, multistage area probability sample within each state and the District of Columbia 2. For this study, the — NSDUH public use files were combined in four, 3-year time intervals: 1 —; 2 —; 3 —; and 4 — Past-year nonmedical use of prescription drugs is defined as using prescription drugs without having a prescription, or using prescription drugs only for the experience or feeling it causes, during the 12 months preceding the survey interview. Past-year use of marijuana, cocaine, or heroin is defined as use of the substance in the 12 months preceding the survey interview. Past-year abuse or dependence of specific substances commonly referred to as addiction was based on diagnostic criteria contained in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition 8. Mortality data from the — Multiple Cause of Death Files from the National Vital Statistics System were analyzed to identify heroin-related drug overdose deaths 9. Heroin-related drug overdose deaths were those assigned an underlying cause of death code of XX44 unintentional , XX64 suicide , X85 homicide , or YY14 undetermined intent with a contributing cause of death ICD code T In addition, the percentage of past-year heroin users who also used at least one other drug in the past year were calculated. Second, to assess high-risk use of other substances among past-year heroin users, the percentages of past-year heroin users who met diagnostic criteria for past-year alcohol, marijuana, cocaine, or opioid pain reliever abuse or dependence were calculated. All rates are based on U. S Census Bureau population estimates. Two-sided t-tests were used to assess statistically significant differences between — rates and earlier survey year groups. To assess trends, bivariate logistic regression models were applied to test p-values of beta coefficients of the year variable. Finally, Pearson's correlation coefficient r was used to assess correlation between the trend in rates of heroin abuse or dependence and heroin-related drug overdose deaths during — The annual average rate of past-year heroin use in — was 2. This rate was significantly higher than the rates for — 1. Similarly, the overall rate of people meeting diagnostic criteria for past-year heroin abuse or dependence increased significantly during the study period, from 1. Rates of past-year heroin use were higher among men than women for all time intervals; the rate in — for men was 3. Both men and women experienced significantly higher heroin use rates during — compared with — and — Among age groups, persons aged 18—25 years experienced the largest increase The rate of past-year heroin use among non-Hispanic whites increased Individuals with no health insurance as well as those with private or other insurance experienced statistically significant increases in heroin use rates between — and — During —, past-year heroin use increased among persons reporting past-year use of other substances. The highest rate was consistently found among users of cocaine; during —, this rate was During the study period, the largest percentage increase, In this group, the past-year heroin use rate increased from In addition, a significant percentage of heroin users met diagnostic criteria for past-year abuse of, or dependence on, other substances Figure 1. The percentage of heroin users with past-year marijuana, cocaine, or alcohol abuse or dependence remained stable during most of the study periods. However, the percentage of heroin users with opioid pain reliever abuse or dependence more than doubled from By —, opioid pain reliever abuse or dependence was more common among heroin users than alcohol, marijuana, or cocaine abuse or dependence. The rate of heroin-related drug overdose deaths was stable at approximately 0. Beginning in , the overdose death rate increased sharply, from 1. There was a significant increase in the rate of past-year heroin use in the United States between — and — However, rates increased significantly across almost all study groups. The greatest increases in heroin use occurred in demographic groups that historically have had lower rates of heroin use: doubling among women and more than doubling among non-Hispanic whites. Of particular note is the near doubling in the rate of people with heroin abuse or dependence during the study period, with a This increase parallels the sharp increase in heroin-related overdose deaths reported since This study also indicates that the problem of heroin abuse or dependence is not occurring in isolation. Past-year alcohol, marijuana, cocaine, and opioid pain reliever abuse or dependence were each significant risk factors for heroin abuse or dependence. Research has identified poly-substance use as a risk factor for overdose death; most overdose deaths involve multiple drugs 10 , Data presented here indicate the relationship between heroin and opioid pain relievers, as well as the relationship between heroin and cocaine, was particularly strong. In fact, abuse or dependence on opioid pain relievers was the strongest risk factor for heroin abuse or dependence. Taken together, these results underscore the significance of heroin use in the context of broader poly-substance use, a finding that should be considered when prevention policies are being developed and implemented. The increased availability and lower price of heroin in the United States has been identified as a potential contributor to rising rates of heroin use This amount quadrupled to 2, kg in Since , increased availability of heroin has been accompanied by a decline in price and an increase in purity, which may contribute to its increased use in the United States This increase in the amount of heroin seized, increased availability and purity, and decreased cost are temporally associated with the increases in heroin use, abuse and dependence, and mortality found in this study. Increasing availability points to the importance of public health and law enforcement partnering to comprehensively address this public health crisis. This study is subject to several limitations. First, NSDUH data are self-reported, and their value depends on the truthfulness and accuracy of individual respondents; under- or over-reporting might occur. Second, because the survey is cross-sectional and different individuals were sampled each year, it is not possible to infer causality from the observed associations. Third, because NSDUH only captures noninstitutionalized civilians, it excludes active duty military personnel, homeless and incarcerated populations, and persons in residential substance abuse treatment programs. Therefore, the drug use estimates in this study might not be generalizable to the total U. These findings indicate significant increases in heroin use across a growing number of demographic groups, including women, the privately insured, and persons with higher incomes. In fact, the gaps in heroin use rates between groups such as men and women, persons with low and higher incomes, and Medicaid and private insurance beneficiaries have narrowed during the past decade. These findings are consistent with recent research documenting significant demographic shifts among people entering heroin addiction treatment over the last 40 to 50 years 4. In addition, persons using heroin are abusing multiple other substances, especially cocaine and opioid pain relievers. A comprehensive response that targets the wider range of demographic groups using heroin and addresses the key risk factors for heroin abuse and dependence is needed. Specifically, a focus on reducing opioid pain reliever abuse is needed given the strong association between opioid pain relievers and heroin abuse and dependence seen in this study, and prior research indicating that the rate of heroin initiation among people with a history of nonmedical use of opioid pain relievers was approximately 19 times greater than those with no history of nonmedical use 3. Interventions such as prescription drug monitoring programs to reduce inappropriate prescribing of opioids and enable the early identification of persons demonstrating problematic use must be strengthened. The increases in the number of people with heroin abuse or dependence and those dying from heroin-related overdose, as well as the recent increases in hepatitis C virus HCV and human immunodeficiency virus HIV associated with injection drug use 15 , 16 , underscore the critical importance of improving access to, and insurance coverage for, evidence-based substance abuse treatment. In particular, medication-assisted treatment for opioid use disorders has been shown to reduce opioid use and mortality, and to reduce risk behaviors that transmit HCV and HIV The increases in abuse or dependence and overdose deaths also highlight the urgent need to expand overdose recognition and response training and broaden access to naloxone to treat opioid pain reliever and heroin overdoses. Corresponding author: Christopher M. Jones, Christopher. Jones fda. TABLE 1. Alternate Text: The figure above is a bar graph showing the annual average percentage of past-year heroin users with past-year abuse dependence on alcohol, marijuana, cocaine, or opioid pain relievers, during four periods: ; ; ; and , based on data from the National Survey on Drug Use and Health surveys during The percentage of heroin users with opioid pain reliever abuse or dependence more than doubled, from Alternate Text: The figure above is a histogram comparing the rates of past-year heroin abuse or dependence and heroin-related overdose deaths in the United States, by year, during , which shows a strong positive correlation between the two. TABLE 2. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. This conversion might result in character translation or format errors in the HTML version. An original paper copy of this issue can be obtained from the Superintendent of Documents, U. Contact GPO for current prices. Skip directly to search Skip directly to A to Z list Skip directly to site content. Protecting People. Search The CDC. Note: Javascript is disabled or is not supported by your browser. For this reason, some items on this page will be unavailable. For more information about this message, please visit this page: About CDC. Share Compartir. Introduction During —, heroin overdose death rates nearly quadrupled in the United States, from 0. Conclusions and Comment There was a significant increase in the rate of past-year heroin use in the United States between — and — Drug-poisoning deaths involving heroin: United States, — NCHS data brief no. SMA Associations of nonmedical pain reliever use and initiation of heroin use in the United States. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry ;—6. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, — and — Drug Alcohol Depend ;— Increases in heroin overdose deaths—28 States, to Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, PLoS One ;8:e American Psychiatric Association. The diagnostic and statistical manual of mental disorders, 4th ed. Increase in fatal poisonings involving opioid analgesics in the United States, — Pharmaceutical overdose deaths, United States, JAMA ;—9. Drug Enforcement Administration. National drug threat assessment summary Office of National Drug Control Policy. National drug control strategy: data supplement State variation in certifying manner of death and drugs involved in drug intoxication deaths. Academic Forensic Pathology ;—7. Community outbreak of HIV infection linked to injection drug use of oxymorphone—Indiana, National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health This increase occurred among a broad range of demographics, including men and women, most age groups, and all income levels. As heroin use, abuse, and dependence have increased, so have heroin-related overdose deaths. From through , the rate of heroin-related overdose deaths nearly quadrupled. Persons often use heroin with other substances, including marijuana, cocaine, alcohol, and opioid pain relievers. This practice is especially dangerous. States play a key role in addressing heroin use, abuse, dependence, and overdose. States can implement strategies to reduce the abuse of opioid pain relievers, the strongest risk factor for heroin abuse or dependence. They can also improve access and insurance coverage for medication-assisted treatment for opioid use disorders and expand access and training for naloxone administration to reverse overdoses. Print Updates Subscribe Listen Download. Key Points. Annual average rate. Overall past-year heroin use. Overall past-year heroin abuse or dependence. Age yrs. Place of residence. Annual household income. Health insurance coverage. Substance use. Past-year opioid pain reliever nonmedical use. Past-year heroin abuse or dependence. Household income annual. Insurance coverage.

Vital Signs: Demographic and Substance Use Trends Among Heroin Users — United States, 2002–2013

Buying Heroin Seeb

Decades of harsh laws that punish and stigmatize people who use drugs and others involved in the drug trade have led to mass incarceration, disease, suffering and violence. Criminalizing drugs does not decrease their use or supply. Instead, it drives the trade underground, increases the harms of using drugs and fuels organized crime, corruption and violence. The prohibition of drugs directly impacts our right to health. People who use drugs are denied access to medical treatment or are deterred from seeking medical assistance for fear of being reported to the authorities. This increases the risk of overdose and other threats to their life and health. Drug policies designed to punish people exacerbate the risks and harms associated with drug use. These policies can lead to increased transmissions of HIV and other diseases. They also obstruct access to drugs for medical purposes, including for pain relief and palliative care, resulting in further harm and suffering for millions of patients. Since then, it has been used by many governments around the world to launch crackdowns on people who use drugs and reduce the trafficking of drugs. These campaigns rely on harsh punishments to deter people from using or selling drugs. Instead, it undermines the rights of millions of people, exacerbates the harms of using drugs, and intensifies the violence associated with illicit markets. It disproportionately affects the poorest and most marginalized communities, who carry the burden of this failed strategy. It traps entire communities in cycles of incarceration, violence and poverty. In June , then-President Rodrigo Duterte launched a brutal campaign against drugs in the Philippines. Since then, thousands of people, the vast majority from poor and marginalized communities, were killed over suspected links to the drug trade. The government acknowledged at least 6, killings at the hands of police or other people with links to the police. Human rights groups report that the real figure could be as high as 30, people killed by anti-drug operations. There remains no genuine accountability for these human rights violations nor justice for families of victims. In fact, the International Criminal Court is currently conducting an investigation into these crimes. The killings continue under the new Marcos administration , with drug-related killings reported during his first year in office. Latin America has seen a particularly sharp growth in prison populations in the last decades, where the population detained for drug-related offences has grown at a faster pace than the overall prison population. Globally, women are imprisoned for drug-related offences more than for any other crime and face harsher obstacles to access non-custodial sanctions and other alternatives to detention than men. The US imprisons more people than any other country. One in five people in US prisons is serving time for a non-violent drug offence. Thousands of other people who use or are suspected of using drugs have been arbitrarily detained and forcibly subjected to mandatory treatment, often without their consent. These centres have been infamous for their deplorable conditions and reports of torture and other ill-treatment. An Amnesty International investigation revealed the punitive and abusive nature of drug-detention centres in Cambodia, where medical facilities and properly trained staff is utterly lacking. Rather than receiving evidence-based treatment, people are detained against their will and face systematic abuse. The use of the death penalty for drug-related offences is perhaps the most extreme manifestation of the punitive approach favoured by many countries. Those sentenced to death for drug-related offences are mostly at the low-end of the drug chain, and often from disadvantaged socio-economic backgrounds. Using the death penalty for drug-related offences is a clear violation of international law. Yet, drug-related offences can still be punished by death in more than 30 countries. Amnesty has continued to document people executed for drug-related charges in a handful of countries, namely China, Iran, Saudi Arabia and Singapore. Vietnam was likely to have carried out such executions as well, although it is difficult to say for sure. Sexual violence used as a form of torture has become a regular part of interrogations, particularly in the context of drug-related operations. Some countries also have in place punishments for drug-related offences that amount to torture and other ill-treatment. In Singapore , for example, drug laws allow for the penalty of life imprisonment and 15 strokes of the cane as the only alternative punishment to a death sentence for people convicted of drug trafficking. In Mexico, drug cartels often recruit women and girls from marginalized backgrounds to carry out dangerous tasks as they are considered expendable if arrested. As a result, young, poorly educated and low-paid women and girls are at particular risk of suffering abuses at the hands of criminal groups. Women are also at risk of being picked up by the police or the military since they are often seen as the weakest link in the trafficking chain and an easy target for arrest. Authorities often attempt to boost figures to show they are tackling organized crime, which leads to group arrests and accusations without evidence. This specifically affects women, who are often unfoundedly accused of being girlfriends, and thus accomplices of people involved in organized crime. This allows them to boost figures in an attempt to show they are tackling organized crime, without targeting those at the top of the drug chain. States have a particular obligation to protect children and adolescents from the risks and harms of drugs, including those stemming from the use of drugs by children or their parents as well as from policing and other law enforcement efforts. While data relating to the use of drugs by children and young people is poor in many countries, evidence suggests that punitive responses to drugs do not deter children from using drugs nor significantly restrict their access to them. Instead, punitive drug policies have produced additional and particular harms to children, including physical and mental health consequences. The UN Special Rapporteur on Belarus estimates that hundreds of children and young people in Belarus are serving lengthy sentences for minor, non-violent drug-related offences. All too often, children and young people in Belarus fall victim to deceptive practices by anonymous individuals who sell drugs online via couriers. Children that are caught by the police have reported being coerced into admitting their guilt and often face multiple human rights violations while in detention. Drug laws are often enforced in a discriminatory way against marginalized groups , including racial and ethnic minorities and the poorest sectors of society. The ACLU found in that Black people across the US are over three times more likely to be arrested for cannabis possession than white people, despite roughly equal rates of use. In the UK, Black people are stopped and searched for drugs at almost nine times the rate of white people. Indigenous young people in Australia were 26 times more likely to be in detention than non-indigenous young people, and Aboriginal and Torres Strait Islander women are more likely to be convicted of a drug-related offence. In Bangladesh, police drug raids which often lead to extrajudicial executions frequently target low-income neighbourhoods. Women have also been disproportionately affected by drug laws , facing increased risks as their participation in the drug trade is on the rise worldwide — especially among women who lack education and economic opportunities. Women who use drugs are also at particular risk of criminalization, especially if they become pregnant. Some US states have laws that are used to arrest and prosecute pregnant women who use drugs based on a belief that they are harming their foetus. Fear of these laws deters pregnant people from accessing healthcare and drug treatment. Governments and civil society organizations are designing new models for regulating and decriminalizing drugs in many places around the world. While some alternatives to current prohibitionist policies have yet to be tested, the evidence available so far shows that decriminalizing the use, possession and cultivation of drugs for personal use, if combined with an expansion of health and social services, does not lead to higher rates of use. Instead, countries where drugs have been decriminalized have seen a beneficial impact on public health, public security and human rights. A few other places are moving away from prohibition and towards better regulation of drugs within legal markets, based on the premise that bringing illicit markets under the control of the government can better protect public health and human rights. Decriminalisation means removing laws that make it a criminal offence, for example around the use or possession of drugs. Decriminalization does not mean that drugs are legal; rather, it means that people who are caught with them will not get a criminal record or face jail time. On the other hand, regulation means adopting a range of legislative and regulatory frameworks to allow drugs to be legally available, but with a level of state control that differs according to the health risks of each substance. Regulation does not mean to allow for the unrestricted access for all people to all drugs. Instead, it sets out rules to allow for the adequate control of specific substances and provide the legal channels for those permitted to access them. This is similar to the way governments regulate alcohol and tobacco. In Portugal, the use and possession of all drugs has been decriminalized since Drugs are still not legally available, but the national strategy focuses on increasing access to drug treatment rather than criminalizing drugs. Instead, people might be sent to a committee made up of legal, health and social work professionals tasked with determining whether there is a problematic use of drugs or if some underlying social or health problem needs to be addressed. They offer services to those in need instead of throwing them in jail. Levels of drug have decreased since , especially for heroin-use. And even with new synthetic drugs and consumption habits growing, they remain below the European average. There has also been a dramatic decrease in new HIV diagnoses among people who inject drugs. Amnesty International is calling for states to shift away from policies based on prohibition and criminalization, in favour of evidence-based alternatives that protect public health and the human rights of people who use drugs and other affected communities. This should include decriminalizing the use, possession, cultivation and purchase of all drugs for personal use , and the effective regulation of drugs to provide legal and safe channels for those permitted to access them. Such policies must be accompanied by an expansion of health and other social services to address drug-related problems as well as other measures to address the underlying socio-economic causes that increase the risks of using drugs and that lead people to engage in the illicit drug trade. Drugs can certainly pose some risks to individuals and societies, and therefore states have an obligation to adopt adequate measures to protect people from the harmful effects of drugs. But it is precisely because of these risks that governments need to take control and regulate how these substances are produced, sold and used. Back to What We Do. Overview Drug control policies are failing. Read our Drug Reform Policy. The use of the death penalty for drug-related offences The use of the death penalty for drug-related offences is perhaps the most extreme manifestation of the punitive approach favoured by many countries. Case Study: Women in Mexico In Mexico, drug cartels often recruit women and girls from marginalized backgrounds to carry out dangerous tasks as they are considered expendable if arrested. The harm of punitive drug policies on young people States have a particular obligation to protect children and adolescents from the risks and harms of drugs, including those stemming from the use of drugs by children or their parents as well as from policing and other law enforcement efforts. Case Study: Children and young people lured to distribute drugs in Belarus The UN Special Rapporteur on Belarus estimates that hundreds of children and young people in Belarus are serving lengthy sentences for minor, non-violent drug-related offences. Drug laws and discrimination Drug laws are often enforced in a discriminatory way against marginalized groups , including racial and ethnic minorities and the poorest sectors of society. Racism is deeply embedded in drug policies in many countries. Alternatives to the prohibition and criminalization of drugs Governments and civil society organizations are designing new models for regulating and decriminalizing drugs in many places around the world. Case Study: Decriminalization of drugs in Portugal In Portugal, the use and possession of all drugs has been decriminalized since What is Amnesty doing to address drug policy reform? Among other things, Amnesty is calling for governments to: Move away from punishing and stigmatizing people who use drugs and instead adopt laws and policies focused on protecting health and human rights to minimize risks and stop the violence associated with illicit markets. Decriminalize the use, possession cultivation, and purchase of all drugs for personal use. Decriminalization policies must be accompanied by an expansion of health and other social services to address the risks related to drug use. Expand evidence-based prevention, harm reduction and treatment programmes and address the root causes that may increase the risks of using drugs or that lead people to become involved in the drug trade, including ill-health, denial of education, unemployment, lack of housing, poverty and discrimination. Regain control and reduce violence by moving towards the effective regulation of drugs , based on a scientific and evidence-based assessment of the risks and harms of each drug, to effectively control substances and provide legal channels for those permitted to access them. Put in place measures that tackle social inequalities and promote social justice , including a wide set of gender-sensitive and holistic socio-economic protection measures tackling the different stages of the drug trade, from cultivation and production to distribution and use.

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