Large increases in heroin use seen in men with low income and education
Heroin use and heroin use disorder have increased significantly among American adults since 2001, according to new research conducted at Columbia University’s Mailman School of Public Health. The portion of Americans using heroin has climbed five-fold in the last decade, and clinically defined heroin dependence has more than tripled. Increases were greatest among males, whites, those with low income and little education, and for heroin use disorder, in younger individuals. The increase in the prevalence of heroin use disorder was more pronounced among whites ages 18-44 than among non-whites and older adults.
The study is the first to account for changes in heroin use and dependence over time in the U.S. The findings are published online in JAMA Psychiatry.
The study reports that heroin use increased from 2001-2002 to 2012-2013, from .33 percent to 1.60 percent, and heroin use disorder rose from 0.21 percent to .69 percent. Past-year prevalence of heroin use increased between 2001-2002 (0.03 percent) and 2012-2013 (0.21 percent). Heroin use was significantly pronounced among whites in 2012 to 2013: compared to non-whites, 1.9 percent versus and 1.1 percent, respectively. Heroin use and use disorder also increased more among the unmarried than married adults.
“In 2001 to 2002, whites and non-whites reported similar prevalence of heroin use. However, in 2012-2013, increases in heroin and related disorders were particularly prominent among whites, leading to a significant race gap in lifetime heroin use by 2013,” said Silvia Martins, MD, PhD, associate professor of Epidemiology at the Mailman School of Public Health.
Non-medical use of prescription painkillers drove some of the uptick in heroin use seen in whites. In 2001-2002, 36 percent of white heroin users had used prescription opioids non-medically before first using heroin, while in 2012-2013, 53 percent of white heroin users reported non-medical prescription opioid use before taking heroin.
“Because the effects of heroin seem so similar to widely available prescription opioids, heroin use appears to have become more socially acceptable among suburban and rural whites,” noted Dr. Martins.
Interestingly, the proportion of heroin users with a lifetime heroin use disorder decreased between the two surveys (63 percent in 2001-2002 vs. 43 percent in 2012-2013), due primarily to changes in DSM-IV abuse criteria.
“Some heroin users, such as those with greater resources and infrequent users, could potentially be less likely to meet criteria for a heroin use disorder in the long term,” said Dr. Martins. “However, if the prevalence of heroin users continues to rise, it is likely that the numbers of those with heroin use disorders will rise as well.”
The researchers analyzed data from 43,000 Americans on lifetime heroin use who were long-term heroin users and met the DSM-IV heroin use disorder criteria using the National Epidemiologic Survey on Alcohol and Related Conditions (2001-2002) and the National Epidemiologic Survey on Alcohol and Related Conditions (2012-2013).
While heroin use is now more widespread among individuals of all social classes and among those with strong bonds to social institutions, relative increases in heroin use and use disorder across time were greater among less-educated and poorer individuals.
The gender gap in lifetime heroin use and use disorder also widened between 2001-2002 and 2012-13; use among males increased more than females, according to Dr. Martins. Among men, prevalence of heroin use rose by 1.89 percent compared to .70 percent for women; male heroin use disorder increased by 0.72 percent versus women at .25 percent.
“These trends are concerning because increases are occurring among vulnerable individuals who have few resources to overcome problems associated with use,” said Deborah Hasin, PhD, “If we added the homeless and the incarcerated in our study results for heroin use and heroin use disorder could be even more startling.”
“Our results underscore the need to expand educational programs on the harms related to heroin use and access to treatment in populations at increased risk,” said Dr. Martins. “Promising examples of prevention and intervention efforts include expansion of access to medication-assisted treatment—methadone, buprenorphine or injectable naltrexone—as well as educational campaigns in schools and community settings, and consistent use of prescription drug monitoring programs.”
Coauthors are Aaron Sarvet MPH and Julian Santaella-Tenorio MSc, Mailman School of Public Health; Deborah S. Hasin, Mailman School of Public Health and Columbia University Department of Psychiatry, College of Physicians and Surgeons; Tulshi Saha, Bridget F. Grant, Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health.
The study was supported by the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse (grants DA R01DA 037866, R01DA034244), and the New York State Psychiatric Institute. Dr. Santaella-Tenorio is funded by the J. William Fulbright and the Colciencias doctoral scholarships.
Columbia University Mailman School of Public Health