Pubdate: Fri, 07 Mar 2014
Source: Washington Post (DC)
Copyright: 2014 The Washington Post Company
Contact: http://mapinc.org/url/mUgeOPdZ
Website: http://www.washingtonpost.com/
Details: http://www.mapinc.org/media/491
Authors: Jerry Markon and Alice Crites
Page: A1

PRESCRIPTION-DRUG BATTLE FUELED A RISE IN HEROIN USE

 From the beginning, the U.S. government's decade-long crackdown on
abuse of prescription drugs has run an unsettling risk: that arresting
doctors and shuttering "pill mills" would inadvertently fuel a new
epidemic of heroin use.

State and federal officials have pressed their campaign against
prescription-drug abuse with urgency, trying to contain a scourge that
kills more than 16,000 people each year. The crackdown has helped
reduce the illegal use of some medications and raised awareness of
their dangers.

But at the same time that some pain medications have become less
available on the street and pricier, many users have switched to
cheaper heroin, since prescription pills and heroin are in the same
class of drugs and provide a comparable euphoric high.

With the nationwide heroin problem gaining greater attention after the
recent death of actor Philip Seymour Hoffman from heroin and other
drugs, experts on addiction say the government's actions contributed
to the problem it is now confronting. The war on drugs, they say, is
an unwieldy conflict where targeting one illicit substance can be an
unintentional boon to another.

"Absolutely, much of the heroin use you're seeing now is due in large
part to making prescription opioids a lot less accessible," said
Theodore Cicero, a psychiatry professor at Washington University in
St. Louis. He co-authored a 2012 study, cited in the New England
Journal of Medicine, that found that a reformulation of OxyContin to
make it harder to abuse caused heroin use to nearly double.

Although policymakers "did the best they could at the time" in
fighting prescription drugs, Cicero said, "there were signs years ago
that this was going to happen, and there was just a lot of inaction."
He said the government could have acted sooner to mitigate heroin's
toll, such as by promoting the use of medicines to fight overdoses and
ease withdrawal symptoms.

The government itself predicted that targeting prescription drugs
could give heroin use an unintended lift. The Justice Department's
drug intelligence arm in 2002 highlighted the potential consequences:
"As initiatives taken to curb the abuse of OxyContin are successfully
implemented, abusers of OxyContin . . . also may begin to use heroin,
especially if it is readily available, pure, and relatively
inexpensive."

A long-emerging trend

Yet those projections did not factor into discussions by top drug
policy officials, even after numerous government reports and
congressional testimony indicated that the shift to heroin was
happening, according to current and former federal officials. Heroin
use began to rise at the end of the Bush administration and has surged
in the Obama years.

John Walters, who ran the Office of National Drug Control Policy as
President George W. Bush's "drug czar," said he doesn't recall "anyone
raising'" the link between prescription drugs and heroin, though the
reports warning of the link were screened by people in his office.
"The heroin problem was getting better, and the real issue was the
growth of pharmaceuticals," he said.

Gil Kerlikowske, who took over as President Obama's drug czar in 2009,
said the connection between prescription drugs and heroin "was not on
the radar screen" during most of Obama's first term and that he
"didn't do everything I should have" to raise awareness of the growing
heroin problem. Now, he said, heroin is a "much larger concern."

Between 2007 and 2012, heroin use rose 79 percent nationwide,
according to federal data. Within the same period, the data show, 81
percent of first-time heroin users had previously abused prescription
drugs.

The likelihood that many prescription-drug abusers will switch to
heroin because it is much cheaper is widely accepted among addiction
treatment professionals and law enforcement officials.

Justice Department officials reject any direct linkage between the
crackdown on prescription drugs and rising heroin use, although it was
a Justice Department unit - the National Drug Intelligence Center -
that warned that the campaign against illegal use of prescription
drugs was fueling heroin use. The center, which closed in 2012, was
separate from the unit employing prosecutors and agents who fight drug
use.

Moreover, these officials defended their fight against prescription
drug abuse, saying those efforts prevented numerous overdose deaths.
Even with heroin use on the rise, they said in interviews, it still
represents a much smaller problem than prescription medications.
Heroin kills about 3,000 people a year, less than a fifth of the toll
from prescription-drug abuse, government data show.

Connection disputed

Joseph T. Rannazzisi, who runs the Drug Enforcement Administration's
Office of Diversion Control, denied that the spike in arrests for
prescription-drug misuse has affected their cost and driven users to
heroin, saying street prices have been generally stable. "I don't
think one thing has anything to do with the other," said Rannazzisi,
who emphasized that the move against prescription pills saved many
lives. The DEA is part of the Justice Department.

Tristram J. Coffin, the U.S. attorney for Vermont, who has been a
leader in the battle against prescription-drug abuse, also remains a
staunch defender of that campaign. "Prescription drugs are incredibly
addictive, incredibly lethal, and we had to deal with them," he said.

But Coffin acknowledged that the crackdown made some doctors reluctant
to write prescriptions for pain medications. "That, in turn, causes
people, because they have an opioid dependency, to turn to heroin," he
said.

In 2010, Justice Department officials told The Washington Post that a
federal probe of prescription drug abuse in Northern Virginia, the
nation's largest such investigation at the time, had caused black
market OxyContin prices to nearly double. Police and addiction
treatment professionals in three states said last week that actions
such as closures of "pill mills" that dispensed massive amounts of
pharmaceuticals had made them harder to get, raising their price as
demand outpaced supply.

Still, "I can't recall anyone at any point having a plan that would
have limited the shift from prescription drugs to heroin," said Marvin
D. Seppala, chief medical officer at the Hazelden Betty Ford
Foundation, a network of drug treatment centers.

Warnings of heroin use

It was without controversy that the Food and Drug Administration
approved OxyContin in 1995. The powerful drug was a godsend for
millions of pain sufferers.

Within a few years, however, authorities learned that addicts were
crushing the time-release tablets and snorting or injecting them,
leading to property crimes and overdose deaths.

A crackdown began at the end of the Bill Clinton administration and
escalated under the George W. Bush administration, which dispatched
anti-drug agents and encouraged state monitoring programs that detect
suspicious prescriptions. Federal arrests for illegal use of
prescription drugs skyrocketed more than 900 percent between 2001 and
2007, according to the National Drug Intelligence Center.

During the same period, federal heroin arrests fell 32 percent as
heroin use was generally stable and even declined among adolescents,
said the center's reports, which cited DEA arrest data.

Bush administration officials said they targeted the more pressing
threat. "Oxy was extremely accessible," said Paul J. McNulty, a former
U.S. attorney in Alexandria and deputy attorney general. "At the same
time, many of us involved in drug policy from the 1980s onward saw
heroin on the decline for a long period."

Throughout the Bush administration and afterward, nearly every year
between 2002 and 2011, the Justice Department's drug intelligence arm
warned that the crackdown could drive drug abusers to heroin.

As early as 2003, the center said, some Oxy users were already making
the switch. "Not only is heroin less expensive, but efforts to control
the diversion of OxyContin may be reducing the availability of
OxyContin in some areas," it wrote that year. The concerns were echoed
in congressional testimony starting in 2008, transcripts show.

Michael F. Walther, the drug center's former director, said the
reports were read in advance by officials at the DEA and the Office of
National Drug Control Policy.

"It never crossed anyone's mind that cracking down on Oxy would lead
to an increase in heroin," said one current federal official involved
in drug enforcement, who spoke on the condition of anonymity to
discuss internal deliberations.

A new focus on heroin

When President Obama took office, his administration also tackled the
epidemic in front of it. "Prescription drugs were much more of a
priority" than heroin, said Timothy Condon, who was a senior science
policy adviser in the the Office of National Drug Control Policy in
2010 and 2011.

As heroin use rose in recent years, the government began reacting.
Since 2009, the DEA has widely circulated a slide called "circle of
addiction" that shows the linkage between pain medications and heroin.

Heroin-trafficking cases rose 52 percent between 2008 and 2012,
federal data show. And the drug czar's office, which has publicly
warned about the link between prescription drugs and heroin for the
past several years, has begun a number of anti-heroin initiatives. The
administration supports the use of naloxone, an anti-overdose
medicine, and drugs such as methadone that help ease heroin withdrawal.

There's no missing the toll of heroin anymore.

"Heroin is taking up a lot more of our attention and time," said
Kerlikowske, who said other measures targeting heroin are in the works.

Experts praised the recent steps but said they should have come much
earlier. "The intent was good, but someone, somewhere, should have
thought it through to say 'now we're going to have a flood of heroin
overdoses,' " said Jim Takacs, executive director of the Licking
County Alcoholism Prevention Program near Columbus, Ohio. He said the
state's recent crackdown on pill mills has driven the price of
prescription medications "way up" and caused heroin abuse to spike.

"They should have known," Takacs said.
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