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Does Prescription Opioid Use Increase the Chances of Heroin Use?

Using prescription opioids with a legitimate medical prescription and according to your doctor’s instruction does not increase your risk for heroin abuse. However, abusing prescription opioids does increase the likelihood that you will later use heroin.

What Is a Risk Factor?

A risk factor is a condition, situation, experience, or attribute that increases the probability that you will develop some type of disorder or disease.

Having a risk factor will not necessarily cause you to develop the condition in question. In fact, most risk factors are not treated as causes by physicians and researchers.

Risk factors are cumulative. If you have several risk factors, the chance that you will develop the disorder or disease in question is increased even further.

For instance, if you eat a lot of red meat, your chances of having some type of cardiovascular problem are increased, but simply eating red meat does not guarantee that you will have cardiovascular issues like high blood pressure. But if you are overweight, smoke, drink alcohol excessively, and eat lots of red meat, the chances that you will develop high blood pressure become significantly increased.

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Heroin Users Who Were Prescribed Opioids

Given all the above data, we can estimate that at best, only 2 percent of people who had a prescription for an opioid wound up using heroin in 2017. This figure is based on the notion that all of the 872,000 people who reported using heroin in 2017 also had a prescription for an opioid, which is most likely not the case.

If all of the 872,000 people who used heroin in 2017 also had a prescription for an opioid in 2017, this will only represent about 2 percent of everyone who had a prescription for opioids.

According to the National Institute on Drug Abuse (NIDA), combining the data from 2002 to 2012, the rate of first-time heroin use was 19 times higher in those who reported having previous nonmedical pain reliever use (prescription opioid abuse) than in those who did not previously abuse prescription painkillers.

Research looking at urban intravenous drug users in 2008 to 2009 uncovered that 86 percent of those people had used opioids prior to using heroin.

These people got the prescription opioids they abused from:

  • Family members.
  • Friends.
  • A valid prescription for the opioid.

The Risk Is Linked to Abuse

Much of the data suggests that simply having a prescription for an opioid does not significantly increase the risk that you will use heroin. However, if you are a heroin user, there is a very good chance that at some time in the past, you abused prescription opioids.

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If you are a heroin user, the data suggests that you likely got prescription opioids from friends, family members, or illicitly, as opposed to having a prescription for them yourself.

The data also suggests that people who abuse prescription opioids most often do not have a prescription for them.

All Opioids Are Not Equal

There might be a connection between the type of prescription opioid you have and later opioid abuse, including heroin use.

For instance, the initial neuropsychological research demonstrated that the likability of certain opioids is higher than it is for others. Likability in these experiments is associated with something called abuse liability, meaning that if a drug is high on the likability scale, it may be more likely to be abused than others.

The initial research in 2008 used participants who had heroin dependence and tested their likability of heroin, buprenorphine, oxycodone, morphine, and fentanyl. The subjects did not know which drugs they were trying. The drug rated with the highest likability among the heroin abusers was oxycodone. Buprenorphine was rated the lowest.

Therefore, it could be that having a prescription for some opioid drugs may predispose some people to abuse them and increase their potential to abuse other opioids, including heroin.

How Long You Had Your Prescription

Some of the features of the prescription may also slightly increase the risk that you will abuse it.

The research does suggest that the longer you have your opioid prescription and the higher the dosage, the greater the risk that you will eventually abuse the drug. Unfortunately, there does not seem to be clear agreement on how long a prescription must last before it begins to increase the risk that you will abuse the drug. Many of the clinical guidelines suggest that for the treatment of nonchronic pain or noncancer pain, prescribing opioids for only a few days is often sufficient

Regarding the dosage aspect of these findings, most of the guidelines for prescribing opioids suggest that prescribers use the lowest effective dosage to control pain. However, tolerance to opioids develops rapidly. People with prescriptions for these drugs for long periods of time may be more prone to increasing dosages from their prescribing physician.

Extended Release vs. Immediate Release

A characteristic of a prescription opioid that may influence its abuse potential or its risk for harm (through overdose) is the formulation of the drug — specifically, whether the drug is an extended-release (ER) version or an immediate-release (IR) version.

There have been several research studies that suggest that ER opioids are associated with elevated risks, including an increased risk to be diagnosed with a substance use disorder (an opioid use disorder) or to suffer either a fatal or nonfatal overdose on the drug.

Developing an opioid use disorder as a result of prescription opioid abuse would certainly represent a significant risk factor associated with later heroin use.

Individual Factors

The medication or drug is not the sole force behind the development of addictive behaviors. People in recovery are urged to take responsibility for their actions and not excuse their substance abuse.

This notion of taking personal responsibility for recovery is almost a universal principle in recovery from any substance use disorder, even though it is widely acknowledged that addiction is a disease.

The general risk factors associated with the development of substance use disorders include:

  • Having a family history of substance abuse, particularly first-degree relatives like parents or siblings.
  • Being diagnosed with any other type of mental health disorder or having a family history of mental health diagnoses.
  • Having a history of significant trauma, abuse, or noteworthy stress at any age, but particularly as a child.
  • Being exposed to substance use early in life, particularly in adolescence or early adulthood.
  • Living in an area where access to illicit drugs like heroin is very easy.
  • Being frequently exposed to the attitude that substance use is an appropriate means to deal with everyday stressors.
  • Having peers who regularly use or abuse drugs or alcohol. This factor is particularly potent if one’s peers regularly use drugs or alcohol.

These are the major risk factors associated with any substance use disorder. They should be considered by physicians when a person is prescribed a powerful opioid that could be substituted with another medication or intervention.

Physical Dependence Alone Is Not Addiction

If you are prescribed an opioid drug and use it for more than just a few weeks, you will very likely develop some level of tolerance to the drug. You may develop withdrawal symptoms if you stop using the drug, or the dosage is decreased significantly.

Physical dependence and withdrawal symptoms always occur after some level of tolerance to the drug has been developed. Physical dependence is a common result of the medical use of many different types of drugs when they are used for an extended period of time.

An addiction, or substance use disorder, is generally only diagnosed when the person’s use of the drug is for nonmedical reasons. In a case where a person continually uses a substance for nonmedical reasons and begins to develop issues with their use, the signs of tolerance and withdrawal can represent symptoms of a substance use disorder.

When the use of the drug is limited strictly to medicinal purposes according to the instructions of the physician, the development of physical dependence is not considered to be a sign that the person has a substance use disorder (addiction).

Conclusion

Having a prescription for an opioid does slightly increase the risk that you might use heroin, but the actual risk is very small. The more likely scenario is that if you use heroin, it is very likely that you had a prescription for an opioid or you abused prescription opioids in the past.

There may be certain features of opioid drugs that make them more likely to be abused and lead to later use of illicit opioids like heroin, but the research findings are still difficult to apply.

More research needs to be performed to determine exactly what type of person would be more vulnerable to using heroin as a result of having a prescription for opioid medication.

Sources

(2019) Risk Factors. World Health Organization. from https://www.who.int/topics/risk_factors/en/

(July 2018) Quick Facts. The United States Census Bureau. from https://www.census.gov/quickfacts/fact/table/US/PST045218

(December 2018) Opioid Prescription Data. Centers for Disease Control and Prevention. from https://www.cdc.gov/drugoverdose/data/prescribing.html

(October 2018) National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration. from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2017/NSDUHDetailedTabs2017.pdf

(January 2018) Prescription Opioids and Heroin. National Institute on Drug Abuse. from https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use

(January 2012) Initiation into prescription opioid misuse amongst young injection drug users. International Journal of Drug Policy. from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3196821/

(April 2008) Relative abuse liability of prescription opioids compared to heroin in morphine-maintained heroin abusers. Neuropsychopharmacology. from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3787689/

Drug Abuse Liability. Cambridge Cognition. from https://www.cambridgecognition.com/research-areas/drug-abuse-liability-research/

(April 2016) CDC guideline for prescribing opioids for chronic pain—United States, 2016. Morbidity and Mortality Weekly Report. from http://revistaamicac.com/revista/2017/Noviembre/cdcguiaprescribiropioide.pdf

(September 2013) Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers–United States, 2002–2004 and 2008–2010. Drug and alcohol dependence, from https://www.ncbi.nlm.nih.gov/pubmed/23410617

(April 2015) Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Internal Medicine. from http://westvicphn.com.au/images/HOME/Health_Professionals/Alcohol_Other_Drugs/Pharmacotherapy/overdose.pdf

(November 2014) Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Medicine from https://academic.oup.com/painmedicine/article/15/11/1911/1835923

(April 2011) Definition of Addiction. American Society of Addiction Medicine. from https://www.asam.org/resources/definition-of-addiction

(January 2018) Is there a difference between physical dependence and addiction? National Institute on Drug Abuse. from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/there-difference-between-physical-dependence

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