Despite widespread news coverage, extensive research, and effective treatments, opioid addiction is reaching new heights—not only in the U.S., but in many parts of the world.
According to data from the National Survey on Drug Use and Health, in 2014about 1.9 million people in the U.S. had substance use disorders related to opioid prescription pain relievers. This was up from about 1.4 million in 2004, but down slightly from the 2012 estimate of 2.1 million.
Accompanying the slight drop in opioid pain reliever disorders has been a sharp increase in heroin use. About 586,000 people aged 12 or older had a heroin disorder in 2014. This was a slight rise over the 2013 total (517,000), but considerably higher than during 2002 to 2010, as the bar graph shows.
Mortality data in the U.S. for 2014 are not yet available, but in 2013,16,235 deaths were attributed to prescription pain relievers, according to a Morbidity and Mortality Weekly Report (MMWR). Heroin-related deaths in 2013 totaled 8,257, according to the Centers for Disease Control (CDC), amounting to a 286 percent increase over 2002.
People addicted to opioids face difficult challenges—medical, legal, and personal. What risks of disease and death do they face? What factors make it more—or less—likely that they’ll ever be able to quit? And what are their chances of ever remaining abstinent?
University of California Study
To answer these questions, a team at the University of California, Los Angeles, studied approximately 250 articles covering long-term patterns of stability and change across the life span of people with opioid dependence.
The authors restricted their search to studies of established addiction. They selected 28 studies from Australia, Asia, Western Europe, and North America. Among other criteria, studies had to include at least three years of follow-up data through February 2014, and had to define abstinence as abstinence from opioids. The authors published the results of their study, summarized below, in the March-April 2015 issue of Harvard Review of Psychiatry.
The authors covered a variety of topics related to opioid dependence, noting that mortality has been well studied, but that potential turning points and critical life events that shift opioid use—such as incarceration—have not.
Opioid addiction is a chronic disorder associated with frequent relapses and often devastating consequences: 25 percent to 50 percent of the study subjects had died within 20 years after study entry. Mortality rates were about 6 to 20 times greater than those in the general population, with overdose being the most common cause of death. Of those who lived 10 to 30 years after entry, fewer than 30 percent ever reached stable abstinence.
Recurring abstinence and relapse were common, with patients in many studies using opioids for six to 10 years before entering addiction treatment. Dropout rates from treatment were generally about 20 percent to 30 percent. As for recovery, the authors noted that “neither age nor the chronicity of use predicts recovery,” and that people addicted to opioids do not “mature out” with age. Instead, “what increases over time is the mortality.”
Users didn’t usually stop using opioids before 10 years had passed. Stable abstinence was unlikely, but if it did occur, and lasted five years, future stable cessation was more likely.
Cessation had a downside, however: many former opioid users continued—or even increased—their use of alcohol and other drugs.
Transitions, Turning Points, and Maintenance
The authors also found:
- Medication-assisted treatment (methadone, buprenorphine, or naltrexone) or abstinence-based rehabilitation was often associated with temporary reductions in opioid use and criminal behavior, but many patients needed repeated treatment episodes before they could quit
- Abstinence after release from imprisonment tended to be brief, but many aging users “burned out,” and never returned to drug use
- Rewarding nondrug activities—employment, vocational training, and relationships with family and friends—helped former users maintain abstinence, but those with a history of sexual or physical abuse, especially women, were less likely to ever recover
- Those who stayed longer in treatment were more likely to remain abstinent; those who had been incarcerated were less likely
Findings were inconsistent as to whether mental health problems tended to precede heroin use and influence its progression.
- About 20% percent to 30% of participants showed symptoms of depression at study entry
- In several studies, 10% to 20% had histories of psychiatric problems or psychiatric treatment
- Post-traumatic stress disorder was diagnosed in about 40% of veterans entering methadone treatment
- Women in some studies reported poorer mental health than men, especially regarding symptoms of suicidality and depression
- Except for those with depressive disorders, a consistent finding was improvement in mental health as time passed
About half the studies, most of them from the U.S., included information on participants’ criminal activities or legal-system involvement. Incarceration was more common and longer-lasting in the U.S. than elsewhere, perhaps due to laws relating to drug offenses.
Drug possession and other drug-law violations were the most common crimes heroin users committed, but violent offenses also occurred. Crime levels appeared to fall when heroin use dropped.
People in the U.S. addicted to opioids were incarcerated in higher percentages, and for longer periods, than those in Europe, reflecting the European custom of treating addiction as a public health issue.
Criminal activity often led to addiction treatment, followed by a drop in criminal offenses. But after repeated incarceration, many started using heroin again, resulting in a large number of deaths from overdose and suicide.
The authors call for reducing treatment barriers, expanding treatment capacity, taking a chronic-care model approach to treatment, implementing long-term care and management strategies, and distributing naloxone to reduce overdose deaths.
They believe that the current situation is urgent, and calls for new approaches:
- Research— to profile opioid users, based on the opioid or opioids they use
- New medications—designed to treat patients in medical offices, not just in clinics
They note that recent treatment options (buprenorphine and naltrexone) include depot formulations that have a longer duration of action, but an unknown long-term impact.
The authors also suggest additional studies of opioid users and former users outside treatment settings to provide “a fuller understanding of the long-term course of opioid addiction.”
Limitations of the Study
Study limitations were minor. Definitions of abstinence differed among countries, and some definitions included measurable outcomes. Some studies used data reported by study participants, but unverified. Differences existed between incarceration rates in various countries, perhaps because of the traditional criminal justice approach of U.S. drug policies.
Hser Y, Evans E, Grella C, Ling W, Anglin D. Long-term course of opioid addiction.Harv Rev Psychiatry.2015; Mar-Apr;23(2):76-89. doi: 10.1097/HRP.0000000000000052. PMID:25747921.
Center for Behavioral Health Statistics and Quality. September 2015. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm. Accessed September 25, 2015.
Centers for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report (MMWR). QuickStats: Rates of Deaths from Drug Poisoning and Drug Poisoning Involving Opioid Analgesics – United States, 1999-2013. January 16, 2015; 64(01);32.
Jones CM, Logan J, Gladden RM, Bohm MK. Vital Signs: Demographic and Substance Use Trends Among Heroin Users—United States, 2002-2013. July 10, 2015. MMWR 2015;64(26):719-725. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6426a3.htm. Accessed September 25, 2015.
Murphy J. Heroin Use Increasing at Alarming Rate; Health Care Providers Can Help. MDLinx. July 9, 2015. http://www.mdlinx.com/family-medicine/article/60. Accessed September 28, 2015.
National Institute on Drug Abuse: Abuse of Prescription Pain Medications Risks Heroin Use. http://www.drugabuse.gov/related-topics/trends-statistics/infographics/abuse-prescription-pain-medications-risks-heroin-use. Accessed September 24, 2015.
Opioid addiction disease 2015 facts and figures. American Society of Addiction Medicine. Chevy Chase, MD; 2015:1-2. http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf. Accessed September 24, 2015.
Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. http://www.samhsa.gov/data/sites/default/files/NSDUHresults2012/NSDUHresults2012.pdf. Accessed September 24, 2015.
Volkow, N. Prescription Opioid and Heroin Abuse. A presentation to the House Committee on Energy and Commerce Subcommittee on Oversight and Investigations, April 29, 2014. http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/prescription-opioid-heroin-abuse. Accessed September 24, 2015.