An old epidemic that many experts say grew from the abundance and abuse of prescription opioids is seeing a resurgence: heroin abuse.

Ameritox, a provider of pain-medication monitoring, is focused on reversing the rampant misuse, abuse, and diversion of prescription painkillers that has proliferated in the United States over the last decade.

At PAINWeek 2014, Rick Tucker, an Ameritox compliance education consultant and former assistant special agent in charge of the DEA, and Mike DeGeorge, PharmD, Director of Medical Affairs at Ameritox, discussed in an interview the roots of the current heroin epidemic facing the United States, and how chronic pain patients prescribed opioids are affected by it.

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How has heroin abuse changed over the last few decades?

Rick Tucker: Heroin in the last decade has attained a degree of social acceptability that it didn’t have before. Persons across all social and economic positions are now using heroin. The proliferation of the abuse of prescription pain medications led to abusers looking for drugs to satiate the need of an opiate. The fact that the abuser basically cannot get enough prescription medications to meet their dependence, coupled with a recent decrease in heroin prices, make heroin a viable alternative for these abusers.

How is the heroin people are abusing today different from older versions?

Rick Tucker: The heroin being used today is coming from four major sources – Southwest Asia, Mexico, Colombia, and to a lesser extent, Southeast Asia. In recent years all of these sources have worked to make a better “product,” resulting in heroin being more pure now than it has ever been. In addition, the price of pure heroin recently decreased to meet the “street price” of prescription medications. The prices of both heroin and prescription pain meds on the street are now basically the same.

What does the typical heroin user look like today?

Rick Tucker: Very few heroin users today used heroin in their first experience with illicit drugs. Increasingly, in the past few years according to U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) research, opiate abusers are found to have taken prescription pain medications for their first “high.” In the 2012 SAMHSA research, 1.88 million respondents age 12-25 years used prescription opiates for their first experience. Only 156,000 used heroin.1

How are prescription painkillers and heroin connected?

Rick Tucker: Typical pain medications and heroin are both opiates. When abusers of pain medications cannot obtain quantities to satiate their dependence, they often turn to heroin. According to a report from the National Institute of Drug Abuse, “although heroin use in the general population is rather low, the numbers of people starting to use heroin have been steadily rising since 2007. This may be due in part to a shift from abuse of prescription pain relievers to heroin as a readily available, cheaper alternative, and the misperception that highly pure heroin is safer than less pure forms because it does not need to be injected.”

What prompted Ameritox to conduct this research?

Mike DeGeorge: As Rick mentioned, heroin use has been on the rise in the U.S. Recent data showed that 75% of heroin users were introduced to opioid use through prescription opioids.2 For that reason, we sought to investigate the use of heroin in a population of individuals prescribed opioids for pain. We did this by examining over 170,000 samples from patients prescribed opioids that were received at our lab.

How is this current heroin epidemic affecting pain patients?

Mike DeGeorge: In our study, we found that 1.3% of the 170,000 samples tested positive for the heroin metabolite, 6-monoacetlymorphine. This is significantly greater than the 0.3% seen in the general population.1

Ameritox: Does Ameritox’s research show that there is a relationship between opioid and heroin abuse?

Mike DeGeorge: Based on our research, there does appear to be a relationship between heroin use and misuse of prescription opioids. We found that when patients were positive for heroin, their urine samples tested negative for their prescribed opioid 56% of the time. In 23% of those same samples we also found evidence of the use of a synthetic opioid without a prescription, including drugs such as methadone, fentanyl and buprenorphine.

What other trends are you finding among chronic pain patients who tested positive for heroin?

Mike DeGeorge: The other trend we saw was that heroin positive samples were more likely to test positive for cocaine, marijuana, a non-prescribed prescription stimulant product, or a non-prescribed sedative hypnotic, including benzodiazepines. Interestingly, heroin positive samples were more likely to test negative for those same sedative hypnotics when they were prescribed to them.

The demographics of the heroin positive patients in our study matched well with those of the general population reported previously. Specifically, males and patients between the ages of 19 and 39 years were most likely to test positive. Geographically, samples from the Midwest and Northeast were the most likely to test positive for heroin. From a payer standpoint, samples from patients who have Medicaid as their primary payer were the most likely to contain evidence of heroin use.

How do “drug cocktails” affect people using heroin?

Mike DeGeorge: When heroin is used with prescription opioids and benzodiazepines, the individual is at greater risk for central nervous system and respiratory depression, which can ultimately lead to an overdose death. In our study, more than 4% of the samples tested positive for heroin, a sedative hypnotic, and a synthetic opioid. Additional, slightly more than 1% of the samples tested positive for the combination of heroin, a sedative hypnotic, a synthetic opioid, and cocaine.

1. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings and Detailed Tables. Available at: Accessed on August 21, 2014.
2. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014; 71(7): 821-826.

This article originally appeared on MPR