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The harrowing rise of heroin, in one chart

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

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There is a popular narrative about the opioid epidemic now killing more than 30,000 Americans a year: People are put on prescription painkillers, maybe after they have an accident or a surgery, and then they get hooked. Sometimes they move on to heroin.

It's a story with some truth. In 2005, more than 80 percent of the people abusing opioids had started with pills, either oxycondone or hydrocodone. Less than 10 percent started with heroin.

But that story is out of date. By 2015, according to research being published in Addictive Behaviors next month, more than 30 percent of opioid abusers were starting with heroin. Oxycodone and hydrocodone had fallen to 52 percent, combined.

Yet the public debate doesn't seem to have caught up with this change. The Senate health committee met Thursday to talk about the opioid crisis, and one attendee noted to me that for the first 30 minutes, the discussion had been focused exclusively on prescription drugs and how to curb their abuse.

"Everyone’s afraid to say heroin," Andrew Kessler, who works on addiction issues at Slingshot Solutions, told me.

Addressing pill abuse, combating trends like the overprescribing of prescription opioids, remains important, of course, if half of opioid abusers are still getting started that way. But it's not sufficient.

The opioid crisis is still evolving, and our policies have to catch up. The news yesterday that Cigna would stop covering OxyContin (brand-name oxycodone) next year, directing patients instead to an abuse-deterrent alternative with which the insurer has a pricing agreement, caught my eye. That kind of step from payers, and any resulting effect on abuse, is worth monitoring.

But that will only help with the prescription painkillers. Heroin requires a different response.

"Yeah, heroin is an opioid, but we don’t talk about heroin as much as we talk about pills," Kessler said. "If they start with heroin, all the prescribing practices in the world are not going to help them."

So how did this happen? The authors started their research with this hypothesis: As painkillers have become harder to get with a crackdown on prescribing, and as heroin became more available and therefore cheaper, more experienced users had made the transition from pills to heroin.

The researchers theorized that at the same time, this proliferation of heroin would have also led more novice drug users to start with heroin in the first place.

The findings suggest they were right, though we need more confirmation to be sure. I also recommend reading Sam Quinones's Dreamland for a deeper understanding of the intersection of painkiller and heroin abuse.

The point is: The ever-deadlier opioid crisis is still shifting beneath our feet. We need to recognize these changes and adapt our response — prevention, prevention, prevention is what advocates would recommend — accordingly.

"We can’t play whack-a-mole with addiction — it’s complicated and involves multiple sectors, from health care to policing to schools, to come together to help individuals and families impacted by addiction," Jessica Nickel at the Addiction Policy Forum told me. "There are genetic components, risk, and protective factors to consider, along with a very large number of innovations we can expand."

Chart of the Day


MIPS! Remember MIPS, the best/worst new health care acronym. It's the major overhaul of Medicare physician payments that Congress set up back in 2015 to get rid of the hated "doc fix." Sarah wrote about the law when it passed.

Well, we have some fresh estimates from Avalere on what MIPS is actually going to mean for doctors and specialists, and physicians stand to gain — or lose — quite a lot under this new system, which is supposed to be focused more on value than on quantity. Take a look at the data.

Kliff’s Notes

With research help from Caitlin Davis

Today's top news

  • “Parties fight over funding children’s health insurance”: “Republicans pushed a bill extending financing for a popular health insurance program for children through a House committee Wednesday, but partisan divisions over how to pay for it suggest that congressional approval will take time despite growing pressure on lawmakers to act.” —Alan Fram, Associated Press
  • “Hurricane Damage in Puerto Rico Leads to Fears of Drug Shortages Nationwide”: “Federal officials and major drugmakers are scrambling to prevent national shortages of critical drugs for treating cancer, diabetes and heart disease, as well as medical devices and supplies, that are manufactured at 80 plants in hurricane-ravaged Puerto Rico.” —Katie Thomas and Sheila Kaplan, New York Times
  • “Feds activate emergency prescription program for uninsured Puerto Ricans”: “The Health and Human Services Department has activated a program that will pay for prescription medications for uninsured Puerto Ricans impacted by Hurricane Maria. The Emergency Prescription Assistance Program (EPAP) allows uninsured patients to get a 30-day supply at participating pharmacies with renewals every 30 days while the program is active.” —Jessie Hellmann, the Hill

Analysis and longer reads

  • “ACA premiums blame game may turn against Republicans”: “For years, Democrats have been on the receiving end of political attacks about rising Affordable Care Act premiums. But the roles are about to be reversed — and it's not clear whether Republicans will be able to avoid the blame.” —Caitlin Owens, Axios
  • “Commission explores managed care Medicaid system in New Hampshire”: “Members of a Medicaid study commission are exploring shifting the state’s Medicaid expansion population onto a managed-care model, a potentially transformative proposal intended to address predicted future premium spikes.” —Ethan DeWitt, Concord Monitor
  • “Reducing The Externalities Caused By Limited Benefit Plans”: “The business practices of limited benefit plans create negative externalities in the ACA-compliant market, which make that market smaller and more expensive than it would otherwise be. It seems reasonable to consider some strategies for minimizing these spillover effects.” —Katherine Hempstead, Health Affairs

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