Introduction

Today, more Americans die from drug overdoses than car accidents.[1]The Centers for Disease Control and Prevention reported that opioids—a class of drugs that include prescription pain medications and heroin—were involved in 28,648 U.S. deaths in 2014. In addition, there has been a continued dramatic increase in heroin-related deaths, as well as a growing increase in synthetic opioid deaths, such as fentanyl. In Illinois, heroin-related overdose deaths increased 22 percent from 2013 to 2014.[2]

Opioid use disorders have affected many communities in urban, suburban, and rural areas. On the rise are users of heroin and opioid prescriptions, such OxyContin® and Vicodin®. In 2014, a Substance Abuse and Mental Health Services Administration survey estimated there were 435,000 Americans who were active heroin users.[3] Communities along with the criminal justice system and public health professionals are struggling to help those suffering from opioid use disorders and save lives. This article provides a basic overview of the opioid epidemic and its causes including the link between high levels of prescription opioids and heroin use. It explores the extent of the problem nationally, as well as in Illinois where data is available.

Heroin distribution and availability

In 2016, Illinois Criminal Justice Information Authority (Authority) researchers surveyed police chiefs and sheriffs for its Illinois Drug Threat Assessment. Over half of respondents identified heroin as the greatest drug threat in the state.[4] Law enforcement reported an increase in heroin distribution (48 percent), transportation (59 percent), and demand (83 percent).[5]Authority researchers also surveyed 19 multi-jurisdictional drug task forces that combat the distribution of drugs in Illinois. Almost all respondents reported that the most serious drug distribution problem was heroin (95 percent). Ten of 21 DEA field divisions, including the Chicago field division, reported heroin was highly available within their jurisdictions in 2015.[6]

The U.S. heroin market is currently dominated by Mexican and Colombian suppliers due to proximity and established drug trafficking methods.[7] Mexican heroin is most prevalent west of the Mississippi River and generally in black tar form. Colombian heroin is most prevalent east of the Mississippi in a white or brown powder form.[8]

Heroin processed in Mexico and South America are transported across the Mexico-U.S. border, mostly in private vehicles or by carriers on commercial airlines. In 2014, the DEA seized more than 5,000 kilograms of heroin, an 81-percent increase since 2010.[9] Cooperation between Mexican and Colombian drug traffickers, a lack of government control over Colombian drug traffickers, and the rise of independent traffickers has led to an increase in production and availability, while decreasing the price of heroin on the street.[10] The production of Mexican heroin increased six-fold, from eight to 50 metric tons from 2004 to 2009.[11] Illinois and the City of Chicago serve as a hub for the transportation, distribution, and availability of heroin and other opioids.[12]

Prescription opioid use: From pills to heroin

The widespread availability and use of prescription opioids, such as OxyContin, Vicodin, codeine, morphine, and fentanyl, has led to an increase in the demand for heroin, spurring a well-documented rise in its production and distribution. Opioid drug use and abuse has been on the rise since the mid-1990s.[13] Opioid drugs are highly effective at relieving pain by intercepting and reducing pain signals in the brain and moderating emotion. Opioids are typically prescribed for pain resulting from injury and surgery, and common prescription opioids include hydrocodone, oxycodone, morphine, and codeine.[14] Though highly addictive, opioids are widely prescribed in the United States. In 2013, more than 207 million opioid prescriptions were filled in the country.[15]

Prescription drug abusers obtain drugs in many ways. Many users rely on friends and family members for drugs[16], and certain abusers, especially teens and young adults, may have easy access to prescription drugs from their family’s medicine cabinets.[17] Prescription drugs are also readily available for purchase online. Some websites allow users to buy prescription drugs with few mechanisms in place to block purchase without a prescription.[18] Abusers also obtain prescription drugs through pain clinics sometimes referred to as “pill mills” and from doctors willing to provide prescription drugs in large quantities for cash, in violation of medical guidelines and regulations.[19] Researchers have attributed increasing prescription opioid addiction to a weak prescription drug monitoring system; misleading information on prescription pain killer addiction; and aggressive pharmaceutical selling tactics, such as product giveaways, downplaying side effects, and broad advertising.[20]

A number of recent studies have linked prescription opioid drugs to the increase in heroin addiction.[21] Many prescription opioid abusers who can no longer afford or obtain prescription opioids turn to heroin, which is less expensive, more pure, and more accessible.[22] From 2002 to 2011, 80 percent of heroin users reported previous abuse of opioids compared to 1 percent of heroin users who had not. Additionally, heroin use was 19-times greater among individuals who reported prescription pain reliever use than among those who have not used prescription pain relievers.[23]

The National Surveys on Drug Use and Mental Health found 77 percent identified using non-medical opioids prior to engaging in heroin use.[24] That survey also found rates of heroin use between 2002-2004 and 2009-2011 significantly increased for women, non-Hispanic Whites, 18-49 year olds, those in lower- to middle-income brackets.[25] Geographically, there was almost no distinction—the increases were across the board. However, while majority of heroin users reported use of non-medical prescription opioids, it is still rare for people prescribed opioids for medical reasons to use heroin.[26]

Between 2002 and 2011, treatment facility admission rates for prescription opioids were on the rise across the country before declining 15 percent from 2011 to 2012.[27] Figure 1 compares U.S. heroin and opioid treatment admissions.

Figure 1

National heroin and prescription opioid treatment admissions

Figure 1
Data source: Treatment Episode Data Set (TEDS), Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.

Fentanyl: A synthetic prescription opioid

Fentanyl is one of the most powerful legal pain killers available at 30 to 50 times more potent than heroin and 100 times more potent than morphine. Fentanyl is administered to cancer patients on chemotherapy and people recovering from surgery who are experiencing extreme pain. Fentanyl comes in pill, injection, and patch form.

Illicit fentanyl use has increased over the past decade. Drug dealers obtain fentanyl for street distribution through pharmaceutical theft, fake prescriptions, and illegal sales from patients, doctors, and pharmacists. Additionally, a growing drug market is illicitly producing fentanyl and fentanyl analogs. Those most affected by fentanyl-related overdose tend to be those living in areas that sell white powder heroin, as fentanyl can be mixed with heroin or disguised as heroin.[28]

According to the DEA, from late 2013 through 2014, fentanyl accounted for more than 700 overdose-related deaths.[29] Fentanyl drug cases reported to state and local forensic labs increased 259 percent during this period, with the Midwest, Northeast, and South having a pronounced amount of reports of fentanyl cases.[30] Emergency room visits due to non-prescription Fentanyl use increased nationally from 15,947 in 2007 to 20,034 in 2011.[31]

Recently, the DEA issued a warning about Carfentanil, another synthetic opioid which is 10,000 times more potent than morphine and 100 times more potent than fentanyl.

Heroin- and opioid-related overdoses and deaths

Opioids accounted for 28,647 deaths in the United States in 2014, a 200-percent increase over the total in 2000.[32] This increase involves both genders, individuals between the ages of 25-44 and over 55, Whites and Blacks, and areas in the Northeast, Midwest, and South of the United States. Heroin and opioid pain relievers accounted for 61 percent of drug overdose deaths in 2014.[33] Additionally, overdose deaths from synthetic opioids, such as fentanyl and tramadol almost doubled the between 2013 and 2014—as the availability of illicit fentanyl increased.[34]

While heroin may not be the most commonly used drug, it is the most deadly. Nationally, though there were five times more cocaine users than heroin users in 2013, twice as many heroin-related overdose deaths were recorded (Figure 2).[35] The increase in heroin-related deaths can be attributed in part to the rising number of prescription opioid abusers who transition to heroin, many of whom are young, inexperienced or new to the drug, and more prone to overdose.[36] In addition, there is an increased risk of drug-related death during the first two to four weeks after release from prison and jail due to individuals seeking a high immediately upon release.[37]

Figure 2

National drug overdose deaths by drug, 1999-2014

Figure 2
Data source: National Institute on Drug Abuse, Overdose death rates. Retrieved from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

Illinois heroin-related deaths increased 22 percent between 2013 and 2014 from 583 deaths to 711 deaths.[38] In Cook County, heroin-related overdose deaths increased 331 percent from 149 in 2010 to 642 in 2014.[39]

In Illinois, cities as well as smaller metropolitan areas have seen increases in heroin use and overdose deaths. Figure 3 shows the rates of heroin-related death in Illinois and they have occurred across the state. The Illinois Consortium on Drug Policy examined smaller metropolitan areas in Illinois and found increases in treatment episodes for heroin. Percentages in heroin use in Peoria and Champaign-Urbana, more than doubled between 2007 and 2012, to 16 percent and 13 percent, respectively. In the Decatur area, meanwhile, the percent of heroin users increased from three to 23 percent in the same five-year period.[40] In the Chicago area, heroin use among White Chicago suburban residents has increased alongside increases among Chicago users.[41]

Figure 3

Figure 3
Data source: Illinois Department of Public Health. Retrieved from http://www.dph.illinois.gov/sites/default/files/publications/Heroin-OD-Report-September-2016.pdf

Due to its large transportation industry and accessible highways and roadways, Chicago and the state of Illinois serve as a major center for heroin and opioid drug trafficking.[42] Figure 4 shows the number of heroin-related death in Illinois by county in relation to the interstates. It appears that high number of deaths appear near the major interstates.

Figure 4

Figure 4
Data source: Illinois Department of Public Health. Retrieved from http://www.dph.illinois.gov/sites/default/files/publications/Heroin-OD-Report-September-2016.pdf

Figure 5 depicts the rates of heroin-related death in Illinois by county along with interstates.

Figure 5

Figure 5
Data source: Illinois Department of Public Health. Retrieved from http://www.dph.illinois.gov/sites/default/files/publications/Heroin-OD-Report-September-2016.pdf

Conclusion

Heroin and other opioid availability and use have increased in in the past 10 years. Research has documented a link between prescription opioid drugs and the increase in individuals with heroin use disorders. The United States and Illinois have experienced increased overdoses and deaths due to heroin and other opioids and Fentanyl has contributed to the number of deaths. In response, communities, the criminal justice system, public health professionals, and legislators have tried to reduce influx of drugs in the community that contributes to abuse, addiction, and overdose, as well as increase access to substance abuse treatment, including harm reduction tactics.

This article provided an overview of the opioid crisis and the extent of the problem. This information can educate individuals in all communities in Illinois about the seriousness of the epidemic. The data indicates a need for increased monitoring of opioid prescriptions and to help individuals with opioid use disorders get the treatment they need.

  1. Xu, J., Murphy, S. L., Kochanek, K. D., & Bastian, B, A. (2016). Deaths: Final data for 2013. National vital statistics reports, 64(2). Hyattsville MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_02.pdf. ↩︎

  2. Illinois Department of Public Health, email communication, October 29, 2015. ↩︎

  3. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C.; Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 national survey on drug use and health (. Retrieved from http://www.samhsa.gov/data/ ↩︎

  4. Gleicher, L., & Reichert, J. (in press). Illinois drug threat assessment 2016: A survey of police chiefs and county sheriffs. Chicago, IL: Illinois Criminal Justice Information Authority. ↩︎

  5. Gleicher, L., & Reichert, J. (in press). Illinois drug threat assessment 2016: A survey of police chiefs and county sheriffs. Chicago, IL: Illinois Criminal Justice Information Authority. ↩︎

  6. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  7. Drug Enforcement Administration. (2015). National drug threat assessment summary 2014. Washington, D.C. ↩︎

  8. Drug Enforcement Administration. (2015). National drug threat assessment summary 2014. Washington, D.C. ↩︎

  9. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  10. Ciccarone, D., Unick, G. J., & Kraus, A. (2009). Impact of South American heroin on the US market 1993-2004. International Journal of Drug Policy, 20, 329-401.; National drug threat assessment. (2011). National Drug Intelligence Center. ↩︎

  11. National Drug Intelligence Center (2011). National drug threat assessment 2011. Washington DC: author. ↩︎

  12. National Drug Intelligence Center. (2011). Chicago high intensity drug trafficking area: Drug market analysis 2011. No. 2011-R0813-008, Washington, D.C. ↩︎

  13. Maxwell, J. C. (2015). The pain reliever and heroin epidemic in the United States: Shifting winds in the perfect storm. Journal of Addictive Diseases, 34, 127-140. ↩︎

  14. National Institute on Drug Abuse. (2014). Heroin. Retrieved from http://www.drugabuse.gov/publications/drugfacts/heroin ↩︎

  15. Volkow, N. D. (2014). America’s addiction to opioids: Heroin and prescription drug abuse [Lecture]. Retrieved from https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/americas-addiction-to-opioids-heroin-prescription-drug-abuse ↩︎

  16. Boyd, C. J., Esteban, S., & Teter, C. J. (2006). Medical and nonmedical use of prescription pain medication by youth in a Detroit-area public school district. Drug and Alcohol Dependence, 81(1), 37–45. Retrieved from http://doi.org/10.1016/j.drugalcdep.2005.05.017 ↩︎

  17. Sham, M. K. (2010). Down on the pharm: The juvenile prescription drug abuse epidemic and the necessity of holding parents criminally liable for making drugs accessible in their homes. Journal of Contemporary Health Law & Policy, 27, 426-452. ↩︎

  18. Califano, J. (2004). Prescription drug pushers on the Internet. A CASA white paper. The National Center on Addiction and Substance Abuse; New York, Columbia University; McCable, S. E., & Boyd, C. J. (2006). Sources of prescription drugs for illicit use. Addiction Behavior, 30(7), 1342-1350; Orizio, G., Schulz, P., Domenighini, S., Caimi, L., Rosati, C., Rubinelli, S., & Gelatti, U. (2009). Cyberdrugs: a cross-sectional study of online pharmacies characteristics. The European Journal of Public Health, 19(4), 375-377. ↩︎

  19. Kennedy-Hendricks, A., Richey, M., McGinty, E. E., Stuart, E. A., Barry, C. L., & Webster, D. W. (2016). Opioid overdose deaths and Florida’s crackdown on pill mills. American Journal of Public Health, (0), e1-e8. ↩︎

  20. Aron, L.Y. (2016). Are policy failures behind the opioid epidemic? Washington, DC: Urban Institute. ↩︎

  21. Jones, C. M. (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, 132(1), 95-100.; Muhuri, P. K., Gfroerer, J. C., & Davies, M. C. (2013). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review, 1-17. ↩︎

  22. Compton, W. M. Hones, C. M., Baldwin, G. T. (2016). Relationship between nonmedical prescription-opioid use and heroin use. New England Journal of Medicine, 374, 154-163.; Gateway Foundation (2015). Prescription drug abuse and the road to heroin. Chicago, IL: Author. ↩︎

  23. Maxwell, J. C. (2015). The pain reliever and heroin epidemic in the United States: Shifting winds in the perfect storm. Journal of Addictive Diseases, 34, 127-140. ↩︎

  24. Muhuri, P. K., Gfroerer, J. C., & Davies, M. C. (2013). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review, 1-17. ↩︎

  25. Muhuri, P. K., Gfroerer, J. C., & Davies, M. C. (2013). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review, 1-17. ↩︎

  26. Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between nonmedical prescription-opioid use and heroin use. The New England Journal of Medicine, 374(2), 154-163. ↩︎

  27. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  28. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  29. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  30. Drug Enforcement Administration, Office of Diversion Control. (2015). National forensic laboratory information system special report: Opiates and related drugs reported in NFLIS, 2009–2014. Springfield, VA: U.S. Drug Enforcement Administration. ↩︎

  31. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  32. Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, M. (2016). Increases in drug and opioid overdose deaths-United States, 2000-2014. Morbidity and Mortality Weekly Report, 64(50), 1378-1382. ↩︎

  33. Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, M. (2016). Increases in drug and opioid overdose deaths-United States, 2000-2014. Morbidity and Mortality Weekly Report, 64(50), 1378-1382. ↩︎

  34. Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, M. (2016). Increases in drug and opioid overdose deaths-United States, 2000-2014. Morbidity and Mortality Weekly Report, 64(50), 1378-1382. ↩︎

  35. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  36. Drug Enforcement Administration. (2015). National drug threat assessment summary 2015. Washington, D.C. ↩︎

  37. Merrall, E. L. C., Karimina, A., Ninswanger, I. A., Hobbs, M. S., Farrell, M., Marsden, J., Hutcinson, S. J., & Bird, S. M. (2010). Meta-analysis of drug-related deaths soon after release from prison. Addiction, 105(9), 1545-1554. ↩︎

  38. Illinois Department of Public Health (2016). Heroin-related drug overdose deaths by sex, age group, race/ethnicity and county, Illinois residents, 2013-2015. Retrieved from http://www.dph.illinois.gov/sites/default/files/publications/Heroin-OD-Report-September-2016.pdf ↩︎

  39. Illinois Department of Public Health, email communication, October 29, 2015. ↩︎

  40. Kane-Willis, K., Aviles, G., Barnett, D., Czechowska, J., Metzger, S., Rivera, R., & Waite, B. (2015). Diminishing capacity: The heroin crisis and Illinois treatment in national perspective. Chicago, IL: Illinois Consortium on Drug Policy. ↩︎

  41. Ouellett, L. J. (2014). Drug abuse patterns and trends in Chicago – Update: January 2014 [Lecture]. Retrieved from https://www.drugabuse.gov/about-nida/organization/workgroups-interest-groups-consortia/community-epidemiology-work-group-cewg/meeting-reports/highlights-summaries-january-2014-2 ↩︎

  42. National Drug Intelligence Center. (2011). Chicago high intensity drug trafficking area: Drug market analysis 2011. No. 2011-R0813-008, Washington, D.C. ↩︎