Deaths from heroin overdoses doubled in much of the country between 2010 and 2012, according to a 2014 report from the U.S. Centers for Disease Control and Prevention.
And while deaths from overdoses of Vicodin, OxyContin and other prescription opioids declined over the same period, deaths from legal painkillers are still almost three times more common than deaths from heroin.
These statistics reflect an increasingly common scenario, says psychologist Jennifer Sharpe Potter, PhD, a substance abuse researcher at the University of Texas Health Science Center in San Antonio. With prescription opioids now harder to get, she says, users are switching to heroin for an easier-to-get high.
"It just makes sense, both in terms of the availability of heroin, the price of heroin and the ratcheting up of regulatory controls of prescription opioids," says Potter, the assistant dean for research and student programs. "It's a natural progression."
Recent regulations, for example, have made it harder for physicians to prescribe opioids and for patients to "doctor shop," or seek prescriptions from multiple providers. The manufacturer of OxyContin reformulated the drug to make it harder to inject or snort. Plus, heroin is much less expensive than prescription drugs. A fix of street heroin costs about $10, The Washington Postopens in new window estimated in a 2014 article, while an equivalent dose of OxyContin sold on the street costs eight times more.
The result of these and other changes has been a shift in who is using heroin, according to new research by Theodore J. Cicero, PhD, of the University of Washington School of Medicine and colleagues (JAMA Psychiatry, 2014).
While the heroin users of the past were typically young, low-income, racial and ethnic minorities from urban areas, that's no longer true. Today's heroin users are increasingly older whites from more affluent suburbs and rural areas, according to Cicero's analysis of data from an ongoing study of patients in substance abuse treatment programs. In contrast to past users, who started out with heroin, three-quarters of the current patients got their first introduction to opioids via prescription drugs.
Treatment is changing, too. While the gold standard for opioid addiction is still medication, says Potter, psychologists are researching how to help patients with heroin and prescription drug addiction. They're investigating whether adding counseling enhances outcomes for patients on medication-based treatment. They're also exploring new ways of getting treatment to patients, whether in primary-care settings or via computer.
Supplementing pharmacological therapy
Pharmacological treatment, such as methadone and buprenorphine, is the basis of most opioid addiction treatment. Can adding psychological interventions increase the chances of treatment success?
"The jury's still out on that," says Potter.
Treatment programs typically include a behavioral component, she explains. In fact, federal law requires providers who prescribe buprenorphine on an outpatient basis to provide some kind of wraparound or behavioral treatment, such as training in life management skills, symptom reduction and other recovery-oriented topics. And the highly regulated dispensing of methadone, whether at a clinic or in take-home dosing, requires intensive case management.
But the evidence from clinical trials on whether that behavioral therapy enhances the pharmacological treatment for opioid addiction treatment remains murky, says Potter.
In a randomized clinical trial of 653 outpatients dependent on prescription opioids, for example, Potter and her co-authors found that individual drug counseling offered no additional benefit over and above the standard buprenorphine treatment (JAMA Psychiatryopens in new window, 2011).
"That doesn't mean the behavioral treatment wasn't useful to those people," she says. "But it wasn't something we were able to capture in that study design as improving outcomes."
Perhaps the problem was the mix or duration of the treatment offered or the population it was offered to, says Potter. In a more recent study, she and colleagues found evidence that patients who had the most severe addiction benefited more from the drug counseling than those with less severe forms of the disease (Drug and Alcohol Dependenceopens in new window, 2014).
"It's really a bit of a mixed picture," says Potter. "What we're really trying to understand now is in what circumstances does what type of behavioral treatment work?"
Psychologist Nancy M. Petry, PhD, professor and director of the REWARD Center at the University of Connecticut School of Medicine, is a fan of contingency management, a behavioral approach that uses incentives to encourage patients to stay drug-free. Patients who achieve and maintain abstinence can earn the chance to win monetary-based prizes when they achieve and maintain abstinence.
The approach works so well that the Department of Veterans Affairs is putting it into practice in its substance abuse treatment clinics, an experience Petry and colleagues describe in a 2014 paper in the American Journal of Addictionsopens in new window.
Although some perceive contingency management to be expensive, Petry has found that lower-cost prizes work just as well as some higher-cost alternatives when it comes to motivating abstinence. In one study, for example, Petry and colleagues found that $300 prizes worked just as well as $900 in incentives when it came to reducing cocaine use in methadone patients (Journal of Consulting and Clinical Psychologyopens in new window, 2014).
"Overall costs of these reinforcement procedures can be less than the costs of more traditional psychotherapies, and they produce better outcomes," she says.
Of course, say Petry and Potter, it would be a mistake to think that behavioral treatment alone would be the optimal way to treat someone with a significant opioid use disorder.
"The addictive nature of the opioid is so profound, it is very difficult to kick it without some kind of opioid replacement therapy," says Potter.
Changing treatment delivery
Psychologists and others are also exploring new ways of delivering care.
The Oregon Health Authority, for instance, is now integrating addiction services into primary care in the 16 coordinated care organizations that serve its Medicaid population.
That kind of integration should be the wave of the future, argues psychologist Dennis McCarty, PhD, who directs the division of health services research at the Oregon Health and Science University in Portland.
That's because the current approach, which relies on specialty addiction treatment, isn't sufficient, says McCarty, noting that while 22 million to 23 million Americans each year meet criteria for dependence or abuse of alcohol or other drugs, just 3 million get treatment. "Most of the 20 million unserved individuals are receiving primary care and acute medical care, however, so integrated care may be more effective at engaging them in care."
That treatment gap has financial as well as human costs, says McCarty, noting that people often end up in the emergency room or the inpatient unit. In a study of patients in two large health systems, McCarty and co-authors found that the mean health-care costs for patients with opioid dependence was $31,055 per year when they received little or no addiction treatment but fell to $13,578 for patients receiving buprenorphine and addiction counseling (Addiction Science and Clinical Practiceopens in new window, 2014). As an added benefit, integrating opioid treatment into primary care also reduces the stigma associated with seeking addiction treatment, says McCarty.
An inadequately prepared workforce is one reason there's such a big gap between the number of people who need treatment and those who get it, says psychologist Lisa A. Marsch, PhD, who directs the Psychiatric Research Center and Center for Technology and Behavioral Health at Dartmouth University's Geisel School of Medicine.
"There just aren't enough addiction treatment specialists," says Marsch. "And it's really tough for more traditional medical settings to embrace behavioral health: They don't have specialists, and primary-care doctors don't have the expertise."
Even in specialty treatment centers, she says, clinicians can have enormous case loads. There's a lot of turnover. Plus, in the more complex context of real life, evidence-based treatments don't always get delivered the way they were designed in a lab environment and may be less effective.
Technology can help, says Marsch. For example, Marsch and colleagues have found that substituting a Web-based intervention for some of the standard counseling methadone patients received resulted in significantly higher rates of abstinence than standard treatment alone (Journal of Substance Abuse Treatment,opens in new window 2014).
"If you offered some of your interventions via a computerized system, you might free up clinicians to have more time to spend with people who are in crisis or have more intensive care needs," says Marsch. "Or you could see more people with the same number of clinicians."
To Potter, all this activity by psychologists is a positive sign.
"The number of psychologists working in addiction in direct clinical care is relatively small," she says. "They need more of a role, to be honest. What's important is that we understand how to intervene, how to customize treatment for patients' particular circumstances and how to provide them with the best behavioral treatment we know that's based on evidence."
Rebecca A. Clay is a journalist in Washington, D.C.
