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Health and Human Services Secretary Donna Shalala joined Office of National Drug Control Policy Director Barry McCaffrey at a National Institute on Drug Abuse (NIDA) conference in Washington, D.C., in September to sound an alarm over the changing nature of heroin use in the United States.
Approximately 500 participants attended the two-day conference, titled "Heroin Use and Addiction: A National Conference on Prevention, Treatment, and Research." First-time heroin use by teenagers has increased fourfold since the 1980’s, Shalala said. In 1995 more than 140,000 people tried heroin for the first time, most of them under age 26.
This trend must be fought through tough law enforcement and better treatment and prevention programs, Shalala commented. Tough law enforcement must "stop the cartels and their street-level dealers long before they can seduce our kids with their poison," she vowed.
Heroin has gone through periods of glamorization in this country. "And each time, the glamour faded - usually because of the death of a celebrity," Shalala noted. She criticized "heroin chic" - the use of strung-out looking models, a practice also slammed elsewhere by President Clinton.
The conference ranged from a historical overview of heroin in the United States (it was first marketed by Bayer pharmaceutical as a nonaddictive cough suppressant for both children and adults) to the latest developments in law enforcement and science.
Mary Jane Kreek, M.D., Ph.D., of the Laboratory on the Biology of Addictive Diseases at Rockefeller University in New York, discussed the history and efficacy of methadone maintenance. In the 1960’s Kreek helped pioneer methadone maintenance along with Vincent Dole, M.D., and the late Marie Nyswander, M.D. Methadone maintenance at adequate doses (which she defined as at least 60 milligrams to 120 milligrams daily) is safe and effective in reducing heroin use and improving the general health of addicts, she said. Voluntary retention of more than 60 percent is not unusual, said Kreek, and illicit opiate use generally drops from 100 percent at admission to less than 20 percent of patients stabilized on methadone for nine to 12 months.
Herbert Kleber, M.D., a member of APA’s Council on Addiction Psychiatry and a former head of the White House’s drug policy office, discussed the problem of psychiatric comorbidity. From 20 percent to 50 percent of heroin addicts are comorbid for other psychiatric disorders, according to Kleber. Treatment dropout and relapse increase if these are left untreated.
Yale University Professor of Psychiatry Thomas Kosten, M.D., is a consultant to the APA Council on Addiction Psychiatry and chief of psychiatry for the Connecticut Veterans Affairs hospital. Kosten worked with Kleber to provide comorbidity data for the heroin conference. He and Kleber spoke with Psychiatric News.
Rates of depression are much higher - 75 percent to 80 percent - in opiate addicts than in the community, observed Kosten. "But what that’s a function of is not clear," he added.
Although comorbidity complicates treatment, the good news is that heroin addicts respond well to antidepressant medication, said Kosten.
"Treating the comorbid disorder doesn’t treat the addiction," added Kleber. "However, if you don’t treat the comorbid depression or anxiety, the likelihood for successful addiction treatment is much lower."
At least 75 percent of heroin addicts with depression were opiate dependent prior to developing depression, according to Kosten. Depression is the most common Axis I disorder seen in heroin addicts, with a lifetime prevalence of 35 percent to 50 percent. The next most frequent malady is antisocial personality disorder, with a lifetime prevalence in heroin addicts of about 25 percent. These rates are "5 to 8 times higher for depression and about 10 times higher for antisocial personality disorder" than in the general population, said Kosten.
"The rate of heroin use is increasing, and it is becoming more of a middle-class phenomenon," Kosten noted. Although fads have their own dynamic, the increased purity, ease of availability, and lower price of heroin have contributed to the growth in use, he observed. In addition, a growing number of cocaine users are now using both drugs, while others have switched entirely to heroin.
Although NIDA’s concern is justified, heroin is not undergoing "the epidemic explosion you saw with stimulants," said Kosten. Among heroin users, however, "those who become dependent tend to have a much longer-lasting addiction," Kosten said.
Estimates range from 600,000 to 1 million heroin addicts at present. Many start using in their 20’s, end up on methadone, and remain on methadone for 25 years or more, said Kosten. Addicts tend to seek methadone treatment about eight years after starting heroin use.
NIDA is "being extremely good at being proactive and doing technology transfer into the community," remarked Kosten. NIDA is "doing a much better job than [it has] ever done in terms of early identification of trends in drug usage and trying to provide the latest research and treatment information so the treatment community can respond appropriately. The sad thing is that there are inadequate funds to implement all these wonderful treatments and there is still no parity" in insurance coverage of treatment for substance abuse, Kosten added.
Ellie Schoenbaum, M.D., is director of the AIDS Research Program in the department of epidemiology and social medicine at Montefiore Medical Center in the Bronx, New York. She discussed the health consequences of heroin addiction at the conference and later spoke with Psychiatric News.
Despite the development of new and better HIV treatments, it will be necessary to design programs facilitating access and adherence to these new treatments to reach the many addicts and others affected by HIV, said Schoenbaum.
"I am strongly in favor of needle exchange," she commented. "I truly believe that drug addiction is a disease. I think giving needles to drug addicts to help them keep from getting other diseases is humane. There’s no evidence that providing needles makes people into addicts any more than giving people condoms makes them have sex."
Any way of engaging patients in some kind of treatment program "however you define it" is better than leaving them on their own, she contended. "Any drug treatment program that may bring them back into society in a productive way and improve their own lives and that of their families and community is worth trying."
She is a strong believer in the concept of "harm reduction," which she described as "basically a philosophy where you don’t view drug addiction as a ‘just say no’ condition" but rather "do incremental improvements and interventions so that you reduce the harm addicts do to themselves." It is unrealistic to make abstinence the sole measure of success, she said. Addiction, like other diseases, is subject to relapse.
One issue that sparked contention at the conference was the prescribing of the latest anti-AIDS drugs to addicts. "We’re now at a point where a lot of physicians don’t want to prescribe the new protease inhibitors to addicts because they perceive them as noncompliers," said Schoenbaum. This, she said, is "a cop-out because people are not addressing how to treat drug addicts so they won’t spread the virus."
Although those opposed to prescribing protease inhibitors to addicts contend that noncompliance may create more resistant forms of HIV, there is "no evidence that if someone has a resistant virus, it’s going to have a population effect," Schoenbaum asserted. Further, there are no data showing addicts are less likely to comply with anti-AIDS treatment than nonaddicts, she added.
The high incidence of HIV among addicts makes collaboration imperative between psychiatrists and internists, said Schoen-baum. "Drug treatment programs, which are often and appropriately within the purview of psychiatrists, need to consider providing the on-site primary medical care that patients need."