I Don’t Prescribe Heroin

While walking through the lobby of the hospital where I am a physician consultant, called on this occasion to evaluate a patient with newly diagnosed colon cancer, I found myself bombarded for the fourth time in a week, but on this occasion from the mounted TV in the lobby, by a message asking for assistance to help fight the heroin epidemic in America.

Having already received communications from the PA Department of Health, the U.S. Surgeon General and the local hospital, imploring me as a physician to aid, in various ways, the fight against heroin use I thought, what next, a text message? Well, I did get an Amber alert on my phone but I digress. Reflexively I figured that I certainly couldn’t be part of the solution because I wasn’t part of the problem: I don’t prescribe heroin. So what role does my work play in the proclaimed heroin epidemic?

And here is where opinions can differ but facts, those stubbornly annoying components of an argument, get in the way of good old-fashioned propaganda. It also serves us well to keep in mind that the communications I received either directly or indirectly were distributed from government entities and knowing the track record of government, honesty is at the bottom of the list.

Now don’t get me wrong. Heroin is a relatively big problem in the U.S. though not so much for the number of people who die using it but rather from the crime, expense, and toll it takes on people who don‘t use it. And keep in mind people don’t wake up one day and decide that it seems like a good day to become a heroin addict. It actually takes some hard work to become a full-fledged addict with prerequisite steps required like in any accomplishment. So is heroin addiction commonly the end result of narcotic use that began after a back injury?

As background, the Drug Enforcement Administration (DEA) classifies 5 schedules of drugs depending upon their accepted medical use and the potential for abuse or dependence. Schedule I includes heroin and marijuana. The federal government technically recognizes schedule I drugs for research purposes only, however given the legalization of “medical” marijuana in a number of states, federal statutory law enforcement appears on hold. All other drugs are within schedules II-V and can be prescribed by physicians, dentists and other medical professionals who have the appropriate licensure. The bottom line however is that you can’t prescribe heroin.

According to the NIH, heroin killed approximately 10,500 people in the U.S. in 2014, up from approximately 2500 in 2010. Other drug-related deaths in 2014 included 8000 from Benzodiazepines (think Valium) and 5500 from cocaine. Where is the war on Valium? A recent CBS News article, available on line, quoted 18,000 yearly deaths from narcotic pain medications. Using SEER data to look at yearly deaths from other causes, recent totals from cancer came in at 590,000 and cardiovascular disease at 615,000. Seems like if people would just stop smoking half of those cancers and cardiovascular deaths would disappear. But we live in a democratic constitutional republic or some sort of formulation, so…

Recently published in the Daily Herald was an article entitled “Study Explains Why People Use Heroin” examining the use of heroin by suburbanites outside Chicago. Fifteen heroin users between the ages of 22 and 31 made up the study population. Highlights of the study included: 1/3 of those studied started using heroin after being addicted to or misusing prescription pain pills such as Oxycontin or Vicodin; greater than 75% of respondents had a concurrent mental health condition such as depression, ADHD or bipolar disease and used heroin to self-medicate; 2/3 of those had ’sensation seeking behaviors; and finally the average age of first use was 18.

In summary, the majority of heroin users had diagnosable mental health issues and/or were bored, greater than half were teenagers and of those, half were minors, 1/3 of people were heroin users due to prior use of narcotics (legally obtained?), and more than 2/3s of those who used heroin did not become addicted as a consequence of medically prescribed narcotics. So overall, most people did not transition to heroin solely due to an underlying narcotic addiction. The study actually makes the point that “Polydrug use to heroin was the most common path to initiation among our sample, with just over one third initiating to heroin in this manner.” The stereotypical picture of initiation to heroin therefore being the escalating use of polydrugs such as alcohol to cannabis to pills to psychedelics/hallucinogens to cocaine to heroin.

Thus far I have not written one word regarding parenting, personal responsibility, or the roles of law enforcement or the legal system because that does not seem to be where the focus of government lies. Presently the scapegoat appears to be the medical profession. We are told that it is the narcotics we prescribe that have turned society into drug-craving zombies. So here is my dilemma. I don’t treat kids and I don’t treat mental illness. What I do treat are people with cancer and I do prescribe, using sound medical judgment, narcotics, and there is nothing I can do that in any way will stop people from using heroin if it’s available and they choose to use it.

And one other little inconvenient fact: According to the National Household Survey on Drugs and Heath, also quoted in the suburban study, it was the use of Cannabis (marijuana) that initiated the use of heroin in 59% of their sample while narcotics was responsible in 17% of instances. So it seems that after all there is an association between heroin use and the prior use of certain drug with medically prescribed narcotics far down the list. One thing is for sure and it’s that I am not responsible for the heroin epidemic because I don’t prescribe heroin. Now, if you’d like to discuss getting set up for some medical marijuana…