A local newspaper—the Oshkosh Northwestern—carried a story last week about a major drug bust in the part of Wisconsin that I call home. According to the story, the 45 people arrested were responsible for the distribution or sale of several million dollars worth of heroin and crack cocaine. The online story features a slide show featuring the mug shots of the people arrested in the bust.

I’ve known a number of people killed by opioid dependence and I have no sympathy for those who decide to peddle desperation and death. But the article reported that of those arrested, 21 were connected to distribution, and the rest were ‘independent users and sellers.’ I realize that most people will look at the rough-looking photos with disgust. But some of the people in the photographs, I know, have stories that would arouse sympathy—particularly if the stories were accompanied by photos from the days before their doctors prescribed pain pills, when they first presented with back pain, with their hair combed and wearing outfits other than orange jumpsuits.

Later, as I was looking for the article on the newspaper’s web site, a search of the keyword ‘heroin’ brought up story after story about burglaries, robberies, arrests, and overdose deaths.  One story described the surge in overdose deaths in Winnebago County, where the largest city has a metro area population well below 200,000 people. In the past five months alone, 17 people died from overdose, and over 40 more were rescued by injections of naloxone from emergency personnel.

The numbers represent dramatic increases over prior years. Over a few years, heroin changed from an uncommon drug used by the most hard-core addicts to the drug of choice for many opioid users, including teenagers.

There are a number of reasons for the new role for heroin. The arrests in Oshkosh last week highlighted the distribution of heroin from Chicago to small towns in Wisconsin, as dealers in the city apparently branched into new markets. I’m reminded of the migration of plasma donation centers, about ten years ago, from inner cities to the suburbs, as the blood product businesses sought out customers with a lower incidence of IV drug abuse and related illnesses. How ironic that those who deal heroin would discover the same market!

I do not have insight into the sources of heroin in this epidemic; whether it comes from Mexico or Afghanistan, for example. I’ve read that our country looks the other way from Afghanistan poppy fields, so that locals have a source of income that makes them less interested in what the Taliban has to offer… but I have no way to separate the truth from political propaganda. Most heroin comes from outside of the US, and my new patients tell me that heroin is potent, cheap, and plentiful, so suffice it to say that apparently, interdiction efforts are not real effective.

One reason for the increased role of heroin has to do with unforeseen consequences. About six months ago, in response to growing demands by the FDA, the manufacturer of Oxycontin (a branded, time-release form of oxycodone) came out with a new, ‘abuse-proof’ formulation. The new formulation is difficult to crush, and when it is crushed, the tablet becomes a thick goopy material that does not dissolve in water. Since then I’ve heard new patients remark that ‘I never thought I’d use heroin, but since OC isn’t around anymore I had no choice.’ I realize that most readers will think, ‘why not just choose to stop using?’ But the non-using life cannot be seen by the active addict, as it lies beyond several months of horrible withdrawal.

The change in Oxycontin formulation had a second, deadlier effect. Oxycodone is a lipid (fat)-soluble molecule, so the drug crosses nasal membranes quickly—almost as quickly as when the drug is injected. Most users of oxycodone were content to snort the drug, as the benefit of injecting was not worth dissolving the crushed tablets and using needles. But heroin burns when it is ‘insufflated’ or snorted, and the molecule crossed lipid membranes more slowly— providing reasons to inject the drug. Many patients tell me that they never considered using needles when Oxycontin was around, but that the only way to get similar effects from heroin was by injecting the drug. In other words, the change in formulation of Oxycontin resulted in an increase in intravenous drug abuse.

Efforts to stem the epidemic appear to take one step forward, only to fall two steps back. Sadly, I expect to read more stories about heroin going forward.

Photo by Elvert Barnes, available under a Creative Commons attribution license.

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    Last reviewed: 18 Jul 2011