WASHINGTON, DC – The conventional wisdom has been that, when prescription opioids became harder to abuse, users turned to street drugs to control pain and maintain a high. That, according to the theory, is why more patients are showing up in your ED overdosed on heroin.

A new study published recently in the Morbidity & Mortality Weekly Report, says it’s not that simple, however.

“Although it has been postulated that efforts to curb opioid prescribing, resulting in restricted prescription opioid access, have fueled heroin use and overdose, a recent analysis of 2010–2012 drug overdose deaths in 28 states found that decreases in prescription opioid death rates within a state were not associated with increases in heroin death rates; in fact, increases in heroin overdose death rates were associated with increases in prescription opioid overdose death rates,” write researchers from the FDA and the CDC.

Instead, they suggest that “multiple, and possible interacting, factors” contribute to the changing pattern of heroin use and overdose deaths.

Whatever the cause, heroin use and overdose deaths have increased significantly in the United States.

Most significant for EDs is the sharp increase in overdose deaths related to heroin use. Those were stable at about 0.7 per 100,000 during 2002–2006, and began to increase gradually through 2009, when the rate was 1.1 per 100,000. Beginning in 2011, the overdose death rate shot up from 1.4 per 100,000 to 2.7 per 100,000 in 2013, a more than 286% increase since 2002.

Meanwhile, annual average rates of past-year heroin use increased from 1.6 per 1,000 persons 12 and older in 2002–2004 to 2.6 per 1,000 in 2011–2013, according to the FDA and CDC researchers.

One of the biggest changes is the evolution in demographics among heroin users. During 2002–2011, rates of heroin initiation were reported to be highest among males, persons aged 18–25 years, non-Hispanic whites, those with an annual household income greater than $20,000, and those residing in the Northeast.

The gap between men and women narrowed during the two study periods, but the more significant change involved age groups; the 18–25 cohort experienced the largest increase in heroin use, 108.6%, between 2002–2004 and 2011–2013. Furthermore, the rate of past-year heroin use among non-Hispanic whites increased 114.3% during that time period. Use also rose among those with higher incomes.

 While the highest rate of heroin use was consistently found among concurrent users of cocaine, the largest percentage increase, 138.2%, occurred among nonmedical users of opioid pain relievers.