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The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013-.

Trends in Heroin Use in the United States: 2002 to 2013

, Ph.D. and , M.S.

Author Information

Published: April 23, 2015.

Background: Heroin is a highly addictive opiate that is illegal and has no accepted medical use in the United States. Tracking trends in heroin use can help focus prevention efforts by identifying whether the rate of use is rising. Method: 2002 through 2013 National Survey on Drug Use and Health (NSDUH) estimates of heroin use, initiation, treatment, perceived availability, and perceived risk of using heroin for persons aged 12 or older were analyzed. Results: Heroin use remains uncommon in the United States, with an estimated 681,000 past year users in 2013 (0.3 percent of the population aged 12 or older). Although the number of heroin users is lower than the number of users of other substances, rates of heroin use were higher in 2013 than they were a decade ago. Similarly, the number of people who received treatment for heroin use during their most recent treatment in the past year has risen from 277,000 people in 2002 to 526,000 people in 2013. In 2013, there were 169,000 past year heroin initiates, which is similar to the number of initiates in most years since 2002. Perceptions of the riskiness of heroin use have slightly declined in the past decade but nevertheless have remained at high levels. With regard to availability, respondents in 2013 perceived that heroin was less easily obtained than respondents perceived a decade ago. Conclusion: Heroin rates, perceptions of the riskiness of heroin use, and perceptions about the ease of obtaining heroin have changed over the past decade, but they have not varied in recent years.

Keywords:

heroin, National Survey on Drug Use and Health, NSDUH, risk, availability, initiation, treatment

In Brief

  • Heroin use remains uncommon in the United States, with an estimated 681,000 past year users in 2013 (0.3 percent of the population aged 12 or older); however, the percentage of people using heroin is higher in 2013 than it was a decade ago.
  • In 2013, there were 169,000 past year heroin initiates, which is similar to the number of initiates in most years since 2002.
  • The number of people aged 12 or older who received treatment for heroin during their most recent substance use treatment in the past year was higher in 2013 (526,000) than it was a decade ago. Since the length of the recovery process varies and often requires long-term support, people who receive treatment may no longer be past year users.
  • The percentage of adolescents aged 12 to 17 perceiving great risk from using heroin once or twice a week was lower in 2013 than in 2002 to 2009; while the percentage of adolescents reporting that it would be easy for them to get heroin if they wanted some was lower in 2013 than the percentages in 2002 to 2011.

Introduction

Heroin is a highly addictive opioid that is illegal and has no accepted medical use in the United States. Although heroin may be smoked or "snorted" (inhaled through the nose), heroin is often "cut" with products such as sugars, starch, or powdered milk and then injected as a liquid. It is an extremely dangerous drug regardless of the method of delivery. Heroin users may develop physical dependence on the drug and experience withdrawal symptoms, such as diarrhea and vomiting, if use is suddenly stopped. Overdose on heroin can seriously depress breathing and may lead to death.1,2

Tracking trends in heroin use can help focus prevention efforts by identifying whether the prevalence of use is rising or declining. Anecdotal information suggests that people abusing pain relievers, which provide a similar high, are switching to heroin because of decreased access to pain relievers3,4 and the relative cost of heroin.5 Media coverage of heroin use and heroin-related deaths at a local level suggest that heroin use is a growing problem. Mortality estimates from 2000 to 2013 indicate there has been an increase in the number of drug-poisoning deaths involving heroin.6 Reasons for increases in drug-poisoning deaths include the availability of high purity heroin causing users to accidentally overdose. Other reasons include some users switching from prescription opioids which have a known dosage amount and chemical composition to heroin that often contains varying purities, dosage amounts and unknown adulterants used to cut costs and increase potency.7 Monitoring trends at a national level can provide a perspective on trends in local use and assist in evaluating the national response to drug use prevention.

The National Survey on Drug Use and Health (NSDUH) collects information about heroin use, initiation, treatment, perceived availability, and perceived risk of using heroin. NSDUH asks respondents aged 12 or older to report whether they have ever used heroin, and if so, how old they were when they first used it and when they last used it. Respondents are also asked questions that gauge their need for substance use treatment and whether they received substance use treatment at a specialty facility.8 Most respondents are classified as needing substance use treatment because they met the criteria for having a substance use disorder.9 Some of them received substance use treatment in the past year while others did not. In addition, respondents who received substance use treatment in the past year but did not meet the criteria for having a substance use disorder were also classified as needing treatment (under the assumption that treatment was provided based on need). NSDUH also asks respondents how easy it would be for them to obtain heroin and how much people risk physical and other harm if they try heroin once or twice or use heroin once or twice a week.10 This issue of The CBHSQ Report examines heroin use, problems associated with heroin use, and beliefs about heroin in the United States. Findings are presented for the U.S. civilian, noninstitutionalized population aged 12 or older during the period from 2002 to 2013. In this report, adolescents will refer to individuals aged 12 to 17 and young adults will refer to individuals aged 18 to 25.

Initiation of Heroin Use

In 2013, an estimated 169,000 individuals aged 12 or older used heroin for the first time in the past year (also known as past year initiates). On average, this represents roughly 460 people initiating heroin use each day. Among individuals aged 12 to 49 who initiated heroin use in the past 12 months, the average age at first use in 2013 was 24.5 years.11

In 2013, 21,000 adolescents used heroin for the first time in the past year (Figure 1). There were 66,000 young adults and 82,000 adults aged 26 or older who initiated heroin use in the past year. The percentages of people aged 12 or older that used heroin for the first time was similar in 2002 to 2013 (ranging from less than 0.04 to 0.1 percent of the population over 12 years of age; data not shown). The number of past year heroin initiates in 2013 (169,000) was not significantly different than the numbers of heroin initiates in most years since 2002 (Figure 2).12 When trends in heroin initiation were examined for the three age groups (i.e., 12 to 17, 18 to 25, and 26 or older), there were no statistically significant differences between 2013 and 2002 through 2012 for any age group.

Figure 1

Figure 1

Past year initiation of heroin among individuals aged 12 or older, by age group: 2013

Figure 2

Figure 2

Past year initiation of heroin among individuals aged 12 or older, by age group: 2002 to 2013

Past Year Heroin Use

In 2013, 0.3 percent of individuals aged 12 or older (an estimated 681,000 people) used heroin in the past year. Young adults were more likely to have used heroin in the past year than were adolescents and adults aged 26 or older (0.7 vs. 0.1 and 0.2 percent, respectively; Figure 3). These percentages translate to 31,000 adolescents, 244,000 young adults, and 406,000 adults aged 26 or older using heroin in the past year.

Figure 3

Figure 3

Past year heroin use among individuals aged 12 or older, by age group: 2013

The number of individuals aged 12 or older who used heroin in the past year remained relatively stable between 2009 and 2013 (Figure 4). However, the number of past year users in 2013 was higher than the number in most years from 2002 to 2008 (ranging from 314,000 to 455,000). 13 Variations in this pattern were seen by age group. Among adolescents, the number of past year heroin users in 2013 (31,000) was similar to the numbers in 2002 through 2012. The number of young adults who were past year heroin users in 2013 (244,000) was similar to numbers in 2009 to 2012 but was higher than the numbers in 2002 to 2008 (ranging from 96,000 to 159,000). Among adults aged 26 or older, the number of past year heroin users in 2013 (406,000) was similar to the numbers in 2008 to 2012 but was higher than the numbers in 2002 to 2005 and in 2007 (ranging from 182,000 to 232,000). Generally similar trends were seen in the percentages of individuals using heroin in the past year (see Additional Table A1).

Figure 4

Figure 4

Past year heroin use among individuals aged 12 or older, by age group: 2002 to 2013

Heroin Dependence or Abuse

In 2013, an estimated 6.9 million individuals aged 12 or older were classified as having an illicit drug use disorder in the past year. Of these, 517,000 were dependent on or abused heroin (representing 0.2 percent of the total population aged 12 or older, and about 8 percent of all those classified with an illicit drug use disorder). The number of individuals who were dependent on or abused heroin in the past year included 10,000 adolescents, 182,000 young adults, and 325,000 adults aged 26 or older (Figure 5). These numbers represent less than 0.1 percent of adolescents, 0.5 percent of young adults, and 0.2 percent of adults aged 26 or older.

Figure 5

Figure 5

Past year heroin dependence or abuse among individuals aged 12 or older, by age group: 2013

The number of individuals aged 12 or older with past year heroin dependence or abuse in 2013 (517,000) was similar to the numbers in 2009 to 2012, but was higher than the numbers in 2002 to 2008 (ranging from 189,000 to 324,000; Figure 6). Although the same general pattern occurred among adults aged 26 or older, different patterns were seen among adolescents and young adults. The number of adolescents with past year heroin dependence or abuse in 2013 (10,000) was similar to those in all other years. Among young adults, the number was higher in 2013 (182,000) than in all years between 2002 and 2010. When trends in the percentages of individuals using heroin in the past year were examined overall and by age group, generally similar trends were seen (see Additional Table A2).

Figure 6

Figure 6

Past year heroin dependence or abuse among individuals aged 12 or older, by age group: 2002 to 2013

Among the 517,000 people with a heroin use disorder, 434,000 were classified with dependence, representing about 84 percent of those with a heroin use disorder (data not shown). This indicates that the majority of people with a heroin use disorder are dependent on heroin; whereas this is not quite the case for other substances. In 2013, for example, of those who had a marijuana use disorder, about 67 percent were dependent, and of those who had an alcohol use disorder, about 46 percent were dependent on alcohol.14

Treatment for Heroin Use

Treatment can occur in a variety of settings, last for different lengths of time, and address the use of multiple substances. In 2013, an estimated 2.2 million individuals aged 12 or older (0.8 percent of the population) received treatment for a problem related to the use of illicit drugs in the past year. Individuals who received treatment were asked to identify the substances for which they received treatment in the past year. Because substance use treatment is a long-term process that involves multiple interventions and regular monitoring, people in treatment may no longer be using illicit drugs but still participate in treatment to maintain their successful recovery. Of the 2.2 million individuals in treatment, 526,000 indicated they received treatment for heroin during their most recent treatment in the past year (Figure 7). The numbers of individuals who received treatment for heroin during their most recent treatment in the past year included 6,000 adolescents, 128,000 young adults, and 392,000 adults aged 26 or older.

Figure 7

Figure 7

Receipt of treatment for heroin use during most recent treatment in the past year among individuals aged 12 or older, by age group: 2002 to 2013

The number of individuals aged 12 or older who received their most recent treatment in the past year for heroin increased from 277,000 people in 2002 to 526,000 people in 2013. Although the number of adolescents who received their most recent treatment in the past year for heroin did not vary between 2002 and 2013, differences were seen for young adults and adults aged 26 or older. Among young adults, the number receiving treatment for heroin was higher in 2013 than in 2002 to 2004 and 2006 to 2008. Among adults aged 26 or older, the number was higher in 2013 than 2003 and 2004.

Perceptions of Risk From Heroin Use

In 2013, most individuals aged 12 or older perceived great risk in trying heroin once or twice or great risk from using heroin on a weekly basis (82.2 and 93.3 percent, respectively; Table 1). Perceptions of risk varied by age with adolescents being less likely than young adults or adults aged 26 or older to perceive great risk from using heroin once or on a weekly basis. It should be noted that perception of great risk increases with age among adolescents, with 68.7 percent of 12 or 13 year olds, 80.5 percent of 14 or 15 year olds, and 89.0 percent of 16 or 17 year olds perceiving great risk in weekly heroin use (data not shown). This may indicate that the lower risk perception among adolescents may be attributable to a general lack of knowledge about heroin among adolescents, especially younger adolescents.

Table 1

Table 1

Perception of great risk from heroin use among individuals aged 12 or older, by age group: 2002 to 2013

In 2013, overall and among all three age groups, the percentage indicating perceptions of great risk from heroin use were similar to the percentages in 2012; however, there were changes in the long term trends. Although the percentage of adolescent perception of great risk from trying heroin in 2013 (58.2 percent) was higher than the percentages from 2004, 2005, 2009, and 2011, the percentage of adolescents perceiving great risk from weekly heroin use was significantly lower in 2013 (79.8 percent) than in 2002 to 2009 (ranging from 80.9 to 82.6 percent). The percentage of young adults perceiving great risk from trying heroin was significantly higher in 2013 (79.2 percent) than in every year between 2002 and 2011 (ranging from 76.8 to 78.1 percent). There were very few differences between 2013 and 2002-2012 in the percentage of adults aged 26 or older who indicated there was a great risk to either trying heroin or using heroin on a weekly basis.

The percentage of adolescents reporting illicit drug use in the past month was higher among those who perceived great risk in trying heroin than among those who did not perceive great risk (11.0 vs. 6.2 percent; Table 2).15 Furthermore, the percentage of adolescents reporting illicit drug use in the past month was higher among those who perceived great risk in weekly heroin use than among those who did not perceive great risk (9.5 vs. 7.0 percent). Among young adults, the percentage who used illicit drugs did not vary between those who did and did not perceive great risk from heroin use. Among all individuals aged 12 and older as well as those aged 26 or older, use of illicit drugs in the past month was generally lower among individuals who perceived great risk from using heroin than among those who perceived moderate, slight, or no risk from such use.

Table 2

Table 2

Past month illicit drug use among individuals aged 12 or older, by perceived risk of harm from heroin use and age group: 2013

Perceptions of the Availability of Heroin

In 2013, 15.2 percent of individuals aged 12 or older reported it would be fairly easy or very easy for them to obtain heroin if they wanted some (Figure 8). Adolescents were less likely than young adults and adults aged 26 or older to believe that it would be easy for them to get heroin if they wanted some (9.1 vs. 15.1 and 15.9 percent, respectively).

Figure 8

Figure 8

Perception that it would be fairly or very easy to obtain heroin if wanted among individuals aged 12 or older, by age group: 2002 to 2013

There was no change in perceived availability of heroin between 2012 and 2013 for adolescents, young adults, or adults aged 26 or older. Although perceived availability of heroin has been steady over the past two years, the long term trends indicate that perceptions of availability have changed. For example, the percentage of people aged 12 or older in 2013 who thought it would be easy to obtain heroin was lower than the percentages who thought this in 2002 to 2009. This pattern varied by age group. The percentage of adolescents who perceived easy availability of heroin in 2013 was lower than in 2002 to 2011 (ranging from 15.8 to 10.7 percent). Among young adults, the percentage who thought it would be easy to obtain heroin was lower in 2013 than in each year between 2002 and 2010 but similar to percentages in 2011 and 2012. The percentage of adults aged 26 or older who thought it would be easy to obtain heroin was lower in 2013 than each year between 2002 and 2009 but similar to the percentages in 2010 to 2012.

Differences in levels and trends in perceived easy availability of heroin between past year and non-past year heroin users over the period 2002 to 2013 are dramatic (Table 3). Among past year heroin users, 80.8 percent believed heroin would be easy to obtain over the two-year period 2012-2013. This is an increase from a low of 69.3 percent in 2004-2005. Among people who did not use heroin in the past year, 15.3 percent thought it would be easy to obtain heroin in 2012-2013 which is lower than the high of 18.3 percent in 2002-2003. Over the 12 year period, perceived easy availability has generally increased among past year heroin users and decreased among non-users.

Table 3

Table 3

Perception that it would be fairly or very easy to obtain heroin if wanted among individuals aged 12 or older, by past year heroin use: percentages, 2002 to 2013

Use of illicit drugs in the past month was generally higher among individuals who hought it would be fairly easy or very easy to obtain heroin than among those who thought it would be fairly difficult, very difficult, or probably impossible to obtain (Figure 9). For example, adolescents who believed that heroin would be fairly or very easy to obtain were more likely to have used illicit drugs in the past month than those who believed it would be fairly difficult, very difficult, or probably impossible to obtain (14.4 vs. 8.6 percent).

Figure 9

Figure 9

Past month illicit drug use among individuals aged 12 or older, by perceived of availability of heroin and age group: 2013

Discussion

Monitoring trends in heroin use, initiation of use, and perceptions about heroin use enables public health providers opportunities to assess the state of heroin use in the United States. Heroin use remains uncommon in the United States, with an estimated 681,000 past year users in 2013 (0.3 percent of the population aged 12 or older).16 In comparison, in the past year, about 33 million people aged 12 or older in 2013 used marijuana (12.6 percent), about 11 million used prescription pain relievers nonmedically (4.2 percent), and about 4 million used cocaine (1.6 percent).14

Although the number of heroin users is lower than the number of users of other substances, rates of heroin use were higher in 2013 than they were a decade ago. Similarly, the number of people aged 12 or older who received treatment for heroin use during their most recent treatment in the past year has also risen from 277,000 people in 2002 to 526,000 people in 2013. The growing number of people getting treatment for heroin may stretch the capacity of treatment providers. For example, according to the 2013 National Survey of Substance Abuse Treatment Services, among outpatient-only substance abuse treatment facilities that treat opioid addiction or dependency through the use of methadone or buprenorphine, 38.9% are operating at capacity (95-105% capacity) and 8.1% are operating at 106% or above capacity.17

The concern that efforts to prevent the illegal use of prescription opioids are causing people to turn to heroin is not supported by the trend data.4 In 2013, there were 169,000 past year heroin initiates, which is similar to the number of initiates in most years since 2002. Although research indicates that people who previously misused prescription pain relievers were more likely to initiate heroin use than people who had not misused prescription pain relievers, most people who misuse prescription pain relievers do not progress to heroin use.18

Perceptions of the riskiness of heroin use have slightly declined in the past decade but nevertheless have remained at high levels. With regard to availability, respondents in 2013 perceived that heroin was less easily obtained than respondents a decade ago. While the majority of respondents still believe that heroin would be difficult to obtain, among past year heroin users there has been an increase in the perception that heroin is easy to obtain. Heroin rates, perceptions of the riskiness of heroin use, and perceptions about the ease of obtaining heroin have changed over the past decade, but they have not varied in recent years.

This issue of The CBHSQ Report finds that the heroin problem in the United States has not improved in the past decade. The findings in this report suggest a continuing need for prevention messages and heroin prevention and treatment programs. The Department of Health and Human Services is engaged in a coordinated multi-agency initiative to decrease opioid overdoses and overdose-related mortality and to decrease the prevalence of opioid use. Additional data on heroin from the NSDUH are available in the 2013 NSDUH national findings report and detailed tables.14,19

For more information and resources on heroin prevention and treatment, call SAMHSA's National Helpline at 1–800–662–HELP (1–800–662–4357) or visit SAMHSA's online Behavioral Health Treatment Services Locator at http://findtreatment.samhsa.gov.

Suggested Citation

Lipari, R.N. and Hughes, A. Trends in Heroin Use in the United States: 2002 to 2013. The CBHSQ Report: April 23, 2015. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Rockville, MD.

Footnotes

1

National Institute on Drug Abuse. (2011). Research report series: Prescription drug abuse (NIH Publication Number 11–4881). Retrieved from http://www​.drugabuse.gov

2

National Institute on Drug Abuse. (2014). Research report series: Heroin (NIH Publication Number 14–0165). Retrieved from http://www​.drugabuse.gov

3

Although heroin is an illegal opiate, other opioid pain relievers, such as morphine (from which heroin is derived), codeine, and synthetic opioid pain relievers such as hydrocodone (active ingredient in Vicodin®) or oxycodone (active ingredient in OxyContin® and Percocet®) are legally available by prescription.

4

Dooley, D. P. (2014). Boston patterns and trends in drug abuse: 2013. Proceedings of the Community Epidemiology Work Group, June 2014. Retrieved from http://www​.drugabuse​.gov/sites/default/files/boston2014.pdf

5

Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry 2014;71:821–6. [PubMed: 24871348]

6

Hedegaard H, Chen LH, Warner M.; National Center for Health Statistics (NCHS). Drug-poisoning deaths involving heroin: States,2000–2013. NCHS data brief, no190. Retrieved from: http://www​.cdc.gov/nchs​/data/databriefs/db190.pdf [PubMed: 25932890]

7

Drug Enforcement Agency (2014). National Drug Threat Assessment Summary 2014 (Publication No. DEA-DCT-DIR-002-15), pp. 16-17. Available at www​.dea.gov/resource-center​/dir-ndta-unclass.pdf

8

Substance use treatment at a specialty facility is defined as treatment received at drug or alcohol rehabilitation facilities (inpatient or outpatient), hospitals (inpatient services only), and mental health centers; it excludes treatment received in an emergency room, private doctor's office, self-help group, prison or jail, or hospital as an outpatient.

9

NSDUH defines substance use disorder as dependence on or abuse of alcohol or illicit drugs using criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which include such symptoms as withdrawal, tolerance, use in dangerous situations, trouble with the law, and interference with major obligations at work, school, or home during the past year. Individuals with alcohol or illicit drug dependence or abuse are defined as having a substance use disorder. For details, see: American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

10

Response categories for the perceived availability questions pertaining to the listed illicit drugs include probably impossible, very difficult, fairly difficult, fairly easy, and very easy. Response choices for the perceived risk questions are no risk, slight risk, moderate risk, and great risk.

11

Average ages at first use are calculated in NSDUH for past year initiates aged 12 to 49 because almost all initiation occurs among individuals younger than 50, and limiting data to people aged 12 to 49 provides a more precise estimate of age of first use. The associated standard error for mean age of first use is 1.26 years.

12

Although there may seem to be differences between some estimates, only those indicated in Figure 2 reach statistical significance. It is important when assessing trends to examine estimates across a range of years, as the proportion of cases for many of these outcomes are very small which in turn can lead to higher sampling variability. This can be observed in the potential spike of past year heroin initiates among the 12 or older and 26 or older populations that occurred between 2008 and 2009 and then rapidly declined from 2009 to 2010. None of these were statistically significant from each other.

13

The estimate for 2006 was determined to be affected by large analysis weights for a small number of heroin users, suggesting that the estimates of past year heroin users in 2006 were statistical anomalies.

14

Center for Behavioral Health Statistics and Quality. (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration.

15

For NSDUH, illicit drugs include marijuana/hashish, cocaine (including crack), inhalants, hallucinogens, heroin, or prescription-type drugs used nonmedically. Nonmedical use is defined as the use of prescription-type drugs not prescribed for the respondent by a physician or used only for the experience or feeling they caused. Nonmedical use of any prescription-type pain reliever, sedative, stimulant, or tranquilizer does not include over-the-counter drugs. Nonmedical use of stimulants includes methamphetamine use.

16

NSDUH does not cover groups of people for whom heroin may be a more serious problem, such as homeless people who are not living in shelters or people in prisons. Therefore, data from NSDUH do not reflect changes in heroin use or heroin-related problems in these special populations.

17

Center for Behavioral Health Statistics and Quality. (2014). National Survey of Substance Abuse Treatment Services (N-SSATS): 2013. Data on Substance Abuse Treatment Facilities. Behavioral Health Services Information System Series S-73, HHS Publication No. (SMA) 14-4890. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

18

Muhuri, P. K., Gfroerer, J. C., &. Davies, M. C. (2013, August). CBHSQ Data Review: Associations of nonmedical pain reliever use and initiation of heroin use in the United States. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality.

19

Center for Behavioral Health Statistics and Quality. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of national findings(HHS Publication No. SMA 14–4863, NSDUH Series H–48). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Copyright Notice

All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Bookshelf ID: NBK343534PMID: 26913325

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