In recent years, there have been a number of mainstream media reports that the abuse of heroin has migrated from low-income urban areas with large minority populations to more affluent suburban and rural areas with primarily white populations.^1-8 Large-scale epidemiological studies have documented significant increases in heroin use^9,10 and overdose-related hospitalizations^9,11 nationwide, particularly over the past 10 years, but there have been few systematic studies on the demographics of today’s heroin users compared with those who used heroin 40 to 50 years ago who were primarily young men from minority groups living in urban areas.^12-19

In August 2010, an abuse-deterrent formulation of the widely abused prescription opioid OxyContin was introduced. The intent was to make OxyContin more difficult to solubilize or crush, thus discouraging abuse through injection and inhalation. We examined the effect of the abuse-deterrent formulation on the abuse of OxyContin and other opioids.

Objectives. To understand important changes in co-occurring opioid and nonopioid drug use (i.e., polysubstance use) within the opioid epidemic in the United States. Methods. We analyzed survey data on the past month co-use of prescription and illicit opioids and 12 nonopioid psychoactive drug classes from a national sample of 15 741 persons entering treatment of opioid use disorder. Results. Past-month illicit opioid use increased from 44.8% in 2011 to 70.1% in 2018, while the use of prescription opioids alone dropped from 55.2% to 29.9%, yet overall remained high (94.5% to 85.2%). Past-month use of at least 1 nonopioid drug occurred in nearly all participants (> 90%), with significant increases in methamphetamine (+85%) and decreases across nonopioid prescription drug classes (range: −40% to –68%). Conclusions. Viewing opioid trends in a “silo” ignores the fact not only that polysubstance use is ubiquitous among those with opioid use disorder but also that significant changes in polysubstance use should be monitored alongside opioid trends. Public Health Implications. Treatment, prevention, and policymaking must address not only the supply and demand of a singular drug class but also the global nature of substance use overall.

Rapid entry of abuse-deterrent formulations (ADFs) of extended-release opioid drugs in the analgesic market reflects an effort to curb epidemic levels of prescription opioid abuse in this country.^1-3 For the reader unfamiliar with the concept of ADFs of opioid analgesics, those who use these medications for nontherapeutic or recreational reasons often chew the pill to release the drug quickly or more commonly crush it for inhalation or solubilize it for injection. The goal of most ADFs is to impose mechanical barriers that make crushing or chewing the pill difficult. Alternatively, some ADFs (eg, Suboxone) incorporate an opioid antagonist (naloxone hydrochloride) that blocks the effects of the parent opioid (in this case, buprenorphine hydrochloride), making the drug unsuitable for obtaining a high, even if crushed into a powder.⁴

From 2010 through 2013, there was a notable downturn in abuse of prescription opioids and a coincident increase in abuse of heroin in the United States.¹ Given that there is some evidence of a relationship between the two trends (e.g., some persons who abuse prescription opioids switch to heroin for a number of reasons and drug interchangeability has been observed),^2-4 we sought to examine this relationship more closely, including the validity of reports suggesting regional differences in the balance between prescription opioid and heroin abuse.⁵