The Two Prongs of the Second Phase

HEROIN
     Suddenly heroin is everywhere. The number of heroin users remained steady through the early part of the prescription opioid epidemic, but it has increased dramatically since 2002-2005, from roughly 300,000 to roughly 900,000.  
     Heroin has become popular because it is cheap, high quality, and widely available.  
     70-80 percent of heroin users have previously used prescription opioids nonmedically. 
     Heroin is far more lethal than prescription opioids, probably because (1) the population that uses heroin is further along the path to addiction, and (2) compared to prescription opioids, it is difficult to measure the amount of active substance in heroin. 
     Through 2005, 1 in 200 past year heroin users died annually of a heroin overdose. 
     As the heroin epidemic has worsened, the mortality rate of past year heroin users has increased.  In 2013 and 2014, more than 1 in 100 past year heroin users died of a heroin overdose.
     The worsening outcome of heroin use has been attributed largely to the fact that more and more heroin is adulterated with illicitly synthesized fentanyl.   

PRESCRIPTION OPIOIDS
     Surprisingly the number of past year nonmedical prescription opioid users has been falling since approximately 2006.  In that year there were 12,600,000 nonmedical users of prescription opioids.  By 2014, the number had fallen to 10,300,000 nonmedical users, a fall of 18%.
     Yet deaths during that time increased from 13,755 to 18,893, a rise of 37%.
     Since 2006, the likelihood that a nonmedical prescription opioid user will die in a given year of a prescription opioid overdose has increased from approximately 1 in 1,000 to 1 in 550 nonmedical users.
     How does this make sense?  
     It turns out that an increasing percentage of nonmedical users are further along a path toward addiction.  A larger percentage of nonmedical users use more frequently, are more out of control, and are more likely to die.

     An overall summary:  More people are dying of opioids than ever before.  While fewer people are initiating use of prescription opioids, the same is not true of heroin, which is more deadly and has become increasingly more deadly over the past few years.