Answer all questions in complete English sentences and use proper APA citation when appropriate

Contents lists available at ScienceDirect

Addictive Behaviors

journal homepage: www.elsevier.com/locate/addictbeh

Short Communication

Increased use of heroin as an initiating opioid of abuse: Further
considerations and policy implications

Theodore J. Cicero⁎, Zachary A. Kasper, Matthew S. Ellis
Washington University in St. Louis, Department of Psychiatry, Campus Box 8134, 660 S. Euclid Avenue, St. Louis, MO 63110, United States

H I G H L I G H T S

• Heroin as the first opioid of abuse has grown significantly in the past decade.
• Past month heroin use continues to grow as prescription opioid abuse declines.
• Opioid policies need to be more inclusive of heroin, rather than prescription opioid-specific.

A B S T R A C T

Introduction: Previously, we reported a marked increase in the use of heroin as an initiating opioid in non-
tolerant, first time opioid users. In the current paper, we sought to update and expand upon these results, with a
discussion of the policy implications on the overall opioid epidemic.
Methods: Opioid initiation data from the original study were updated to include surveys completed through
2017 (N = 8382) from a national sample of treatment-seeking opioid users. In addition, past month abuse of
heroin and prescription were analyzed as raw numbers of treatment program entrant in the last five years
(2013–2017), drawing from only those treatment centers that participated every year in that time frame.
Results: The updated data confirm and extend the results of our original study: the use of heroin as an initiating
opioid increased from 8.7% in 2005 to 31.6% in 2015, with increases in overall Ns per initiation year reflecting a
narrowing of the “treatment gap”, the time lag between opioid initiation from 2005 to 2015 and later treatment
admission (up to 2017). Slight decreases were observed in treatment admissions, but this decline was totally
confined to prescription opioid use, with heroin use continuing to increase in absolute numbers.
Conclusions: Given that opioid novices have limited tolerance, the risk of fatal overdose for heroin initiates is
elevated compared to prescription opioids, particularly given non-oral administration and often unknown
purity/adulterants (i.e., fentanyl). Imprecision of titrating dose among opioid novices may explain observed
increases opioid overdoses. Future policy decisions should note that prescription opioid-specific interventions
may have little impact on a growing heroin epidemic.

1. Summary of previous article

In a recent article in this journal, Increased use of heroin as an in-
itiating opioid of abuse (Cicero, Ellis, & Kasper, 2017), we concluded
that there was a significant increase in the number of treatment-seeking
opioid users whose first experience with an opioid was with heroin,
rather than the more recently commonplace pattern of initiating opioid
use with prescription drugs. These results suggest that novice, non-
tolerant opioid users may have a much higher risk of overdose death
due to inexperience in the titration of dose, particularly if fentanyl
analogues are involved, and that these may be contributing to

continued increases in heroin-related overdose fatalities and emergency
room visits (O’Donnell, Gladden, & Seth, 2017; Rudd, Seth, David, &
Increases in Drug, 2016; Seth, Scholl, Rudd, & Bacon, 2018). However,
there were some ambiguities in our data given the relatively low
numbers of individuals represented in more recent years for which we
had data. Thus, we felt the need to update our data after the original
article went to press in order to validate our original findings and un-
derscore the importance of the ‘treatment gap’ in interpreting our data.
That is, there is a time lag between initial opioid exposure and treat-
ment admission, which accounted for the lower overall numbers in
more recent years. In addition, the brevity of our article did not allow

https://doi.org/10.1016/j.addbeh.2018.05.030
Received 7 May 2018; Received in revised form 29 May 2018; Accepted 30 May 2018

⁎ Corresponding author at: Department of Psychiatry, Washington University in St. Louis, School of Medicine, Box 8134, 660 S. Euclid Ave., St. Louis, MO 63110, United States.
E-mail address: [email protected] (T.J. Cicero).

Addictive Behaviors 87 (2018) 267–271

Available online 31 May 2018
0306-4603/ © 2018 Published by Elsevier Ltd.

T

http://www.sciencedirect.com/science/journal/03064603

https://www.elsevier.com/locate/addictbeh

https://doi.org/10.1016/j.addbeh.2018.05.030

https://doi.org/10.1016/j.addbeh.2018.05.030

mailto:[email protected]

https://doi.org/10.1016/j.addbeh.2018.05.030

http://crossmark.crossref.org/dialog/?doi=10.1016/j.addbeh.2018.05.030&domain=pdf

us to expand on two areas of concern. First, our article did not fully
assess policy implications of our data and the extent of concern they
might appropriately generate on the public health burden of the opioid
epidemic. Second, we also did not sufficiently discuss how recent in-
terventions to reduce the supply of prescription opioids may have im-
pacted the opioid epidemic as a whole, in particular its influence on this
new pathway to heroin initiation, which bypasses the more commonly
studied progression from prescription opioids to heroin. As such, we felt
the need to more clearly remove some ambiguity in our data and, most
importantly, to more intensely discuss the policy implications of our
work in this clarification article. To do so, we have included an updated
report on our previously published data, as well as a supplemental
analysis of opioid treatment admission data and the implications of
these data for policy development.

2. Methods for original, updated and supplemental data

While the specifics of our data analysis can be reviewed in the
original article, briefly, our data are sourced from the ongoing nation-
wide Survey of Key Informants’ Patients (SKIP) Program, a key element
of the Researched Abuse, Diversion and Addiction-Related Surveillance
(RADARS®) System, a comprehensive series of programs that collect
and analyze post-marketing data on the abuse and diversion of pre-
scription opioid analgesics and heroin (Cicero et al., 2007; Dart et al.,
2015a). The SKIP Program consists of a Key Informant network with
annual participation of approximately 150 public and privately funded
treatment centers which recruit adult clients entering their substance
abuse treatment program with a primary diagnosis of opioid use dis-
order to complete an anonymous paper survey. Initially, SKIP re-
spondents, analyzed from 2011 to 2016, were asked the specific opioid
they first regularly used (i.e. 2+ times a month), categorized as ‘hy-
drocodone’, ‘oxycodone’, ‘heroin’, or ‘other prescription opioids’ [bu-
prenorphine, fentanyl, hydromorphone, methadone, morphine, oxy-
morphone, tapentadol and tramadol], and the age they began to
regularly use opioids. The year regular use began was calculated (Year
of survey completion – Age at survey completion + Age of first regular
opioid use = Year of beginning regular opioid use), with the analyses
restricted to those initiating use within the past ten years (2005–2015;
N = 5885) to limit long-term recall and survival bias (no respondent
who completed a survey in 2016 initiated opioid use in that same year),
a time-period shown to have stable recall for opioid abuse (Shillington,

Cottler, Mager, & Compton, 1995). These data have been updated for
this report using the same criteria and analysis period, with the inclu-
sion of data from surveys received through the end of 2017.

We also conducted an analysis of the absolute numbers of in-
dividuals who entered and were recruited from each treatment program
per year, restricting our analysis to only those sites that recruited in
every year of the analysis period (N = 66) to analyze a stable sample of
treatment providers. These sites were located in 33 states and saw a
mean number of 53.3 new opioid patients per quarter (range: 5–400),
with a breakdown of 54.5% private, 30.3% public and 15.2% both
private and public. Data are presented as the total number of partici-
pants entering treatment and recruited by the site, with a breakdown of
the number of whom endorsed past month abuse of heroin and/or a
prescription opioid from the past five years (2013–2017), with the data
not mutually exclusive.

3. Results

3.1. Heroin as an initiating opioid

Fig. 1 shows trendlines from the original published figure, re-
presented as dotted lines, and updated trendlines (solid line). The lower
numbers on the x axis represent the original N at each time point
whereas the upper numbers shows the increase in Ns after the inclusion
of data through 2017 (N = 8382). As can be seen, there was a con-
siderable increase in numbers as data has accumulated, but the trends
remained the same. Heroin use as a first opioid grew sharply from 8.7%
of the sample in 2005 to almost 31.6% in 2015. It should be noted that
the numbers in more recent years increased due to the addition of new
data bridging the treatment gap. That is, there is a time gap between
initial opioid exposure which occurred from 2005 to 2015 and treat-
ment admission from 2011 to 2017, which accounts for the lower
overall numbers in more recent years. But, as this figure demonstrates,
as data continue to be collected, these overall numbers will continue to
increase as the treatment gap narrows.

3.2. Opioid treatment admissions

To adjust for the treatment gap (i.e. decrease in the Ns over time),
we expressed data in Fig. 1 as the proportion of the total who used a
prescription opioid or heroin as their initial opioid. This mode of data

Fig. 1. First opioid of regular abuse among opioid initiates from 2005 to 2015 (N = 8382).

T.J. Cicero et al. Addictive Behaviors 87 (2018) 267–271

268

presentation, while a correct representation of the data, could be sus-
pect if the number of people entering treatment selecting either a
prescription opioid or heroin declined, particularly if prescription
opioids declined at a faster rate than heroin. To test the validity of this
hypothetical scenario we examined the raw number of patients entering
the treatment clinics participating in the SKIP program in the last five
years who indicated past month abuse of heroin and/or a prescription
opioid. These data are shown in Fig. 2. The total number of those en-
tering our stable sample of treatment centers decreased modestly over
time (from 1598 to 1421) implying a decrease in overall opioid use if
viewed as a whole. However, this overall decrease was solely attribu-
table to decreases in past month prescription opioid abuse (from 1453
to 1197) The numbers of those endorsing past month abuse of heroin
continually increased over the past five years (from 723 to 980). While
participants could endorse both prescription opioids and heroin, the
data is presented separately in order to depict the total number of users
for each drug category.

4. Discussion

4.1. Overview of results

Our data support prior research which indicate that supply reduc-
tion efforts centered on prescription opioids appear to be having an
effect in reducing abuse of prescription opioids (Dart et al., 2015b). The
most dramatic reductions we observed was for oxycodone and hydro-
codone, with modest, variable increases in other prescription opioids.
While the foregoing data represent the positive news in a sense, there
are two issues highlighted by these data. First, as our opioid initiation
data continue to be updated with increasing Ns, the trend of increases
in heroin initiation remain prevalent and of grave concern. Second,
while the raw numbers of treatment admissions for opioid use disorder
show slight decreases, this looks to be attributable solely to decreases in
past month prescription opioid abuse. Specifically, prescription opioid
abuse decreased, but heroin use increased in absolute numbers. While
prescription opioid abuse still outweighs heroin use at the moment,
these data suggest supply side interventions focused on prescription
opioids alone may have little impact on heroin use. In fact, the decrease

in overall opioid treatment admissions seen in our data may be tem-
porary, with the real possibility that the overall number of opioid
treatment admissions will go back up over time as heroin use continues
to increase and outweighs prescription opioid abuse.

4.2. Importance of increases in heroin use

Prior research has demonstrated the progression to heroin from
those initiating with prescription opioids, often as a result of practical
issues (e.g., cost), reformulations of preferred opioids, or due to re-
ductions in the ability to obtain prescription opioids (Unick,
Rosenblum, Mars & Ciccarone, 2013; Cicero & Ellis, 2015; Compton,
Jones, & Baldwin, 2016; Harocopos & Allen, 2015). However, heroin
markets have apparently markedly ramped up production and dis-
tribution of this drug into the United States, seeking to capitalize on the
demand for opioid drugs (Opsina, Tinajero, & Jelsma, 2018;
Rosenblum, Unick, & Ciccarone, 2014). Coupled with reports of a re-
duced stigma in the use of heroin among previously risk-averse popu-
lations (Cicero, Ellis, Surratt, & Kurtz, 2014), it is perhaps not surprising
that widely available and cheap heroin would supplant prescription
opioids as an initial opioid of abuse. While it is hard to say one – pre-
scription opioid or heroin – is better/worse than the other, it cannot be
denied that new initiates to opioid use through heroin are at increased
risk of overdose than those with prior experience to prescription opioid
due to a number of factors: 1) as opposed to prescription pills with
marked dosage, heroin typically has a purity unknown to the user; 2)
additives such as the far cheaper fentanyl and its dangerous analogues
(e.g., carfentanyl) may be mixed with the heroin; 3) estimating the dose
is difficult for even experienced users; and 4) an opioid naive individual
who has not yet become tolerant to opioids may be at risk of overdose
with even a singular exposure due a combination of one or more of
these factors. The risk of overdose is thus markedly higher in these new
users than it would be in maximally tolerant, long-term users. This may
account for the rapidly escalating number of overdose deaths experi-
enced in recent years (Rudd et al., 2016; Seth et al., 2018). While most
overdose data lacks information relevant to the characteristics of opioid
exposure, it is difficult not to conclude that at least some of this increase
is due to inexperienced, first time users underestimating their dose. Of

723
829

889 874
980

1453 1443
1341

1256
1197

0

200

400

600

800

1000

1200

1400

1600

2013 2014 2015 2016 2017

N
um

be
r o

f t
re

at
m

en
t a

dm
is

si
on

s
(n

)

Year

Past Month Heroin Past Month Prescrip�on Opioid

n=1598 n=1629

n=1558

n=1502
n=1421

Fig. 2. Number of treatment-seeking opioid users recruited from a stable sample of 66 Key Informant sites from 2013 to 2017, with the number of those endorsing
past month heroin use and/or past month abuse of at least one prescription opioid, with data not mutually exclusive.

T.J. Cicero et al. Addictive Behaviors 87 (2018) 267–271

269

course, the growing rise in the use of fentanyl analogues as an addition
to street purchased heroin has certainly increased the risk of overdose
in all users, but it is hard to disagree that heroin use in opioid naive
individuals isn’t a definitive risk factor contributing to this increase in
opioid overdose deaths.

4.3. Policy implications

Our data indicate that while supply reduction efforts targeting
prescription opioid abuse may have been successful in easing the pre-
scription opioid epidemic, they have done little to reduce either past
month abuse or opioid initiation of heroin. In fact, these prescription
opioid-specific interventions may also have contributed, to some extent,
to part of this increase in heroin use. However, our data suggest the
possibility of a stand-alone heroin epidemic that current prescription
opioid-centered interventions will have little to no effect on as the
prescription opioid to heroin pathway is replaced by initiation to
opioids with heroin directly. Clearly, there needs to be a concerted
effort to adjust our prevention, intervention and treatment protocols to
more adequately prepare for an expanding heroin epidemic.

While we need to continue to consider supply-side interventions in
the context of both prescription opioids and heroin, there are several
other factors that need to be taken into account in order to develop an
effective, multi-level policy approach. First, harm-reduction should
play a central role in policy development, including expansion of needle
exchanges, safe injection sites, fentanyl tests strips and Narcan. These
can provide immediate intervention to saving lives, but they must also
be coupled with an increase in evidence-based prevention efforts and
programs that emphasize the high risk of overdose for not only ex-
perienced users, but those who lack any opioid tolerance whatsoever.
Second, expanding access to medication-assisted treatment (MAT) is
both crucial and time-sensitive. A number of provider level barriers
need to be immediately addressed such as training, reimbursement,
access to mental health services, access to specialists for non-addiction
specialists and dissemination of information to dispel myths or bias of
MAT (DeFlavio, Rolin, Nordstrom, & Kazal Jr, 2015; Huhn & Dunn,
2017; Kermack, Flannery, Tofighi, McNeely, & Lee, 2017). Finally, the
demand side is equally, if not more important as a point of interven-
tion/prevention. If individual users’ attraction to an opioid continues to
escalate, it matters not which opioid they’ve taken, but rather what is so
reinforcing about these drugs. Until we recognize this, the number of
people dependent on opioids will continue to rise, as will the devasta-
tion of opioid overdose deaths. Several reports have emphasized the
role mental health treatment and prevention will play in reducing the
opioid epidemic in the long-term (Howe & Sullivan, 2014; Srivastava &
Gold, 2018), but it needs to be stressed that the opioid epidemic is a
layered one, and the policy response must be as well in order to reduce
the current opioid epidemic in the United States.

Role of funding source

The national data were collected from a subset of participants from
the Survey of Key Informants’ Patients (SKIP) Program, a component of
the RADARS® (Researched Misuse, Diversion and Addiction-Related
Surveillance) System. The RADARS System is supported by subscrip-
tions from pharmaceutical manufacturers for surveillance, research and
reporting services. RADARS System is the property of Denver Health
and Hospital Authority, a political subdivision of the State of Colorado.
Denver Health retains exclusive ownership of all data, databases and
systems. Subscribers do not participate in data collection or analysis,
nor do they have access to the raw data. Dr. Cicero serves as a paid
consultant on the Scientific Advisory Board of the RADARS® System.
None of the authors have a direct financial, commercial or other re-
lationship with any of the subscribers of the RADARS® System.

Contributors

The corresponding author oversaw the development, implementa-
tion and management of the studies involved and takes responsibility
for the integrity of the data and the accuracy of the data analysis, which
was conducted by Ellis and Kasper, in conjunction with the corre-
sponding author. Authors Cicero and Ellis developed and wrote the
manuscript. All authors have reviewed and approved the manuscript.

Conflict of interest

Author Cicero serves as a consultant on the Scientific Advisory
Board of the non-profit post-marketing surveillance system, RADARS®.
Authors Ellis and Kasper have no conflicts of interest to report.

Acknowledgements

The national data were collected from a subset of participants from
the Survey of Key Informants’ Patients (SKIP) Program, a component of
the RADARS® (Researched Misuse, Diversion and Addiction-Related
Surveillance) System. The RADARS System is supported by subscrip-
tions from pharmaceutical manufacturers for surveillance, research and
reporting services. RADARS System is the property of Denver Health
and Hospital Authority, a political subdivision of the State of Colorado.
Denver Health retains exclusive ownership of all data, databases and
systems. Subscribers do not participate in data collection or analysis,
nor do they have access to the raw data.

References

Cicero, T. J., Dart, R. C., Indiardi, J. A., Woody, G. E., Schnoll, S., & Munoz, A. (2007).
The development of a comprehensive risk-management program for prescription
opioid analgesics: Researched Abuse, Diversion and Addiction-Related Surveillance
(RADARS®). Pain Medicine, 8, 157–170.

Cicero, T. J., & Ellis, M. S. (2015). Abuse-deterrent formulations and the prescription
opioid epidemic in the United States: Lessons learned from OxyContin. JAMA
Psychiatry, 72(5), 424–430.

Cicero, T. J., Ellis, M. S., & Kasper, Z. A. (2017). Increased use of heroin as an initiating
opioid of abuse. Addictive Behaviors, 74, 63–66.

Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin
use in the United States: a retrospective analysis of the past 50 years. JAMA
Psychiatry, 71(7), 821–826.

Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between nonmedical
prescription-opioid use and heroin use. The New England Journal of Medicine, 374,
154–163.

Dart, R. C., Surratt, H. L., Cicero, T. J., Parrino, M. W., Severtson, S. G., Bucher-Bartelson,
B., & Green, J. L. (2015b). Trends in opioid analgesic abuse and mortality in the
United States. The New England Journal of Medicine, 372, 241–248.

Dart, R. C., Surratt, H. L., Cicero, T. J., Parrino, M. W., Severtson, S. G., Bucher-Bartelson,
B., & Green, J. L. (2015a). Supplementary appendix: Trends in opioid analgesic abuse
and mortality in the United States. The New England Journal of Medicine, 372,
241–248.

DeFlavio, J. R., Rolin, S. A., Nordstrom, B. R., & Kazal, L. A., Jr. (2015). Analysis of
barriers to adoption of buprenorphine maintenance therapy by family physicians.
Rural and Remote Health, 15, 3019 (Epub 2015).

Harocopos, A., & Allen, B. (2015). Routes into opioid analgesic misuse: emergent typol-
ogies of initiation. Journal of Drug Issues, 45(4), 385–395.

Howe, C. Q., & Sullivan, M. D. (2014). The missing ‘P’ in pain management: how the
current opioid epidemic highlights the need for psychiatric services in chronic pain
care. General Hospital Psychiatry, 36(1), 99–104.

Huhn, A. S., & Dunn, K. E. (2017). Why aren’t physicians prescribing more buprenor-
phine? Journal of Substance Abuse Treatment, 78, 1–7.

Kermack, A., Flannery, M., Tofighi, B., McNeely, J., & Lee, J. D. (2017). Buprenorphine
prescribing practice trends and attitudes among New York providers. Journal of
Substance Abuse Treatment, 74, 1–6.

O’Donnell, J. K., Gladden, R. M., & Seth, P. (2017). Trends in deaths involving heroin and
synthetic opioids excluding methadone, and law enforcement drug product reports,
by census region — United States, 2006–2015. MMWR. Morbidity and Mortality
Weekly Report, 66, 897–903.

Opsina, G., Tinajero, J. H., & Jelsma, M. (2018, April 16). Poppies, Opium and Heroin.
Production in Colombia and MexicoTransnational Institute (Accessed May 5, 2018 at
https://www.tni.org/en/publication/poppies-opium-and-heroin-production-in-
colombia-and-mexico).

Rosenblum, D., Unick, G. J., & Ciccarone, D. (2014). The entry of Colombian-sourced
heroin into the US market: the relationship between competition, price, and purity.
The International Journal on Drug Policy, 25(1), 88–95.

T.J. Cicero et al. Addictive Behaviors 87 (2018) 267–271

270

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0005

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0005

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0005

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0005

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0010

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0010

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0010

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0015

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0015

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0020

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0020

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0020

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0025

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0025

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0025

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0030

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0030

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0030

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0035

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0035

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0035

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0035

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0040

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0040

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0040

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0045

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0045

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0050

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0050

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0050

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0055

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0055

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0060

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0060

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0060

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0065

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0065

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0065

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0065

https://www.tni.org/en/publication/poppies-opium-and-heroin-production-in-colombia-and-mexico

https://www.tni.org/en/publication/poppies-opium-and-heroin-production-in-colombia-and-mexico

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0075

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0075

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0075

Rudd, R. A., Seth, P., David, F., & Increases in Drug, S. L. (2016). Opioid-involved
overdose deaths — United States, 2010–2015. MMWR. Morbidity and Mortality Weekly
Report, 65, 1445–1452.

Seth, P., Scholl, L., Rudd, R. A., & Bacon, S. (2018). Overdose deaths involving opioids,
cocaine, and psychostimulants — United States, 2015–2016. MMWR. Morbidity and
Mortality Weekly Report, 67, 349–358.

Shillington, A. M., Cottler, L. B., Mager, D. E., & Compton, W. M. (1995). Self-report

stability for substance use over 10 years: data from the St. Louis Epidemiologic
Catchment Study. Drug and Alcohol Dependence, 40, 103–109.

Srivastava, A. B., & Gold, M. S. (2018). Beyond supply: How we must tackle the opioid
epidemic. Mayo Clinic Proceedings, 93(3), 269–272.

Unick, G. J., Rosenblum, D., Mars, S., & Ciccarone, D. (2013). Intertwined epidemics:
National demographic trends in hospitalizations for heroin-and opioid-related over-
doses. PLoS One, 8(2) (e54496).

T.J. Cicero et al. Addictive Behaviors 87 (2018) 267–271

271

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0080

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0080

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0080

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0085

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0085

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0085

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0090

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0090

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0090

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0095

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf0095

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf9095

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf9095

http://refhub.elsevier.com/S0306-4603(18)30467-2/rf9095

Increased use of heroin as an initiating opioid of abuse: Further considerations and policy implications
Summary of previous article
Methods for original, updated and supplemental data
Results
Heroin as an initiating opioid
Opioid treatment admissions

Discussion
Overview of results
Importance of increases in heroin use
Policy implications

Role of funding source
Contributors
Conflict of interest
Acknowledgements
References

Place your order
(550 words)

Approximate price: $22

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
The price is based on these factors:
Academic level
Number of pages
Urgency
Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

Read more

Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more

Fair-cooperation guarantee

By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.

Read more
Open chat
1
You can contact our live agent via WhatsApp! Via + 1 929 473-0077

Feel free to ask questions, clarifications, or discounts available when placing an order.

Order your essay today and save 20% with the discount code GURUH