Getting High is an Global Problem

Package with a drug against the passports and U.S. dollars

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Looking at information gleaned from the 2014 World Drug Report suggests two drug trends to expect over the next few years. A bumper crop of opium poppies globally (particularly in Afghanistan), points to an increased worldwide problem with heroin. Afghanistan grew about 80% of the world’s opium poppies in 2013. Second, the development of new psychoactive substances (NPS) has accelerated and doesn’t appear to be slowing down anytime soon. By December of 2013, there were 348 known NPS, an increase of 200% since 2009. There are now more NPS than the number of substances under international control (234).

Globally, an estimated 243 million people aged 15-64 used an illicit drug in 2012. The three primary groups of illicit drugs were: cannabis, opioids, and cocaine or amphetamine-type stimulants (ATS). Generally, men are two to three times more likely than women to have used an illicit substance. While there are regional trends to consider, overall global drug use seems to be stable. The extent of problem drug use, determined by the number of regular drug users and those with drug use disorders, was also stable globally, at around 27 million people. The estimated number of global drug users by drug type is in the table below.

Global Drug Use by Drug Type


Amphetamine-like stimulants



(heroin, opium)

Opioids (opiates and synthetics)



Users in millions







% of global population 15-64







There has been an increase in global opioid and cannabis use since 2009, while the use of opiates, cocaine and ATS has either remained stable or decreased. Reports on the types of drugs individuals seek treatment for can provide information on which drugs have the highest impact on health in the various geographic regions. Cannabis treatment is prevalent in Africa, the Americas and Oceania. It should be noted that between 2003 and 2012 that those seeking treatment for cannabis increased in Western and Central Europe (19% to 25%), Eastern and South Eastern Europe (8% to 15%), Latin America and the Caribbean (24% to 40%) and Oceania (30% to 46%).

Opioids dominate treatment requests in Eastern and Southern Europe and Asia. Cocaine is major treatment factor in the Americas, especially in Latin America and the Caribbean.  ATS use disorders are responsible for a significant proportion of the treatment demand in Asia and Oceania.

Global estimates are that one in six problem drug users got treatment in the past year. However, there are large regional differences. One in 18 problem drug users receive treatment in Africa (mostly for cannabis use), while one in five problem users in Europe, one in four in Oceania and one in three in North America receive treatment.

Drug-related deaths were estimated to be around 183,000 in 2012. Overdose deaths from opioids (heroin and non-medical use of prescription opioids) are the main drug type implicated in those deaths. Most overdoses occur when opioids are mixed with other sedating substances, like alcohol and benzodiazepines. See the global data in the table below from the 2014 World Drug Report.

Table 2

North America continues to be a major market for illicit drug use. It has the largest percentage of opioid users, cocaine users and cannabis users. It was second in percentage of ATS users. Cocaine use has been declining since 2006, partly because of a sustained shortage. Yet there has been a slight increase in prevalence recently. Columbia’s recent decision to stop spraying coca crops could stimulate a greater resurgence in cocaine use.

In the United States, opioid-dependent drug users are increasingly turning to heroin because of its greater availability and lowered cost to regular users. The greater availability of heroin in the United States is likely due to higher levels of heroin production in Mexico and Mexican traffickers expanding into “white heroin” markets. Anecdotal evidence is that Mexican drug cartels are switching from growing marijuana to opium poppies due to the lower demands for marijuana in the United States. See “The Economics of Heroin.”

The rapid growth of NPS has led to a key supply control strategy of restricting the availability of the precursor chemicals necessary to manufacture them. Most drugs, whether they plant-based or synthetic, require chemicals to change them into the final product. While chemical are only one of the components required for the illicit manufacture of plant-based drugs like heroin and cocaine, ‘they constitute the essential components of illicitly manufactured synthetic drugs.”

NPS are found throughout the globe. Of the 103 countries that gave information for the World Drug Report, 94 countries reported the emergence of some kind of NPS in their markets. The increase from August 2012 to December 2013 of newly identified NPS was mostly due to new synthetic cannabinoids (50% of newly identified new psychoactive substances) followed by new phenethylamines (17%), other substances (14%) and new synthetic cathinones (8%). See the following chart from the 2014 World Drug Report.

figure 60Reviewing this report on worldwide drug use reminds me that getting high is an everywhere problem. This year the transition from pharmaceutical painkillers to heroin and the higher cultivation levels of opium poppies suggests a pending increase in heroin addicts and overdose deaths. The rapid explosion of new psychoactive substances onto the drug scene in the past few years feels like a “back to the future” move to the days of patent medicines, when heroin was a cough suppressant and cocaine was a toothache cure. Teething medications contained morphine. Coca-Cola (with cocaine) was a temperance drink and tonic, “a cure for all nervous affections.”

Cannabis is becoming more potent and toxic just as legalization movements gain steam and increase its use and availability. Coca eradication efforts that seemed to have had an effect on the cocaine market are to be suspended—perhaps leading to a resurgence in cocaine use. Getting high is an everywhere problem and it seems like it’s not going away anytime soon.


The Opioid-Heroin Cycle

© Ouroboros tattoo by Sahua | Stockfresh.com

© Ouroboros tattoo by Sahua | Stockfresh.com

Since the death of Philip Seymour Hoffman on February 2, 2014, there has been a series of calls for the distribution of naloxone or Narcan, which is a prescription medication that reverses an opioid overdose. But it seems that the price of Narcan has doubled over the past year. The Fix and others report that the price of naloxone has recently gone from $51.50 per kit, to nearly $100 per kit. These are the Luer-Jet™ kits sold by Amphastar Pharmaceuticals, the only US company currently selling nasal kits. There is a cheaper injectable form of narcan, but it is supposed to be less user friendly.

Within four days of Hoffman’s death, The New York Times published an article by an emergency physician, noting how greater availability of Naloxone could prevent deaths. He referred to a report in the Annals of Internal Medicine that suggested up to 85 percent of users overdose in the presence of others, providing the opportunity for others to intervene. In Forbes Magazine David Kroll said the CDC reported that naloxone was used in over 10,000 opioid-overdose reversals between 1996 and mid-2010. He also expressed his concerns over potential shortages of naloxone.

Victoria Kim for The Fix reported that Amphastar’s president blamed the price increase of their naloxone product on “steadily increasing” manufacturing costs. But Matt Curtis, the policy director for a New York advocacy group said there had been a fairly steady price for several years. “Then these big government programs come in and now all of a sudden we’re seeing a big price spike. . . . The timing is pretty noticeable.” The Hill reported that Senator Bernie Sanders and Representative Elijah Cummings sent a letter to Amphastar complaining about the price increase and how it is “an obstacle in efforts by police departments to equip officers with the drug.”

Areille Pardes of Vice said that after the CDC said there was an opioid epidemic in 2008, the manufacturer of naloxone, Hospira, increased the price of a dose of naloxone from $3 to a little more than $30. Pardes also reported that the supposed difficulty of a lay-friendly delivery system has also been used to justify the high costs of epipens (around $400) and the naloxone auto-injector, EVIZO (Over $600 for a kit of 2 auto-injectors at Walmart, Sams Club, Target and other retail outlets). However a study found few differences between trained and untrained overdose rescuers in their abilities to use the syringes in a naloxone rescue kit. “Anyone with common sense could figure it out, even without training.”

It does seem that the timing of the price increases for naloxone (a generic drug) and its delivery systems occurred just as the epidemic of overdoses took place. The CDC reported in a March 2015 NCHS Data Brief that from 2000 to 2013 the rate of drug overdoses quadrupled, from .7 deaths per 100,000 to 2.7 deaths per 100,000. Overdoses are now the number one cause of injury-related death in the US. While the overdose deaths involving (prescription) opioid analgesics have leveled off in recent years, those from heroin have almost tripled. See Figure 1 of the NCHS Data Brief. While the heroin overdose rates increased among all age brackets, the highest rate of increase was among 25-44 year olds. Geographically, while there were increases in all regions of the country, the greatest increase took place in the Northeast and the Midwest. See figure 5 of the NCHS Data Brief.

There is some sense that effort to curb problems with overprescribing pain medications has inadvertently led to a boom in the misuse of heroin. Richard Juman reported for The Fix that while some treatment providers suggest that is the case, others note that there is evidence that heroin use was increasing before any state or federal interventions with prescribed opioids were implemented. According to Andrew Kolodny, MD:

The idea that efforts to curb prescription drug misuse have led to a spike in heroin use or overdose has become a common media narrative, but the facts don’t support it. It is the overprescribing of opioids itself that has caused increases in opioid addiction of all kinds, not the efforts to control the prescribing. The transition from prescribed opioids to heroin has been happening since the beginning of the epidemic, and there is no evidence that the interventions brought forth to reduce the overprescribing have been fueling the increase in heroin use or overdoses. Because of the epidemic of opioid addiction, you now have markets for heroin that you didn’t have in the past. So there has been an increase in heroin overdose deaths, but that increase was prior to states’ implementation of Prescription Monitoring Programs or any of the changes from the FDA.

I tend to agree with Dr. Kolodny’s assessment. There is a price factor in the shift for many opioid users switching to heroin. And there has been a global market increase in heroin production that paralleled the rise of prescription opioid use. Increased heroin use in the US is market driven. What does seem to be related to increased heroin availability in the US is the diversification of Mexican drug cartels into growing opium poppies, as their market for marijuana dries up. See “The Economics of Heroin.”

There is something very wrong with the cycle of Pharma marketing for increased use of opioids, leading to overprescribing opioids, leading to increased heroin use and increased overdoses, leading to an increased need for narcan, leading back to increased profits with drug companies, where the cycle began. The ouroboros pictured above is a symbol in Greek mythology of a dragon eating its own tail. It symbolizes something that constantly re-creates itself, which seems to be happening here with the opioid-heroin cycle.