Historical trends in self-reported US heroin initiation

Illegal opioids create challenges for public health and safety. There is imperfect understanding of when use of illegally manufactured opioids increased. This paper examined data on self-reported year of first heroin use in the United States.

Secondary analysis of general population survey data.

United States.

1 708 720 across 38 surveys from 1979 to 2023.

The U.S. National Survey on Drug Use and Health and its predecessors ask respondents about their year of first use for various substances. In any single survey, few report initiating heroin in a specific year, but combining multiple surveys improves precision, enabling the plotting of time trends. Those who initiate can be broken down by age and by whether they report having misused pain relievers before they first used heroin.

Self-reported heroin initiation appears to have been rare before the late 1960s, although data for those years are sparse. It rose sharply to a peak in 1972, fell by almost half, and remained stable from 1978 to 1994. It rose by about 75% in the late 1990s and a further 85% by the early 2010s. The proportion reporting misuse of prescription opioids before first using heroin increased from about one-third before 1990 to one-half by 2000 and 80% by 2010. The proportion who were over age 40 at the time of first heroin use increased from nearly 0 before 1990 to 10% in 2012 and about 40% in 2020-2021.

In the United States, heroin initiation that is self-reported to have occurred after 2000 differs in magnitude and character from that from the late 1970s through mid-1990s. Changes began before dates commonly associated with restrictions on opioid prescribing. This appears consistent with a view that "trading down" from prescription opioid misuse to consumption of illegally manufactured opioids did not only occur after implementation of policies to reduce opioid prescribing.