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Historical trends in self-reported US heroin initiation.
Jonathan P Caulkins1, Bishu Giri1
1Carnegie Mellon University's Heinz College, Pittsburgh, PA, USA.
Addiction (Abingdon, England)
|February 24, 2026
Summary
Heroin initiation in the U.S. surged in the late 1990s and early 2010s, with increasing numbers of users misusing prescription opioids beforehand. This trend of trading down from prescription opioids to heroin began before policies restricted opioid prescribing.
Area of Science:
- Public Health
- Epidemiology
- Substance Abuse Research
Background:
- Illegal opioids pose significant public health and safety challenges.
- Understanding the historical trends of illegally manufactured opioid use is crucial.
Purpose of the Study:
- To examine trends in self-reported first-time heroin use in the United States.
- To analyze the relationship between prescription opioid misuse and heroin initiation over time.
Main Methods:
- Secondary analysis of large-scale, general population survey data from the U.S. National Survey on Drug Use and Health and its predecessors.
- Inclusion of 1,708,720 participants across 38 surveys from 1979 to 2023.
- Analysis of self-reported year of first heroin use, age at initiation, and history of prescription pain reliever misuse.
Main Results:
- Heroin initiation peaked in 1972, stabilized from 1978-1994, then rose sharply in the late 1990s and early 2010s.
- The proportion of individuals misusing prescription opioids before heroin initiation increased significantly, reaching 80% by 2010.
- Initiation among individuals over age 40 increased substantially, comprising 40% of new users by 2020-2021.
Conclusions:
- Self-reported heroin initiation post-2000 differs notably from earlier periods in magnitude and characteristics.
- The observed "trading down" from prescription opioids to heroin predates common opioid prescribing restrictions.
- Findings suggest that shifts towards illicit opioid use may not solely be a consequence of policies aimed at reducing prescription opioid prescribing.
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