Oct 29, 2015 - Supplement to: Cicero TJ, Ellis MS, Harney J. Shifting patterns of prescription opioid and heroin abuse in the. United States. N Engl J Med 2015 ...
correspondence 4. Berenson A. Sales of impotence drugs fall, defying expecta-
peutic indications for this class of drugs.3 Clearly, the long-term benefits of phosphodiesterase type 5 inhibitors in patients with these chronic diseases have led to clinically significant imDOI: 10.1056/NEJMc1510178 provements in functional status, so that patients have been able to return more readily to ambulaThe Authors Reply: We agree with Sauri that tory lifestyles. there have been rare reports of clinical deteriora- Thomas Michel, M.D., Ph.D. tion in patients who abruptly discontinue silde- Joseph Loscalzo, M.D., Ph.D. nafil,1 but this may simply reflect the substantial Brigham and Women’s Hospital efficacy of the drug — and it certainly does not Boston, MA Since publication of their article, the authors report no furreflect a major threat to the public health. The much more common and serious adverse effect is ther potential conflict of interest. a consequence of the coadministration of phos- 1. Keogh AM, Jabbour A, Hayward CS, Macdonald PS. Clinical after sildenafil cessation in patients with pulmophodiesterase type 5 inhibitors and organic ni- deterioration nary hypertension. Vasc Health Risk Manag 2008;4:1111-3. trate vasodilators; this known mechanism-based 2. Kloner RA. Cardiovascular effects of the 3 phosphodiesterdrug interaction may lead to fatal hypotension.2 ase-5 inhibitors approved for the treatment of erectile dysfunction. Circulation 2004;110:3149-55. However, new observations on the salutary ef- 3. Kass DA. Cardiac role of cyclic-GMP hydrolyzing phosphodifects of phosphodiesterase type 5 inhibitors in esterase type 5: from experimental models to clinical trials. Curr the treatment of heart failure and pulmonary hy- Heart Fail Rep 2012;9:192-9. pertension have created a broader base of thera- DOI: 10.1056/NEJMc1510178 tions. New York Times. December 4, 2005 (http://www.nytimes .com/2005/12/04/business/yourmoney/sales-of-impotence-drugs -fall-defying-expectations.html?_r=0).
Shifting Patterns of Prescription Opioid and Heroin Abuse in the United States To the Editor: From 2010 through 2013, there was a notable downturn in abuse of prescription opioids and a coincident increase in abuse of heroin in the United States.1 Given that there is some evidence of a relationship between the two trends (e.g., some persons who abuse prescription opioids switch to heroin for a number of reasons and drug interchangeability has been observed),2-4 we sought to examine this relationship more closely, including the validity of reports suggesting regional differences in the balance between prescription opioid and heroin abuse.5 Data on opioid abuse in the previous month were collected quarterly from January 1, 2008, through September 31, 2014, with the use of self-administered surveys that were completed anonymously by independent cohorts of 15,227 patients with opioid dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, who were entering nonmethadone-maintenance treatment programs throughout the United States. Of these patients, 267 agreed to online interviews to gather quali tative information in order to amplify and in-
terpret findings from the structured national survey. Figure 1 shows the unadjusted rates of abuse of prescription opioids only, abuse of prescription opioids and heroin, or abuse of heroin only among respondents who reported such abuse in the previous month from 2008 through 2014. Rates of exclusive prescription opioid abuse remained stable from 2008 through 2010, at 70%, but then decreased steadily, with an average annual reduction of 6.1%, to less than 50% in 2014. Conversely, concurrent abuse of both heroin and prescription opioids in the previous month increased, with an average annual increase of 10.3%, from 23.6% in 2008 to 41.8% in 2014. Although the exclusive use of heroin was low in this population, it more than doubled from 2008 through 2014 (from 4.3% to 9.0%). The national data obscure important regional differences (Fig. S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). The Northeast showed the most striking shifts in patterns of abuse. The West followed closely behind, with concurrent heroin
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correspondence
80
70 Prescription opioids only
Primary Drug (% of respondents)
60 Annual percent change=−6.1
50
40
30
Annual percent change=+10.3
Heroin and prescription opioids
20
10
0
Annual percent change=+14.4
Heroin only
2008 (N=1283)
2009 (N=1529)
2010 (N=1668)
2011 (N=2936)
2012 (N=3276)
2013 (N=2664)
2014 (N=1871)
Figure 1. National Rates of Abuse of Opioids in the Previous Month among 15,227 Respondents. P values calculated with the use of the Cochran–Armitage trend test showed significance between all groups (P
