The total number of respondents was 800 500. Joinpoints identified indicate significant changes in nonlinear trends using Bayesian information criterion. Past-year heroin use for 2002-2016 had an annual percentage change (APC) of 7.6 (95% CI, 6.3-9.0; P < .001) and for 2016-2018, APC, –7.1 (95% CI, –36.9 to 36.7; P = .69). Past-year heroin use disorder for 2002-2008 had an APC of 4.3 (95% CI, –0.4 to 9.1; P = .07); for 2008-2015, APC, 11.3 (95% CI, 8.0-14.7; P < .001); and for 2015-2018, APC, –2.4 (95% CI, –13.0 to 9.6; P = .65). AAPC indicates average annual percentage change.
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Han B, Volkow ND, Compton WM, McCance-Katz EF. Reported Heroin Use, Use Disorder, and Injection Among Adults in the United States, 2002-2018. JAMA. 2020;323(6):568–571. doi:10.1001/jama.2019.20844
Heroin-related morbidity and mortality have increased over the past 17 years in the United States, including an increase in overdose deaths from 2089 in 2002 to 15 259 in 20181 and an increase of multiple outbreaks of HIV and hepatitis infections related to injection drug use.2-5 Yet research has not examined whether heroin injection is increasing.
Data were from adults aged 18 years or older who participated in the 2002-2018 National Surveys on Drug Use and Health (NSDUH), providing representative data among US civilian, noninstitutionalized populations,6 including sociodemographic characteristics and past-year heroin use, heroin use disorder (based on diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition]), and heroin injection. The NSDUH data collection was approved by the institutional review board at RTI International. Data were collected by interviewers in personal visits, using audiocomputer-assisted self-administered interviews. Verbal informed consent was received from respondents. The annual mean weighted response rate of the 2002-2018 NSDUH was 62.7%.
Using logistic and linear regressions, we examined trends in reported past-year heroin use, heroin use disorder, and heroin injection (examined by sex, age, race/ethnicity, and US Census region), and past-year heroin injection among those with past-year heroin use and heroin use disorder (statistical significance, P < .05; 2-sided t test). We used SUDAAN software (release 11.0.1) to conduct analyses accounting for the NSDUH’s complex design and sampling weights. Using the Joinpoint Regression Program (version 4.7; National Cancer Institute), we tested for significant changes (joinpoints) in nonlinear trends using a Bayesian information criterion.
Based on 800 500 adult respondents during the 17-year period (mean age, 34.5 [SD, 15.9] years; 53.2% women), the reported past-year prevalence of heroin use, heroin use disorder, and heroin injection increased in the United States during 2002-2018 (Figure). Prevalence of heroin use increased from 0.17% in 2002 to 0.32% in 2018 (average annual percentage change [AAPC], 5.6; 95% CI, 1.0-10.5; P = .02), specifically increasing during 2002-2016, for an annual percentage change [APC] of 7.6 (95% CI, 6.3-9.0; P < .001) and plateauing during 2016-2018 (APC, –7.1; 95% CI, –36.9 to 36.7; P = .69). The prevalence of heroin injection continuously increased from 0.09% in 2002 to 0.17% in 2018 (AAPC, 6.9; 95% CI, 5.7-8.0; P < .001). The prevalence of heroin use disorder increased from 0.10% in 2002 to 0.21% in 2018 (AAPC, 6.0; 95% CI, 3.2-8.8; P < .001), specifically remaining stable during 2002-2008 (APC, 4.3; 95% CI, –0.4 to 9.1; P = .07), increasing during 2008-2015 (APC, 11.3; 95% CI, 8.0-14.7; P < .001), then plateauing during 2015-2018 (APC, –2.4; 95% CI, –13.0 to 9.6; P = .65).
During the years 2002-2018, the reported past-year prevalence of heroin injection increased continuously among both men and women, those aged 35 through 49 years, non-Hispanic whites, and adults residing in the Northeast or West regions (Table). For those aged 18 through 25 years and for adults in the Midwest region, heroin injection changed from an increase to a plateau but had an overall increase during 2002-2018. In 2018, past-year heroin injection was highest in adults residing in the Northeast region (0.32%); those aged 26 through 34 years (0.31%), 35 through 49 years (0.22%), and 18 through 25 years (0.21%); men (0.21%); and non-Hispanic whites (0.19%). Prevalence of heroin injection did not increase among adults with heroin use (n = 3200; 44.07% in 2002-2004 and 49.36% in 2017-2018; P = .55) or heroin use disorder (n = 2000; 56.59% in 2002-2004 and 58.21% in 2017-2018; P = .83).
During the years 2002-2018, reported past-year prevalence of heroin use, heroin use disorder, and heroin injection increased among adults in the United States. The stable prevalence of injection among heroin users and those with heroin use disorder over these years suggests that increases in heroin injection are related to overall increases in heroin use rather than increases in the propensity to inject. Study limitations include likely underestimated heroin use, heroin use disorder, and heroin injection because the NSDUH excludes jail and prison populations and homeless people not in living shelters. The NSDUH is subject to recall bias. The recent leveling off of heroin use might reflect shifts from heroin to illicit fentanyl-related compounds. Future research needs to examine differences in heroin injection trends across subgroups.
In response, HIV and hepatitis testing and treatment, sterile syringe provision,6 and use of US Food and Drug Administration–approved medications for opioid use disorders should be expanded, particularly among populations at greatest risk (ie, adults residing in the Northeast region, adults aged 18-49 years, men, and non-Hispanic whites). In parallel, interventions to prevent opioid misuse and opioid use disorder are needed to avert further increases in injection drug use.
Accepted for Publication: December 2, 2019.
Corresponding Author: Beth Han, MD, PhD, MPH, Substance Abuse and Mental Health Services Administration, 5600 Fishers Ln, 15E17B, Rockville, MD 20857 (firstname.lastname@example.org).
Author Contributions: Dr Han had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Han, Volkow, McCance-Katz.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Han.
Administrative, technical, or material support: Han, Volkow, McCance-Katz.
Supervision: Han, Volkow, McCance-Katz.
Conflict of Interest Disclosures: Dr Compton reported having ownership of stock in General Electric Co, 3M Co, and Pfizer Inc. No other disclosures were reported.
Funding/Support: This study was jointly sponsored by the Substance Abuse and Mental Health Services Administration and the National Institute on Drug Abuse of the National Institutes of Health.
Role of the Funder/Sponsor: The sponsors supported the authors who were responsible for preparation, review, and approval of the manuscript and the decision to submit the manuscript for publication. The sponsors had no role in the design and conduct of the study; analysis and interpretation of the data; preparation of the manuscript; or decision to submit the manuscript for publication. The sponsors reviewed and approved the manuscript.
Disclaimer: The findings and conclusions of this study are those of the authors and do not necessarily reflect the views of the Substance Abuse and Mental Health Services Administration, the National Institute on Drug Abuse, or the US Department of Health and Human Services.
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