Stepping off the Heroin and Methamphetamine Treadmill

Measurable progress is being made – slowly but surely – in addressing the opioid epidemic in the United States. The rate of prescriptions being written for synthetic opioids is decreasing. Physician trainings and awareness campaigns are altering prescribing behaviors. Legislation aimed at reducing both the writing and filling of opioid prescriptions for non-pain related indications appears to be working, as well.

The opioid epidemic is still a serious public health crisis, though. What is not so clear to policymakers, government agencies, and law enforcement is the role of polysubstance use in perpetuating this crisis. Polysubstance use means exactly what it sounds like – using more than one substance at a time. This includes mixing alcohol with any drug of misuse, prescribed or illicit.

In particular, more attention needs to be paid to the rising trend of individuals misusing heroin alongside methamphetamine as their access to prescription opioids is reduced by the latest set of prescribing policies and guidelines.

Polysubstance Use Disorders: Heroin and Methamphetamine

To continue making significant progress in addressing the opioid crisis, prevention and intervention efforts need to expand their scope to include the reality of polysubstance misuse among those diagnosed with opioid use disorders (OUDs).

Individuals living with OUD may turn to additional substances in order to mitigate the undesirable effects of opioids. Heroin users, for example, wishing to counteract the extreme drowsiness associated with opioid use, are increasingly turning to illicit medications that energize them and enable them to make it through the day.

New reporting on illicit drug misuse reveals that heroin users seek methamphetamine – commonly known by its shortened name, meth – more than any other illicit drug. Driving this specific instance of polysubstance abuse are the following:

  • Users seeking a specific feeling that simulates that of powerful synthetic prescription opioids. The street name of combined use of methamphetamine and heroin is goofball. This name is supposed to describe the euphoria of combined heroin/methamphetamine use.
  • Greater supply in illicit drug markets of heroin and meth as access to prescription opioids has been successfully blockaded through intervention efforts. Public health officials describe the uptake in heroin and meth use as the “balloon effect” of the intervention efforts designed to end the opioid crisis: as these efforts squeeze one part of the balloon, the air moves and changes the shape of the balloon, rather than disappearing. Another way to think of this phenomenon is that intervention efforts can seem like playing a game of whack-a-mole. As soon as one risk area is identified and mitigated, another pops up.
  • The relative affordability of methamphetamine compared to heroin entices heroin users to substitute methamphetamine in order to save money, or as a way to continue to afford heroin. Heroin is a very expensive drug. Therefore, heroin addiction can quickly drive one to seek less expensive alternatives.
  • Methamphetamine use can alleviate some of the uncomfortable symptoms of opioid withdrawal.
  • Users looking for an energy boost to meet work demands.

This last bullet point evokes the image of the polysubstance heroin/methamphetamine user on a treadmill they’re less and less likely to step off as time passes.

As heroin use increases, tolerance develops and the user needs more heroin to achieve the same effect. The need for more heroin, given its cost, drives users to work more, for longer hours, or in multiple jobs. This, in turn, drives users to seek sources of energy that enable them to generate more income – hence the addition of methamphetamine to their drug use patterns.

One reporter likened the use of meth and heroin as drinking coffee in the morning to get a boost for work, then drinking wine in the evening to wind down.

Treatment in the Era of Methamphetamine and Heroin Polysubstance Abuse

Awareness of the increasing polysubstance misuse of heroin and methamphetamine is one important step in ending the frustrating game of whack-a-mole that characterizes the current interventions addressing the opioid crisis. So too is greater awareness about unique treatment issues associated with polysubstance SUDs.

Successful treatment plans for OUDs should now include screening for other possible drugs of abuse – in particular, methamphetamine. Treatment plans for OUDs often include medication treatments that can significantly reduce cravings. But no such medication treatment options exist – at the moment – for methamphetamine cravings.

Preventing relapse and promoting recovery for those individuals living with combined heroin and methamphetamine SUDs will likely require the integration of non-medication treatments that address cravings for methamphetamine, and further research into medication-assisted treatment for methamphetamine withdrawal.

Helping people successfully step off the polysubstance misuse treadmill also requires sensitivity to the appeal of methamphetamine even after individuals enter a stable recovery period from OUD. Treatment providers should be aware of the very real possibility that recovery from one does not necessarily mean recovery from the other, and collaborate with patients to formulate a plan that simultaneously promotes sustained recovery from the disordered use of both substances.