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Looking for clues driving concurrent painkiller and heroin abuse, researchers conducted online interviews with 267 addiction patients. This group was culled from more than 15,000 addicts entering drug treatment centers in 49 U.S. states.
Three-quarters of the respondents said heroin's lower cost and greater availability led them to try it, researchers found.
But heroin is even more dangerous than prescription painkillers, also known as opioid painkillers.
"Not only is [heroin] more addictive, but one isn't sure how pure it is, so overdoses are quite common," said Theodore Cicero, a professor of neuropharmacology at Washington University in St. Louis and lead researcher on the new study.
According to the White House, abuse of narcotic painkillers along with heroin is "epidemic" in the United States.
Heroin use began climbing in recent years after the federal government tried to shut down "pill mills" and doctors who illegally prescribe painkillers. This made it harder to obtain the prescription drugs, Cicero explained.
At the same time, painkiller formulations were changed to deter abuse, said Dr. Scott Krakower, assistant unit chief of psychiatry at Zucker Hillside Hospital in Glen Oaks, N.Y.
As the supply of narcotic painkillers decreased and the price increased, addicts added cheaper, plentiful heroin to the mix, Krakower and Cicero said.
"Prescription narcotics have become so expensive, and the access is fairly limited, that a number of people who would have previously shunned using heroin are now willing to use it because it is more accessible and cheaper," said Cicero.
However, he said, very few people go completely from prescription narcotics to heroin because of concerns about becoming a "stereotypical" drug addict.
The switch to heroin is most striking in the Northeast, the study found. On the West and East Coasts, Cicero said, the combined use of heroin and narcotic painkillers is greater than exclusive use of narcotic painkillers. In the Midwest and South, use of narcotic painkillers remains high and heroin use is less common, he said.
For the study, published Oct. 29 in the New England Journal of Medicine, researchers initially surveyed 15,000 addicts starting treatment between 2008 and 2014. All were asked about use of narcotic painkillers in the previous month.
The study found that among those interviewed, exclusive painkiller use declined from 70 percent to less than 50 percent in 2014. Meanwhile, concurrent use of heroin and painkillers increased from 24 percent in 2008 to 42 percent in 2014.
At the same time, exclusive heroin use more than doubled, climbing from 4 percent to 9 percent.
Earlier this month, President Barack Obama announced a major initiative to combat prescription painkiller and heroin abuse.
Dozens of major medical groups, leading pharmacy chains, law enforcement agencies, media outlets and anti-drug groups will take part in the government-led effort, the White House said.
"Prescription drug abuse and heroin use have taken a heartbreaking toll on too many Americans and their families, while straining law enforcement and treatment programs," the White House said in a statement. The new programs are "aimed at addressing the prescription drug abuse and heroin epidemic."
Addressing one of the complexities of addiction, Krakower said, "Narcotic painkillers may lead to increased tolerance, which in turn may drive people to take higher quantities."
What's especially alarming, he added, "is the gradual switch toward heroin, especially in the younger age population."
Cicero said that preventing drug addiction starts with finding out what makes drugs attractive to some people.
"A lot of these people have severe psychological disturbances," he said. "They have low self-esteem, depression, anxiety and stressful lives -- often self-perceived," Cicero said. "They find that narcotics are useful in helping them escape from life."
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SOURCES: Theodore Cicero, Ph.D., professor, neuropharmacology, Washington University School of Medicine, St. Louis, Mo.; Scott Krakower, D.O., assistant unit chief, psychiatry, Zucker Hillside Hospital, Glen Oaks, N.Y.; Oct. 29, 2015, New England Journal of Medicine