Historical Trends in U.S. Heroin Use: Study Finds That Initiation After 2000 Differed from Earlier Patterns
The production, distribution, and consumption of illegal opioids create problems for public health and safety in many countries. Overdose rates are particularly high in Canada and the United States, which experienced three waves of deaths associated first with prescription opioids, then heroin, and most recently, illegally manufactured fentanyl. But we know little about historical patterns of initiation into use of such drugs.
In a new study, researchers combined data from 1.7 million respondents to general population surveys over more than four decades to examine historical trends in U.S. individuals’ self-reported first year of heroin use. They found that heroin initiation that occurred after 2000 differed in magnitude and character from initiation in the late 1970s through mid-1990s.
Those changes began soon after the great expansion in opioid prescribing and thus well before subsequent efforts to reduce diversion of prescription opioids. That is important, according to the authors, because the surge in deaths from illegal opioids has sometimes been blamed on prescription opioid restrictions pushing people into switching to heroin and fentanyl.
The study, by researchers at Carnegie Mellon University, appears in Addiction.
“Our findings revealed two trends,” says Jonathan P. Caulkins, professor of operations research and public policy at Carnegie Mellon’s Heinz College, who led the study. “First, after nearly 20 years of stability, heroin initiation changed in the late 1990s. Second, by 2010, fully 80% of people reporting heroin initiation say they had already misused prescription opioids before then.”
Researchers mined data from the U.S. National Survey on Drug Use and Health and predecessor surveys from 1979 to 2023, which asked respondents about their first year of use of various substances. Few reported starting heroin in a specific year, but by combining multiple surveys, the researchers improved precision, enabling them to plot time trends. Among their findings:
- Self-reported heroin initiation appears to have been rare before the late 1960s, although data for those years are sparse.
- It rose sharply to a peak in 1972, fell by almost half, and remained stable from 1978 to 1994.
- It rose by about 75% in the late 1990s and a further 85% by the early 2010s.
- The proportion of respondents reporting misuse of prescription opioids before first using heroin increased from about one-third before 1990 to one-half by 2000 and 80% by 2010.
- The proportion of respondents who were over age 40 at the time of first heroin use increased from nearly zero before 1990 to 10% in 2012 and about 40% in 2020-2021.
“This appears consistent with a view that ‘trading down’ from prescription opioid misuse to consumption of illegally manufactured opioids did not occur only after implementation of policies to reduce the prescribing of opioids.”
Among the study’s limitations, the authors note that some people may not respond to general population surveys or may under-report use if they do. In addition, non-response and under-reporting may be particularly pronounced for people who develop the most problems with use. Therefore, the authors suggest that the trends they identified are more reflective of the subset of users who do not escalate to highly problematic use. However, initiation trends within that subset are of interest, and they may parallel trends in initiation that lead to problematic use.
The study was funded in part by the National Science Foundation.
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Summarized from an article in Addiction, "Historical Trends in Self-Reported Heroin Initiation," by Caulkins, JP (Carnegie Mellon University), and Giri, B (Carnegie Mellon University). Copyright 2025 Society for the Study of Addiction. All rights reserved.
About Carnegie Mellon University's Heinz College of Information Systems and Public Policy
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