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Heroin Highways:
Fueling the Opioid Epidemic

Photo: dried opium poppies

As doctors cut back on opioid prescriptions, illegal drugs are filling the vacuum.  

Of the 42,249 Americans who died from opioid overdoses in 2016, over a third died from heroin. The opioid epidemic began in the late 1990's as a prescription drug crisis. Fifteen years later, it has morphed into an illegal drug crisis. This story explores how—and where—this shift has occurred. 

—Daniel Kenis, Senior Editor, LiveStories.

 

Opioid Overdose Deaths (per 100,000 residents)
Source: Centers for Disease Prevention and Control
Deaths from opioids, have exploded since 2010—particularly in the Rust Belt and Northeast.

Drag the time slider to see the progression.

West Virginia had the highest rate of opioid deaths in the nation in 2016. Legal and illegal versions of opioids have destroyed whole communities in the state, leaving public health officials reeling to respond effectively. Located in the center of the so-called Rust Belt, West Virginia's demographics might as well form the public face—or caricature—of the epidemic.

But the Rust Belt is not the only region of America facing high rates of opioid overdoses. New England is nearly as bad off. The state with the second highest rate of opioid deaths is New Hampshire.  

Why these states, and not others? Why are overdose deaths so much more common in central and northeastern America than they are in the South and West?

There are no simple answers in this 15-year-long crisis. But the geography of the heroin supply seems to play an increasingly important role. Unlike prescription drugs—which could be available anywhere with doctors—heroin and other illegal opioids are more constrained by supply lines, emanating from certain population centers. 

Heroin Overdose Deaths (per 100,000 residents)

The different trajectories of heroin death rates between states is striking, and appears to be regionally clustered. West Virginia had no reported heroin deaths in the early years of the crisis. But the state is only a few hours drive from big cities in Ohio and Maryland. By the 2010's, enough heroin had found its way into West Virginia to yield the country's third highest overdose death rate from the drug.

The opioid epidemic was already well on its way by 2010. Heroin dealers did not create the opioid crisis in West Virginia. But they are pouring fuel on the fire. 

Opioid Supply and Demand—and More Supply

Health experts trace the roots of the opioid crisis to the overprescription of opioid pain relievers, beginning in the late 1990’s. It is now widely acknowledged that many prescription opioids are dangerously addictive. Increasingly, doctors have taken steps to limit their distribution. Since 2010, the amount of opioids prescribed in the United States has decreased each year. 

However, the demand for opioids remained. Heroin deaths began spiking nationwide around 2010, just as deaths from prescription opioids had begun to level off. Of new heroin users, three out of four have previously abused prescription opioids

Further complicating the crisis is black market fentanyl, often sold alongside or mixed with heroin. Fentanyl is a synthetic opioid that is legally available with a prescription. But in recent years, huge quantities of illegally manufactured fentanyl have entered the drug supply. Based on reports of fentanyl seized by law enforcement and analyzed by forensics labs, the drug's prevalence closely tracks the geography of heroin deaths.

In much of the country, but particularly in the Rust Belt and Northeast, demand for opioids and supply from illegal drug dealers have morphed into a self-reinforcing cycle. In most states, deaths from illegal opioid overdoses are spiking—none more than Ohio.

Overdose Deaths from Fentanyl and Other Synthetic Opioids, Excluding Methadone (per 100,000 residents)
Fentanyl has become even deadlier than heroin in some states. The data in this map includes other synthetic opioids as well as fentanyl, and is not limited to illegal supplies of the drugs. But a huge spike in deaths—centered in the Rust Belt and Northeast—is apparent after 2013.

How Heroin Infected Ohio 

Ohio has the highest rate of heroin overdose deaths in the nation. The map below shows how heroin spread throughout the state's counties. 

Total Heroin Overdose Deaths
Twenty-two counties in Ohio reported at least 10 heroin-related deaths in 2016. In 1999, only two counties reported ten or more heroin deaths.

Drag the time slider to see the progression.

Why Ohio? Going back to the roots of the crisis—the overprescription of opioid medication—Ohio does not stand out much. According to a NCBI report, during the peak of opioid overprescription in 2008, Ohio doctors were giving 630 mg per resident on average. That number is slightly higher than the national rate of 547 mg, but far lower than many states in the South and West that are not experiencing the same scale of crisis, such as Alabama (749 mg), Arkansas (834 mg), and Nevada (1,150 mg). Ohio's rate was also much lower than its neighbors—West Virginia and Kentucky.   

Until recently, the state was relatively unremarkable in terms of its opioid death statistics. From 1999 to 2009, Ohio's overall opioid overdose death rate hovered right alongside the national average (shown as a dotted black line in the charts below). Heroin was present in Ohio's big-city counties in 1999, and the state trended slightly above the national rate for heroin deaths. But Ohio didn't explode—until 2010, when heroin suddenly flooded the state, judging from death rates.

2008 Opioid Prescription Rate (mean mg per resident)
Source: NCBI, "Geographic Variation in Opioid Prescribing in the U.S," Table 2. (link)
Opioid Overdose Deaths (per 100,000 residents)
Heroin Overdose Deaths (per 100,000 residents)

The question of "Why Ohio?" could well be posed to illegal drug traffickers. What did they see in Ohio that made it seem like a lucrative investment for market expansion? 

To get a full answer to this question, one has to look at Ohio's surrounding geography. Before 2010, West Virginia was already ground zero of the opioid crisis, even before heroin entered the picture. Kentucky, Ohio's other southern neighbor, was trending well above the national average for years. 

Ohio shares a long border with both of these states. It is also less than a day's drive from Connecticut, Massachusetts, and Maryland, three other top states for heroin deaths. Ohio's heroin death rate cannot be separated from the gravitational pull of its neighbors. 

California is Holding the Line Against Heroin

Since 1999, California has remained stable both in terms of overall opioid deaths and heroin deaths. It is well below the national figure for both.

Total Heroin Overdose Deaths

Heroin deaths are not spiking everywhere in America. Most of the Great Plains states have no reported heroin deaths in 2016, and neither did Arkansas. But these states have small populations and are relatively isolated from major metropolitan areas. California's case is remarkable because it is the most populous state in the country, with a ready supply of heroin at the beginning of the crisis.

California actually shares important similarities with Ohio. It is a large, populous state with multiple big cities. These cities have long had heroin supplies present. And California, like Ohio, borders states with high demand for opioids, at least judging from death rates. Nevada, like West Virginia, had extremely high opioid death rates during the first decade of the crisis, as well as the highest prescription rate in the country in 2008.  

California is one of only a few large states that has not seen a big spike in its heroin deaths.

Drag the time slider to see the progression.
2008 Opioid Prescription Rate (mean mg per resident)
Source: NCBI, "Geographic Variation in Opioid Prescribing in the U.S," Table 2. (link)
Opioid Overdose Deaths (per 100,000 residents)
Heroin Overdose Deaths (per 100,000 residents)

Just like Ohio, California had a ready heroin supply, and a ready heroin demand from its bordering states. So why has California avoided Ohio's fate?

Can the Southwest point the way forward?

An important caveat to comparing death rates in Ohio and California, or elsewhere: a higher heroin death rate does not necessarily indicate a larger heroin supply. Differences in healthcare access and quality from state to state may also explain differences in heroin death rates. In other words, California may not have that many fewer opioid-related deaths than Ohio, but rather, better healthcare for people who do overdose.

Nevertheless, it is a fact that far fewer people per capita are dying of heroin doses in California than in Ohio. 

Change in Heroin Overdose Death Rate, 2008-2016

Texas is another bright spot in the data. Like California, Texas has held a low, flat line in opioid-related deaths. Though the state is experiencing an uptick in heroin deaths, it is still far below the national average. 

Texas, like California, is a very large, populous state, and it is sunny and warm. But the similarities end there. Texas is much less expensive, has very different industries and politics, and has far more people lacking healthcare coverage (23.4 percent versus 11.4 percent for California, according to 2015 BRFSS data). So why have these two very different states managed to avoid the fate of most other large states in America when it comes to heroin overdose deaths? 

It is difficult to find silver linings in the opioid crisis. But the data suggests that California and Texas have more going for them than sunny weather. 

The second wave: this chart shows how heroin death rates have changed from 2008 to 2016, as doctors began pulling back on prescribing opioids. (States with no heroin deaths in one or both years are excluded.)

See the shape of the opioid death toll throughout the country.

Select a state:

Note: Fentanyl/synthetic opioid deaths are not mutually exclusive with heroin deaths; the drugs may be mixed.
Total Opioid Overdose Deaths

Sources

Centers for Disease Prevention and Control: Opioid Data Analysis

National Center for Biotechnology Information: Geographic Variation in Opioid Prescribing in the U.S.

Healthcare Cost and Utilization Project: Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014 (pdf)

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