Among the recurring narratives of the opioid epidemic, is that many current people who use heroin began their dependency with opioid pain medication.

Studies have shown that in the 2000s, 75% or more of individuals who identified as having a dependency on heroin also noted that they had used prescription opioids prior to heroin—a reversal of trends set in the 1960s, when more than 80% of opioid-dependent individuals stated that their use began with heroin.

Now, those numbers may have reset themselves, as a new study appears to indicate that heroin may have overtaken prescription opioids as the initiating opioid in dependency.

Researchers from Washington University of St. Louis’ Department of Psychiatry, who published their findings in the November 2017 issue of Addictive Behaviors, wanted to know if the relative ease in finding heroin had caused an increase in experimentation with the drug as the first opioid for users. They drew on data from individuals entering substance use disorder (SUD) treatment for opioid dependency from 2010 to 2016, and restricted their research to first-use instances of opioids that occurred in the previous 10 years (from 2005 to 2015).

What they found was that in 2005, only 8.7% of individuals reported initiating their opioid use with heroin, but that number increased dramatically to 33% within the following decade. Use of the most commonly prescribed opioids—oxycodone and hydrocodone—plunged from 42.4% and 42.3% respectively, to 24.1% and 27.8% in that same time frame.

That reversal elevated heroin as the primary initiating opioid for users instead of the more commonly cited prescription opioids.

A number of factors can be cited as contributing to this suggested increase. Heroin remains relatively cheap and easy to find when compared to prescription opioids, which have decreased in accessibility due to legislation and public awareness.

As study author Theodore J. Cicero noted in a 2014 interview about heroin use, “The price on the street for prescription painkillers, like OxyContin, got very expensive. It has sold for up to a dollar per milligram, so an 80mg tablet would cost $80,” he noted. “Meanwhile, [users] can get heroin for $10.” 

Studies have also suggested that opioid dependency is often caused by ease of availability, not chronic pain. A National Survey on Drug Use and Health found that 75% of all opioid misuse (prescription or otherwise) began with prescription drugs that were provided by someone else—a friend, family member, or dealer.

Another study, published in JAMA Internal Medicine in 2014, found that just 13% of emergency room admissions for opioid overdose in 2010 had a prior chronic pain condition.

However, as the study authors suggest, given the inaccuracy often associated with heroin use, the increase in that drug as the initiating opioid may also have been responsible for—and may continue to be responsible for—an uptick in heroin-related overdose fatalities, which stands at nearly 14,000 between 2002 and 2015.