NJ Governor Chris Christie opens the "Solutions for a New Way Forward" panel discussion on the national opioid addiction epidemic at Jersey Shore University Medical Center. STAFF VIDEO BY THOMAS P. COSTELLO

New Jersey has a heroin problem. More people are using it, and more are dying from it. But we also have a problem with prescription painkillers that are helping to fuel the heroin crisis. Are doctors the primary cause for the spike in addictions? Do we need tougher laws, or should we reverse course and consider legalization as a means of regulating access and quality? We asked a pair of experts and received some very different perspectives.

We must tackle overprescription of opioid drugs

By Elaine Pozycki

When we use the term heroin “epidemic,” is that too strong a word? Or do you think that properly describes the scope of the current heroin problem in New Jersey?

There is a national epidemic of opioid addiction to opioid-based prescription painkillers and to heroin, their illegal street cousin, according to the Centers for Disease Control and Prevention. And New Jersey is no exception. It is the leading cause of accidental death in the United States and in New Jersey, taking 28,893 lives nationally in 2014, 18,893 from prescription painkillers and 10,574 from heroin. More than 1,250 New Jerseyans died from drug overdoses in 2014. The heroin death rate in New Jersey is three times the national rate.

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Why now? Heroin has been around for a long time, after all. Do you trace this back to the increased use of prescription opiods?

Over-prescribing is the main cause of today’s opiate epidemic. Opioids are the most commonly abused drugs in the United States. In 2014, more than 200 million prescriptions for opioid-based painkillers, such as Oxycodone and Vicadin, were written and over time there has been marked increases in the dosages prescribed until patients achieve pain relief. A recently released John Hopkins University School of Public Health Report on the Opiate Epidemic, which strongly recommends tightening up prescribing practices, notes, “Doctors often prescribe pain medications in quantities and for conditions that are excessive, and in many cases, beyond the evidence base.” When people who become addicted can no longer get opioid prescription painkillers, they often turn to heroin. Four out of five heroin addicts began with prescription painkillers..

While heroin use is increasing to some degree, what’s really getting so much attention is the spike in related deaths. The two figures don’t entirely correlate, so what’s happening? Is the available heroin more dangerous, or are users becoming more reckless?

Increases in opioid presciptions coincide with increases in prescription opioid overdose deaths and.heroin use is increasing at a rapid rate. But a significant contributing factor is the sale of heroin laced with fentanyl — which is a particularly dangerous combination, greatly amplifying the impact of the heroin.

If the illegality of heroin contributes to the danger, why not legalize and regulate it? That’s one of the arguments out there, not just for heroin but many drugs.

The main danger of heroin is not that it is illegal; it is that it is opioid-based and as a result, highly addictive and life-destroying. There are still substantially more overdose deaths nationally from legal prescription painkillers than from illegal heroin. Legalizing it is not the answer. It is a step in the wrong direction that would likely spur an increase in heroin addiction. Providing more easily accessible, high-quality medication-assisted treatment with methadone and suboxone, however, is an important part of the solution.

A Harvard professor whose own Q&A on the subject is running as a companion to this piece would go as far as allowing heroin to be sold in supermarkets, even packaged with a supply of Narcan. That sounds extreme, but also practical in a way. What’s your reaction to that?

It is a recipe for making the problem much worse. All you have to do is look at the results from over-prescribing opioid-based painkillers to see that this is a truly bad idea..

Can you provide some perspective on just how addictive and damaging heroin can be in comparison to other drugs?

Compared to other drugs, it is far more addictive and disruptive of the ability to perform day-to-day functions. As stated above, overdoses of opioids-prescription painkillers and heroin is the leading cause of accidental death nationally and New Jersey.

So in combating the state’s heroin problem, where should the emphasis be? Law enforcement to keep drugs off the streets? Awareness programs to keep potential users from starting, or rehab efforts to overcome the addiction?

A comprehensive approach is required but it begins with preventing abuse of opioids in the first place. And that means stopping over-prescribing in its tracks by fundamentally changing prescribing practices. The bottom line is we’re not seeing consistent, effective, appropriate prescribing of painkillers across the nation, according to Dr. Tom Frieden, director of the CDC, “and this is a problem because of the deaths that result.”

Are there any pieces of legislation in the works that you feel would help the cause and deserve support? Or on the other side, do you see any governmental dangers on the horizon that would be counterproductive to the cause?

The Parent Notification Bill (3424) sponsored by Assemblyman Joseph A. Lagana, D-Bergen, Passaic, requires this conversation when an opiate is prescribed for youth. It will provide parents with the critical information needed to make an informed decision about whether their teenager should be prescribed an opiate. It will let parents know there are alternatives and if a parent makes a decision to go forward with an opiate prescription, this legislation provides the added benefit of alerting them to be on the lookout for any signs of dependence developing. Research shows that the still developing adolescent brain is at particular risk from opiates. Additionally, prescribed opioid use as a teenager increases the risk of future addiction by 33 percent. A more expansive version of this legislation, put forward by senators Loretta Weinberg and Joe Vitale, requires a conversation with adult patients as well. It passed the state Senate 36-1 at the end of 2014. It is long past time for the Assembly to act.

Additionally, Lagana is sponsoring legislation to require prescribers to be trained on best prescribing practices in treating pain as the Office of Natonal Drug Control Policy recommends. Since continuing education generally is a required of all physicians, this is in no way onerous. Other legislation in the works includes requiring emergency rooms to limit any opioid pain-releiver prescription to three days and to limit any new opioid prescription to seven days.

Elaine Pozycki is co-chair of the Partnership for a Drug-Free New Jersey.

Heroin deaths rising, legalization of drug would help save lives

By Jeffrey Miron

Let’s start by characterizing this properly, in your view. Do we have a heroin epidemic in this country? Or a heroin problem? Or are we trying too hard to label something that doesn’t need to be labeled? After all, people die in car crashes every day, but we don’t describe it as a “driving problem?”

The United States has a heroin problem, which is that heroin is illegal: this generates unsafe use, such as sharing contaminated needles. The data are mixed on whether heroin use is increasing: self-reports suggest only modestly, while overdose death rates suggest more strongly. In either case, however, the word “epidemic” seems too strong; only a tiny fraction of the population uses heroin.

It is true, though, that we’ve seen a significant increase in heroin overdose deaths, correct?

Yes, the United States has experienced a substantial increase in heroin overdoses. Some of this plausibly reflects increased use; some more unsafe use; and some reporting artifacts.

Meanwhile, heroin use has also skyrocketed. Why?

Heroin use does not appear to have skyrocketed; self-reported data on drug use suggest only a modest increase, if any.

One plausible explanation for whatever increase we have observed is that law enforcement’s attempts to discourage use of prescription opioids have caused demand to shift to illicit opioids like heroin.

You have argued, however, that the spike in deaths does not directly correlate with the increases in usage. Some other factor, therefore, is also contributing to the increase in deaths. What is that factor?

The increase in deaths relative to use per se has most likely occurred because new, inexperienced users have shifted to heroin in response law enforcement crackdowns on prescription opioids. These users may inadvertently take higher doses than desired, especially because accurate information on purity is scarce in black markets.

You favor legalization of drugs on a broad scale in part because it will help regulate the product and curb the dangers of unpredictable black-market quality. But wouldn’t that also increase overall use? If so, is that worth the tradeoff?

Use may well increase under legalization. That said, existing evidence suggests a modest rather than a dramatic increase. Further, some of this increased use will be beneficial for users, such as people suffering chronic pain who cannot now get adequate opioid medication from the medical system or who avoid even seeking such medications because of excessive fears about the risks of these substances.

We should probably put the scope of your support for legalization in perspective. You’d go as far as making heroin, for instance, available on supermarket shelves, perhaps packaged with a Narcan antidote just in case. True?

In my judgment, it should be legal for grocery stores to sell heroin legally, with or without Narcan. I am not sure how many would do so; community pressure might make such a practice an unappealing business decision. Thus heroin might only be available in pharmacies, for example.

As a society we can’t even seem to decide whether medicinal marijuana should be legalized, yet you’re suggesting we go far beyond that in making even harder drugs readily available. Do you consider yourself a contrarian, or ahead of your time?

My view is that I am going where the evidence leads. Opioids like heroin and morphine were entirely legal and widely available before 1914, when the Harrison Narcotic Act outlawed most of the currently illegal drugs (federal law did not ban marijuana until 1937). When heroin and morphine were fully legal, the country was not full of “addicts” and “junkies”. In fact, opioid use fell substantially during the decades leading up to 1914.

Is it too cynical to suggest the uproar over a heroin “epidemic” is fueled primarily by its spread into white suburbia? After all, heroin problems have been with us for a long time.

The fact that heroin is (allegedly) being used more frequently by whites, and middle class teenagers in particular, may play a role in the recent uproar. More broadly, however, uproars over various illegal drugs have come and gone for decades. These episodes may be good ways for prohibitionist forces to gain power and influence.

Jeffrey Miron is a senior lecturer and director of undergraduate studies in the Department of Economics at Harvard University, as well as a senior fellow at the Cato Institute.