

A new study shows the shifting demographics of heroin use. (AP Photo/Robert F. Bukaty)

Welcome to Health Reform Watch, Jason Millman's regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Jason with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, or sign up here to receive it straight from your inbox. Read previous columns here.

There are plenty of recent signs of heroin's move away from cities into the suburbs and rural areas. Vermont Gov. Peter Shumlin (D) even devoted his entire 2014 state of the state address to what he labeled a "full-blown heroin crisis" after the state saw treatment for the drug increase by 250 percent since 2000.

Now a new study in JAMA Psychiatry underscores just how dramatically heroin abuse has shifted away from predominately minority men living in cities. Compared to 50 years ago, heroin users today are older, live in nonurban areas, and are almost evenly male and female. Perhaps most strikingly, these users probably came to heroin after taking a prescription opioid, the study shows.

Theodore Cicero, vice chairman of research at the Washington University School of Medicine, analyzed survey responses of patients in a treatment program spanning 150 publicly and privately funded centers across the country. Some participated in further interviews for the study.

The shifting demographics are quite dramatic, according to Cicero's research:

While 82.8 percent of heroin users in the 1960s were men, about an equal rate of men and women are now seeking treatment.

The rate of heroin users seeking treatment who are white increased from just above 40 percent in the 1960s to 90.3 percent by 2010.

And the mean age of those seeking treatment increased from 16.5 years old in the 1960s to 22.9 years old in 2010.

How people come to use heroin has also greatly changed. In the 1960s, more than 80 percent said heroin was the start of their opioid use. In the 2000s, though, that had reversed dramatically, with 75 percent reporting they used a prescription opioid before turning to heroin.

Early data from the current decade shows that trend is starting to reverse, with heroin becoming more and more the first opioid of abuse. People who had past or current opioid use but indicated heroin was their primary drug overwhelming said they preferred the high heroin gave them (98.1 percent), and that the drug was cheaper and easier to obtain (94 percent) than prescription opioids.

Cicero attributes the shifting demographics of heroin users to two other major factors, aside from cost and access. First, the greater use and misuse of opioid prescription drugs among populations not previously exposed to them (like white, middle-class men and women) led to more experimentation with heroin. Secondly, there's "widespread acceptance" of heroin use among prescription opioid abusers, he wrote.

We know that people who need specialized substance abuse treatment just aren't getting it. Just 10.8 percent of people who needed treatment for drug or alcohol abuse received it from a specialty facility in 2012, according to that year's National Survey on Drug Use and Health.

The Affordable Care Act and a 2008 mental health parity law are supposed to greatly expand coverage of substance abuse treatment. It's one of 10 required Obamacare benefits that new individual and small-group health plans must cover starting this year, and coverage for substance abuse is supposed to be provided on par with medical treatment. A recent Kaiser Health News story, though, pointed to some struggles delivering on the expanded benefits. Namely, there's a shortage of substance abuse providers and available beds.

Cicero, the study author, said he anticipates further access and treatment issues for these new heroin users.

"I think the new generation of heroin users — predominately white middle class males and females living in suburban and rural areas — who need help with their heroin addiction will have difficulty finding places that treat addiction to heroin since most treatment centers in suburbs and rural areas tend to be private pay and will have little experience with heroin as a primary drug," Cicero said.

Top health policy reads from around the Web:

Employees facing higher insurance costs. "More employees are getting hit with higher health insurance premiums and co-payments, and many don't have the money to cover unexpected medical expenses, a new report finds. ... Employees are worried about covering their medical costs: 49% have less than $1,000 to pay for unexpected out-of-pocket medical expenses; 53% would borrow from their 401(k)s or credit cards to cover unexpected medical costs; 66% say they wouldn't be able to adjust to the large financial costs associated with a serious injury or illness." Nanci Hellmich in USA Today.

Health care has the worst data security. "Healthcare organizations are rife with insecurity, and it's only a question of when a Target-like attack puts millions of patient health information (PHI) files on the black market, a new study suggests. ... Of four industries the study analyzed, healthcare saw the largest surge in attacks and was slowest to respond, taking more than five days to remediate security issues. By comparison, finance took about 3.5 days, and retail and utilities combatted issues within approximately four days." Alison Diana in Information Week.

Some Democrats don't fear Obamacare. "Not long ago, many Democrats were in a defensive crouch when it came to health care, amid public anger about the botched rollout of the federal website to sign up for insurance and stories of people who lost existing coverage because it didn't meet federal standards. ... Now, in at least half a dozen competitive Senate and gubernatorial races, Democrats and their allies are airing TV commercials that directly support the legislation, focusing on its guaranteed coverage for pre-existing conditions, preventive-care benefits and a ban on charging women more for insurance." Laura Meckler in the Wall Street Journal.