There has been a lot of talk in the news lately about rising rates of heroin use among young people across the United States. From Minnesota to Kentucky, California to Vermont, reports of skyrocketing overdose deaths, opioid addictions as well as the public push for greater availability of lifesaving drugs like naloxone are defining the dynamics of America’s next big addiction epidemic.

But one facet of the nation’s newest fix lurks below the surface when it comes to the health of our nation’s injection drug users—the hepatitis C virus (HCV). According to national disease surveillance data from the U.S. Centers for Disease Control and Prevention (CDC), new cases of the liver disease are increasing for the first time since the early ’90s. Many say drugs are to blame.

CDC data shows that between 2003 and 2010, acute hep C prevalence remained steady at 0.3 cases per 100,000. In other words, about 1 in 330,000 Americans contracted the disease annually. But since 2012, that prevalence has gone up to 0.4 per 100,000, or about 1 in 250,000 people.

Today, an estimated 3.2 million people in the United States are currently living with hepatitis C, with the large majority unaware of their status. It is the most common blood-borne infection in the country, and new infections are growing fastest among America’s youth.

Why this population? The full picture involves young people, prescription painkillers, heroin and hep C. It’s complicated. To find answers, Hep went to both the data and the experts, talking with Daniel Raymond—the policy director at Harm Reduction Coalition (HRC), a national advocacy organization that helps address the health and dignity of injection drug users (IDUs)—and Judith Feinberg, MD—a practicing physician and professor of medicine and infectious diseases at Ohio’s University of Cincinnati who’s fighting some of the highest hep C prevalence rates in the country.

Opioids, Heroin and Hepatitis C

CDC stats show that in 2012, the largest increase of new hepatitis C cases occurred among people between the between the ages of 20 and 29. Prevalence rates of new acute infections in this group went up from 0.75 to 1.18 cases per 100,000, making young people today more than twice as likely to be newly infected with hep C than the national average. In addition, acute cases of hep C among people younger than 19 doubled during this time period, from a 0.05 prevalence up to 0.1 per 100,000 population.

Between 2006 and 2012 at least 30 states have experienced increases in their hep C infection rates, with more than half reporting at least a 200 percent increase in acute infections among their under-30 populations. Overall, the prevalence of acute hep C cases among people under 30 rose from 36 to 49 percent in just six years.

Daniel Raymond at the HRC says that a combination of opioids and heroin is driving the epidemic among the nation’s youth. He recalls first making the connection while working in a syringe exchange in Massachusetts.

“Before the early 2000s, the national picture was that it seemed like injectors were by and large an aging population,” Raymond says. “We started to see more and more young people toward the end of the ’90s, and it was during that time period that I saw my first person who said that their drug of choice was OxyContin.”

As it turns out, this may not be an uncommon path: abuse of prescription painkillers leads to injection drug use (sometimes shooting up versions of the pills before moving on to street heroin), which in turn leads to hepatitis. In fact, the latest stats show that 77 percent of new youth-based hep C infections reported today are among injection drug users. The majority, or 56 percent, come from suburban and rural settings. Eighty-five percent are white, and 76 percent say they tried a prescription painkiller before shooting up.

Coincidentally, the early 2000s were also a hot spot for the prescription pill market. Between 2001 and 2011, the number of prescribed opioids for pain quadrupled. Drugs like hydrocodone (brand name Vicodin, Lorcet, Lortab, Norco), oxycodone (OxyContin, Percocet) and morphine (Kadian, Avinza, MS Contin) were given out to patients after dental surgeries, back problems or broken bones at alarmingly high rates. Today, Americans consume nearly 80 percent of the world’s pain pills, despite making up just 5 percent of the international population. And the sales to small-town communities across the country have since had their effect. Surveys show that almost one in four people ages 18 to 25 say they’ve used a prescription painkiller not as recommended by a medical professional.

Judith Feinberg, who works at UC researching the HIV, hep C and heroin epidemics in the Midwest, while running a new syringe exchange program throughout Southern Ohio and Northern Kentucky, says the link between young people and opioids is complex.

“Many people who shoot up heroin in this part of the world started with prescription drugs. Some of them may have had a legitimate medical need for painkillers but were given too much and kind of got used to it,” Feinberg says. “Other people have looked into these pills for their abuse potential since the beginning.”

Raymond and Feinberg say heroin soon followed people’s tastes for opioids for two reasons:

First, was the government’s 2010–2012 crackdown on “pill mills”—medical facilities where doctors prescribed huge amounts of prescription painkillers to make money on the growing addiction market. The feds limited refills, mandated more visits to doctors to obtain a script and even pushed pharmaceuticals to reformulate their drugs into non-injectable forms. As a result, the number of Americans saying that opioids were their drugs of choice actually fell from 35.6 percent to 12.8 percent in just two years. However, heroin use doubled. In fact, many advocates claim that instead of stopping the addiction, federal regulators simply hastened the switch to heroin.

“Now that the drug has been reformulated, if you pulverize it and heat it, it just becomes a kind of goo. It’s not really injectable anymore, and that made the stuff scarcer,” Feinberg says. “So even people who said, Well yeah, I really liked opioids but I would never get involved with needles ended up turning to injecting [heroin] pretty quickly.”

It’s also important to note that prescription painkillers and heroin are basically the same drug. They both come from the poppy plant, have very similar chemical structures and bind to the same chemical receptors in the brain. Both opioids and heroin give users an increased pain tolerance, a feeling of euphoria, drowsiness and, at high enough doses, slowed breathing rates. Both also trigger tolerances and are highly addictive.

But there’s a second component to the rise in heroin use among painkiller addicts: Big business. “It seems like even if there hadn’t been a crackdown, just the economics of it would have driven a subset of people to seek out heroin,” Raymond says. “The drug trade has expanded to new areas following the rise in prescription opioid use, so it’s almost a kind of black market supply and demand.”

Feinberg agrees: “You can buy a bag of heroin in Cincinnati for less than a pack of cigarettes, for $5.” By comparison, she says, prescription pills go for about $1 to $2 per milligram. “Drug dealing is a very capitalist enterprise, and where there’s a vacuum, markets will develop.”

All this addiction is coming at a huge cost for young IDUs. It is estimated that 31,000 young people may be infected with hepatitis C every year in the United States through injection drug use. One study on IDU hep C rates at New York City’s Center for Drug Use and HIV Research estimated that around 66 percent of addicts would become infected with hepatitis C at some point in their lives, though estimates range from 10 to almost 100 percent among different IDU demographics.

Experts say these high rates can be answered, in part, because hepatitis C is a blood-borne infection that is both very contagious and highly resilient. It is thought to be 5 to 20 times more infective than HIV. Lab studies also show that, unlike HIV, hep C can live on surfaces for anywhere between two weeks up to 63 days after it leaves the body. That means it’s not just sharing needles that can transmit the virus—it’s also sharing injecting equipment like “cookers,” filters, swabs, tourniquets and even water.

Raymond, who started out his work in harm reduction during the HIV epidemic, says the way we’ve been reaching out to drug users since the ’80s may not be as relevant when it comes to hepatitis C. “The message that everybody gets is, Don’t share needles. With HIV that seems to be enough [to stop infections].”

But, he says, adding the idea that you can’t share a cooker, a swab or even a tourniquet with others is a new and somewhat complicated message for young folks. Already, nearly 50 percent of young addicts report sharing needles, and 82 percent say they’ve shared other paraphernalia to cook their drugs. National surveillance stats also suggest that up to 72 percent of young injectors living with hepatitis C are unaware of their infections.

Dealing With Hep C and Heroin Hot Spots

Another complicated facet of the hep C-heroin epidemic is that it’s not uniform across the country. In 2012, hepatitis C rates increased twice as much among America’s non-urban population than urban, with new infections heavily concentrated in areas east of the Mississippi River.

Over the past year, Hep has covered several of these hep C “hot spots” via our online newsfeed. Here’s a sample:

•    The New River Valley Region, Virginia

•    Minnesota

•    Cape Cod, Massachusetts

•    Northern Kentucky

The five states that are currently experiencing the worst hep C outbreaks among young people are: Kentucky, Tennessee, Georgia, Indiana and Florida.

The regional trends present a unique problem, says Raymond, because “regularly distressed rural areas do not have a whole lot of resources or infrastructure in terms of medical care, in terms of access to drug treatment, in terms of public health services.” That can make both treatment and prevention tactics nearly impossible, especially among a secretive group like young addicts.

In addition, he says, the political battle has been uphill for harm reduction approaches since HRC started out in the early ’90s.

For one thing, syringe access is actually regulated by state law. That means access to harm reduction can vary depending on the political beliefs of a region’s governing party.

Getting money for these kinds of programs has also proved to be quite difficult for harm reduction advocates. In 2009, Congress actually lifted the ban on the use of federal funds for syringe exchanges. But two years later, lawmakers re-imposed it despite a large body of evidence showing that making syringes available doesn’t lead to higher rates of drug use.

Currently, there are just 194 syringe exchange programs across 33 states, and experts estimate that they are reaching less than 3 percent of all the injections.

“We know that education may increase knowledge, but it’s not always enough to change behavior,” Raymond says. “We think it’s going to be the structural things that will have a bigger impact on prevention.”

Judith Feinberg, back in Ohio, agrees. “I think it makes great sense to do sort of one-stop shopping. People come in for their daily methadone; they can also get their daily hepatitis C pill. It’s enough to deal with getting over your substance abuse, but now if you have to get over your hep C as well…that’s a lot for someone to accomplish successfully.”

Hence why Feinberg helped start the Cincinnati Exchange Project, a medical van that has been doing both syringe exchange and overdose prevention training as well as testing and education for hepatitis C and HIV across her community since early February. But everywhere she turns, the political pushback seems to follow.

“We were open for six weeks, and then we got shut down in the neighborhood that had given us the original permission,” Feinberg says. “And then we opened up again in June in a location inside the city, and that was going just fine until a couple of weeks ago, when the Cincinnati prosecutor said that he would get nasty about it. We’ve had a lot of ups and downs.”

Currently, there are no stand-alone syringe exchanges in Kentucky, West Virginia, Mississippi, Missouri, Texas, Oklahoma, Arkansas, Iowa, Colorado, Idaho or either of the Dakotas.

“They are going to get worse, no question,” says Feinberg, when asked about the state of the heroin hep C epidemic among young IDUs. “We need to have the kinds of places that really connect with people, who don’t stigmatize them, who understand what they’ve been through and who can be a resource for people when they come in and say, ‘I’ve had enough, help me.’”