Heroin overdose deaths are skyrocketing. Here are 2 theories for why.

Heroin overdose deaths are skyrocketing. From 2011 to 2013, these deaths nearly doubled from about 4,400 to more than 8,200.

There are a few theories for why this is happening. One is that addicts are moving from painkillers to heroin after a crackdown on prescription drug abuse. Another is that cultural shifts massively influence drug use. The first theory shows how the war on drugs can have negative side-effects, and the second shows why the drug war is so hard to truly win.

Prescription painkillers and heroin are both opioids — and some evidence suggests that the drugs might be interchangeable for addicts.

When prescription painkiller deaths began to rise through the 2000s, state and federal officials went after “pill mills” in which doctors and pharmacists provided painkillers unscrupulously or for non-medical purposes. Federal officials also increased restrictions on many opioids through the scheduling system, and encouraged the development of abuse-resistant pills that can’t be snorted or injected as easily. The idea was to cut off the supply of painkillers at the source by halting an abundance of faulty prescriptions.

This seems to have worked: prescription painkiller deaths have leveled off at around 16,000 after increasing for years, from around 8,500 in 2003.

But when many addicts lost access to their painkiller prescriptions, they seemed to turn to heroin. A 2014 study published in JAMA Psychiatry backed this point, suggesting that addicts switched to heroin because it’s relatively cheap and accessible in the black market. And during the past few years, heroin deaths spiked to more than 8,200 in 2013, from around 2,000 10 years before.

This doesn’t necessarily mean that cracking down on prescription drug abuse was the wrong move. Keith Humphreys, drug policy expert at Stanford University, explained in February that no policy is ever going to stop all drug use. The objective, instead, is to minimize the harm of drugs. For instance, if cracking down on pill mills helped stop a rise in tens of thousands of deaths from painkiller overdoses, but led to a few thousand deaths from heroin, that’s still a potential net gain of thousands of lives saved.

“There’s always choices,” Humphreys said. “There is no framework available in which there’s not harm somehow. We’ve got freedom, pleasure, health, crime, and public safety. You can push on one and two of those — maybe even three with different drugs — but you can’t get rid of all of them. You have to pay the piper somewhere.”

Sometimes drug use is driven by cultural shifts, not policy.

Baby boomers in their late teens and early 20s reportedly used nearly every drug — with the big exception of painkillers — at much higher rates than similarly aged millennials, although millennials are using drugs at higher rates than the generation born in the 1960s through 1970s.

What explains these differences? Part of the answer is cultural shifts. The 1960s and 1970s were huge for counterculture movements, when baby boomers were at the prime age (late teens and early 20s) for recreational drug use. But Generation X, which followed the baby boomers, saw the negative effects of widespread drug use, particularly cocaine and heroin, and built a bigger stigma toward such drugs. Some millennials seem to have shrugged off those lessons, taking up marijuana, heroin, and prescription painkillers at elevated rates.

The sway of cultural shifts is one reason the war on drugs will never fully eradicate substance abuse, although different policies, including those that focus on rehabilitation and harm reduction instead of criminal prohibition, might minimize the negative effects of drugs and the illicit market surrounding them. The idea, drug policy experts like Humphreys say, is to find the right balance of policies, instead of hoping for a panacea that will likely never come.