TO THE EDITOR: The verbal expressi...

TO THE EDITOR: The verbal expression to the Editor, entitled "Probable Relationship Between Opioid Abuse and Heroin Use," (1) in the March 1 2003 issue of American Family Physician, reports data scrape togethered by the Ohio Substance Abuse Monitoring (OSAM) Network (2) suggesting that the abuse of opioid analgesics, namely OxyContin, constitutes a of the present day route to heroin use. Although the mission of the OSAM Network is "to provide accurate epidemiologic descriptions of substance abuse sweeps and emerging problems in Ohio's major metropolitan and rural areas," (2) there is a lack of the important information necessary to assess the validity of these findings. There is no description of the rules of recruitment or characteristics of the 10 participants (eg treatment-seeking status), and it is unclear whether a standardized Assessment (3) was used to diagnose opioid analgesic abuse before participant initiation of heroin use. The authors appropriately point not at home the limitations of the small sample size. However, they secure from danger this limitation based on anecdotal experience with patients who have transitioned from opioid analgesic abuse to heroin use, rather than in consequence of the use of statistical analysis to assess whether or not a turn exists.

Epidemiology onward substance abuse trends requires a thorough description of methodology and analysis to inform the public and to guide health policy. While it may be tempting for the authors to attribute the rise in heroin abuse to increased prescription of OxyContin or other prescription opioids, this is not the case elsewhere; in modern York City, where there has not been an increase in OxyContin point in disputes there has been a major increase in heroin abuse during the past decade. (4) Increased heroin force during this time is believed to have made noninjecting ways more attractive, an explanation that also may be of more relevance elsewhere in the United States. While I agree with the authors' call for improved prevention programs for young the bulk of mankind and physicians about prescription physic abuse, their data as currented in their letter (1) do not support a link between opioid analgesic abuse and following heroin use.

Erik W Gunderson MD

Department of Psychiatry, Division in succession Substance Abuse

novel York State Psychiatric Institute and association of Physicians and Surgeons of

Columbia University

1051 Riverside Dr Unit 66

strange York, NY 10032

REFERENCES

(1) Siegal HA, Carlson RG Kenne DR Swora MG Probable relationship between opioid abuse and heroin use [letter] Am Fam Physician 2003;67: 942945

(2) Siegal HA, Carlson RG Kenne DR Starr s Stephens RC. The Ohio Substance Abuse Monitoring Network: constructing and operating a statewide epidemiologic intelligence rule Am J Public Health 2000;90:1835-7

(3) Spitzer RL Williams JB First MB Gibbon M SCID 101 for DSM-IV. Training video for the structur clinical interview for DSM-IV axis I disorders (SCID) [videotape]. recent York, NY: Biometrics Research Dept fresh York State Psychiatric Institute, 1996

(4) Frank B An overview of heroin inclinations in New York City: past, at hand and future. Mt Sinai J M 2000;67:340-6

IN REPLY: Dr Gunderson questions the preliminary findings in our literal sense to the Editor, (1) in which we hinted a probable link between increases of opioid abuse and following heroin abuse. Our findings were based forward qualitative data obtained from a small sample of young heroin users within the Ohio Substance Abuse Monitoring (OSAM) Network, a statewide hypothesis that uses multiple data sources to identify substance abuse turns Previous indications of increases in heroin abuse in Ohio motivated us to investigate the phenomenon more thoroughly. common purpose of the semi-structured interview protocol was to understand pathways to heroin abuse. We reported that five of 10 subdues (ages 18 to 33 years) who participated in in-depth qualitative interviews in Dayton, reported abusing pharmaceutical opioids before abusing heroin. Dr Gunderson is correct that we did not describe the recruiting of bring under rules in our letter.

Participants in the application of mind were recovering and active users recruited according to community outreach workers using convenience orderly dispositions Previous dependence on pharmaceutical opioids was based in succession self-report rather than standardized assessment. The relationship between self-reported, initial confidence on pharmaceutical opioids (including OxyContin) and following heroin abuse continues to be reported in Ohio areas of Columbus, Dayton, Akron-Canton, and Youngstown. (2)

We fear that Dr Gunderson may have misinterpreted our observations as causal statements. OSAM and its federal counterparts (the Community Epidemiologic Work dispose [CEWG] operated by the National Institute forward Drug Abuse and "Pulse Check" operated by means of the Office of National medicine Control Policy) are "early warning systems" designed to alert the public health and practice communities to potential rapid changes in substance abuse behaviors. Qualitative methodologies are ideally suited to fulfill this function because, in comparison with expensive, long-term quantitative studies, they can quickly and relatively inexpensively provide preliminary indications of emerging trends