An article in yesterday’s Wall Street Journal, “Heroin Makes a Comeback”, highlights an old problem with a new and deadly twist. Although, prescription pain killers surpassed heroin as the number one new cause of opioid addiction two years ago, the upsurge in heroin use causes new concerns as it now appears as a cheaper alternative to the more expensive pill habit. Many patients who tire of doctor shopping end up buying their pharmaceuticals from a street dealer. Instant “one stop shopping”. There are two special problems with this. First, heroin use gives even chronic pain pill users an incredible high when it is first used. I’ve been told that it’s “like Kissing God”. Dangerous stuff. Second, overdose is much more likely because of the varying strength of heroin that users buy. The number of pills used is easily calculated; the strength of “Brown Sugar” is not. Especially by the neophyte user. While many of my opioid patients are driven to treatment because the increasing cost of their pill addiction is breaking them financially, those who have started heroin are usually sicker, more desperate and come to treatment later. Of note, there are a few who recognize right away that the incredible increase in pleasure that heroin brings is “too good”. How does that recognition occur in some people and not in others? Would that we could determine the differences in people in their timing of seeking help. Just another way of asking why is one addict’s bottom so different from another’s.