The heroin epidemic in New York City: current status and prognoses

Public Opinion and Public Policy: Heroin and Other Opioids

Virginia, much like other states, has experienced unprecedented rates of heroin and prescription opioid abuse, overdoses, and deaths. Given the wide range of competing voices concerning drug policy and the complicated situation of the contemporary opioid epidemic, this study examines whether public opinion is reflected in public policy toward illicit involvement with opioids. The 2016 Commonwealth Public Policy Survey, a statewide representative sample of 1,000 Virginia residents, found that Virginians are supportive of treatment over arrest for heroin and prescription pill abusers and factors such as race, education, and political affiliation are predictive of support for treatment over arrest. More importantly, the results of this poll converge with legislative policies of the 2017 General Assembly, supporting the notion that public support can have an influence on the policymaking process. Policy implications are discussed.

White opioids: Pharmaceutical race and the war on drugs that wasn't

The US 'War on Drugs' has had a profound role in reinforcing racial hierarchies. Although Black Americans are no more likely than Whites to use illicit drugs, they are 6-10 times more likely to be incarcerated for drug offenses. Meanwhile, a very different system for responding to the drug use of Whites has emerged. This article uses the recent history of White opioids - the synthetic opiates such as OxyContin® that gained notoriety starting in the 1990s in connection with epidemic prescription medication abuse among White, suburban and rural Americans and Suboxone® that came on the market as an addiction treatment in the 2000s - to show how American drug policy is racialized, using the lesser known lens of decriminalized White drugs. Examining four 'technologies of whiteness' (neuroscience, pharmaceutical technology, legislative innovation and marketing), we trace a separate system for categorizing and disciplining drug use among Whites. This less examined 'White drug war' has carved out a less punitive, clinical realm for Whites where their drug use is decriminalized, treated primarily as a biomedical disease, and where their whiteness is preserved, leaving intact more punitive systems that govern the drug use of people of color.

Projecting and Monitoring the Life Course of the Marijuana/Blunts Generation

Since the 1990s, marijuana has been the drug of choice among American youths, especially those that tend to sustain arrests. Previous birth cohorts had greater use of crack, powder cocaine, or heroin. This paper summarizes prior research that strongly suggests drug eras tend to follow a regular course. These insights then serve as the basis for projecting trends in marijuana use both for the general population nationwide and for Manhattan arrestees. To the extent that current trends persist, the prospects for the "Marijuana/Blunts Generation" (born 1970 and later) may be relatively good. These young persons may successfully avoid "hard drugs" as well as the attendant health, social, and legal problems for their entire life, but they may experience higher levels of smoking-related ailments. The conclusion presents issues for continued drug surveillance and ethnographic research to more accurately understand the Marijuana/Blunts Era and to provide an indicator of future changes as they occur.

White Chicks on Dope: Heroin and Identity Dynamics in New York in the 1990s

We examined heroin use among 15 White middle-class women using data from in-depth qualitative interviews and ethnographic observation between May 1996 and April 1999. These women represent a subsample of a diverse group of 550 in an ethnographic study of heroin use and dealing in New York City. Our analysis is organized into four sections: (1) a demographic sketch, (2) the first time, (3) mode of administration and patterns of use, and (4) heroin in the medicine cabinet. Heroin use among these women was not related to poverty or lack of opportunity, social disenfranchisement, defective or addictive personalities, childhood trauma, or seeking membership into deviant subcultures. While some of these discourses of adversity and thrill seeking may have surfaced in individual stories, the dominant theme that emerged from the data was that of active struggles around identity, struggles over who and how one does and does not want to be.

Characteristics and Patterns of use among Regular Heroin Sniffers

The purpose of this paper is to characterize persons who sniff heroin by examining their experiences prior to first heroin use, experiences at first use, current drug use patterns, and factors associated with progression to the daily use of heroin. Relatively little has been published about the lives and career trajectories of heroin sniffers who have little or no history of drug injection. A sample of 250 African-American, Hispanic/Latino, and non-Hispanic White men and women who sniffed heroin were interviewed for this study. Most people first sniffed heroin in a social setting where heroin use was not preplanned. Heroin sniffing has become a sustained pattern of use for many of these users; the majority have progressed to daily sniffing of heroin and are polydrug users for whom crack is an important substance; and heroin sniffers have experienced a range of life and health problems including a high prevalence of HIV.

Opioid Use Trajectories, Injection Drug Use, and Hepatitis C Virus Risk Among Young Adult Immigrants from the Former Soviet Union Living in New York City

Available evidence suggests that young former Soviet Union immigrants in New York City have high rates of non-medical prescription opioid and heroin use, drug injection and injection-related risk behavior, making them vulnerable to hepatitis C virus (HCV)/human immunodeficiency virus (HIV) infection, overdose and associated harms. This group has been the focus of little research, however. This paper presents quantitative and qualitative data from 80 former Soviet immigrants (ages 18-29) to characterize their opioid use trajectories, injection risk behavior, HCV/HIV testing histories and self-reported HCV/HIV serostatus, and provides clinically meaningful data to inform tailored education, prevention and harm reduction interventions.

Correlates and contexts of US injection drug initiation among undocumented Mexican migrant men who were deported from the United States

Preventing the onset of injection drug use is important in controlling the spread of HIV and other blood borne infections. Undocumented migrants in the United States face social, economic, and legal stressors that may contribute to substance abuse. Little is known about undocumented migrants' drug abuse trajectories including injection initiation. To examine the correlates and contexts of US injection initiation among undocumented migrants, we administered quantitative surveys (N = 309) and qualitative interviews (N = 23) on migration and drug abuse experiences to deported male injection drug users in Tijuana, Mexico. US injection initiation was independently associated with ever using drugs in Mexico pre-migration, younger age at first US migration, and US incarceration. Participants' qualitative interviews contextualized quantitative findings and demonstrated the significance of social contexts surrounding US injection initiation experiences. HIV prevention programs may prevent/delay US injection initiation by addressing socio-economic and migration-related stressors experienced by undocumented migrants.

The social production of substance abuse and HIV/HCV risk: an exploratory study of opioid-using immigrants from the former Soviet Union living in New York City

Background

Several former Soviet countries have witnessed the rapid emergence of major epidemics of injection drug use (IDU) and associated HIV/HCV, suggesting that immigrants from the former Soviet Union (FSU) may be at heightened risk for similar problems. This exploratory study examines substance use patterns among the understudied population of opioid-using FSU immigrants in the U.S., as well as social contextual factors that may increase these immigrants' susceptibility to opioid abuse and HIV/HCV infection.

Methods

In-depth interviews were conducted with 10 FSU immigrants living in New York City who initiated opioid use in adolescence or young adulthood, and with 6 drug treatment providers working with this population. Informed by a grounded theory approach, interview transcripts were inductively coded and analyzed to identify key themes.

Results

The "trauma" of the immigration/acculturation experience was emphasized by participants as playing a critical role in motivating opioid use. Interview data suggest that substance use patterns formed in the high-risk environment of the FSU may persist as behavioral norms within New York City FSU immigrant communities - including a predilection for heroin use among youth, a high prevalence of injection, and a tolerance for syringe sharing within substance-using peer networks. Multiple levels of social context may reproduce FSU immigrants' vulnerability to substance abuse and disease such as: peer-based interactional contexts in which participants typically used opioids; community workplace settings in which some participants were introduced to and obtained opioids; and cultural norms, with roots in Soviet-era social policies, stigmatizing substance abuse which may contribute to immigrants' reluctance to seek disease prevention and drug treatment services.

Conclusion

Several behavioral and contextual factors appear to increase FSU immigrants' risk for opioid abuse, IDU and infectious disease. Further research on opioid-using FSU immigrants is warranted and may help prevent increases in HIV/HCV prevalence from occurring within these communities.

Estimating the prevalence of injection drug use among black and white adults in large U.S. metropolitan areas over time (1992--2002): estimation methods and prevalence trends

No adequate data exist on patterns of injection drug use (IDU) prevalence over time within racial/ethnic groups in U.S. geographic areas. The absence of such prevalence data limits our understanding of the causes and consequences of IDU and hampers planning efforts for IDU-related interventions. Here, we (1) describe a method of estimating IDU prevalence among non-Hispanic Black and non-Hispanic White adult residents of 95 large U.S. metropolitan statistical areas (MSAs) annually over an 11-year period (1992--2002); (2) validate the resulting prevalence estimates; and (3) document temporal trends in these prevalence estimates. IDU prevalence estimates for Black adults were calculated in several steps: we (1) created estimates of the proportion of injectors who were Black in each MSA and year by analyzing databases documenting injectors' encounters with the healthcare system; (2) multiplied the resulting proportions by previously calculated estimates of the total number of injectors in each MSA and year (Brady et al., 2008); (3) divided the result by the number of Black adults living in each MSA each year; and (4) validated the resulting estimates by correlating them cross-sectionally with theoretically related constructs (Black- and White-specific prevalences of drug-related mortality and of mortality from hepatitis C). We used parallel methods to estimate and validate White IDU prevalence. We analyzed trends in the resulting racial/ethnic-specific IDU prevalence estimates using measures of central tendency and hierarchical linear models (HLM). Black IDU prevalence declined from a median of 279 injectors per 10,000 adults in 1992 to 156 injectors per 10,000 adults in 2002. IDU prevalence for White adults remained relatively flat over time (median values ranged between 86 and 97 injectors per 10,000 adults). HLM analyses described similar trends and suggest that declines in Black IDU prevalence decelerated over time. Both sets of IDU estimates correlated cross-sectionally adequately with validators, suggesting that they have acceptable convergent validity (range for Black IDU prevalence validation: 0.27 < r < 0.61; range for White IDU prevalence: 0.38 < r < 0.80). These data give insight, for the first time, into IDU prevalence trends among Black adults and White adults in large U.S. MSAs. The decline seen here for Black adults may partially explain recent reductions in newly reported cases of IDU-related HIV evident in surveillance data on this population. Declining Black IDU prevalence may have been produced by (1) high AIDS-related mortality rates among Black injectors in the 1990s, rates lowered by the advent of HAART; (2) reduced IDU incidence among Black drug users; and/or (3) MSA-level social processes (e.g., diminishing residential segregation). The stability of IDU prevalence among White adults between 1992 and 2002 may be a function of lower AIDS-related mortality rates in this population; relative stability (and perhaps increases in some MSAs) in initiating IDU among White drug users; and social processes. Future research should investigate the extent to which these racial/ethnic-specific IDU prevalence trends (1) explain, and are explained by, recent trends in IDU-related health outcomes, and (2) are determined by MSA-level social processes.

New injectors and the social context of injection initiation

BACKGROUND

Preventing the onset of injecting drug use is an important public health objective yet there is little understanding of the process that leads to injection initiation. This paper draws extensively on narrative data to describe how injection initiation is influenced by social environment. We examine how watching other people inject can habitualise non-injectors to administering drugs with a needle and consider the process by which the stigma of injecting is replaced with curiosity.

METHOD

In-depth interviews (n=54) were conducted as part of a 2-year longitudinal study examining the behaviours of new injecting drug users.

RESULTS

Among our sample, injection initiation was the result of a dynamic process during which administering drugs with a needle became acceptable or even appealing. Most often, this occurred as a result of spending time with current injectors in a social context and the majority of this study's participants were given their first shot by a friend or sexual partner. Initiates could be tenacious in their efforts to acquire an injection trainer and findings suggest that once injecting had been introduced to a drug-using network, it was likely to spread throughout the group.

CONCLUSION

Injection initiation should be viewed as a communicable process. New injectors are unlikely to have experienced the negative effects of injecting and may facilitate the initiation of their drug-using friends. Prevention messages should therefore aim to find innovative ways of targeting beginning injectors and present a realistic appraisal of the long-term consequences of injecting. Interventionists should also work with current injectors to develop strategies to refuse requests from non-injectors for their help to initiate.

Estimating the prevalence of injection drug users in the U.S. and in large U.S. metropolitan areas from 1992 to 2002

This paper estimates the prevalence of current injection drug users (IDUs) in 96 large U.S. metropolitan statistical areas (MSAs) annually from 1992 to 2002. Multiplier/allocation methods were used to estimate the prevalence of injectors because confidentiality restrictions precluded the use of other commonly used estimation methods, such as capture-recapture. We first estimated the number of IDUs in the U.S. each year from 1992 to 2002 and then apportioned these estimates to MSAs using multiplier methods. Four different types of data indicating drug injection were used to allocate national annual totals to MSAs, creating four distinct series of estimates of the number of injectors in each MSA. Each series was smoothed over time; and the mean value of the four component estimates was taken as the best estimate of IDUs for that MSA and year (with the range of component estimates indicating the degree of uncertainty in the estimates). Annual cross-sectional correlations of the MSA-level IDU estimates with measures of unemployment, hepatitis C mortality prevalence, and poisoning mortality prevalence were used to validate our estimates. MSA-level IDU estimates correlated moderately well with validators, demonstrating adequate convergence validity. Overall, the number of IDUs per 10,000 persons aged 15-64 years varied from 30 to 348 across MSAs (mean 126.9, standard deviation 65.3, median 106.6, interquartile range 78-162) in 1992 and from 37 to 336 across MSAs (mean 110.6, standard deviation 57.7, median 96.1, interquartile range 67-134) in 2002. A multilevel model showed that overall, across the 96 MSAs, the number of injectors declined each year until 2000, after which the IDU prevalence began to increase. Despite the variation in component estimates and methodological and component data set limitations, these local IDU prevalence estimates may be used to assess: (1) predictors of change in IDU prevalence; (2) differing IDU trends between localities; (3) the adequacy of service delivery to IDUs; and (4) infectious disease dynamics among IDUs across time.

Long-term recovery from heroin use among female ex-offenders: Marisol's story

Ex-offenders experience various difficulties in successfully reentering communities post-incarceration. For those with a history of opioid misuse, despite various interventions, long-term recovery rates are relatively low. Additionally, the difficulties ex-offenders experience reintegrating with their families and communities are further compounded by the stigma and structural barriers posed by prior criminal and drug use histories. This qualitative study, using in-depth interviews conducted during an 18-month period between mid 2004 and late 2005 examines the process of creating and maintaining abstinence among 25 former heroin users, mostly Latino and African American New York City ex-offenders who have remained abstinent from heroin use for a period of 5 yr or longer. Focusing primarily on the story of one female respondent and in participants' own words, the factors that they found to be most salient in enhancing their recovery efforts (positive peer support, motivational tools, exercise, meditation, skills enhancement) are examined. The study findings suggest that reentry programs and policies can help ex-offenders sustain long-term abstinence and prosocial lifestyles by supporting the various coping strategies that they identify as being particularly valuable.

A five-year review of the medical outcome of heroin body stuffers

The medical outcome of heroin body stuffers has rarely been described. This study was performed to illustrate the clinical course of heroin body stuffers. A retrospective chart analysis was performed on all cases of heroin body stuffers received by a metropolitan poison control center from 2000-2004. We identified 65 heroin body stuffers. Sixty-nine percent were men with a mean age of 35 years. The stated quantity of heroin containers ingested ranged from 1 to 30, with 65% reported as being wrapped in plastic. Six patients (9.2%) developed symptoms of opiate intoxication. All symptoms began within an hour after the ingestion. Three patients (4.6%) needed naloxone. The mean length of observation was 24 h. Opiate intoxication from heroin stuffing is uncommon. Those patients that developed symptoms did so early in their course. These data indicate a benign clinical course in most heroin body stuffers.

Young heroin users in Baltimore: a qualitative study

This study describes the characteristics of 67 young heroin users, interviewed using a semistructured qualitative questionnaire (QQ) as part of a larger study of 18- to 25-year-old heroin users seeking detoxification with buprenorphine at a drug treatment center in Baltimore. This new generation of heroin users has a different demographic profile compared to older heroin users in this area. Our data, supported by data from another clinic and from the Maryland State Alcohol and Drug Abuse Administration, seem to indicate that the younger heroin users in treatment settings are predominantly White, with a high proportion of women, often living in the suburbs. Based on responses to the QQ, all subjects initiated heroin use intranasally, usually in a group setting; 75% had subsequently gone on to use intravenously. The typical young heroin user in Baltimore Metropolitan area appears to be a young White man or woman from a middle/working-class background, with exposure to drug use among close contacts while growing up, experimenting with gateway drugs with peers before proceeding first to intranasal, and then intravenous heroin use, engaging in criminal activities to support the habit, repeatedly seeking help with assistance from family, but failing to sustain abstinence due to continued exposure to drug using peers and a poorly implemented plan of aftercare. Further research should focus on efforts to engage peer groups and families in order to improve treatment outcomes in young heroin users.

The new heroin users among Manhattan arrestees: variations by race/ethnicity and mode of consumption

The incidence of heroin use among Manhattan arrestees interviewed by the Arrestee Drug Abuse Monitoring (ADAM) program remained around 20% from 1987 through 2001. However, the authors had expected a decline because the heroin injection epidemic peaked back in the 1960s and early 1970s. A detailed analysis found differences across race/ethnicity. Black arrestees born since 1955 (who came of age since the heroin injection epidemic) were much less likely to use heroin than those born between 1945 and 1954 (who came of age during the epidemic). Hispanic arrestees born since 1970 (but not those born between 1955 and 1969) were also less likely to use heroin, suggesting that the decline in heroin use started among Blacks before Hispanics. During the 1990s, sniffing replaced injecting as the predominant mode of heroin consumption for Black and Hispanic arrestees, even among older arrestees. In strong contrast, the prevalence of heroin use among White arrestees did not decline in the 1990s and injection was still their most popular method of consumption. The discussion highlights implications for further research and drug treatment.

An invisible barrier to integrating HIV primary care with harm reduction services: philosophical clashes between the harm reduction and medical models

Overall AIDS mortality in the United States has declined in recent years, but declines have not been consistent across all populations. Due to an array of barriers to care, minorities and poor people who are active substance users have not benefited as others have from advances in the treatment of HIV disease. One way to address this problem is to integrate HIV primary care into harm reduction programs that already effectively serve this population. Such collaborations, however, are difficult to initiate and sustain. Philosophical differences between the medical model and the harm reduction model, which often remain invisible to the parties involved, underlie these difficulties. This article addresses the issue by describing a partnership in the Bronx, NY, between CitiWide Harm Reduction Inc. (CitiWideHR) and the Montefiore Medical Center. It focuses specifically on the sources of philosophical differences between models, and briefly assesses the potential for successful collaborations of this sort.

Updating the infection risk reduction hierarchy: preventing transition into injection

Current approaches to prevention of blood-borne infections in injection drug users include referral to drug abuse treatment, access to sterile syringes, bleach disinfection of injection equipment, and education about not sharing equipment. However, rates of some blood-borne infections (e.g., hepatitis C virus) remain elevated among injection drug users, especially early after initiation into injection drug use. With lower infection rates in noninjectors and transition into injection drug use occurring most commonly among these noninjectors, prevention of transition into injection drug use as an additional step to reduce risk for acquisition and transmission of blood-borne infections merits closer attention.

The social course of drug injection and sexual activity among YMSM and other high-risk youth: an agenda for future research

The cumulative epidemiologic literature indicates that many injecting drug users (IDUs) initiate injection as a mode of drug administration during late adolescence or early adulthood. Recent studies have shown that IDUs are often exposed to viral infections relatively early in the course of injection, highlighting the importance of understanding this initiation process for both epidemiology and prevention. Epidemiologic evidence similarly suggests that at least some youth populations, most notably young men who have sex with men (YMSM), are at substantial risk for exposure to HIV and other sexually transmitted diseases (STDs) from early sexual activity. Despite the importance of this issue for both epidemiology and prevention, however, surprisingly little information is available on the social course of injection initiation, including the individual, social, or ecological factors that might mitigate or exacerbate transmission risks within the critical phase of early injection drug use. Similarly, we know little about the ways that YMSM and other high-risk youth understand risk, the kinds of exchanges and relationships in which they participate in the context of initiating sexual activity, or how drug use is operant in these exchanges and early sexual experiences. In this article, we explore key dimensions of the early initiation of injection and sexual risk, and discuss how a social network approach might be instrumental in understanding the social course of drug injection and sexual activities among youth and young adult populations.

The current New York City heroin scene

This article discusses the use and distribution of heroin in New York City, both historically and especially currently. Data on the current situation derive in large measure from the Heroin Project, a recently completed five-year ethnographic study of heroin in New York City funded by the National Institute on Drug Abuse. Findings about the new, young heroin user, particularly in regard to demographic characteristics, patterns of use, modes of ingestion, and involvement in crime, and some of the ways in which the new user is similar and different from the "old time" heroin user are presented. In addition changes in the New York City heroin markets over the years are discussed. We note the effectiveness of methadone maintenance treatment in terms of its impact on heroin-related crime, make suggestions as to how methadone treatment could be expanded, and review current heroin policy and the War on Drugs, with a focus on the New York State Rockefeller drug laws and the need for policy reform in this area.

The role of methadone in drug-related deaths in the west of Scotland

AIMS

To determine the incidence of methadone as either the principal cause of death or as a contributing factor in drug related deaths in the Strathclyde Police region of Scotland and to assess the impact of supervised consumption of methadone on the number of deaths that occurred within each health board area within this region.

DESIGN

Retrospective analysis of records held within the Department of Forensic Medicine and Science based at the University of Glasgow over the 11-year period 1991-2001.

SETTING

The Strathclyde Police region of Scotland (population approximately 2.25 million).

FINDINGS

In 1991, there was one death recorded which was attributable to methadone. Following the introduction of the methadone maintenance programme (MMP) in Glasgow during 1994, there was a 100% increase in these deaths compared to the previous year, a trend which continued over the subsequent 2 years. Following a confidential enquiry into these deaths and a greater compliance from pharmacies supervising methadone consumption, deaths involving methadone had decreased by 48% in 1997. This was particularly evident in the Greater Glasgow Health Board Area, where methadone prescribing has continued to rise annually. However, some difficulties still exist. Multiple take home doses are sometimes prescribed when a pharmacy is closed, which may lead to inadvertent overdose or facilitate diversion of legitimate supplies. In addition, continued use of heroin was found in approximately one-fifth of MMP patients, suggesting possible underdosing.

CONCLUSIONS

A growing prevalence of heroin misuse has resulted in an increase in the number of individuals entering the MMP. Despite a continuing increase in the amount of methadone prescribed, methadone deaths in Strathclyde have decreased since 1996 due possibly to changes in both prescribing and clinical care. With efficient management to establish that the patient is complying with the guidelines of the programme and has stopped heroin misuse, methadone can be a safe drug for substitution therapy.

Reasons for selecting an initial route of heroin administration and for subsequent transitions during a severe HIV epidemic

AIM

To identify the most important reasons for selecting a particular route of heroin administration and for subsequent transitions during a period of epidemic HIV transmission. To study temporal trends in these reasons.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Nine hundred heroin users in three Spanish cities: 305 in Seville, 297 in Madrid and 298 in Barcelona.

MEASUREMENTS

A separate analysis was made of the reasons for five types of behaviour: (a) selecting injection as the initial usual route of heroin administration (URHA); (b) changing the URHA to injection; (c) never having injected drugs; (d) selecting the smoked or sniffed route as the initial URHA; and (e) changing the URHA to a non-injected route. Subjects were invited to evaluate the importance of each reason included in a closed list. Spontaneously self-perceived reasons were also explored in an open-ended question for each of the five types of behaviour studied.

FINDINGS

The primary reason selected for each type of behaviour was: (a) pressure of the social environment; (b) belief that injection is a more efficient route than smoking or sniffing heroin; (c) concern about health consequences (especially fears of HIV and overdose), and fear of blood or of sticking a needle into one's veins; (d), pressure of the social environment and (e) concern about health consequences and vein problems. For women, having a sexual partner who injected heroin played a decisive role in initiating or changing to injection. Few people spontaneously mentioned market conditions for purchasing heroin as an important reason for any behaviour, nor did many mention risk of overdose as reasons for (c) or (d).

CONCLUSIONS

These findings should be considered when designing interventions aimed at preventing initiation of injecting or facilitating the transition to non-injected routes.

Behavioral naltrexone therapy: an integrated treatment for opiate dependence

Treatment of opiate dependence with naltrexone has been limited by poor compliance. Behavioral Naltrexone Therapy (BNT) was developed to promote adherence to naltrexone and lifestyle changes supportive of abstinence, by incorporating components from empirically validated treatments, including Network Therapy with a significant other to monitor medication compliance, the Community Reinforcement Approach, and voucher incentives. An overview is presented of the BNT treatment manual. In an uncontrolled Stage I trial (N = 47), 19% completed the 6-month course of treatment. Retention was especially poor in the subsample of patients who were using methadone at baseline (N = 18; 39% completed 1 month, none completed 6 months), and more encouraging among heroin-dependent patients (N = 29; 65% completed 1 month, 31% completed 6 months). Thus, attrition continues to be a serious problem for naltrexone maintenance, although further efforts to develop interventions such as BNT are warranted.

The dynamics of heroin use; implications for intervention

STUDY OBJECTIVE

To use a readily available dataset to detect periods of epidemic change and to examine the progression of heroin epidemics in different geographical areas. To consider the implications of epidemic change for strategies to tackle drug misuse.

DESIGN

Comparison of trends in new treatment demand, observed incidence, and age specific population rates for treated heroin users in two geographical areas.

PARTICIPANTS

Heroin users recorded to have sought treatment.

MAIN RESULTS

The areas studied seem to show differences with respect to trends in new treatment demand, incidence of heroin use and distribution of age specific population rates; indicating that they may be at different epidemic stages.

CONCLUSIONS

These analyses show how areas may differ with respect to epidemic progression of heroin use. It is essential that government strategies, and local responses to these, should be cognisant of these dynamics.

Injection-related risk behaviors in young urban and suburban injection drug users in Chicago (1997-1999)

We compared injection-related risk practices between urban and suburban injection drug users (IDUs) in a large cross-sectional sample of young IDUs. From 1997 to 1999, we recruited 700 active IDUs aged 18 to 30 years in Chicago and its suburbs. A suburban residence was reported by 38% of participants. Participants were interviewed at four urban locations and screened for HIV and hepatitis C virus antibodies. Receptive sharing of syringes and other paraphernalia by urban and suburban IDUs in the preceding 6 months was compared using univariable and multivariable models. Sharing injection paraphernalia in the total sample was high, with 50% of participants reporting receptive syringe sharing and 70% reporting sharing cotton, cookers, and/or rinse water. After adjusting for demographic characteristics, injection settings, frequency, and duration of injection as well as ease of acquiring new syringes, suburban IDUs were significantly more likely than urban IDUs to share syringes (adjusted odds ratio = 1.7; 95% confidence interval: 1.1-2.5); however, the likelihood of sharing cotton, cookers, or rinse water was roughly equal. Despite overall higher risk profiles among suburban IDUs, HIV and hepatitis C prevalence levels were significantly lower than among urban participants. Current high levels of injection risk behaviors in suburban groups represent a potential for rapid dissemination of infection.

Pharmacologic treatment of heroin-dependent patients

Patients with heroin dependence frequently present to internists and other physicians for heroin-related medical, psychiatric, and behavioral health problems and often seek help with reducing their heroin use. Thus, physicians should be familiar with the identification and diagnosis of heroin dependence in their patients and be able to initiate treatment of heroin dependence both directly and by referral. Recent research has provided much information concerning effective pharmacologically based treatment approaches for managing opioid withdrawal and helping patients to remain abstinent Methadone maintenance and newer approaches using L-alpha acetylmethadol and buprenorphine seem to be particularly effective in promoting relapse prevention. Although these treatments are currently provided in special drug treatment settings, recent and ongoing research indicates that the physician's office may be an effective alternative site for these treatments.

Withdrawal syndromes

The pathophysiology of substance withdrawal is elucidated by a review of classic and cutting-edge research. The manifestation and evaluation of the associated withdrawal syndromes from ethanol, sedative-hypnotics, opioids, and baclofen, are compared. The general management of and pharmacotherapy for these patients are discussed.

Phenotypic and functional assessments of immune status in the rat spleen following acute heroin treatment

Heroin use is associated with an increased incidence of several types of infections, including HIV. Yet few studies have assessed whether heroin produces pharmacological alterations of immune status that might contribute to the increased rate of infections amongst heroin users. The present study investigated whether a single administration of heroin to rats produces dose-dependent alterations in functional measures of immune status and in the distribution of leukocyte subsets in the spleen. The results showed that heroin produces a dose-dependent, naltrexone-reversible suppression of the concanavalin A-stimulated proliferation of T cells, lipopolysaccharide-stimulated proliferation of B cells, production of interferon-gamma and cytotoxicity of natural killer (NK) cells in the spleen. Heroin's suppressive effect on NK cell activity results in part from a heroin-induced decrease in the relative number of NKR-P1A(hi) CD3- NK cells in the spleen. Heroin also decreases the percent of a splenic granulocyte subset, the CD11b/c+ HIS48(hi) cells, whose function currently is unknown. In contrast, heroin does not alter relative numbers of CD4+ CD3+ T cells, CD8+ CD3+ T cells, CD45+ B cells, NKR-P1A(lo) CD3+ T cells, CD11b/c+ ED1+ (or CD11b/c+ HIS48-) monocytes/macrophages or CD11b/c+ ED1- (or CD11b/c+ HIS48+) total granulocytes in the spleen. Collectively, these findings demonstrate that heroin produces pharmacological effects on functional and phenotypic measures of immune status.

Cohort changes in illegal drug use among arrestees in Manhattan: from the Heroin Injection Generation to the Blunts Generation

This paper identifies three inner-city cohorts differing by birth year and preferred drugs that routinely passed through Manhattan's criminal justice system from 1987 through 1997: The Heroin Injection Generation born 1945-54, the Cocaine/Crack Generation born 1955-69, and the Blunts (marijuana plus tobacco) Generation born since 1970. The future prospects for the Blunts Generation may be modestly enhanced by their continued avoidance of cocaine, crack, and heroin--despite the fact that many of them are being reared in severely distressed households and are developing few skills for legal jobs.

Heroin Sniffing as Self-Regulation among Injecting and Non-Injecting Heroin Users

This paper examines sniffing as a mode of administration among three subgroups who sniff heroin: those who had never injected, those who were also injecting, and those who had ceased injection. Modified life-history interviews were conducted in 1994 with 26 people currently sniffing but not Injecting, recruited in street-based settings in conjunction with an ongoing study of risk behavior and seroprevalence among drug injectors. These were supplemented by survey interviews and brief open-ended interviews with 23 people who combined heroin injecting with heroin sniffing, recruited from a parallel component of the ongoing study, based at a hospital detoxification ward. Not merely a brief precursor to heroin injecting, heroin sniffing can continue for long periods, and persist during and after periods of injection. Each subgroup uses heroin sniffing to regulate different perceived risks: heroin tolerance and financial expenditure (among those who have never injected), situational risks (among current injectors), and personal crises (among former injectors). These findings suggest the importance of personal factors over syringe availability or fear of HIV in use of modes of heroin administration.

Dope Sniffers in New York City: An Ethnography of Heroin Markets and Patterns of Use

This article examines the use patterns of non-injecting heroin users (NIUs) or ‘dope sniffers’ and their relationship to the heroin markets on the Lower East Side of New York City. The study is based on ethnographic research with 23 NIUs during 1996 and 1997. The paper ethnographically explores 1) the shifting dynamics of the retail heroin markets on the Lower East Side, 2) how these market conditions affected non-injecting heroin users' routes of administration and patterns of use, and 3) the ways in which NIUs adapt to illegal heroin markets experiencing increased levels of repression and enforcement.