Heroin⁺

Heroin has surpassed crack as the drug associated with the most serious consequences—that is, medically, legally, societally, or otherwise—as perceived by 27 sources in 17 sites: Boston, New York, Philadelphia, and Portland (ME) in the Northeast; Baltimore, Columbia (SC), El Paso, Miami, New Orleans, and Washington, DC, in the South; Chicago, Detroit, and St. Louis in the Midwest; and Denver, Honolulu, Los Angeles, and Seattle in the West. In five of those cities—Baltimore, Boston, Chicago, Philadelphia, and Portland—sources also consider heroin the most widely used illicit drug (methadone treatment sources, however, are excluded from that count because heroin is, by definition the most commonly used drug in their programs).

Compared with the last Pulse Check reporting period, the Miami epidemiologic source believes that heroin has replaced diverted OxyContin® as the drug with the most serious consequences. Two sources in Portland, ME, believe that heroin has replaced either other opiates or cocaine as the most commonly abused drug, and the Washington, DC, methadone treatment source believes it has replaced crack as such. Additionally, some aspect of heroin abuse is considered as an emerging problem in four cities: Billings, Boston, Denver, and Memphis.

How available is heroin across the 20 Pulse Check cities (fall 2001)?

According to law enforcement sources (N=19)*...

*The law enforcement source in Baltimore did not respond.

HEROIN: THE DRUG

How available is heroin, in its various forms, across the country?
(Exhibits 1, 2, and 3) Approximately half of the Pulse Check law enforcement sources (10 of 19) and epidemiologic/ethnographic sources (11 of 20) consider heroin to be widely available in their communities. Sources in the Northeast and South are about twice as likely to report wide availability as their counterparts in the Midwest and West.

Exhibit 2 How has overall heroin availability changed (spring 2001 vs fall 2001)?*

*The Baltimore law enforcement source did not respond.

As in the past two Pulse Check reports, high-purity snortable South American (Colombian) white heroin is the most common type, cited as widely available by law enforcement and epidemiologic/ethnographic sources in 10 cities across the Northeast, South, and Midwest (Baltimore, Boston, Chicago, Columbia [SC], Detroit, Miami, Philadelphia, Portland [ME], New York, and Washington, DC). Mexican black tar, a lower purity, injectable heroin, is ranked as widely available by sources in six cities, mostly in the West (Denver, Honolulu, El Paso, Los Angeles, St. Louis, and Seattle); and sources in four of those cities (Denver, El Paso, Los Angeles, and St. Louis) similarly rate Mexican brown heroin as widely available. Southeast Asian heroin is considered widely available in only two cities (New Orleans and Washington, DC), and Southwest Asian heroin is the least common form, with wide availability reported only in New Orleans.

Heroin availability remained stable between spring and fall 2001, according to the majority of law enforcement (15 of 19) and epidemiologic/ethnographic (14 of 20) sources. Increases are reported in only seven sites across the Northeast, South, and Midwest, while declines are reported in two sites, both in the West. Similarly, the various forms of heroin remain generally stable in availability, with any exceptions listed in exhibit 3. The St. Louis epidemiologic source, who has been monitoring the possible introduction of white Nigerian heroin into the city, reports no more seizures since the last Pulse Check.

Which heroin varieties have changed in availability (spring 2001 vs fall 2001)?*

*The Baltimore law enforcement source did not respond.

How pure is heroin across the country?
(Exhibit 4) According to law enforcement and epidemiologic/ ethnographic sources, street-level Colombian heroin ranges from a low of 40 to 90 percent, with both extremes reported in Philadelphia. Street-level Mexican black tar heroin purity ranges from 14 percent in Seattle to 70 percent in Billings. Purity levels have remained generally stable since the last reporting period, except for increases in Boston, El Paso, and Portland (ME) and declines in Denver, New Orleans, and Seattle.

A wide range of heroin adulterants continue to be reported by law enforcement and epidemiologic/ethnographic sources, particularly in the Northeast and South. The most recent harmful adulterants reported are cocaine in Portland (ME), a roach spray in New York, and a shaving of ecstasy enclosed in a bag of heroin in New York.

What are street-level heroin prices across the country?
(Exhibit 4) As reported in the last Pulse Check, sales units of 0.1 gram still cost as little as $4 for Colombian heroin in Boston to as much as $120 for Mexican black tar in Seattle. Prices are generally stable since the last reporting period, except for increases in Denver and Seattle and declines in El Paso and Washington, DC. A few other shifts, however, are noted:

• Baltimore, MD^E: White heroin is being sold in larger capsules than during the last reporting period. Thus, even though capsule prices have increased from $6 (or two for $10) to $10, actual prices have remained fairly stable.
  
  
• Chicago, IL^E: The price range for a gram of white powder has widened, from $100–$200 during the last reporting period to $60–$275 during the current period.
  
  
• Los Angeles, CA^L: The price range for a 0.25 gram "hit" has narrowed, from $20–$40 to $30–$35.
  
  
• New York, NY^L: Cheaper Southwest Asian heroin is about to pose a significant challenge to Colombian heroin.

What are the prices and purity levels of different types of heroin in 19 Pulse Check cities?*

MOST COMMON STREET UNIT						1 GRAM
City/Source		Unit	Size	Purity/Change**	Price/Change**	Purity/Change**	Price/Change**
	Baltimore, MDE	capsule	NR	NR/NR	$10/
	Boston, MAL	“bundle”	0.1 gm	80%+/	$4–$6/
	Chicago, ILL	“hit”	0.2 gm	NR/NR	$20/	NR/NR	$150/
	Columbia, SCL	“bindle”	0.2 gm	62%/	$20–$25/	NR/NR	$125–$130/
		“bundle”	2 gm	NR/NR	$225/
	Detroit, MIL	“dime”	0.1 gm	NR/NR	$10/	NR/NR	$100–$150/
	Miami, FLL	NR	1 gm			NR/NR	$120/
	Miami, FLE	“bag”	NR	NR/	$10/	NR/	$150–$200/
	New York, NYL	“bag”	1 hit	80–90%/	$10–$14/
	New York, NYE	“bag”	0.1 gm	60%+/	$10/
	Philadelphia, PAL	“bag”	0.3 gm	40–90%/	$10–$20/
		“bundle”	10–13 bags	40%/	$100–$120/	70–75%/	$85–$95/
	Philadelphia, PAE	“hit”	NR	73%/NR	$10/NR
	Portland, MEL	“bag”	0.1 gm	70%+/	$25–$30/
		“bundle”	1 gm			70%+/	NR/NR
	Billings, MTL	“bindle”	1 gm			50–70%/	$260/
	Denver, COL	“balloon”	0.2 gm	20–30/	$25–$30/
	Denver, COE	NR	1 gm			36%/	$50–$100/
	El Paso, TXL	NR	0.1 gm	NR/NR	$20/
	El Paso, TXE	“dime”, “dieme”	2-3 person hit	NR/	$2.50–$3.00/
	Honolulu, HIL	“bindle”	0.1 gm	NR/NR	$50–$75/	NR/NR	$150–$300/
	Honolulu, HIE	“paper”	0.25 gm	NR/NR	$50–$75/
		NR	0.25 oz	NR/NR	$750/
	Los Angeles, CAL	“hit”	0.25 gm	NR/NR	$30–$35/	NR/	$90–$100/
	Memphis, TNL	NR	0.1 gm	NR/NR	$50–$50/	NR/NR	$400–$450/
	Seattle, WAL	NR	0.1 gm	14–58%/	$90–$120/NR
	Seattle, WAE	NR	1 mg	21%/	$1.15/	NR/	$30–$50/
	St. Louis, MOL	NR	1 gm			NR/NR	$100/
	Boston, MAE	“bag” (powder)	0.1 gm	NR/NR	$10/
		“bundle” (powder)	10-bag	NR/NR	$60–$80/
	Chicago, ILE	“dime bag”	NR	NR/NR	$10/
	Detroit, MIE	“hit” (white)	NR	10–50%/	$10–$12/
		“bundle” (white)	NR	10–50%/	$100–$150/
	New Orleans, LAL	“hit”	.45 gm	7%/	$20–$25/
		“paper”	0.12 gm	7%/	$10/
	Washington, DCL	“dime bag” (white)	50–75 mg	10–15%/	$10/	60–70%/	$120–$140/
	Washington, DCE	“scramble” (white)	bag	23%/	$10/
		“bone” or “raw”	bag	40–80%/	$30–$40/
		“scramble” (white)	1 mg	23%/	$1.05/	23%/NR	$120–$150/
Sources: Law enforcement and epidemiologic/ethnographic respondents *Respondents in Sioux Falls did not provide this information. **Arrows indicate up, down, or stable between spring and fall 2001. NR= not reported South American (Colombian) white Mexican black or brown tar Unspecified

How is heroin referred to across the country?
(Exhibit 5) Street names and dealer brand names proliferate in the Northeast and the South and are rarer in the Midwest and the West. Since the last Pulse Check, many of the more recent brand or street names relate to the September 11 terrorist attacks, particularly in New York ("twin towers," "9/11," "world trade center," and "WTC") and in Washington, DC ("bin laden"). "Red devil" and "bulldog" are new street names in Portland (ME), and pink heart logos are new in Columbia (SC). In Philadelphia, where brand names change frequently, 18 new ones have been identified since the previous reporting period (including "old navy," "bomb," "one way," "life," and "one hundred percent"). Brand names also change frequently in Washington, DC, typically when a dealer's product gets a bad reputation or becomes too well known by law enforcement. In Boston and Detroit, however, dealers are using fewer brands or labels than in the past for fear that drugs can be traced back to them.

How is heroin packaged?
The most common packaging across the country, as reported in the last Pulse Check, continues to be plastic, cellophane, glassine, or coin bags, often the "zippe" type. These bags sometimes come in colors for dealer identification, as reported in Boston, Portland (ME), and Washington, DC, while in Chicago some bags have a small candy or popcorn kernel inside to identify the sellers and the heroin purity. Other common packaging includes plastic or cellophane wrap, wax paper, foil, and balloons. Some unusual packaging is reported during this period: condoms in New York; watertight "seal-a-meal" type of closures, small enough to be swallowed, in some of Boston's outlying communities (such as Lawrence and Lowell) and in Portland (ME); balloons that can be put into a cheek and swallowed if necessary in El Paso; brown packaging tape inside of duct tape in Billings; and "speedwrapping," in Boston, which involves 10 untaped bags laid on top of one another, rolled, and held together with a rubber band. Since the last Pulse Check, the Baltimore ethnographic source reports fewer cellophane bags on the street.

Exhibit 5

How is heroin referred to, and what types of heroin predominate, in different regions of the country?*

H, boy, dope, smack, big H, horse, dog food, s--t, heron, train, 747, doogie, stuff, chiva, carga, foil, papers, jerry springer, he, manteca, joint (bag of dope), billie (bag of dope), scramble (lower purity), bone (higher purity), raw (higher purity), negro, doozy, tammy, diesel, white, mud, bin laden Murder one, white dragon, no limit, the real one, playboy, skull and crossbones, pluto, pink hearts

H, boy, dope, smack, horse, diesel, dees, heron, packets, dimes, china white, manteca (=lard), mantecilla (=butter), pabajo (=down), let it in, high party, sick call, dead president, NBA, spider, flying high, y2k, high class, blue, top drool, hot party, sin city, sosa, twin towers, polo, monkey business, lexus, heavyweight, playboy, MVP, creeper, powder, tomohawk, rush, double nut, one way, alan iverson, bat boy, magum 357, bingo, exposition, trinidad, hot water, red devil, bull dog 9/11 world trade center, son of sam, WTC, old navy, bomb, scorpion, one way, life, cobra, one hundred percent, monster dose

*Italics refer to dealer brands, which are sometimes interchanged with user street names. Bolded names are new this reporting period. Sources: Law enforcement, epidemiologic/ethnographic, and treatment respondents

HEROIN: THE SELLERS

Who sells heroin?
(Exhibit 6) Law enforcement sources tend to report heroin dealers as young adults (18–30 years) who work independently. Adults older than 30, however, are reported as the predominant sellers in Billings, Honolulu, and Washington, DC, while dealers in El Paso and Portland (ME) are equally likely to be from either age group. Organized sales structures are reported in Chicago, Denver, Memphis, Miami, and Seattle, while both independent and organized dealers operate in El Paso and Philadelphia.

Epidemiologic/ethnographic sources are more likely than their law enforcement counterparts to report more than one kind of sales structure, sometimes quite separate but sometimes intricately related, as in the following examples:

• Boston, MA^E: Two distinct groups sell heroin: independents, who tend to be older adults and are very likely to use the drug; and organized dealers who are generally younger adults and are only somewhat likely to use the drug. The organized dealers use beepers and pagers, arrange meetings with clients, and hire steady middlemen and runners on bikes. A third sales system consists of addicts who act as liaisons: they spend their days procuring heroin for other users and, in the process, increase the price or take some heroin "off the top."
  
  
• Denver, CO^E: Mexican nationals control polydrug distribution to small autonomous street sellers, with little oversight once the drugs get on the street.
  
  
• Honolulu, HI^E: On Oahu, sellers tend to be older and independent. On Hawaii, Maui, and Kauai, they tend to be adolescents who are flown in from Mexico, stay for 3 or 4 months, and then leave.
  
  
• New Orleans, LA^E: A series of loose connections consist of dealers who have four or five sellers each.
  
  
• Washington, DC^E: Independent addicts tend to be older adults who sell heroin in order to support their habits, while organized "crews" of younger adults are not very likely to use the drug.

Since the last Pulse Check, no major changes are reported among the sellers in the various cities, with one possible exception: the Baltimore ethnographic source mentions unsubstantiated reports of some "young guys" trying to take over part of the market.

Exhibit 6

How likely are heroin sellers to use their own drug?*

Sources: Law enforcement and epidemiologic/ethnologic respondents
*Any missing bar implies that one source did not provide this information. Neither source in Sioux Falls provided this information.

How is street-level heroin sold?
Caution and wariness rule drug sales in many cities: referrals, beepers, cell phones, prearranged meeting places, home deliveries, and multi-tiered market structures are playing increasing roles, as in the following examples:

• Boston, MA^L,E: Sales continue to go more underground than in the past, with more beeper use and home deliveries. Sellers have a customer list, with a small clientele.
  
  
• Baltimore, MD^E: Sellers won't sell to anyone they don't know. Instead of hand-to-hand sales, a system of "touters" and "runners" adds layers between the buyer and seller. The touter deals directly with the buyer, receiving money and handing over the drugs; the runner deals with the seller (although sometimes the touters and runners are the same, depending on the complexity of a particular market). Most runners are young males on miniature bicycles. Therefore, in some neighborhoods, police patrol areas on bicycles.
  
  
• Chicago, IL^L: In order to reduce risk, several layers of people are often involved in a drug sale. In some locations, especially in public housing areas, the buyer asks for the drug on one floor, pays on the next floor, and then is told by someone where to go to obtain the drug. Some open drug markets, however, still exist in certain neighborhoods.
  
  
• El Paso, TX^L,E: Sellers are "very paranoid" and won't sell to strangers. A buyer needs a contact to make introductions. Cell phones and drive-by meetings are common, and open-air markets are rare.
  
  
• New Orleans, LA^E: Deliveries and meetings are commonly arranged via beepers, cell phones, and home phones. Code words are used over the phone to designate names and locations. Street sellers use referrals.
  
  
• Seattle, WA^L: Buyers need to know where to go. Beepers and cell phones are common. Open-air markets are relatively confined and limited in number, but they still exist.

By contrast, in some cities heroin sales are still more open. Washington, DC, for example, has more than 100 open-air markets, and sellers approach potential customers. In certain Philadelphia neighborhoods, one can simply drive by, roll down the car window, and buy drugs hand-to-hand.

What other drugs do heroin dealers sell?
(Exhibit 7) Heroin dealers continue to sell additional drugs in nearly every Pulse Check city. Only a few changes are reported since the last Pulse Check:

• Baltimore, MD^E: Marijuana, while not regularly distributed by heroin sellers, is reported as occasionally "floating in and out" during this reporting period.
  
  
• Boston, MA^E: Sales of both heroin and crack, which used to be rare, have increased during the past year.
  
  
• New York, NY^L,E: The trend toward polydrug sales continues. Ecstasy is increasingly being sold by heroin dealers, along with their other staples: crack, powder cocaine, and marijuana. An increasing number of arrests involve all five drugs.
  
  
• St. Louis, MO^E: Instead of the onestop-shops reported in the last Pulse Check, with heroin, crack, and marijuana sold "as if in a candy store," now it is more common for buyers to place an order for other drugs ahead of time.
  
  
• Washington, DC^L: Many crack dealers are thinking of switching to heroin because they don’t have to sell as much to make the same profit and because the penalties are not as strict.

What other drugs do heroin dealers sell?*

	City	Crack	Powder Cocaine	Marijuana	Other	No other drug sold
	Boston, MA
	New York, NY				Ecstasy
	Philadelphia, PA
	Portland, ME				OxyContin® Other pharmaceutical opiates
	Baltimore, MD
	Columbia, SC
	El Paso, TX				Rohypnol
	Memphis, TN				Morphine, hydromorphone (Dilaudid®), other opiates
	Miami, FL				Ecstasy
	New Orleans, LA
	Washington, DC
	Chicago, IL
	Detroit, MI
	St. Louis, MO
	Billings, MT				Methamphetamine
	Denver, CO				Methamphetamine
	Honolulu, HI				Methamphetamine
	Los Angeles, CA
	Seattle, WA

Sources: Law enforcement and epidemiologic/ethnographic respondents
*Respondents in El Paso, Los Angeles, and Sioux Falls did not provide this information.

What type of crimes are related to the heroin sales scene?
According to law enforcement and epidemiologic/ethnographic sources, heroin sellers in 12 Pulse Check cities engage in some form of violent crime: Boston, New York, and Philadelphia in the Northeast; Baltimore, El Paso, Memphis, New Orleans, and Washington, DC, in the South; Chicago, Detroit, and St. Louis in the Midwest; and Denver in the West. Sometimes, these crimes are related to turf protection (Baltimore) and involve internal killings (New Orleans). Other specific violent crimes mentioned include gun sales (Philadelphia), robberies (New Orleans), assaults (New York), and use of weapons (St. Louis). The Boston ethnographer, however, notes that drug-related violence has been declining over the last few years.

Gang-related activities are reported by law enforcement or epidemiologic/ethnographic sources in all four regions: New York in the East; Baltimore, El Paso, and Memphis in the South; Chicago and Detroit in the Midwest; and Denver and Seattle in the West.

Prostitution, on the part of either users or sellers, is reported by law enforcement or epidemiologic/ethnographic sources in all Pulse Check cities except for Billings, Miami, Seattle, and Washington, DC.

Heroin sellers, users, or both often engage in numerous other forms of nonviolent crimes, as reported by law enforcement or epidemiologic/ethnographic sources in all Pulse Check cities except Chicago and Memphis. Typical crimes, often on the part of the users, include burglaries, petty larceny, and thefts (Billings, Los Angeles, New York, Philadelphia, and St. Louis); shoplifting (El Paso and Washington, DC—in the latter, meat shoplifting is a common activity, with the perpetrators commonly called "cattle rustlers"); panhandling (New York); disorderly conduct (New York); car theft (El Paso); and check cashing (Detroit). Nonviolent crimes specific to sellers include pharmaceutical diversion (Portland, ME) and money laundering (Miami).

Where is heroin sold?
Law enforcement and epidemiologic/ethnographic sources generally agree that most heroin sales take place in central city areas, as reported in past Pulse Checks. Additionally, suburban or rural areas are occasionally mentioned in El Paso, Memphis, Miami, New York, Portland (ME), and St. Louis. In Philadelphia, suburbanites often buy heroin from central city dealers, and then resell the drug in the suburbs. Conversely, people from Boston often travel to outlying cities (such as Lawrence and Lowell) to buy heroin because purity is higher there than in the city.

Sales on the street are reported by all 18 law enforcement sources who discussed this question (the Sioux Falls source did not). The next most commonly reported sales settings are public housing developments (in all sites except Detroit and Portland) and private residences (in 14 sites). Less than half of the sources name other sales settings:

• Crack houses: All sites in the Northeast except Portland; Columbia (SC), Memphis, and Miami in the South; only Chicago in the Midwest; and Honolulu and Los Angeles in the West.
  
  
• Inside cars: All sites in the Northeast except Philadelphia; Memphis, Miami, and Washington, DC, in the South; and all sites in the West except Los Angeles.
  
  
• Playgrounds or parks: Boston and New York in the Northeast; Memphis and Washington, DC, in the South; Chicago and St. Louis in the Midwest; and Billings and Honolulu in the West.
  
  
• Nightclubs or bars: New York in the Northeast; Memphis and Miami in the South; Chicago and St. Louis in the Midwest; and Billings, Honolulu, and Seattle in the West.
  
  
• Private parties: Boston and New York in the Northeast; Memphis and Miami in the South; St. Louis in the Midwest; and Billings in the West.
  
  
• Hotels or motels: New York in the Northeast; Memphis and Miami in the South; St. Louis in the Midwest; and Billings, Denver, and Los Angeles in the West.
  
  
• Around alcohol or drug treatment clinics: New York and Philadelphia in the Northeast; Memphis and Washington, DC, in the South; St. Louis in the Midwest; and Honolulu in the West.
  
  
• In or around schools: New York in the Northeast; Miami and Washington, DC, in the South; Chicago and St. Louis in the Midwest; and Billings in the West.

The settings least commonly mentioned by law enforcement sources are raves (in Billings, Miami, New York, and Portland [ME]), college campuses (in Billings, Miami, New York, and Seattle), in or around shopping malls (in Billings, Miami, New York, and St. Louis), in or around supermarkets (in Billings, Columbia [SC], and New York), and in alleyways (in Philadelphia). The Boston ethnographic source adds that benzodiazepines, rather than heroin, are sold around drug or alcohol treatment clinics.

Only a few changes in sales settings are reported since the last Pulse Check:

• Baltimore, MD^E: Law enforcement efforts are causing sellers and users to keep shifting their street locations.
  
  
• Honolulu, HI^E: Heroin sales and use in beach parks have recently declined because police have been clearing those areas. Some of this market disruption is a side effect of more police using laptop computers: they tend to write their reports in beach parks.
  
  
• Washington, DC^L,E: Recent media coverage has focused on the visible sales of drugs, usually pills (particularly pharmaceutical opiates), but sometimes heroin. Many such sales have historically taken place around treatment clinics. Legislative efforts are under way to stiffen penalties for selling drugs near treatment clinics, similar to penalties for selling within 1,000 feet of schools, public housing, parks, and playgrounds.

HEROIN: THE USERS

Who uses heroin?
(Exhibit 8) Overall, as reported in previous Pulse Checks, the predominant heroin users tend to be White males, older than 30, who live in central city areas. However, as the table shows, much variation occurs across the different sites and source categories. Furthermore, younger adults (18–30 years) are frequently named as the predominant group or else constitute substantial proportions of users. Clients in methadone programs are more likely than those in non-methadone programs to be high school graduates and to be employed.

What demographic groups predominate among heroin users, according to different Pulse Check sources?*

	City	Age			Race/Ethnicity			Residence
		E	N	M	E	N	M	E	N	M
	Boston, MA	>30	18–30	>30	Whites	Whites	Whites	Central city	Central city	Suburbs
	New York, NY	>30	>30	>30	Hispanics	Black; Hispanics	Hispanics	Central city	Central city	Central city
	Philadelphia, PA	18–30;>30	18–30	18–30	Whites	Whites; Blacks	Whites; Blacks	Central city	Central city	Central city
	Portland, ME	>30	18–30	>30	Whites	Whites	Whites	Central city	Central city	All
	Baltimore, MD	>30	NR	>30	Whites	NR	Blacks	Central city	NR	Central city
	Columbia, SC	>30	Low numbers	18–30	Whites; Blacks	Low numbers	Whites	Central city	Low numbers	Suburbs
	El Paso, TX	18–30	>30	18–30	Hispanics	Hispanics	Hispanics	Central city	Central city; Suburbs	Central city
	Memphis, TN	18–30;>30	NR	NR	Whites	NR	NR	Central city	NR	NR
	Miami, FL	18–30	>30	18-30; >30	Whites	Hispanics	White; Hispanics	Central city	Central city	Central city
	New Orleans, LA	>30	18–30;>30	18–30	Blacks	Blacks	Whites	Central city	Central city	Suburbs
	Washington, DC	>30	18–30	>30	Blacks	Blacks	Blacks	Central city	Central city	Central city
	Chicago, IL	18–30	>30	>30	Blacks	Blacks	Blacks	Central city	Central city	Central city
	Detroit, MD	>30	18–30	>30	Whites	Blacks	Blacks	Central city; Suburbs	Central city	Central city
	St. Louis, MO	18–30;>30	18–30	>30	White, Blacks	Blacks; Hispanic	Whites	Central city	Central city; Suburbs	Suburbs
	Sioux Falls, SD**	18–30	18–30	NA	Whites	Whites	NA	Suburbs; Rural	Central city	NA
			Low numbers			Low numbers			Low numbers
	Billings, MT**	13–17	18–30	NA	Whites	Whites; American Indians	NA	Central city	Central city; rural	NA
			18-30			Whites			Central city
	Denver, CO	>30	>30	18–30	Whites	Whites	Whites	Central city	Suburbs	Central city
	Honolulu, HI	>30	NR	18–30	Whites	NR	Whites	Central city	NR	Central city
	Los Angeles, CA	18–30	Low numbers	>30	Whites; Hispanics	Low numbers	Blacks; Hispanics	Suburbs	Low numbers	Central city
	Seattle, WA	>30	18–30	>30	Whites	Whites	Whites	Central city	Suburbs	Central city

Sources: Law enforcement and epidemiologic/ethnographic respondents
*Respondents in Sioux Falls did not provide this information. **Arrows indicate up, down, or stable between spring and fall 2001. NR= not reported

According to epidemiologic/ethnographic sources, the most noticeable shifts since the last Pulse Check involve increasing heroin use among younger people, many of whom are suburban Whites:

• Baltimore, MD^E: While users in the central city are primarily older adults (>30 years), those in the suburbs are primarily young adults (18–30). Adolescent users (<18) continue to increase in suburbs.
  
  
• Chicago, IL^E: Heroin users are primarily young adult Black males of low socioeconomic background, who reside in the central city. However, an emerging group is reported, also young adult males, but they are White, low and middle socioeconomic, suburban residents.
  
  
• Denver, CO^E: While the predominant users continue to be White male older adults in the central city, an emerging group continues to grow: White male suburban high school students and young adults. Eight deaths in a recent 6-month period involved users from that emerging group.
  
  
• St. Louis, MO^E: Older users are low socioeconomic central city residents; younger users have more diverse socioeconomic status and live both in the central city and the suburbs.
  
  
• Washington, DC^E: In addition to the predominant adult user group, an emerging young adult group of snorters has two subgroups: suburban, mid-socioeconomic Whites; and central city, low-socioeconomic Blacks. Heroin users of all ages, however, are increasingly moving to the suburbs.

Increases among young people are not, however, limited to the suburbs:

• Boston, MA^E: Aside from the traditional aging cohort of midsocioeconomic blue-collar Whites in their thirties, several populations of younger users have continued to emerge over the past few years: younger adult blue-collar Whites who are switching to heroin after abusing prescription pills (mostly the Percocet® form of oxycodone); the late-teenage sons and younger brothers of the oxycodone abusers who are going straight to heroin abuse; and Hispanic users in their twenties, who live in the central city, in the suburbs, and in surrounding cities (Lowell and Lynne) and also sell heroin.
  
  
• Chicago, IL^E: Young adults, who are the predominant heroin users, seem to getting even younger as a group.
  
  
• Miami, FL^E: Heroin is showing up in adolescent fatalities.
  
  
• New Orleans, LA^E: Increases are reported in both the >30 group, suggesting an aging cohort, and in the 20–24 group.
  
  
• Portland, ME^E: While adults (>30) are the predominant users, a younger (16–22 years) group continues to emerge. Their numbers, however, remain low. Another possible new user group to watch for are older OxyContin® users who might switch to heroin.

Similarly, several treatment sources report that although heroin-using clients in their programs are most likely to be older than 30, users in their twenties are increasing:

• Billings, MT^N
• Boston, MA^M
• Portland, ME^M
• St. Louis, MO^M

Other residence shifts and variations are noted:

• Billings, MT^N: Whites, who reside in the central city, and American Indians, who tend to live in rural areas, are equally likely to use heroin.
  
  
• Memphis, TN^E: In the last Pulse Check, heroin users were reported as residing primarily in central city areas. However, with the increasing spread to the suburbs, users are now equally likely to reside in either area.
  
  
• New Orleans, LA^E: Three major housing projects were recently torn down, and their residents were relocated throughout the area. As a result, treatment, arrest, and crime numbers have declined but not because the problem has declined: rather it has been scattered, scattered, along with any relevant data. These shifts are expected to turn up in various datasets over the next 6 months.

Besides the increases among Whites in some suburban areas, only one other racial/ethnic shift is reported: according to the Philadelphia epidemiologic source, Hispanics are increasingly using heroin. Whites, however, are still the predominant users in that city.

Two shifts in Chicago... The non-methadone treatment source notes two recent increases among heroin clients: The number with comorbid illnesses, such as depression, suicidal, anxiety, and some psychosis The number of treatment referrals of people who have been serving hard time in the penitentiary

Males are generally more likely to use heroin than females. Several Pulse Check sources, however, report that both sexes are equally likely to use: the epidemiologic/ethnographic sources in Los Angeles, Memphis, and Sioux Falls; the non-methadone treatment sources in Chicago, Denver, Detroit, Portland (ME), St. Louis, and Washington, DC; and the methadone treatment sources in Baltimore, Chicago, Columbia (SC), New Orleans, and Seattle. Furthermore, women are increasingly using heroin in some cities:

• Denver, CO^M: While the majority of heroin-using clients are males, they are increasingly moving toward an even gender split.
  
  
• Memphis, TN^E: In the last Pulse Check, heroin users were reported as predominantly males; however, with an increase in female users, the two genders are now evenly split.
  
  
• New Orleans^E: Females continue to increase.
  
  
• Portland, ME^E: Males continue to predominate, but an increase among females has been noted since the last Pulse Check, particularly in the homeless population.

How do users administer heroin?
(Exhibit 9) As reported in past Pulse Check issues, injecting remains the most commonly reported route of administration overall. Snorting, however, does predominate in many sites, particularly in the Northeast and Midwest. Since the last Pulse Check reporting period, snorting and smoking have increased in some sites, often among younger users and in suburban, rather than central city, areas:

• Baltimore, MD^E: While injecting predominates in central city areas, snorting ("bipping") predominates in the suburbs.
  
  
• Boston, MA^E: The emerging group of young Hispanic users tend to snort heroin. By contrast, the older users have a long history of injection: sometimes their veins collapse, so they inject under the skin or into a muscle, making them prone to infections.
  
  
• Boston, MA^M: More snorting is reported among younger users.
  
  
• Denver, CO^E,M: Injection remains the predominant route, but snorting and smoking are more common among the emerging group of young adults in the suburbs.
  
  
• Honolulu, HI^E: "Chasing the dragon" is occasionally reported.
  
  
• Miami, FL^M: Younger clients are more likely to snort because of AIDS concerns.
  
  
• New Orleans, LA^L,E: Snorting has increased slightly since the last reporting period, but injecting, by far, remains the predominant route of administration.
  
  
• New York, NY^N: Snorting continues an upward trend.
  
  
• Philadelphia, PA^M: Snorting continues to increase because of increased purity.
  
  
• St. Louis, MO^E: Snorting predominates among younger users, while injecting is more common among older ones. In rural areas, however, injection still predominates.
  
  
• Washington, DC^E: While injecting predominates, snorting and smoking have increased.

Some people, however, are shifting from snorting to injecting:

• Boston, MA^N: The program's snorting-to-injecting ratio since the last reporting period has changed from 70:30 to 55:45. This increase in injecting might be due either to declining purity or increased tolerance.
  
  
• New York, NY^E: Young people in the suburbs continue to shift from snorting to injecting. In the city, however, this trend is not being seen. One explanation is that more drugs are available and it is easier to "hustle" drugs in the city, whereas on Long Island these young users have to "make do" with what they’ve got unless they want to make the trip into the city. By injecting, they "get more bang for the buck" when they don’t have enough drugs to satisfy their needs.

Exhibit 9

How do users administer heroin?

	Injecting is most common in...	Snorting is most common in...
	Boston, MAE,M*	Boston, MAN,M*
	New York, NYM	New York, NYE,N
	Philadelphia, PAN	Philadelphia, PAE,M
	Portland, MEE,M	Portland, MEN
	Baltimore, MDE,M	Miami, FLM*
	Columbia, SCE,M	New Orleans, LAN*
	El Paso, TXE,N,M	Washington, DCN
	Memphis, TNE
	Miami, FLE,N,M*
	New Orleans, LAE,N*,M
	Washington, DCE,M
	Chicago, ILM	Chicago, ILE,N
	Detroit, MIM	Detroit, MIE*,N
	Sioux Falls, SDE*,N*	Sioux Falls, SDE*,N*
	St. Louis, MOE*,N,M	St. Louis, MOE*
	Billings, MTN,M	Billings, MTE
	Denver, COE,N,M
	Honolulu, HIE,M
	Los Angeles, CAE,M
	Seattle, WAE,N,M

*Respondent considers injecting and snorting as approximately equal.
NOTE: The Columbia (SC), Los Angeles, and one of the Sioux Falls non-methadone treatment sources did not provide this information.

Pilot needle program in New York... New York, NYE: In a program piloted in February 2001, pharmacies can voluntarily decide to sell needles. It is still too early to assess the impact.

What other drugs do heroin users take?
In some cities, polydrug use is the norm. In Philadelphia, for example, the non-methadone source explains that all clients are polydrug users: they use whatever they can get their hands on, whatever is available. Heroin and crack are the most common drugs used in that city, as in many others. Several shifts and variations are reported in cocaine use by heroin addicts, particularly in the Northeast and South:

• Baltimore, MD^E: While "speedball" (heroin plus powder cocaine) injecting is common, older, more chronic users avoid cocaine use.
  
  
• Boston, MA^E: The predominant older users inject speedballs containing crack or, if available, powder cocaine. Use of alcohol and cocaine is emerging among young Hispanics.
  
  
• Denver, CO^E: The predominant, older, heroin-using group uses powder cocaine in speedballs; the emerging users tend to use cocaine less frequently and sequentially with heroin.
  
  
• El Paso, TX^E: The combination of heroin plus powder cocaine is known as a "belushi."
  
  
• Memphis, TN^E: The only heroin combination reported in the last Pulse Check involved crack (speedballs). During this reporting period, however, powder cocaine has been replacing crack in speedballs.
  
  
• Miami, FL^E: Heroin and powder cocaine are usually injected in speedball combinations; however, snorting a line of each is also reported.
  
  
• Portland, ME^E: Speedballs are no longer reported.
  
  
• Philadelphia, PA^E: Heroin users are experimenting more with powder cocaine.
  
  
• Washington, DC^E: The emerging young adult users also occasionally use powder cocaine and crack.

Several sources report changes in prescription drug abuse among heroin addicts:

• Baltimore, MD^E: Because heroin availability is down since the last Pulse Check, abuse of benzodiazepines, such alprazolam (Xanax®), and prescription opiates has increased.
  
  
• Boston, MA^E: The emerging group of young blue-collar Whites often shift into heroin use from oxycodone, other oral opioids, and benzodiazepines. Recent increases in heroin overdose mortality are related to polydrug abuse, particularly involving clonazepam (Klonopin®).
  
  
• Memphis, TN^E: The opioid hydromorphone (Dilaudid®) is reported during this period as either combined with heroin or taken immediately afterwards as a "chaser." Several other drugs (including methamphetamine, amphetamines, and PCP) are similarly reported.
  
  
• New York^M: Interest in and abuse of diverted OxyContin® has increased. Abuse of benzodazepines, amitriptyline (Elavil®, an antidepressant), and phenobarbital continues.
  
  
• Portland, ME^E: Methadone is increasingly reported as a heroin substitute.
  
  
• Seattle, WA^E: Sequential swallowing of clonazepam or alprazolam with heroin has increased since the last Pulse Check.
  
  
• Washington, DC^E: Hydromorphone and diverted OxyContin® are sometimes used as heroin substitutes, while alprazolam, clonazepam, and other diverted pharmaceuticals are used either to boost or "take off the rough edges from" heroin.

A few shifts involve use of marijuana:

• Denver, CO^E: The emerging group uses marijuana as a secondary drug.
  
  
• New Orleans^L: Younger users are lacing marijuana cigarettes with heroin.
  
  
• Washington, DC^E: The emerging young adult group take marijuana sequentially.

The Miami epidemiologic source notes that heroin is sometimes used to "parachute down" after using ecstasy. Ecstasy is not cited by any other source.

Where and with whom is heroin used? Heroin use continues to take place primarily in private, small group settings, according to the majority of epidemiologic/ethnographic, non-methadone treatment, and methadone treatment sources. Several changes or interesting observations are noted since the last Pulse Check:

• Boston, MA^E: The most common use settings are private residences and public restrooms. Group use is more common than solo use for several reasons: poor users tend to pool their resources; more affluent users see it as a social drug; and when people use heroin in groups, fatalities are less likely to occur.
  
  
• Boston, MA^M: The emerging group of younger clients are starting to use heroin in more public settings.
  
  
• El Paso, TXE: Multigenerational use and sales within families are common in this city, whose unique culture is apparent in all aspects of how drugs are sold and used.
  
  
• Honolulu, HI^E: Heroin users commonly use in public, but public use has declined.
  
  
• Memphis, TN^E: Heroin users are increasingly taking the drug privately, in small groups: during the last Pulse Check reporting period, public and private use were equally likely; during the current period, private use predominates. In the last Pulse Check, solo use was reported as predominant; now, users are equally likely to take heroin both while alone and in groups, among friends.
  
  
• Miami, FL^N: Emerging use settings include clubs, parks, parties, and hotels/motels.
  
  
• New Orleans, LA^E: Before their recent demolition, abandoned areas around housing projects were frequently the scene of heroin use. Now use is shifting to the back rooms of private residences, particularly porches in backs of “shotgun houses” (a type of housing design with a series of rooms connected without any hallways).

HEROIN: THE COMMUNITY

How do heroin clients wind up in treatment?
Heroin users in methadone programs are much more likely to be self-referred than court referred (as reported by 14 versus 4 sources). Conversely, those in non-methadone programs are much more likely to be court referrals than self-referrals (12 versus 5 sources).

How available is methadone treatment in Pulse Check communities?
Methadone maintenance is still not available in Billings or Sioux Falls. As reported in the last Pulse Check, in the remaining cities, about half of the epidemiologic/ethnographic sources—mainly in the South—consider methadone to be available in selected areas only, while the other half consider it to be available throughout their areas. About half (9 of 17) of those sources report waiting lists for admission to public methadone programs, while the other 8 report adequate capacity. Only one epidemiologic source (in Honolulu) reports a waiting list for private methadone treatment, while the Baltimore source reports that private programs have too much capacity.

Since the last Pulse Check reporting period, public methadone treatment has become more available in Chicago and somewhat more available in Baltimore and Washington, DC. Private methadone treatment has become more available in Chicago, Detroit, and Portland (ME), and somewhat more available in Denver and Seattle. Public program slot capacity has declined somewhat in Boston and Detroit and increased greatly in Baltimore; private capacity has increased somewhat in Columbia (SC) and Seattle and increased greatly in Denver and Portland.

---

+The following symbols appear throughout this chapter to indicate type of respondent: ^LLaw enforcement respondent, ^EEpidemiologic/ethnographic respondent, ^NNon-methadone treatment respondent, and ^MMethadone treatment respondent.

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