Part I: Heroin
The rise in the availability of higher purity heroin and increased use that began in Northeastern cities in the early 1990s has now reached all areas of the country. In this round of calls, some sources report increases in the number of heroin users entering treatment facilities as well as increased numbers of emergency room episodes and overdose deaths related to heroin. Law enforcement sources report that heroin is part of both the street drug trade and the club drug market and is being sold by a wider range of dealers who are likely to sell both heroin and cocaine. In short, heroin has made a comeback almost everywhere, and it is no longer confined to older addicts from another generation of drug users. Many sources report that it is once again a flourishing part of the drug culture in their areas.
Ethnographers and Epidemiologic Sources (Table 1)
Sources report that heroin use is increasing or high in all areas. Sources from areas across the country, such as Seattle, Miami, New York State, Atlanta, San Francisco, and Austin report that the presence of heroin is rising in their areas. Bridgeport and Denver sources report that heroin is stable at a high level. As has been reported in past Pulse Checks, the majority of heroin users are still long-term users who inject, but there is an increasing number of young, new users who primarily snort the drug.
Reporters in Bridgeport, Atlanta, and Miami indicate that there is evidence that some crack users are switching to heroin. These crack users may be older users who have turned to heroin to supplement their crack use, or at-risk youth who may have become heavy crack users in an earlier era, but now experiment with heroin due to its high availability. This is significant because there has traditionally been two different types of user groups for heroin and crack. The Bridgeport source describes some young crack users' claims that they started using heroin as an "antidote" to crack, touting its calming effect, only to find that they had later developed a heroin habit. The differences between the two groups are emphasized in the comments of the Atlanta source, who reports that older heroin users are uncomfortable with crack users who switch to heroin or add it to their drug use. These longer-term heroin users are forming their own "shooting galleries" (a more traditional setting for heroin users), rather than frequenting "get off houses," locations for both heroin and crack use. In addition, young users in Atlanta claim that they snort partially because they are unable to find older users who willing to teach them to inject. This is described in more detail in the special section on changes in heroin use patterns at the end of this report.
For the first time, San Antonio/El Paso, Miami, Seattle, and New York State sources report a rise in the number of emergency room (ER) episodes and overdose deaths in their areas, primarily among older addicts, in the last six months. The most recent Drug Abuse Warning Network (DAWN) data (for 1995) show that the proportion of heroin-related ER episodes accounted for by persons 35 and older has more than tripled since 1978, and now accounts for 55 percent of all such episodes. In short, few older users are novices. They are more often persons who have abused heroin for many years, or users who have returned to drugs after years of abstinence. Particularly in the latter case, users may not be accustomed to the increased purity of today's heroin and may overdose.
Four sources report that "double-breasting" -- joint sales of heroin and cocaine -- occurs in their areas (i.e., Atlanta, Bridgeport, San Francisco, and San Antonio/El Paso). For example, in Atlanta, until recently, crack was available everywhere while heroin was sold only in a few neighborhoods. Now both drugs are available in many neighborhoods throughout the city. In Bridgeport, joint sellers of heroin and cocaine are generally in their early twenties, not users themselves, and organized into crews. The Bridgeport ethnographer reports that despite recent police crackdowns in dealing areas, there is still a high volume of sales of both heroin and cocaine. The majority of dealers sell powdered cocaine, crack, and heroin. However, the heroin volume has increased over the last year and has overcome the once dominant position of crack. The ethnographer reports that in selling both drugs, "these guys talk about making crazy money all night long -- real mad loot." The success which results from selling both drugs in an organized fashion is attracting young, individual entrepreneurs as well as more organized groups or gangs.
Sources in Miami, Seattle, and Bridgeport report that the purity of heroin has risen in their areas. For example, there was considerably more low grade or heavily cut heroin ("scramble") available in Connecticut six months ago; now there is little deviation from the high end product on the street. Even in Atlanta, where purity has declined somewhat in the past six months, it is still over 50 percent. Purity of heroin is high everywhere except the Southwest Border region where there is little or no Southeast Asian or South American heroin; both sources in Texas report that there is only black tar heroin in the region. However, there have been some indications that a higher purity Mexican black tar heroin, that can be snorted, has emerged in Texas. This appears to be an attempt to compete with the higher purity varieties that are available in other regions. The street unit price remains around $10-20 for 1/10-2/10 gram bags, balloons, or paper in most areas. Larger quantities like "eightballs" (1/8 ounce units) or bundles for ten $10 bags are also available through many street level dealers.
New users typically begin by snorting -- which is only possible with high purity powder. Since high purity powder is widely available, young or novice users often initiate use this way. However, if they continue, and dependence is established, they are likely to switch to the more efficient method of injection, or to a combination of injection and snorting. In the Southwest Border region, typically only low purity Mexican black tar heroin is available, therefore, all users, even novices, inject. Established users always inject the drug. There have been reports of more creative ways to use heroin; in the San Antonio/El Paso area, some users dissolve it and squirt it intra-nasally. Some users in Atlanta dissolve crack along with heroin and inject it in a crack/heroin speedball, or sprinkle heroin over a piece of crack and smoke it.
In Miami, there is still far less consumption than in other areas, but use is rising nonetheless. Heroin is appearing in "after hours" clubs where it is used to enhance the "partying" activity of a young, affluent clientele. These users are often injecting or skin-popping (i.e., injecting a drug under the skin into soft tissue rather than directly into the bloodstream) in places where injection marks are not apparent, such as between the toes, to avoid the appearance of being an injection drug user.
Law Enforcement Sources (Table 2)
Six of the ten law enforcement sources report that the availability of heroin is high in their areas (i.e., Baltimore, Chicago, New York, Bridgeport, Washington, D.C., and Columbia); the other three describe heroin availability as stable. In Baltimore, the number of arrests related to heroin has tripled. Police sources report that the drug is showing up at unlikely places as city dealers move into the county and is even appearing at some area high schools. Washington, D.C. police sources report that they are "starting to see heroin like we used to see crack." The expanded presence of heroin is evident in many ways: more busts of dealers at all levels; more paraphernalia or evidence of use on the streets; and more arrestees for all crimes being heroin users.
Most law enforcement sources report that the majority of heroin users are "old timers" (older, long-term users who inject). However, sources in all areas report that they see new, young users, who are most often snorting. In general, users represent all ethnicities and both genders. New York police report that young club goers are starting to use heroin in addition to the many popular club drugs. "[T]he ones who are into designer drugs" are now experimenting with snorting heroin. Like the ethnographers, law enforcement sources state that heroin dealers are now more evident in club areas as there is money to be made in this market.
Sellers vary according to their market. In most cases they are young males, and dealers of varying ethnicities sell in their respective neighborhoods. Along the Texas border, sellers are typically linked to the Mexican Mafia, though unrelated selling "families" have made inroads into the market. In the Baltimore/Washington area, heroin is sold more frequently in open air markets along with cocaine. Bridgeport police report that they increasingly find dealers with many different drugs for sale, rather than geographically distinct drug markets.
Street level prices remain stable at $10-20/bag and street level purity is reportedly high (20-50%) in most areas. Again, the exception is the Southwest Border, where there is only black tar heroin available; its purity is typically below 5 percent at the street level.
Treatment Providers (Table 3)
Treatment providers in three regions (Northeast, Midwest, and West/Southwest) report that the number of clients who enter treatment for heroin abuse has risen since the last Pulse Check. This rise was concentrated in the Northeast (Region 1) and the West/Southwest (Region 4), where 62 percent and 44 percent of programs, respectively, report more heroin clients than the last Pulse Check. Even programs in rural areas of the country, where there has traditionally been little or no heroin use report some clients entering treatment with heroin abuse problems.
In areas where the number of heroin clients increased the most -- the Northeast and the West/Southwest -- approximately half of the clients inject and the other half snort. A California program director stated that he was amazed that 85 percent of his heroin treatment clients reported that they primarily snort the drug given that only a few years ago snorting heroin was "almost unheard of." In contrast, a large program in Washington state provides a different profile: 35 percent of the clients are heroin users; of those, 70 percent are injecting. However, these clients are not the older heroin addicts who have injected for years, but young, fairly new users. A program director in Oklahoma City notes that the progression from first use, to addiction and then to treatment has become quicker due to the availability of high purity heroin: "They are 'more hooked
Over 45 percent of heroin treatment clients in all regions are over 31 years old. This is consistent with the fact that most heroin users are older, long-term drug abusers. A large Brooklyn program reports that over 50 percent of their clients who report heroin as their primary drug of abuse are over 40 years old. Programs in Massachusetts and Missouri report similar statistics -- three-fourths of clients are over 30, with one-half over 40. In general, it takes months or even years of use before a narcotics user reaches such a point of " burnout" or life problems that he or she seeks treatment.
However, when programs report an increasing number of addicts in their early twenties, this shows that the age of initiation and/or serious abuse was during teen years. Several programs in the Mid-Atlantic and South report more heroin clients, and the majority of these new clients are younger users. For example, two large suburban Maryland programs report that the number of heroin clients is increasing, and over half of these new clients are under 20 years old. The West/Southwest region also reports more young heroin clients in the 20-30 year-old range than in previous Pulse Check reports. A treatment provider in San Francisco comments that in that program, "heroin users are getting younger and cocaine users are getting older."
As has been reported in prior Pulse Checks, most heroin users in treatment have had prior treatment. This indicates that they are, by and large, experienced drug users. In the Northeast, Mid-Atlantic/South, and Midwest, over seventy percent of clients have had prior treatment, and even in the West/Southwest, this proportion is close to 60 percent.
Alcohol is still the most commonly mentioned secondary drug in all regions, followed by cocaine and marijuana. The popularity of amphetamines is apparent in the higher percentage of amphetamine mentions (31%) for programs in the West/Southwest region. Some programs in places like Iowa and Missouri report clients using methamphetamine.
