Differences in characteristics of heroin inhalers and heroin injectors at admission to treatment: a preliminary study using a large database of client records

AIMS: To compare the characteristics of heroin injectors vs. inhalers at their first admission to publicly funded treatment in Texas. METHODS: The sample consisted of 9732 unique clients who entered publicly funded treatment programs in Texas between 1997 and 2001 and who had a primary problem with either injected or inhaled heroin, which they had used in the past 30 days. The records were analyzed using a generalized linear model of logistic regression with the outcomes modeled as binomial and multinomial distribution and a hierarchical linear model for continuous outcomes to compare heroin inhalers and injectors. FINDINGS: There were large statistically significant differences between injectors and inhalers. Inhalers were more likely to be older at first use of heroin, to have entered treatment sooner, to have minor children at home, to have higher annual incomes, to be first admissions to treatment, and to have a secondary drug problem with crack cocaine. They were also more likely to be Hispanic [odds ratio (OR) = 1.74] or African-American (OR = 12.32). CONCLUSIONS: Even though the race/ethnic differences in the Texas population and the type of heroin available for use in Texas differs from that studied elsewhere, many of the characteristics of heroin users are similar. Inhalers have more strengths in many areas, and these findings raise the possibility that there are factors, particularly among African-American participants in Texas, that lessen the risk of injecting heroin. Efforts should be directed to providing therapeutic interventions to discourage the transition to injecting and to encourage inhalers to enter treatment earlier rather than progressing on to injecting. This analysis is the first part of a larger study of heroin users in public and private treatment.     

Heroin and Methamphetamine Injection: An Emerging Drug Use Pattern

Objective: We sought to describe an emerging drug use pattern characterized by injection of both methamphetamine and heroin. We examined differences in drug injection patterns by demographics, injection behaviors, HIV and HCV status, and overdose. Methods: Persons who inject drugs (PWID) were recruited as part of the National HIV Behavioral Surveillance (NHBS) system in Denver, Colorado. We used chi-square statistics to assess differences between those who reported only heroin injection, only methamphetamine injection, and combined heroin and methamphetamine injection. We used generalized linear models to estimate unadjusted and adjusted prevalence ratios to describe the association between drug injection pattern and reported nonfatal overdose in 2015. We also examined changes in the drug reported as most frequently injected across previous NHBS cycles from 2005, 2009, and 2012. Results: Of 592 participants who completed the survey in 2015, 173 (29.2%) reported only injecting heroin, 123 (20.8%) reported only injecting methamphetamine, and 296 (50.0%) reported injecting both drugs during the past 12 months. Injecting both heroin and methamphetamine was associated with a 2.8 (95% confidence interval: 1.7, 4.5) fold increase in reported overdose in the past 12 months compared with only injecting heroin. The proportion of those reporting methamphetamine as the most frequently injected drug increased from 2.1% in 2005 to 29.6% in 2015 (p < 0.001). Conclusions: The rapid increase in methamphetamine injection, and the emergence of combining methamphetamine with heroin, may have serious public health implications.     

Polydrug Use and HIV Risk Among People Who Inject Heroin in Tijuana,Mexico: A Latent Class Analysis

Background: Although most people who inject drugs (PWID) in Tijuana, Mexico, primarily inject heroin, injection and non-injection use of methamphetamine and cocaine is common. We examined patterns of polydrug use among heroin injectors to inform prevention and treatment of drug use and its health and social consequences. Methods: Participants were PWID residing in Tijuana, aged ≥18 years who reported heroin injection in the past six months and were recruited through respondent-driven sampling (n = 1,025). Latent class analysis was conducted to assign individuals to classes on a probabilistic basis, using four indicators of past six-month polydrug and polyroute use: cocaine injecting, cocaine smoking or snorting, methamphetamine injecting, and methamphetamine smoking or snorting. Latent class membership was regressed onto covariates in a multinomial logistic regression. Results: Latent class analyses testing 1, 2, 3, and 4 classes were fit, with the 3-class solution fitting best. Class 1 was defined by predominantly heroin use (50.2%, n = 515); class 2 by methamphetamine and heroin use (43.7%, n = 448), and class 3 by methamphetamine, cocaine, and heroin use (6.0%, n = 62). Bivariate and multivariate analyses indicated a group of methamphetamine and cocaine users that exhibited higher-risk sexual practices and lower heroin injecting frequency, and a group of methamphetamine users who were younger and more likely to be female. Conclusions: Discrete subtypes of heroin PWID were identified based on methamphetamine and cocaine use patterns. These findings have identified subtypes of heroin injectors who require more tailored interventions to reduce the health and social harms of injecting drug use.     

Cold Preparation of Heroin in a Black Tar Market

Background: Black tar heroin is typically prepared for injection with heat which decreases the risk of HIV transmission by inactivating the virus. We received reports that persons who inject drugs (PWID) in Tijuana, Baja California, Mexico, a black tar heroin market, were using only water to dissolve heroin. Objectives: Because Tijuana abuts San Diego County, CA, United States, we undertook the present analyses to determine the prevalence of this practice among PWID in San Diego, California. Methods: PWID completed quarterly behavioral assessments and serological testing for blood-borne viruses. Bivariate and multivariable logistic regression models were constructed to assess for individual, social, and structural correlates of preparing heroin without heat within the preceding 6 months. Results: Nearly half of black tar heroin users (149/305) reported they had prepared heroin without heat within 6 months. In multivariable analysis, cold preparation was independently associated with younger age (10 year decrease; AOR = 1.25; 95% CI 1.03, 1.53), more drug injecting acquaintances (per 5 acquaintance increase; AOR = 1.05; 95% CI 1.01, 1.09) and prefilled syringe use (injecting drugs from syringes that are already filled with drugs before purchase; AOR = 1.86; 95% CI 1.14, 3.02). Conclusions/Importance: To our knowledge, this is the first paper to report that PWID living in a black tar heroin market are preparing heroin without heat. Additional research is needed to determine whether this is an endemic practice or PWID are engaging in new forms of drug preparation in response to changes in the environment.     

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.     

Heroin overdose among young injection drug users in San Francisco

OBJECTIVES: We sought to identify prevalence and predictors of heroin-related overdose among young injection drug users (IDU). METHODS: A total of 795 IDU under age of 30 years were interviewed in four neighbourhoods in San Francisco, California, USA. Participants were recruited as part of a broader study of HIV, hepatitis B and C among injecting drug users in San Francisco using street outreach and snowball techniques. Independent predictors of recent heroin overdose requiring intervention were determined using regression analysis. RESULTS: Of 795 injecting drug users under age of 30 years, 22% (174/795) of participants reported a heroin overdose in the last year. In stepwise multiple logistic regression, independent predictors of recent heroin overdose were lifetime incarceration exceeding 20 months (odds ratio (OR) = 2.99, 95% confidence interval (CI) = 1.52-5.88); heroin injection in the last 3 months (OR = 4.89, 95% CI = 2.03-11.74); cocaine injection in the last 3 months (OR = 1.67, 95% CI = 1.14-2.45); injection of heroin mixed with methamphetamine in the last 3 months (OR = 1.74, 95% CI = 1.15-2.65); ever tested for hepatitis B or C (OR = 1.66 per year, CI = 1.09-2.54) and ever having witnessed another person overdose (OR = 2.89, 95% CI = 1.76-4.73). CONCLUSIONS: Individuals with high levels of incarceration are at great risk of overdose, and prison or jail should be considered a primary intervention site. Further research on the role of cocaine and amphetamine in heroin-related overdose is indicated.     

舒通安胶囊对海洛因依赖者血单胺类递质的影响

目的:了解5-羟色胺(5-HT)、5-羟吲哚乙酸(5-HIAA)、多巴胺(DA)、去甲肾上腺素(NE)在海洛因依赖发病中的意义,观察舒通安胶囊对海洛因依赖者单胺类递质的影响。方法:用荧光分光光度法检测56例海洛因依赖者(注射组35例、烫吸组21例)治疗前后和23例正常人血浆及血小板5-HT、5-HIAA、DA和NE含量。结果:海洛因依赖者血浆5-HT、5-HIAA、DA和NE含量均高于对照组(P<0.01),烫吸组血浆DA、5-HIAA含量低于注射组(P<0.05,P<0.01),经舒通安胶囊治疗后血浆5-HT、5-HIAA、DA和NE含量显著降低(P<0.01),其中烫吸组NE高于注射组(P<0.05)。海洛因依赖者血小板5-HT、5-HIAA、DA和NE含量均高于对照组(P<0.01),烫吸组血小板5-HT、DA含量低于注射组(P<0.01),经舒通安胶囊治疗后血小板5-HT、5-HIAA、DA和NE含量显著降低(P<0.01),其中烫吸组DA、5-HT、NE高于注射组(P<0.01,P<0.05)。结论:单胺类递质在海洛因依赖的病理过程可能有重要意义,舒通安胶囊可调节海洛因依赖者外周单胺类递质水平。     

The characteristics and recent growth of heroin injecting in a Kenyan coastal town

This article discusses the challenges of estimating levels and patterns of heroin use in a setting where there were no official records. Ethnographic fieldwork, carried out in a Kenyan Coastal town, utilised a range of qualitative research methods in an attempt to estimate numbers of male and female users and the proportion of them who were injectors of heroin. In the town of at least 85?000 people, it was estimated that there were perhaps about 600 heroin users, of whom about 30 were women. The ratio of male to female users was estimated to be 20?:?1. Fifty per cent of users in the town were estimated to be injectors of heroin. They were found to have poor injecting techniques, to share equipment from time to time and to have low awareness of the link between injecting drug use and HIV infection. An urgent need for harm reduction strategies was identified.     

The Differences between Male and Female Drug Users: Community Samples of Heroin and Cocaine Users Compared

Although gender-related issues are often cited as playing an important part in determining patterns of illicit drug use, little is known about me differences between male and female drug users outside treatment settings. In the present study, 558 heroin and cocaine users recruited from a range of community settings were interviewed by Privileged Access Interviewers. The women were found to be younger than the men. Differences existed in their drug use; women used smaller amounts, for a shorter duration, and were less likely to inject than their male counterparts. No differences existed between treatment contact for the heroin users, but differences were found among die cocaine-using sample, with men being more likely to have contacted a treatment agency. Men were financing themselves through more criminal activities than women. Drug-using sexual partners were found to be an important influence over women's drug use, with most female injectors having been given their first injection by a male sexual partner. Structural differences in patterns of drug use found among female drug users and the influence of male sexual partners are likely to play an important role in determining appropriate treatment options for women drug users.     

Lemon Juice as a Solvent for Heroin in Spain

Preliminary observations and responses to interviews in Valencia, Spain reveal that injecting drug users (IDUs) dissolve heroin before injection with two or three drops of lemon juice. Solution in lemon juice makes heating of heroin in water unnecessary. This pattern apparently developed spontaneously in Spain, but is almost unknown elsewhere in the world. Its implications for IDUs' health remain speculative, but use of lemon juice to dissolve heroin for injection deserves further scientific study.     

Heroin is More Than Just Diamorphine

Heroin isn't just heroin anymore. Over the last two decades, there has been diversification in the forms and ‘brands’ of heroin which exist in both the domestic as well as international marketplaces. Closer examination reveals important differences between these ‘brands’. Black market heroin may now be obtained in either the form of salt (hydrochloride) or the separated base. Importantly, the different forms have different suitabilities for use by injection or by ‘chasing the dragon’, with the salt form being most suitable for injecting, whilst many of the base forms are either used by ‘chasing’ or are chemically transformed to the salt before injection. Country of origin and obvious physical characteristics such as colour are strong predictors of ‘salt’ or ‘base’ status. When consideration is given to the more recent technique of chasing the dragon, a new interpretation can be attached to some of the other drugs found in samples of black market heroin (often described as ‘impurities’). New data have identified that several of these additional drugs increase substantially the proportion of heroin which sublimates and can successfully be recovered by the heroin ‘chaser’, and these increases can be seen in the extent of recovery of both salt and base forms of heroin. Finally, new policy options are explored in the light of this new evidence-options that include the proposed development and promotion of NIROAs (non-injectable routes of administration), and the possible constructive manipulation of the heroin marketplace through differential application of interdiction efforts so as to promote the move from injecting to ‘chasing’ as the chosen method of heroin use.     

Heroin discriminative stimulus effects of methadone,LAAM and other isomers of acetylmethadol in rats

Abstract Rationale. LAAM (α-l-acetylmethadol) is a derivative of the synthetic mu-opiate agonist methadone and is one of the four isomers of acetylmethadol. Methadone and LAAM have similar pharmacological properties and both are approved medications for the treatment of heroin dependency disorders. Few studies have reported on the pharmacology of acetylmethadol's other isomers and most of these have focused on their potential analgesic activity. Objectives. The purpose of the present investigation was to examine the discriminative stimulus effects of LAAM, the other isomers of acetylmethadol, and methadone in rats trained to discriminate heroin from water, and to compare the duration of the discriminative stimulus effects of heroin, methadone, and LAAM. Methods. Long-Evans rats were trained to discriminate 0.3 mg/kg heroin from water under a fixed ratio 10 (FR10) schedule of food reinforcement. Dose-response functions for heroin, methadone, LAAM, three other isomers of acetylmethadol: α-d-acetylmethadol, β-d-acetylmethadol, β-l-acetylmethadol, and its precursor, β-l-methadol were examined. Additionally, the time course effects for heroin, methadone, and LAAM were examined. Results. LAAM and methadone dose-dependently occasioned heroin-like discriminative stimulus effects. Two of acetylmethadol's isomers, α-d-acetylmethadol and β-d-acetylmethadol, were more potent than LAAM in producing heroin-like effects. The β-l-methadol precursor and β-l-acetylmethadol did not fully substitute for heroin's discriminative stimulus. LAAM elicited heroin-like discriminative stimulus effects for at least 6 h and generated partial generalization up to 36 h following administration. Conclusions. Methadone, LAAM, β-d-acetylmethadol and α-d-acetylmethadol, but not β-l-acetylmethadol and β-l-methadol evoke heroin-like discriminative stimulus effects. Electronic Publication     

Perceived Treatment Need and Latent Transitions in Heroin and Methamphetamine Polydrug Use among People who Inject Drugs in Tijuana,Mexico

People who inject drugs (PWID) in Tijuana, Mexico, use heroin and/or methamphetamine. While polydrug use is associated with HIV risk behavior, less is known about the stability of polydrug use patterns over time and how polydrug use is related to perceived treatment need. Within a cohort of PWID in Tijuana (N = 735) we sought to (1) characterize subgroups of polydrug and polyroute use from baseline to six months; (2) determine the probabilities of transitioning between subgroups; and (3) examine whether self-reported need for help for drug use modified these transition probabilities. Latent transition analysis (LTA) identified four latent statuses: heroin-only injection (38% at both baseline and follow-up); co-injection of heroin with methamphetamine (3% baseline, 15% follow-up); injection of heroin and methamphetamine (37% baseline, 32% follow-up); and polydrug and polyroute users who injected heroin and both smoked and injected methamphetamine (22% baseline, 14% follow-up). Heroin-only injectors had the highest probability of remaining in the same latent status at follow-up. The majority reported great or urgent need for treatment (51%) and these PWID had greater odds of transitioning to a higher-risk status at follow-up, emphasizing the need for evidence-based drug treatment options for PWID.     

A Rapid Assessment of Heroin Use in Mombasa,Kenya

This article reports on a rapid assessment (RA) carried out in the city port of Mombasa, Kenya in March 2004 by the Omari Project to inform the scaling up of their services to heroin users. Heroin has been a street drug in Mombasa for over 25 years. From 1998, white crest, probably from Thailand, started to replace brown sugar, and there was a major shift from inhalation of the vapor (“chasing the dragon”) to injecting. The Omari Project has been monitoring the heroin situation in Mombasa and treating heroin users from Mombasa since 1997. In the course of the RA, 496 heroin users were interviewed of whom 95% were men and 5% were women. A range of methods were used, including mapping of the Mombasa region, work with a key informant/guide who was a heroin user, administration of a brief questionnaire and informal interviews, and feedback of findings to other local agencies working with drug users. Respondents were from a wide range of cultural/ethnic groups, the two largest being Mijikenda and Swahili, who are indigenous to the Kenya coast. Overall, 15% of respondents had “ever injected” heroin, and 7% were current injectors (n = 37). These data indicate a shift away from injecting but also reflect the death of many established injectors, either through overdose or AIDS or hepatitis. The figure of 7% of the sample reporting being current injectors is likely to be an underestimate. Syringes were available from a number of pharmacies and most injectors reported using a syringe for 1–3 days. The majority reported injecting in a group of three or more and described risk behaviors for HIV transmission. The results of the assessment highlight the need for a range of services, including needle exchange, counseling, and referral to residential treatment programs. However, progress toward responding to the findings of the RA by establishing effective services are hampered because of legal impediments to operating needle exchange programs in Kenya.     

Meperidine in Detoxification of Hospitalized Heroin Addicts

Forty-six heroin abusers were hospitalized and treated with meperidine either alone or in association with clonidine. Meperidine was given orally in rapidly decreasing doses according to three different schedules. The majority of patients (87 %) successfully completed the detoxification program. The best meperidine starting posology was 200 mg four times daily, which allowed stoppage of the opioid treatment after gradual reduction of the daily dose in a mean time of 9.5 days. Association with clonidine was not proven to be useful. This study shows that meperidine can be effectively used in rapidly decreasing doses in the pharmacological detoxification treatment of hospitalized heroin addicts.     

Characteristics of Psychopathology and the Relationship Between Routes of Drug Administration and Psychiatric Symptoms in Heroin Addicts

ABSTRACT

The objective of this study was to explore the characteristics of comorbid psychiatric symptoms and the relationship between different routes of drug administration and psychiatric symptoms. Five hundred and nine heroin addicts were studied in Drug Detoxification and Rehabilitation Centers in Yunnan and Heilongjiang provinces of China. The measure instrument, including demographic characteristics, history of drug abuse, and the Symptom Checklist-90 (SCL-90) scale (Chinese version), was administered to eligible heroin addicts. Among the subjects, comorbid psychopathology conditions were more severe on all dimensions of SCL-90 comparing with normal adults and the average score of Depression was highest among the 9 dimensions in heroin addicts; psychiatric symptoms were more severe in heroin injecting group than in “chasing the dragon” group and only the difference in Obsessive-Compulsive was significant, but more significant differences were found between snorting heroin addicts and chasing or injecting heroin addicts, and the average score of each dimension of SCL-90 was higher in the snorting group than in the other 2 groups. The reasons of the results and meaning for the present study are discussed. In summary, comorbid psychiatric symptoms in the heroin addicts were very common and severe and their severity varied with different routes of drug administration, suggesting that routes of drug administration should be considered as an important risk factor to mental health of heroin addicts.     

The Ethnographic Accessing,Sampling and Screening of Hidden Populations: Heroin Sniffers in New York City

This article discusses various ways in which ethnographic methods were employed in a cohort study of HIV risk and transitions to injecting among non-injecting heroin users (NIUs), or ‘sniffers’, in New York City. In preparation for and in conjunction with an epidemiologic questionnaire survey and biological specimen collection, ethnographic methods were used to explore the meaning of non-injecting and injecting routes of heroin administration for NIUs, how non-injecting heroin use was imbedded in the everyday life of the user, and the relationship of users to the retail markets for heroin. The study utilised different ethnographic techniques to access, sample, and screen heroin ‘sniffers’ for the epidemiologic survey. These techniques included ethnographic accessing, targeted canvassing, and interactive screening. The article concludes that ethnographic methods can be fruitfully integrated with epidemiologic survey research and are necessary for conducting research among non-institutionalised, ‘hidden’ populations of drug users.     

Incarcerated intravenous heroin users: Predictors of post-release utilization of methadone maintenance treatment

Incarcerated intravenous heroin users have more problematic patterns of heroin use, but are less likely to access methadone maintenance treatment by their own initiative than heroin users in the community. The present study examined predictors for receiving methadone maintenance treatment post-release among incarcerated intravenous heroin users within a 24-month period. This cohort study recruited 315 incarcerated intravenous heroin users detained in 4 prisons in southern Taiwan and followed up within the 24-month period post-release. Cox proportional hazards regression analysis was applied to determine the predictive effects of sociodemographic and drug-use characteristics, attitude toward methadone maintenance treatment, human immunodeficiency virus serostatus, perceived family support, and depression for access to methadone maintenance treatment after release. There were 295 (93.7%) incarcerated intravenous heroin users released that entered the follow-up phase of the study. During the 24-month follow-up period, 50.8% of them received methadone maintenance treatment. After controlling for the effects of the detainment period before and after recruitment by Cox proportional hazards regression analysis, incarcerated intravenous heroin users who had positive human immunodeficiency virus serostatus (HR = 2.85, 95% CI = 1.80–4.52, p < .001) and had ever received methadone maintenance treatment before committal (HR = 1.94, 95% CI = 1.23–3.05, p < .01) were more likely to enter methadone maintenance treatment within the 24-month follow-up period. Positive human immunodeficiency virus serostatus with fully subsidized treatment and previous methadone maintenance treatment experiences predicted access of methadone maintenance treatment post-release. Strategies for getting familiar with methadone maintenance treatment during detainment, including providing methadone maintenance treatment prior to release and lowering the economic burden of receiving treatment, may facilitate entry of methadone maintenance treatment for incarcerated intravenous heroin users.