The Movement Toward Intranasal Use and Other Emergent Trends

Most available epidemiologic data from large urban sectors across the United States, particularly northeastern cities, indicates the re-emergence of heroin as a significant drug of abuse. This has been confirmed by a series of indicators including publicly funded treatment admissions data, hospital emergency room data, police reports, and ethnographic accounts of street based populations (Community Epidemiology Work Group (hereafter, CEWG) Dec. 1992; 1993; June 1994; Agar 1994). The heroin on the streets in the 1990s has been characterized as some of the most potent in modern times. The Drug Enforcement Administration reported that the average nationwide purity level for retail heroin was 37 percent in 1992. In some major cities such as New York, average purity levels are even higher ranging from 54 to 70 percent; in Philadelphia average heroin purity was 58 percent (CEWG Dec. 1993). Further, it has also been recognized in many cities as highly available, easy to acquire, and relatively inexpensive, based on its purity level (CEWG, Dec. 1992, 1993; June 1994; Agar & Murdoch 1994). Comparatively, the purity of heroin reported in the 1960s and early 1970s was most often less than 10 percent; in 1985 the average purity of street heroin in the United States was roughly five percent.

This analysis reviews the current epidemiological data on heroin use in the United States (particularly the Northeast), examines the shift toward intranasal use (and smoking), emergent, nontraditional user subgroups, and discusses the pattern of concurrent heroin and cocaine abuse. A profile of changing patterns of heroin use in Philadelphia will also be presented. This includes: 1) CEWG epidemiologic reports over the last five years; 2) admissions data from a Veterans Administration-based methadone clinic from 1987 to 1993 looking at route of administration shifts; 3) ethnographic data that were collected through participant observation of a methadone maintenance-based self-help group, and from two needle exchange sites in heavy drug use areas of the city.

These issues regarding shifting patterns of use, routes of administration, and new user groups are of particular importance because of their implications in understanding changes in HIV transmission, use of alcohol and other drugs, and on ascertaining the etiologies, natural addiction histories, and treatment trajectories of emergent user groups.
 

Epidemiologic Indicators of Resurgence in Heroin Use

The reported use of heroin has been increasing in several cities across all regions of the United States since 1989. Treatment admissions data, emergency room episodes, criminal justice data and ethnographic street accounts have indicated that heroin is making a substantial comeback in many major cities including Boston, Chicago, Los Angeles, Washington, D.C., Atlanta, Detroit, Miami, Denver, Newark, Philadelphia, New York, Minnesota, St. Louis, San Francisco, and Seattle (CEWG, June 1994). While the use of heroin is increasing steadily in these localities across a diverse user population, the route of administration among users has also shifted significantly in many cities. For example, intranasal use is increasing, while injecting use is declining in Boston, Chicago, Newark, New York, Washington, D.C., San Francisco, Seattle, Detroit and to a lesser extent Philadelphia (CEWG, Dec. 1993).
 

Profile of Heroin Use in Philadelphia

In Philadelphia, information from street users not in treatment, recent treatment admissions to public sector programs, and outreach workers associated with needle exchange sites who serve primarily heroin users, all report that heroin has increased substantially in availability, that the purity is good, and the price is reasonable (CEWG, June 1994). For the first time in years, methadone maintenance programs in Philadelphia have begun to report the existence of a waiting list for treatment. Like other reports from large urban centers across the country, Philadelphia-based epidemiologists have concluded that the crack cocaine epidemic has to an extent fueled the increase in heroin use in the city.

Despite a slight increase in intranasal use between 1991 and 1992, this mode of ingestion does not seem to be making significant inroads over injecting. Approximately 20 percent of treatment admissions for heroin (as the primary drug of abuse) to publicly funded facilities from 1991 to 1993 reported snorting as the primary route of administration (CEWG, Dec. 1993). Like other cities, intranasal use appears to be more common among younger and new users.

In addition to the shift toward intranasal use, other patterns associated with the heroin resurgence in the 1990s are the emergence of "nontraditional" user groups and the concurrent use of heroin and cocaine. Each of these areas will be discussed in the following section.

Shifting Epidemiologic Patterns Associated with the Heroin Resurgence of the 1990s

1) The Movement from Injection to Intranasal Use

What appears to most distinguish heroin use today from the last significant heroin use period (1965-1973; often demarcated as the Vietnam Era cohort) is the increased proportion of intranasal users and the general movement, even among established, long-term injection users, to snort and smoke as well as shoot the drug. It is likely that the combined effects of an increase in heroin purity (at a relatively low cost), its availability, and the spread of HIV/AIDS (particularly among injecting drug users) have promoted in part this route of administration shift (Agar 1994).

Historically, drug users have suggested that the low purity of street heroin led to injection of the drug in order to optimize its pharmacological effect. The increased potency and lower cost of recent street heroin makes snorting and smoking the drug a more viable option than injecting it, given the dangers and difficulties of needle use (and sharing needles or works which is often concomitant to needle use). Concurrently, it is likely that the fear of acquiring AIDS through injection drug use has promulgated a movement toward the snorting and to a lesser extent the smoking of heroin. Most of the available epidemiological indicators suggest that this pattern should continue across the country throughout the 1990s.

Shifting Routes of Heroin Administration at a Philadelphia Methadone Clinic: Admissions data col-lected at a Philadelphia VA Methadone Clinic in 1987, prior to the influx of highly potent heroin into the city (when street-based heroin in the city was reported as roughly 10 percent pure at best), depicted that less than one percent of new admissions reported using heroin by intranasal use (McNicholas 1994). Of the 104 men admitted to the clinic five years later in 1992, approximately 30 percent reported snorting heroin in the 30 days prior to their admission. Of this group, 53 percent stated that they had snorted heroin daily over the 30-day period. While the 1993 admissions data were less striking, it confirmed an already apparent pattern of the movement away from injection heroin use by a significant subgroup of admissions. Of the 99 men admitted to the program in 1993, 23 percent reported intranasal heroin use over the preceding month; 56 percent of this group reporting daily heroin snorting during this time.

While heroin injection is still the most dominant route of administration reported at admission, there appears to be a shift by a significant percentage of men toward intranasal use. This shift should not be taken as a complete movement from one route of administration to another in all cases. A significant proportion of reported snorters stated that they had also injected heroin over the prior month and six-month periods.

Based upon the 1992-1993 clinic data, there emerged roughly three subgroups of users, based upon those admissions who reported using heroin over the prior month: 1) pure injectors, 2) mixers, who tended to be "chippers" (occasional heroin users), some who reported more injection use versus snorting, and others who predominantly snorted yet injected heroin on occasion, and 3) pure snorters. For the two-year period, the pure injectors represented 71 percent of the population, some combination of mixers approximately 15 percent, and pure snorters 14 percent. The emergence of these subgroups, which do not have clearly demarcated boundaries, support the findings of D.C. Des Jarlais et al. (1994) in New York City.

2) Changing User Profile

One of the more surprising epidemiological shifts associated with the resurgence of heroin in the United States is the reported incidence of increased heroin use (mainly snorting) among "nontraditional" users such as the educated, middle-class college populations, women, teenagers/adolescents and the affluent.

A recent report for the White House Office of National Drug Control Policy assessed the "pulse" of the nation's drug problem through key informant interviews with epidemiologists, ethnographers, treatment providers, and law enforcement agents for 13 cities across the country and documented this emergence of heroin use by "nontraditional" groups. This group includes teenagers, young adults, females, and middle and upper-middle income populations (Hunt & Rhodes, Spring 1993). In what may be indicative of the beginning of an emergent national trend, one of the largest treatment programs in Washington, D.C., reported a significant increase in new admissions of young adults for snorting heroin, with no other reported drug use.
Heroin has become re-glamorized among many in the music, art and film world as a chic drug for "stylishly tortured souls" (Gabriel 1994). Other reports itidicate that heroin has emerged as a recreational drug on college campuses across the United States, and newer, intranasal users are significantly younger than their injecting counterparts (CEWG, June 1994; Spring 1995; Hunt & Rhodes 1993).

3) Heroin and Cocaine

There has been a significant increase in the reported prevalence in the late 1980s and 1990s of concurrent heroin and cocaine use, most commonly as an injectable "speedball," or the combination of crack smoking and heroin snorting or smoking. Speedballing has become particularly popular among IDUs in this country. In Philadelphia, for example, the typical heroin injector (in both treatment and street-based populations) usually shoots heroin and cocaine together (Navaline 1995).

This pattern was relatively uncommon during the 1965-1973 heroin epidemic. The combination of crack cocaine and heroin snorting or smoking is clearly unique to the 1990s user cohort.

Epidemiologic reports for select cities since 1988 have captured the emergent concern of heavy crack and cocaine user's concurrent use of heroin (CEWG, Dec. 1989, 1992, 1993). The CEWG reports for 1988 and 1989 first documented crack use combined with smoking and/or snorting of heroin in New York, Newark, and Philadelphia, cities where higher purity heroin was first cited (CEWG 1990). Both Drug Use Forecasting or DUF data and treatment admissions data across the country have confirmed this pattern of combined heroin and cocaine use. The "Pulse Check" report of drug abuse trends in 13 cities, based upon informant interviews with ethnographers, police and treatment providers, documented that speedballing and crack/ heroin use is widespread (Hunt & Rhodes 1993).

Urine data collected at the Philadelphia VA Methadone Clinic cited earlier depicted that over 60 percent of the active clients had used heroin and cocaine concurrently at some time over a six-month period. Seventy-eight percent of the addicts who appeared at four needle exchange sites in Philadelphia (based upon a random sample drawn weekly at each site; this represents all needle exchange efforts in the city and draws street addicts from all across Philadelphia) over a three-month period reported that they typically injected heroin and cocaine together. Pure heroin injectors were the clear minority (22 percent) and "speedballers" only reported using heroin alone when they were "sick" (needed a fix). Thirty-nine percent of this needle exchange population also reported smoking crack cocaine in the 30 days prior to the interview (Navaline et al. 1995).

Ethnographic data collected by this author from Philadelphia has documented that street-level dealers are distributing "free" heroin samples to their crack clientele, or selling single bags or "bundles" at half price as "trial size" packages to hook people. A few informants confided that on well-known street corners where crack is typically sold, users are given free bags of potent heroin. It is likely that a growing percentage of crack cocaine users are becoming hooked on relatively potent heroin as an adjunct or outgrowth of their cocaine dependence. Heroin is reported to be the perfect antidote to being strung out on a cocaine high, giving the user quick relief (as opposed to alcohol or benzodiazepines which take much longer) from the psychophysiological effects of intensive cocaine use.

Discussion and Conclusions

It is likely that the high purity and generally lower cost of heroin, in combination with the perceived threat of acquiring HIV through needle use, have led to a significant shift in route of administration from injection to intranasal use among many addicts across the country. While sniffing heroin is not a potent a way to put heroin in one's body, and serious dependence is not as likely to occur as through injection, it is still addictive and often leads to abuse and dependence.

The combination of increase in heroin purity and the shift (and greater acceptance) toward snorting have opened the door for "nontraditional" user groups to become involved with the drug. The movement toward heroin snorting appears to have allowed younger, less experienced users and other "nontraditional" users who may have a "needle barrier," which may have precluded injection use. While males still dominate the heroin scene across all epidemiological indicators, there is an increasing proportion of females represented in the national data on reported use at treatment admission. Intranasal use is more commonly reported among females, but this "gender" factor varies considerably from city to city and by other factors such as duration of heroin use. Interestingly, and in contradistinction to our understanding of the epidemiology of heroin use in the '60s and early '70s, heroin has recently been reported as a "recreational" drug on college campuses across the country (CEWG, Dec. 1993).

It is clear that heroin snorters are not a homogenous category and that the factors that predispose a person to snort rather than inject are complex. For some, it is likely that heroin sniffing is part of the early stage of their heroin career, which usually leads to either combining sniffing, injecting and smoking or just injection. Even in this age of high purity heroin and AIDS, heroin injection is still more commonplace than sniffing. Of particular concern is the newly emergent heroin snorting cohorts who are mainly younger and less experienced in drug use. This group is particularly at risk for overdosing because of their lack of experience with the drug. One key question that needs to be explored is whether a proportion of this group will progress to injection heroin use, or heroin smoking as part of their "natural history," particularly if heroin purity levels shift downward, as they have in the past (Casriel et al. 1990).

It is the combination of changes in worldwide poppy production, alterations in the way heroin is marketed at the street level, increased heroin purity levels, fear of HIV, greater public acceptance of heroin as a "recreational" drug (particularly among segments of the middle and upper-middle class), shifts in the cocaine market, and other shifts in the user base which lend themselves to explaining the recent heroin resurgence, as well as the shift away from injection use toward intranasal use.

Many of the new and established heroin users are those with an already existent cocaine dependency or a concurrent heroin and cocaine dependency . The long term trajectories of this newly emergent dually addicted population of users has yet to significantly impact the treatment system because of the lag between initiation, developing a dependence and seeking treatment, or their entering into the treatment system through criminal justice entanglements.

While it has been conjectured that HIV/AIDS has played a significant role in facilitating the shift away from injection use and toward more "harm reduced" approaches in administering heroin, little is known about how HIV/AIDS particularly affects user groups. Is the fear of acquiring HIV based upon direct contacts with an increased number of HIV-infected people, are they directly involved in heroin subculture social networks, or has the understanding been derived from secondary sources such as outreach, needle exchange programs, clinic admonitions, public service announcements and the like. From a "harm reduction" perspective, and in the need to generalize this understanding to "at risk" groups, the role that HIV/AIDS may play in the conversion process from injection to intranasal use is important to understand. If the change is based upon interactions within user social networks rather than exogenous sources such as outreach teams, needle exchange programs and clinics, these subcultures need to be the focus of in-depth ethnographic research in order to ascertain the phenomenology of the change process.

Eric Cohen, Ph.D., is an assistant professor of sociology at Penn State University, Fayette Campus, PO. Box 519, Uniontown, PA 15401. He has recently completed a NIDA-funded epidemiological study focusing on crack abusing, African-American women.

REFERENCES

Agar, M.H. and R.O. Murdoch, 1994. "Investigating Recent Trends in Heroin Use in Baltimore City: A Pilot `Quantitative' Research Project," CESAR: Special Topics on Substance Abuse, Number 94-1, February.

Casriel, C., D. Des Jarlais, R. Rodriguez et al., 1990. "Working with Heroin Sniffers: Clinical Issues in Preventing Drug Injection." Journal of Substance Abuse Treatment, Vol. 7, pp. 1-10.

Community Epidemiology Work Group, "Epidemiologic Trends in Drug Abuse: Dec. 1989." Rockville, MD: National Institute on Drug Abuse, 1990.

Community Epidemiology Work Group, "Epidemiologic Trends in Drug Abuse: Dec. 1993." Rockville, MD: National Institute on Drug Abuse, 1994.

Community Epidemiology Work Group, "Epidemiologic Trends in Drug Abuse: June 1992." Rockville, MD: National Institute on Drug Abuse, 1992.

Community Epidemiology Work Group, "Epidemiologic Trends in Drug Abuse: June 1994." Rockville, MD: National Institute on Drug Abuse, 1994.

Des Jarlais, D.C., S.R. Friedman, J.L. Sotheran, J. Wenston, et al., 1994. "Continuity and Change Within an HIV Epidemic: Injecting Drug Users in New York City, 1984 Through 1992." Journal of the American Medical Association.January 12, Vol. 271:2, p. 121-127.

Gabriel, T. 1994. "Heroin Finds a New Market Along Cutting Edge of Style." New York Times, May 4.

Hunt, D.E., and W. Rhodes, 1993. "Tracking the Incidence of Heroin Use: Is There a Possible Epidemic?" Abt Associates Inc. Spring.

McNicholas, L., J. Cornish, G. Woody, C. O'Brien, 1993. "Intranasal Heroin Users in Treatment." Paper presented at the 55th Annual Scientific Meeting of the College on Problems on Drug Dependence, Toronto, Canada.

Navaline, H., D. Metzger, D.J.P. Hammond, L. Lax, 1995. "Random Survey of Participants in a Needle Exchange Program." Paper presented at the 57th Annual Scientific Meeting of the College on Problems on Drug Dependence, Scottsdale, Arizona.