The New York State Division of Substance Abuse Services is mandated to assess the problem of drug abuse in the state—to determine its magnitude, its trends, the drugs of choice, the populations-at-risk, and the development of incipient epidemics. Consequently, the agency has a strong commitment to an epidemiologic study of the drug abuse problem.

 

I want to describe for you the everyday work of the epidemiology section of the agency, and then to describe the way in which we tracked the current heroin crisis in the state.

 

Our epidemiology section is divided into three units which reflect the three research strategies we use—the indirect indicator unit, the direct survey unit, and the ethnography or street studies unit.

 

The indirect indicator unit gathers data from a variety of official sources. Included among these data are drug-related arrests, drug-related emergency room episodes, cases of serum hepatitis, drug-related deaths, and admissions to drug treatment programs. Although the exact nature of the association between drug abuse and these indicators is not known, they are thought to reflect changes in drug use trends.

 

Each of the indicators is confounded by many problems: problems associated with the policies of the agencies that do the data collecting; problems associated with the vagaries and vicissitudes of data collection; and problems intrinsic to the indicators, irrespective of policy decisions and data collection. Epidemiologically, each indicator is only an imperfect reflection of the drug problem. If, however, most of the indicators point in the same direction and follow a similar trend over time, there is strong evidence that the problem is increasing or decreasing.

 

The direct survey unit, unlike the indirect indicator unit, generates its own data through the conduct of population surveys and does not rely on data generated by other agencies. Also, unlike the indicator unit that primarily analyzes trends, the survey unit can estimate incidence and prevalence of drug abuse. For instance, school children (in the 7th through 12th grades) a population particularly at risk of drug abuse, were randomly sampled and surveyed using a questionnaire that was self-administered. The results were statistically weighted and projected to the total population of school children in the 7th through the 12th grades in New York State to give an estimate of drug abusers in that population. Currently, the unit is supervising a computer-directed telephone survey of household residents in the state. The survey inquires into the use of a variety of drugs; the frequency, recency, and intensity of use; age at first use; and dysfunctionalities associated with use. The findings from the carefully selected sample will be weighted and projected to the total household population. Thus, estimates of drug abusers among the household population will be calculated.

 

Direct population surveys, however, like indirect indicators, have their shortcomings. First, surveys are useful in describing the characteristics of a large population. When, however, a rare behavior is studied, such as drug abuse, it is necessary to sample a very large population, and perhaps over-sample segments of the population having the highest use rates in order to achieve statistical reliability. This, in turn, increases the cost, making this research strategy considerably more expensive than the others. Furthermore, surveys cannot measure actual drug activity; they can only collect self-reports of recalled past action or of prospective action. Many respondents hesitate to give completely candid information about behavior that is so stigmatized. Finally, we know that direct surveys are not helpful in determining the prevalence of heroin abuse. The heroin-abusing segments of the population usually do not surface in school surveys and traditional household surveys, and if they do, they are probably unlikely to report their heroin use.

 

Finally, there is the street studies unit. In order to get timely data and knowledge of current drug use and availability, it is often necessary to study drug activity in the field and in its natural habitat. Consequently, the members of the street studies unit regularly observe the availability and prices of drugs sold in the "street"—on the illicit market. These workers are themselves former drug users who are knowledgeable about the behavior they observe and who physically resemble the population engaged in drug activity. Occasionally, the field workers try to engage in conversation with dealers, buyers, and onlookers to gather more information about use patterns and shifts in use.

 

In addition, the field unit has selected a sample of secondary schools that its members observe and monitor twice a year so that changes may be determined in any drug activity that may exist outside the school among the school-aged children. When special situations develop, the field unit is often asked to explore the situation by observing the scene. For instance, a newspaper article carried a story about teenage drug dealing in Manhattan. The field unit was asked to study several areas in the city to determine the extent of teenage drug dealing.

 

Street studies, like indirect indicators and direct surveys, have their weaknesses. The informal sampling and uncertain representativeness of the observations are shortcomings in themselves. It is not clear how far-reaching and how generalizable the findings are. An additional weakness is the danger involved in being a mere observer: since the field workers do not engage in drug using or dealings, and their identities as researchers are not revealed, their presence in these areas is often difficult to justify to those participating in the drug subculture.

 

Thus, given our three units and the research strategies they use and the limitations in each, we proceed very cautiously by using at least two of the strategies in assessing particular drug activity. In the literature of social research, the use of several research strategies in the study of a problem is called "triangulation." One sees our attempt at this approach when the heroin problem began to escalate in New York City in 1979.

 

For several years during the middle of the 1970s, heroin activity seemed to be declining. Trends in indirect indicators of heroin use were going down, the street studies unit found diminished availability, and the direct surveys were certainly not finding heroin use among respondents. In fact, the state agency was devoting more and more of its energy to combating illicit non-narcotic drug abuse and prescription drug misuse.

 

In the middle of 1979, the street studies unit was bringing back the word that more white heroin than the Mexican brown heroin was appearing on the streets, and that dealers in Harlem were talking glowingly of the purity of newly available heroin.

 

In 1979 we carefully watched the indicators. By the third quarter of 1979, some interesting trends started to develop. Readmissions to methadone programs in New York City had been declining steadily since 1975 to a low point in 1978. In the first three quarters of 1979, however, readmissions to New York's methadone programs started to increase. In fact they increased 22 percent over the comparable period in 1978. Similarly, the percentage of morphine positive urine samples among methadone clients doubled from early 1979 to the middle of 1979—from two percent to four percent of the samples. Thus, the indicators gave us some interesting clues, that addicts were returning to treatment, that heroin was probably the drug of abuse, and that those in methadone treatment were also abusing heroin.

 

By the end of 1979, when other indirect indicator data were available, the trend was unmistakable in New York City. Between 1978 and 1979:

 

• opiate-involved felony arrests in New York City showed an increase of nine percent (from 4,123 to 4,503);

• heroin emergency room episodes reported for a sample of New York SMSA hospitals increased 49 percent (from 480 to 713);

• deaths due to intravenous narcotism increased 92 percent (from 246 to 472); and

• treatment admissions with heroin as the primary drug of abuse increased 26 percent (from 18,644 to 23,464).

 

At the beginning of 1980, the street studies unit conducted interviews with 150 heroin users and/or dealers in 30 locations in New York City. The responses indicated that the quality of the heroin was excellent. Many informants compared it to the heroin of the past: "The stuff out there is like the O.D. bags of the sixties." "The shit is so good it makes you think you are back in the days." Furthermore the purity was so high that a series of dealers were able to dilute the heroin many times and still preserve the "kick." Some dealers said:

 

"I got it man, I got the real deal. I can give you a good play on some pure (ie, unadulterated heroin). This is on a fifteen (ie, can be diluted 15 to one and still have strength)". "So now I give it a 20 or a 22 and sell it for pure; they can put a five or a three on it and still get over."

 

The dealers and users recognized the fact that it was heroin coming from a new source—Southwest Asia. For instance, this dialogue was reported:

 

"Wow I haven't seen or heard of that kind of shit in years." "Well my people got it man. Straight off the boat."

"I wonder where it comes from?"

"Man I think its from Iran! Yep Iran man!"

 

During 1980 we continued to track the indicators, our field unit continued to observe the street, and we kept alerting the executive managers of our agency to the findings. But, given the vagaries and vicissitudes of data collection, there were some changes in indicators. For instance, readmissions to methadone treatment programs were no longer available since that methadone registry ceased to exist and another registry started up, which lost the distinction between new admissions and readmissions. The sample of consistently reporting hospital emergency rooms changed somewhat, and a new trend was established. Nevertheless, the increasing trend in heroin activity in New York City was generally more pronounced in 1980 than it was in 1979. Between 1979 and 1980:

 

• heroin admissions to emergency rooms increased 82 percent (from 1,924 to 3,494);

• preliminary numbers of deaths due to intravenous narcotism showed a 33 percent increase (472 to 630);

• cases of serum hepatitis B+, which is considered an indicator of incidence or new use of intravenous drug use and which had remained stable between 1978 and 1979, increased 18 percent from 1979 to 1980 (487 to 577);

• admissions of inmates to the detoxification program on Riker's Island also had remained relatively stable between 1978 and 1979, but rose 34 percent between 1979 and 1980 (from 7,239 to 9,704);

• the Drug Enforcement Administration in its studies of purity of street samples found relative consistency of three percent in Harlem, but an increase from 8.5 percent to 12.6 percent for street bags on the Lower East Side;

• finally, heroin treatment admissions, rather than increase, declined 10 percent (from 23,464 to 21,107), simply because treatment programs could not accommodate additional clients. By the end of 1980, waiting lists existed in methadone maintenance programs, residential drug-free and ambulatory detoxification programs. Currently, the waiting lists number more than 1,000 names.

 

Again, the street studies unit brought back its reports. Heroin dealing was taking place throughout the city and street bags were averaging about $10 per bag. What was most disconcerting was their finding that six or seven dealers were selling heroin for $4 per bag, a price that was unheard of since the 1960s. Coupled with the high purity found on the Lower East Side, there findings signaled a very serious problem.

 

Thus, from indirect indicators and street observation, we have had a close watch on the current heroin situation. Perhaps a look at the epidemiologic triad of agent, environment and host can shed some additional light.

 

First, the "agent." What has exacerbated the current heroin problem is the increased availability of heroin in the last few years, chiefly from Southwest Asia. In 1979, the US Drug Enforcement Administration estimated that the opium cultivation in the world was almost 1,800 metric tons. This volume can be best appreciated when it is compared to the volume produced during the heroin epidemic years of the 1960s and early 1970s. At that time an annual production of only about 80 metric tons of opium from Turkey was responsible for the heroin traffic to the United States. Although not all the current opium produced in the world will find its way to the United States, opium cultivation is considerable, it will find its way to where the profits are the greatest, and it is produced in countries with which diplomatic relations are extremely strained (Iran and Afghanistan). Furthermore, the DEA expects production levels to remain high through 1981, somewhat diminished in Southwest Asia but increased in Southeast Asia or the Golden Triangle countries of Thailand, Burma, and Laos.

 

Another important consideration is the fact that opium cultivation is only the first step in an already well-developed operation. Raw opium is converted to morphine base in clandestine laboratories in Middle Eastern countries and converted to heroin principally in French and Italian laboratories. The laboratories of the "French Connection" days are back in business once again, in the hands of very experienced entrepreneurs who have renewed old Mafia connections in the United States. Thus, the experience of the past has quickly made this a well-coordinated operation put in place fairly easily and very effectively.

 

A final comment about the "agent" concerns the way heroin is currently used. Although heroin is usually injected, the media carries news of how heroin is now being snorted and smoked. Little is known about the consequences of this form of use, although we know that the major problem of addiction in Asia was opium smoking. Nevertheless, the smoking of marijuana and the snorting of cocaine have become socially more acceptable and less stigmatized in this country. It is conceivable that the smoking and snorting of heroin may also gain wider acceptance among the vastly larger number of marijuana and cocaine users.

 

As for the "environment," this country's heroin problem tends to concentrate in northeastern cities, such as New York, Newark, Philadelphia, and Washington, although it is reported in Detroit and Phoenix as well. Unlike the late 1960s and early 1970s when large metropolitan areas throughout the United States had to deal with increased heroin activity, the current problem seems to be contained in several cities. A few reasons are offered for the very different pattern of distribution. The Drug Enforcement Administration believes that Mafia connections and the networks of independent entrepreneurs are so well-established in the New York-Washington region that there is no need to go elsewhere. Furthermore, the demand is greatest in New York City. In fact, it is still believed that half the addicts in the United States reside in New York City. Second, other regions have their special drug interests. For instance, Miami is dominated by cocaine traffic. Heroin traffickers may not even want to challenge the cocaine interests. In Chicago and the midwest, the Mexican heroin interests tend to dominate. Although Mexican heroin has diminished in availability, that criminal network may exert enough influence to prevent other heroin from entering. These well established dealing and criminal networks can distribute heroin if and when supplies are obtained.

 

Although these conjectures cannot be verified, the fact remains that during the two years that the heroin problem has increased, heroin availability seems to be confined to the northeastern corridor. The implications of the current situation—unlike the situation several years ago—are that those who are interested in heroin would have to migrate to the places where heroin is available and would therefore be attracted to the northeastern region of the country. In past years, the supply would follow the demand, today the situation might be quire different. Again this is in the realm of conjecture.

 

As for the "host," the distinguishing characteristic of current heroin abusers is their age. From emergency room data, treatment admissions, death data, it appears that the addicts currently most visible are those over the age of 30. Many of these are probably former addicts who have been lured back by the white heroin; some probably had been using all along but the heroin now available may have brought their use to dysfunctional levels. Whatever the pattern, many of these users have already had an immediate and overwhelming impact on the treatment system.

 

We expect, however, a second wave of users to impact the treatment system. These are the new abusers. The usual history of heroin addiction shows that it takes a year to two years (what is euphemistically called the "honeymoon" period) before the addict surfaces in treatment. We may have begun to see these users surfacing in the criminal justice system among adolescent inmates in New York City admitted to the detoxification program on Riker's Island and in the health system in the recent increase in cases of serum hepatitis B+.

 

There may even be a third wave of abusers who will be seeking treatment, those who start by snorting and smoking heroin and whose addiction histories may take a longer time to develop.

 

In any case the overall epidemiologic implications of the current heroin crisis are grave and the solutions require considerable resources on the local, state, federal and international levels in terms of increased treatment capability, more effective law enforcement, more effective programs in prevention, and, surely, strategic diplomacy at the international level.

 

We in the epidemiology section will continue to do our monitoring. We look forward to the time when we may report to you that the trends are declining and the crisis has passed.