Heroin uncertainties: Exploring users’ perceptions of fentanyl-adulterated and -substituted ‘heroin’

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Researchpaper

Heroin uncertainties: Exploring users ’ perceptions of fentanyl-adulterated and -substituted ‘heroin’

DanielCiccarone*,JeffOndocsin,Sarah G. Mars

DepartmentofFamilyandCommunityMedicine,UniversityofCalifornia,SanFrancisco,500ParnassusAve.,MU-3E,Box900,SanFrancisco,CA94143-0900, UnitedStates

ARTICLE INFO

Articlehistory:

Received10May2017

Receivedinrevisedform1June2017 Accepted12June2017

Keywords:

Heroin Fentanyl Opioids Overdose Mortality Qualitativeresearch

ABSTRACT

Background:TheUSisexperiencinganunprecedentedopioidoverdoseepidemicfosteredinrecentyears byregionalcontaminationoftheheroinsupplywiththefentanylfamilyofsyntheticopioids.Since 2011opioid-relatedoverdosedeathsintheEastCoaststateofMassachusettshavemorethantripled, with75%ofthe1374deathswithanavailabletoxicologypositiveforfentanyl.Fentanylis30–50Xmore potent thanheroinand itspresence makes heroinuse more unpredictable.A rapid ethnographic assessmentwasundertakentounderstandtheperceptionsandexperiencesofpeoplewhoinjectdrugs soldas‘heroin’andtoobservethedrugsandtheiruse.

Methods:AteamofethnographersconductedresearchinnortheastMassachusettsandNashua,New HampshireinJune2016,performing(n=38)qualitativeinterviewswithpersonswhouseheroin.

Results:(1)Thecompositionandappearanceofheroinchangedinthelastfouryears;(2)heroinischeaper andmorewidelyavailablethanbefore;and(3)heroin‘types’haveproliferatedwithseveralproducts beingsoldas‘heroin’.Theseconsistedoftwotypesofheroin(alone),fentanyl(alone),andheroin–

fentanylcombinations.Intheabsenceofavailabletoxicologicalinformationonretail-levelheroin,our researchnotedahierarchyoffentanyldiscernmentmethods,withembodiedeffectsconsideredmost reliableindeterminingfentanyl’spresence,followedbytaste,solutionappearanceandpowdercolor.

Thispaperpresentsanew‘heroin’typologybasedonusers’reports.

Conclusion:Massachusetts’heroinhasnewappearancesandiswidelyadulteratedbyfentanyl.Persons whouseheroinaretryingtodiscernthesubstancessoldasheroinandtheirpreferencesforeachform vary.Theherointypologypresentedisinexactbutcanbevalidatedbycorrelatingusers’discernment withdrugtoxicologicaltesting.Ifvalidated,thistypologywouldbeavaluableharmreductiontool.

Furtherresearchonadaptationstoheroinadulterationcouldreducerisksofusingheroinandsynthetic opioidcombinations.

Introduction

TheUnitedStateshasseenadramaticincreaseintheadverse consequences of heroin use. Between 2010 and 2014 heroin- relatedoverdosemortalityratestriplednationallyfrom1.0to3.4 per100,000(Rudd,Aleshire,Zibbell,&Gladden,2016),increasing another20.9% from 2014to2015 (Rudd, Seth, David,& Scholl, 2016).Thisepidemicisintertwinedandoverlapswiththelarger prescriptionopioidmisuseepidemicthatprecededit(Compton, Jones, & Baldwin, 2016; Unick, Rosenblum, Mars, & Ciccarone, 2013).Thataportionoftheat-riskpopulationistransitioningfrom onesourceofopioids(prescriptionpills)toafullyillicit source

(heroin) is supported by both qualitative (Mars, Bourgois, Karandinos,Montero,&Ciccarone,2014)andquantitativestudies (Cicero,Ellis,Surratt,&Kurtz,2014).

Adding fuel to this ﬁre is the emergent and intensifying contamination of the heroin supply with powerful synthetic opioids, especially fentanyl and its chemical analogues (Drug EnforcementAdministration,US, 2016a).Fentanylis thecentral chemicalin afamily ofovertwentyanalogues;it isa synthetic opioid withpotentm^-receptor^activity, registering30–50times more potent by weight compared with heroin (lead author calculation).

Nationaloverdosedeathsattributedtofentanylbegantorisein 2013fromastablelevelofapproximately1600annuallyin2010– 2012to1905in2013andthenbyafurther120%to4200in2014 (Warner,Trinidad,Bastian,Miniño,&Hedegaard,2016).Inopioid overdosedeaths,heroin replacedoxycodoneasthenumberone

*Correspondingauthor.

E-mailaddress:daniel.ciccarone@ucsf.edu(D.Ciccarone).

ContentslistsavailableatScienceDirect

International Journal of Drug Policy

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a te / d r u g p o

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causeasof2012andfentanylmovedfrom9thin2012to5thmost commonopioidinoverdosedeathsin2014.Ofthedeathsprimarily attributedtofentanyl,64%had twoormoreconcomitantdrugs identiﬁed:heroin(23%)wasthemostcommonwithanadditional 9%co-attributedtomorphine(i.e.,abreakdownproductofheroin andafewothersemi-syntheticopiatesaswellasmorphineitself) (Warneretal.,2016).

Drug seizures data from the US Drug Enforcement Admin- istration’s (DEA) National Forensics Laboratory Information Service (NFLIS) reveal the increase in illicit fentanyl supply:

amongsamplestested,fentanylreportsincreasedfromapproxi- mately600annuallyduring2010–2012to14,051in2015.Muchof this increase (1400%) occurred between 2013 (934) and 2015 (14,051). The mostfrequent fentanyl analognoted in the most recentNFLISreportisacetylfentanylwith2412reportsin2015 (DrugEnforcementAdministrationDiversionControlDivision,US, 2016).

Connectingdrugsupplyevidencewithpublichealthoutcomes data, a study from the US Centers for Disease Control and Prevention(CDC)reportsapositivecorrelation(r=0.95)between risesinNFLISfentanylreportsandincreasesinsyntheticopioid (non-methadone)deathratesin27USstates,2013–2014(Gladden, 2016). The fentanyl responsible for these deaths is likely manufacturedillicitlyratherthan pharmaceutically;whileseiz- uresofillicitfentanylhaveincreased(DrugEnforcementAdminis- tration, US, 2015a), there is no correlation between fentanyl prescriptionratesandtheriseinsyntheticopioiddeaths(Gladden, Martinez,&Seth,2016).

There is a strongregionalpattern in the fentanylepidemic;

threeUSregionshadthehighestyear-over-yearincreases,2013– 2014,in synthetic(mostlyfentanyl) overdosedeaths: Northeast (Massachusetts,Maine,andNewHampshire),Midwest(Ohio),and South(Florida,Kentucky,Maryland,andNorthCarolina)(Gladden etal.,2016).TheUSNortheastandMidwestregionsalsohavethe highestratesofheroin-relatedoverdosedeath(Hedegaard,Chen,&

Warner2015)andhospitalization(Unick&Ciccarone,2017).

Massachusetts,thefocusofthisstudy,hadthesecondhighest increaseinsyntheticoverdosedeathsofthe27statesexaminedby theCDC.Thestatereachedapinnacleopioiddeathratein2015:

25.8deathsper100,000residents,a32%increasefrom2014anda triplingintheratesince2010.Fentanylwasfoundin75%ofopioid overdosedeathscases withavailable toxicology(Massachusetts DepartmentofPublicHealth,US2017).

Theaimofthisresearchwastogainanunderstandingofthe experiencesofheroinuserslivingthroughthispublichealthcrisis.

Wechosequalitativeinquirygiventheextensiveunknownsinthis rapidlychanging environment,thus, ourresearchquestionsare broad, e.g., how has heroin changed? And, what are users’ experienceswiththisnew‘heroin’?Theperspectivesofpersons whouseheroinhavebeenlargelymissingfromthediscussionof the current heroin/fentanyl crisis and can provide important insightsintochangesintheheroinsupplyandotheraspectsofthe riskenvironment.Forinstance,recentqualitativeresearchamong heroininjectorsinBaltimoreshowedthatnewformsof‘heroin’are perceivedashighlyvariableandunpredictable,resultinginarange of responsesand strategies(unpublished data). We relate here users’experienceswithand perceptionsoffentanyl-adulterated and -substituted ‘heroin’ (FASH) and other heroin types in Massachusetts.

Wereportonfieldwork,includingqualitativeinterviewswith activeheroinusers,performedinthreetownsinMassachusettsin June 2016.We choseMassachusetts and the specificfield sites basedontheabovestatisticaldataaswellaspreliminaryfindings, sincepublished, fromanethnographer, regardinglocal fentanyl useandoverdose(Somervilleetal.,2017;Zibbell,2016).Therapid ethnographicapproachusedhereallowsforbriefbutmeaningful

immersionintothelivesofanaffectedmarginalizedpopulation (Needleetal.,2003;Rhodes,Stimson,Fitch,Ball,&Renton,1999).

Methods

‘Rapidethnographic assessment’ isa form ofhighly focused ethnographywhichenablesresearcherstogainin-depthknowl- edgeaboutarapidlyemerginghealthprobleminashortperiodof time(Harris,Jerome,&Fawcett,1997).Ithasarecordofsuccessin bothdomesticandinternationalsettings(Trotter,Needle,Goosby, Bates,&Singer,2001).TheHeroininTransitionstudy(NIH/NIDA R01DA037820,PI:Ciccarone)usesarapidassessmentapproachto speciﬁcallyinvestigatereportsofnewandevolvingherointypes.

Following information about high levels of ‘heroin’-related overdose in Massachusetts, contact was made withlocal harm reductionservicesinthenortheasterncitiesofWorcester,Lowell and Lawrence. Data were collected through semi-structured interviews and ethnographic observation carried out in June 2016. Recruitment in Massachusetts was aimed at gaining an overall impressionacrosssiteschosen.Choice of siteswas also aimedatavoidingduplicationoftherecentstudyinsoutheastern Massachusetts, see Somerville et al., (2017). Initially New Hampshire was intended to comprise a contrasting location in the study.However, onceinterviewsrevealed thatNew Hamp- shire’sheroinwas suppliedfromMassachusetts, adecisionwas made tofocus theremainingrecruitmentsolely ontheMassa- chusettssites.

Withthehelpofstafffromlocalsyringeexchangesandother harmreductionworkers,individualsusingheroinwererecruited during the course of their daily activities including living at a homelessencampment,sittingaroundoutside,meetingupwith friends, aswell asvisiting harm reductionservices. Mostwere introducedtotheresearchersbyharmreductionworkersbutsome snowballsamplingwas alsocarriedout. Samplingof thetarget populationwasmoresuccessfulinLawrenceandLowellthanin Worcester.

Inordertobeeligibleforthestudy,participantshadtobeat least 18 yearsof ageand self-reportedcurrent heroin injectors eitherlivinginorcommutingtoMassachusetts.Particularefforts weremadetorecruitwomenwhoareoftenunder-representedin substanceuseresearch.InterviewswereconductedinSpanishand English, dependingontheinterviewee’s ﬁrst language. Spanish languageinterviewsweretranscribed,translatedandanalyzedby ethnographerFernandoMontero.

Thesemi-structuredinterviewswerecarriedoutbyateamof three ethnographersand thePI(DC)immediately uponrecruit- ment. Interviewees received a small cash sum of $20–25 in compensation for the time it took to conduct each interview (approximately0.5–1h).Allparticipantswereinterviewedatleast once while some provided additional in-depth interviews and neighborhood tours.Aminority ofparticipantswereasked and consentedtobeingﬁlmedduringdrugpreparationandinjection sequencesinvariouslocationsincludinghomelessencampments, inside tents and in the researchers’ car. Various criteria were involvedindecisionsaboutﬁlminginjecting,includingpractical ones regarding available locations, privacy, scheduling and personalsafetyconsiderations.

An interview guide provided a general structure to the conversation, includingquestionsontherespondents’historyof druguse,atypicaldayintheirlife,perceivedchangesintheheroin supply, knowledge of fentanyl, methods of use, preferences in heroin type, perceived effects of heroin vs. fentanyl, historical changes in the local heroin scene and medical complications including experiences of overdose. Further questions were generatedbytheinterviewees’responses.Duringtheinterviews, respondentswereshownswatchesofpaintcolors inthemes of

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white,grey,brownandbeigetoidentifythecolorsof‘heroin’they hadencountered both dryand in solution.These wereused to compare responses across the interview data. The color range shownwasbasedonpreviousethnographicstudies.

Thirty-eightcurrentheroininjectorswereinterviewedandfive injection sequences were filmed. All interviews were audio recordedandtranscribedintheirtotality.JOverifiedtranscriptions againstthe audiorecording for accuracy. Data not capturedby audio or video recording were extensively documented using written fieldnotes. Detailed observations were made of the participants’ livedenvironments,thesocial aspects ofdrug use andtheappearanceand useof thesubstances. Fieldnoteswere drafted collaboratively at the end of each research day and finalizedafterthetrip.

AnalysisofthedatawasdiscussedweeklybyJOandSMwho thenproduced analytic memosfor each interview, seeChristo- poulos et al. (2015), swapping them to add further analytical contributions.The analysiswas inductive, based upon observations from which patterns are discerned and inferences made.

Thematiccategorieswerederivedfromtheinterviewguideand thefieldnotedocumentation.Thefirstauthorselectedkeyaspects ofthefindingsforanalysisanddrewouttheirsignificance.

Theanalysisforegroundedthewaysinwhichpeoplewhoinject drugsinMassachusettsexperience‘heroin’atpresent,usingthe consistenciesof theirresponses toconstruct a pictureof their shared reality. The University of California, San Francisco Committee on Human Research approved the study protocol and a FederalCertiﬁcate of Conﬁdentialityissued by NIH/NIDA protectsthedata(anditscollection).

The sample of 38 current persons who use heroin included 23menand12women.Ofthosestatingtheirethnicity,16were white,3wereAfrican-American,10wereHispanicand7wereof mixed ethnicity. Their ages ranged from 19 to 52 years old.

Participantsreportedusingheroinfromlessthan1yearto35years.

Results

Locations

Theﬁeldworkwasconductedinthreelocations:Worcesterin centralMassachusetts,thesecondmostpopulouscityinthestate;

Lowell–thestate’sfourthmostpopulouscity–andLawrencein northeasternMassachusetts.LowellandLawrence,situatedinthe MerrimackRiverValley,werehistoricalcentersfortextilemilling, whileWorcesterwasaprominentlarge-scalemanufacturinghub.

All three cities have been severely affected by post-WWII deindustrializationin the regionand have experienced uneven economicrecoveries.LawrenceandLowellsharelonghistoriesof immigrationandlaborconﬂicts,buttheeconomicprospectsofthe twocitieshavedivergedinrecentyears.Lawrencehasthehighest povertyrateofthethreecitiesat29%(UnitedStatesCensusBureau, 2015). The three towns also vary by the ethnicity of their populations.NearlythreequartersoftheLawrencepopulationis ofLatinodescent(primarilyDominicanandPuertoRican),much higher than the two other ﬁeldsites, which are predominantly white.

Massachusettshashadsyringeexchangeprogramssince1993, andbegan a peer-naloxonedistributionprogram in2006 (Doe- Simkins,Walley,Epstein,&Moyer,2009;Sealetal.,2005;Walley etal.,2013).Oftheﬁeldsites,onlyWorcesterhadanofﬁcialsyringe exchangeprogram,beguninearly2016(Kotsopoulos,2016),while Lawrenceand Lowellhadinformalsyringeaccessand naloxone distributionprograms.

InMassachusetts,SoutheastAsianandSouthwestAsianheroin shared the market until the mid to late 1990s when the northeastern US became almost exclusively supplied by South

American-producedheroin(Ciccarone,Unick,&Kraus,2009;Drug EnforcementAdministration,US,2015c).LawrenceandLowell,in theGreaterBostonarea,havebeenamongtheprimaryregional distribution points since at least 2001, while Worcester is considered a secondary distribution center (National Drug Intelligence Center, US, 2001). The proximity of Lawrence and LowelltotownsinsouthernNewHampshireneartheMassachu- setts border has contributed to a commuter narcotics market, centeredinLawrence.Dealersarenotedforactivelymarketingto young,whitevisitorsfromNewHampshire,believedtobevisiting tobuydrugs:

LikeallyouneedtodoishaveNewHampshireplatesanddrive throughLawrenceincertainareas.Andifyoudon’thaveadrug dealerdownthereyouhavealotofpeoplethrowing[free]samples atyouandgivingyoutheirnumber.

Q: Yeah,they’reproﬁlingyou justbecauseof the platesoralso becauseyou’rewhite?

A:BecauseI’mawhite,younggirlwithNewHampshireplates... They’reveryaggressive.Theyknowwhatyou’redowntherefor.

They’reverygoodatpickingoutwhyyou’redownthere.

(Rachel,womaninher20s,injectingheroinfor5years)

Theethnographersobservedthatthisechoedearlierresearch carried out in Philadelphia which found heroin distribution concentrated among particularethnic groups byethnicallyand economicallysegregatedneighborhood,andvisitorsofconspicu- ouslydifferent‘race’liabletosuspicionbyresidentsofbeingdrug customers(Rosenblumetal.,2014).

Risein‘heroin’variants

Inthelastfewyears,likesince2013,2014[heroin]haschanged alot.

(Hector,maninhis40s,usingheroinonandofffor26years) Interview data on the introduction of perceived fentanyl- adulteratedor-substitutedheroin(FASH)intotheregionalheroin supplypointtoaround2013asapivotaltime.Long-timeinjectors inMassachusetts indicatedthathistoricallyheroinwasa tanor brownpowderwhichwhenmixedwithwaterbecameamedium- to-darkbrownsolution.Whilestillinpowderform,usersbroadly noted changes in heroinpowder and solution color, aswell as perceivedphysiologicaleffects.

Althoughlong-termusersreportedvariableheroinqualitysince the early 1990s along with periodic instances of FASH, they describedmajorchangessincearound2013.Theseconstituteda proliferation of ‘heroin’ variants in powder heroin from the traditional source-form, with FASH making up a signiﬁcant, possiblydominantportionoftheheroinmarketplace.HereLarry, amaninhis30susingheroinfor18years,describeditsincreased adulterationwithsynthetics:

Q:Sotheherointhatisoutthererightnow,howlonghasthatbeen around?Havetherebeenanychanges?

A:It’sbeenchanging,like3-1/2yearsago,maybe4.2012–2013,it’s likethat’swhenlikethebullshitstartedcomingin.Likemother- fucker’srealized,ifIgot 3gramsofdope Ican put3 gramsof bullshitonit

Q:Whatdoyoumeanbybullshit?

A:Likecut.Well,thefakecutorfentanylorwhatever[...] Users’recall ofthetimingof this mostrecentemergenceof FASHcorrespondstidilytodataonrisesintheregionalfentanyl