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

https://doi.org/10.1016/j.drugpo.2017.06.004Get rights and content

Abstract

Background

The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30–50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as ‘heroin’ and to observe the drugs and their use.

Methods

A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n = 38) qualitative interviews with persons who use heroin.

Results

(1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin ‘types’ have proliferated with several products being sold as ‘heroin’. These consisted of two types of heroin (alone), fentanyl (alone), and heroin–fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl’s presence, followed by taste, solution appearance and powder color. This paper presents a new ‘heroin’ typology based on users’ reports.

Conclusion

Massachusetts’ heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users’ discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.

Introduction

The United States has seen a dramatic increase in the adverse consequences of heroin use. Between 2010 and 2014 heroin-related overdose mortality rates tripled nationally from 1.0 to 3.4 per 100,000 (Rudd, Aleshire, Zibbell, & Gladden, 2016), increasing another 20.9% from 2014 to 2015 (Rudd, Seth, David, & Scholl, 2016). This epidemic is intertwined and overlaps with the larger prescription opioid misuse epidemic that preceded it (Compton, Jones, & Baldwin, 2016; Unick, Rosenblum, Mars, & Ciccarone, 2013). That a portion of the at-risk population is transitioning from one source of opioids (prescription pills) to a fully illicit source (heroin) is supported by both qualitative (Mars, Bourgois, Karandinos, Montero, & Ciccarone, 2014) and quantitative studies (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 Enforcement Administration, US, 2016a). Fentanyl is the central chemical in a family of over twenty analogues; it is a synthetic opioid with potent μ-receptor activity, registering 30–50 times more potent by weight compared with heroin (lead author calculation).

National overdose deaths attributed to fentanyl began to rise in 2013 from a stable level of approximately 1600 annually in 2010–2012 to 1905 in 2013 and then by a further 120% to 4200 in 2014 (Warner, Trinidad, Bastian, Miniño, & Hedegaard, 2016). In opioid overdose deaths, heroin replaced oxycodone as the number one cause as of 2012 and fentanyl moved from 9th in 2012 to 5th most common opioid in overdose deaths in 2014. Of the deaths primarily attributed to fentanyl, 64% had two or more concomitant drugs identified: heroin (23%) was the most common with an additional 9% co-attributed to morphine (i.e., a breakdown product of heroin and a few other semi-synthetic opiates as well as morphine itself) (Warner et al., 2016).

Drug seizures data from the US Drug Enforcement Administration’s (DEA) National Forensics Laboratory Information Service (NFLIS) reveal the increase in illicit fentanyl supply: among samples tested, fentanyl reports increased from approximately 600 annually during 2010–2012 to 14,051 in 2015. Much of this increase (1400%) occurred between 2013 (934) and 2015 (14,051). The most frequent fentanyl analog noted in the most recent NFLIS report is acetyl fentanyl with 2412 reports in 2015 (Drug Enforcement Administration Diversion Control Division, US, 2016).

Connecting drug supply evidence with public health outcomes data, a study from the US Centers for Disease Control and Prevention (CDC) reports a positive correlation (r = 0.95) between rises in NFLIS fentanyl reports and increases in synthetic opioid (non-methadone) death rates in 27 US states, 2013–2014 (Gladden, 2016). The fentanyl responsible for these deaths is likely manufactured illicitly rather than pharmaceutically; while seizures of illicit fentanyl have increased (Drug Enforcement Administration, US, 2015a), there is no correlation between fentanyl prescription rates and the rise in synthetic opioid deaths (Gladden, Martinez, & Seth, 2016).

There is a strong regional pattern in the fentanyl epidemic; three US regions had the highest year-over-year increases, 2013–2014, in synthetic (mostly fentanyl) overdose deaths: Northeast (Massachusetts, Maine, and New Hampshire), Midwest (Ohio), and South (Florida, Kentucky, Maryland, and North Carolina) (Gladden et al., 2016). The US Northeast and Midwest regions also have the highest rates of heroin-related overdose death (Hedegaard, Chen, & Warner 2015) and hospitalization (Unick & Ciccarone, 2017).

Massachusetts, the focus of this study, had the second highest increase in synthetic overdose deaths of the 27 states examined by the CDC. The state reached a pinnacle opioid death rate in 2015: 25.8 deaths per 100,000 residents, a 32% increase from 2014 and a tripling in the rate since 2010. Fentanyl was found in 75% of opioid overdose deaths cases with available toxicology (Massachusetts Department of Public Health, US 2017).

The aim of this research was to gain an understanding of the experiences of heroin users living through this public health crisis. We chose qualitative inquiry given the extensive unknowns in this rapidly changing environment, thus, our research questions are broad, e.g., how has heroin changed? And, what are users’ experiences with this new ‘heroin’? The perspectives of persons who use heroin have been largely missing from the discussion of the current heroin/fentanyl crisis and can provide important insights into changes in the heroin supply and other aspects of the risk environment. For instance, recent qualitative research among heroin injectors in Baltimore showed that new forms of ‘heroin’ are perceived as highly variable and unpredictable, resulting in a range of responses and strategies (unpublished data). We relate here users’ experiences with and perceptions of fentanyl-adulterated and -substituted ‘heroin’ (FASH) and other heroin types in Massachusetts.

We report on fieldwork, including qualitative interviews with active heroin users, performed in three towns in Massachusetts in June 2016. We chose Massachusetts and the specific field sites based on the above statistical data as well as preliminary findings, since published, from an ethnographer, regarding local fentanyl use and overdose (Somerville et al., 2017, Zibbell, 2016). The rapid ethnographic approach used here allows for brief but meaningful immersion into the lives of an affected marginalized population (Needle et al., 2003; Rhodes, Stimson, Fitch, Ball, & Renton, 1999).

Section snippets

Methods

‘Rapid ethnographic assessment’ is a form of highly focused ethnography which enables researchers to gain in-depth knowledge about a rapidly emerging health problem in a short period of time (Harris, Jerome, & Fawcett, 1997). It has a record of success in both domestic and international settings (Trotter, Needle, Goosby, Bates, & Singer, 2001). The Heroin in Transition study (NIH/NIDA R01DA037820, PI: Ciccarone) uses a rapid assessment approach to specifically investigate reports of new and

Locations

The fieldwork was conducted in three locations: Worcester in central Massachusetts, the second most populous city in the state; Lowell – the state’s fourth most populous city – and Lawrence in northeastern Massachusetts. Lowell and Lawrence, situated in the Merrimack River Valley, were historical centers for textile milling, while Worcester was a prominent large-scale manufacturing hub. All three cities have been severely affected by post-WWII deindustrialization in the region and have

Discussion

Participants reported an increased diversity of heroin-like products beginning around 2013. This timing corresponds with national reports of rises in fentanyls in the drug supply (Drug Enforcement Administration, US, 2015b) and synthetic opioid overdose deaths (Gladden et al., 2016). Discernment of FASH by users is possible although a diversity of opinion existed among users over how reliably they could distinguish different ‘heroin’ types and the presence of fentanyl. A hierarchy of

Conflicts of interest

None.

Acknowledgements

Fieldwork such as presented in this report requires a large team to organize, facilitate and carry out. We are grateful to compassionate front-liners Gary Langis, Harry Leno, Louie Diaz and Irving for their assistance in gaining entry to our field sites in Massachusetts and with recruitment of participants. Likewise, in New Hampshire we appreciate the efforts of providers Kevin Irwin, Wendy LeBlanc and Jaime Gormley. We thank our ethnographic staff Eliza Wheeler, Mary Howe and Fernando Montero

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