Research paper
“Every ‘Never’ I Ever Said Came True”: Transitions from opioid pills to heroin injecting

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Abstract

This qualitative study documents the pathways to injecting heroin by users in Philadelphia and San Francisco before and during a pharmaceutical opioid pill epidemic. Data was collected through in-depth, semi-structured interviews (conducted between 2010 and 2012) that were, conducted against a background of longer-term participant-observation, ethnographic studies of street-based drug users and dealers in Philadelphia (2007–12) and San Francisco (1994–2007, 2012). Philadelphia and San Francisco were selected for their contrasting political economies, immigration patterns and source type of heroin. In Philadelphia the ethnographers found heroin injectors, usually white users, who had started their opiate using careers with prescription opioids rather than transitioning from other drugs. In both Philadelphia and San Francisco, most of the young heroin injectors interviewed began, their drug-use trajectories with opioid pills – usually Percocet (oxycodone and acetaminophen), generic short acting oxycodone or, OxyContin (long-acting oxycodone) – before transitioning to heroin, usually by nasal inhalation (sniffing) or smoking at first, followed by injecting. While most of the Philadelphia users were born in the city or its suburbs and had started using both opioid pills and heroin there, many of the San Francisco users had initiated their pill and sometimes heroin use elsewhere and had migrated to the city from around the country. Nevertheless, patterns of transition of younger injectors were similar in both cities suggesting an evolving national pattern. In contrast, older users in both Philadelphia and San Francisco were more likely to have graduated to heroin injection from non-opiate drugs such as cannabis, methamphetamine and cocaine. Pharmaceutical opioid initiates typically reported switching to heroin for reasons of cost and ease-of-access to supply after becoming physically and emotionally dependent on opioid pills. Many expressed surprise and dismay at their progression to sniffing and subsequently to injecting heroin. Historically and structurally these users found themselves caught at the intersection of two major developments in the opiate supply: (1) an over 500% increase in opiate pill prescription from 1997 to 2005 resulting in easy access to diverted supplies of less stigmatized opiates than heroin and (2) a heroin supply glut, following the US entry of Colombian-sourced, heroin in the early 1990s, that decreased cost and increased purity at the retail level. A nationwide up-cycle of heroin use may be occurring among young inner city, suburban and rural youth fueled by widespread prescription opioid pill use.

Section snippets

Background

Historians and social scientists have long pondered the extent to which individuals choose their own paths or are acted upon by wider forces. The entrée of Colombian-sourced heroin into the eastern US heroin market in the 1990s led to a rise in purity and fall in prices nationwide followed by a leveling out of prices in the early 2000s (Ciccarone et al., 2009a, Rosenblum et al., 2013). As well as offering cheapness and potency, Colombian heroin was inserted into the existing crack cocaine

Methods

This investigation arose from the Heroin Price and Purity Outcomes study (HPPO) (PI: Ciccarone) funded by the US National Institutes of Health, National Institute of Drug Abuse (NIH/NIDA) which aims to place local understandings of heroin injectors’ drug use, beliefs, behavior and health within a regional and national US structural context. In the two contrasting cities of Philadelphia and San Francisco it uses ethnography and qualitative interviewing which are then set against a wider picture

Early ethnographic observations

The ethnographers in Philadelphia witnessed an influx of young heroin users, generally from nearby poor white working class neighborhoods and declining suburbs, but also from more affluent areas. They and the PI were alerted to the opioid pills-to-heroin transition phenomenon on a tour of outdoor shooting galleries in Philadelphia on September 29, 2011. The following is an excerpt from their fieldnote:

On the way back, two middle-aged white running partners approach us and strike up a

Discussion

Although the epidemic of extra-medical opioid use and its links with heroin injecting have been reported, (e.g. OSAM, 2002, U.S. Department of Justice, 2001) there have been very few in-depth studies of the experiences of users transitioning between these drugs, their modes of administration and the contexts in which these developments take place (see Daniulaityte et al., 2006, Lankenau et al., 2012). To our knowledge, this is the first qualitative paper to compare the contexts of initiation

Conclusion

From the accounts of younger/recent heroin injectors in this study, it is evident that since the rise of the opioid pill epidemic, the barriers to heroin use and to injection have been reduced by the normalized pervasiveness of these pharmaceuticals. The widespread availability of opioid analgesics outside sanctioned channels and, paradoxically, medical and regulatory attempts to curb this through monitoring and limiting prescribing, appear to be drawing a new generation into higher risk heroin

Limitations

The limitations of our study are the usual ones for qualitative research. Ethnographic and qualitative research is subject to a number of biases including subjective sampling and response biases. Given that the events reported often occurred some years before the interview, the possibility of recall bias is important to bear in mind. These are lessened somewhat by the length of immersion in the study sites and interview styles grown out of extensive experience.

Conflict of interest

None declared.

Acknowledgements

We thank our Heroin Price and Purity Outcomes study colleagues Jay Unick and Daniel Rosenblum, the interviewees and also Jason Fessel, Galen Joseph and Kimberly Koester for helpful comments on earlier drafts. We would also like to thank Mary Howe for her help in arranging interviews in San Francisco and Paul Yabor for his work conducting interviews in Philadelphia. Finally the authors would like to acknowledge the helpful comments provided by two anonymous peer reviewers. Funding: NIH/NIDA/NIAID

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