Ethnography of Heroin and Nonmedical Opioid Use

Ethnography of Heroin and Nonmedical Opioid Use: Understanding Contextual and Local Factors Moira O’Brien, M. Phil. Epidemiology Research Branch National Institute on Dug Abuse National Institutes of Health Department of Health and Human Services October 19, 2016

Presentation Objectives Describe contextual and local factors related to heroin use and nonmedical use of opioid drugs, and associated overdose risk. Highlight ethnographic studies of different drug using populations to understand risk behaviors, and subcultural, social and contextual influences.

Contextual and Local Factors • Heroin sources, forms and purity • Routes of administration Ethnographic Study: Heroin use in San Francisco and Philadelphia • Polysubstance use Ethnographic Study: Prescription Drug Use among Young Adults who Attend Nightlife Venues In NYC • Overdose locations and social context • Use of mobile phones

Rapidly changing drug landscape • Increasingly diverse Illicit drug market in 2016 due to introduction of new illicitly manufactured synthetic psychoactive substances. • Emergence of non-pharmaceutical fentanyl and fentanyl variants is fueling local spikes in overdoses in several states (e. g. , New Hampshire, Ohio, and Florida). Fentanyl is 50 -100 times more potent than morphine and can be lethal in small amounts. • Non-pharmaceutical fentanyl has been mixed with heroin and has been detected as the sole compound in seized items. • The DEA reports authentic-looking counterfeit pills containing fentanyl in the illicit drug market. Between January and March 2016, nine people died from counterfeit Xanax ® pills containing fentanyl in Florida. (DEA, July 2016). • Important take home message: Users do not always know what drug they are taking and drug users not seeking opioid drugs may be unwittingly exposed to opioids.

Resource on current and emerging drug trends: National Drug Early Warning System https: //www. drugabuse. gov/related-topics/trendsstatistics/national-drug-early-warning-system-ndews U 01 DA 038360, PI: Eric Wish, Ph. D.

Routes of Administration • Heroin can be injected, inhaled by snorting or sniffing, or smoked. • Opioid pills can be taken orally or, depending upon formulation, crushed to snort or inject the powder. An ethnographic study of socially active young adults attending nightlife venues in NYC also noted the inhalation of prescription pills through smoking or vaporization (Kelly et al, 2015). In this subcultural context, the normative manner of consumption is via the oral route and smoking represents a more extreme method that decreases time to onset of effects and increases the intensity of the high. • Intravenous injection is the most concentrated and efficient way to introduce opiates in to the bloodstream and overdoses are often linked with injection.

Ethnographic study: Heroin Injectors in San Francisco and Philadelphia Heroin Price, Purity and Outcomes Study, RO 1 DA 027599, PI: Daniel Ciccarone, M. D. Study to examine heroin-related overdose and the influences of heroin markets, marketing and source-types (Mars et al, 2015). • Qualitative study of injecting drug users (18 and older) of black tar heroin in San Francisco and of powder heroin in Philadelphia. • Included in-depth, semi-structured interviews conducted in 2012 against a background of longer-term ethnographic studies of drug users and dealers in Philadelphia and San Francisco. • Interviewees: 22 in Philadelphia and 19 in San Francisco

Findings: Sales of heroin in the two cities represent different retail models and flows of information about products, with implications for overdose risk: • Philadelphia powder heroin sales conducted outdoors outside particular locales with dealers working rival corners, calling their brand names to potential customers and offering free samples. There is a lot of networking and information sharing among purchasers in this open-type market in pursuit of the best (most potent) product. • “Branding” products often accomplished via adulteration (addition of substances to enhance or alter the effect), which is easier with powder heroin than BTH. .

. Findings: • SF context, with revitalized neighborhoods, new buildings and high rents, limits street sales. Drug sale interactions instead are with private BTH dealers spread across the city. Branding and free samples are uncommon. Since dealers are harder to access, people may pool resources to share a larger purchase, facilitating use in groups. • Cell phone ownership was more common in SF enabling buyers to contact dealers dispersed throughout the city. • In both cities, users referred to cases of overdose as an “advertisement” for the quality of heroin. A difference, however, was the greater ease with which Philadelphia users in the open market can locate the overdose-implicated sources.

Polysubstance use is common among drug users and can impact overdose risk, particularly use of multiple central nervous system depressants such as opioids, benzodiazepines and alcohol. • Benzodiazepines were involved in 31% of the opioid-analgesic poisoning deaths in the US in 2011, up from 13% in 1999 (Chen et al, 2014). • 40% of patients in an inpatient opioid detox setting reported use of a benzodiazepine in the past 30 days and/or had positive toxicology (Stein et at, 2016). • Heroin is also co-injected with stimulant drugs: heroin is often combined with cocaine (“speedball”) and co-injection with methamphetamine (“goofball”) was recently reported in San Diego (Meacham et al, 2016) where methamphetamine is a prominent drug.

Ethnographic study: Prescription Drug Use among Young Adults who Attend Nightlife Venues In NYC Prescription drug abuse in club subcultures: contexts and risks, RO 1 DA 025081, PI: Brian Kelly, Ph. D. , Study to assess patterns and prevalence of prescription drug misuse in combination with other substances among young adults (18 -29) in nightlife scenes in New York City (Kelly et al, 2014). • Time-space sampling using nightlife venues as basic unit of sampling, randomized venues and days/times attending venue • Venues included bars, clubs, lounges and performance venues • Sample: 1653 young adults

Findings: • Of those who reported any prescription drug misuse, 65. 9% used prescription drugs in combination with at least one of the illicit drugs assessed in the past 6 months. • The most common combination was marijuana followed by alcohol, cocaine, ecstasy, and psychedelics. .

Overdose locations A recent study of bystander-administered naloxone in the State of Maryland revealed that in 78 cases of bystander-administered naloxone (Doyon et al. ): • most cases (78. 2%) occurred in the home • 12. 8% occurred in a public setting such as public restrooms or gas stations • 5. 1% occurred in a car • one occurred in each of the following: homeless shelter, recovery house, and high school.

Overdose Locations and Social Context A qualitative study of young adults in NYC who reported use of prescription opioids in prior 30 days, many of whom also used heroin, described overdoses occurring in a variety of social contexts including (Frank et al, 2015): • Parties • Informal social gatherings at local hangouts such as parks or wooded areas • At friends’ houses, often when parents were at work • Within social contexts where individuals gathered to use drugs • Some participants reported overdoses alone but this was the exception rather than the rule

Use of mobile phones A 2014 -2015 study interviewed 251 individuals at a residential substance abuse treatment center in Washington, D. C. , catering to low income adults, about use of mobile phones (Dahne and Lejuez, 2015). • Most patients owned mobile phones prior to treatment entry (86. 9%) and expected to own mobile phones after leaving treatment (92. 6%). • The majority of the phones were (68. 5%) or will be smartphones (72. 4%) on which patients reported utilizing mobile applications (prior to treatment: 61. 3%; post treatment: 64. 3%) and accessing the Internet (prior to treatment: 61. 3%; post treatment: 65. 9%).

Use of mobile phones A survey of 266 urban, substance abuse treatment patients (ave. age 41, 57% with annual income less than $15, 000) enrolled at eight drug-free, psychosocial or opioid-replacement therapy clinics (Mc. Clure et al, 2013) showed that: • The majority reported access to a mobile phone (91%), and to SMS text messaging (79%). • Keeping a consistent mobile phone number and yearly mobile contract was higher for White participants, and for those with higher education, and enrolled in drug-free, psychosocial treatment. • Internet, e-mail, and computer use was much lower (39– 45%), with younger age, higher education and income predicting greater use. No such differences existed for the use of mobile phones.

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