ArticlePDF Available

The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis

Authors:

Figures

Content may be subject to copyright.
Contents lists available at ScienceDirect
International Journal of Drug Policy
journal homepage: www.elsevier.com/locate/drugpo
Commentary
The triple wave epidemic: Supply and demand drivers of the US opioid
overdose crisis
Daniel Ciccarone
Department of Family and Community Medicine, University of California San Francisco, United States
ARTICLE INFO
Keywords:
Fentanyl
Heroin
Opioid
Overdose
Injection drug use
Introduction
The US mortality rate has gone up three years in a row from 2014 to
2017 (Xu, Murphy, Kochanek, & Arias, 2016;Murphy, Xu, Kochanek, &
Arias, 2018;Kochanek, Murphy, Xu, & Arias, 2017). Correspondingly,
life expectancy at birth has declined; the rst triple year decline since
World War One and the devastating inuenza pandemic one hundred
years ago (Tejada Vera, Bastian, & Arias, 2017). Most of the top ten
causes of death are declining year over year; however, the third leading
cause of death, unintentional injuries, has climbed in rate and rank
since 2014 (Xu et al., 2016). Driving this are deaths due to drug poi-
soning which exceeded 70,000 in 2017 (Hedegaard, Miniño, & Warner,
2018). Annual deaths due to drug overdoses now exceed those from
motor vehicle deaths, gun violence and even HIV at the height of the
1990s HIV epidemic (Katz, 2017).
The triple wave epidemic: opioid pills, heroin and synthetic
opioids
The US is suering a triple wave epidemic of overdose deaths from
three classes of opioids: prescription opioid pills (semi-synthetic
opioidsin Fig. 1), heroin and synthetic opioids other than methadone
(Ciccarone, 2017). Fig. 1 shows three waves of opioid mortality, each
wave cresting on top of the one before it. In the rst wave, overdoses
related to opioid pills, started rising in the year 2000 and have steadily
grown through 2016. The second wave saw overdose deaths due to
heroin, which started increasing clearly in 2007, surpassing the number
of deaths due to opioid pills in 2015. The third wave mortality has
arisen from fentanyl, fentanyl analogues and other synthetic opioids of
illicit supply, climbing slowly at rst, but dramatically after 2013. Data
from 2017 show synthetic opioid deaths continuing to rise, reaching a
peak of over 28,000, while opioid pill and heroin overdose deaths
leveled o, albeit at very high levels of approximately 15,000 deaths in
each category (Hedegaard et al., 2018).
Supply and demand drivers
To address this crisis, its supply and demand drivers need to be
better understood; both forces are needed to create the immense waves
of consumption and their consequences that are occurring. Historians
have observed the implications of supply in several opioid misuse cycles
beginning with morphine in the latter half of the 19
th
century
(Courtwright, 2001b;Musto, 1999). Isolated in 1805 by the German
pharmacist Friedrich Serturner, morphine was mostly dispensed by
physicians in America, particularly to women (Courtwright, 2001a).
Thus the subsequent misuse problem was iatrogenic, exacerbated by the
technological advance of the hypodermic syringe (Courtwright, 2001b,
2001b).
Heroin (diacetylmorphine) had a short life as a licit medication.
There have been a number of illicit heroin waves beginning around the
1920s, the rst of which may have been due to restriction on licit
supplies driving its use underground. Consumption of all kinds occurs
within an economic and cultural framework and both demand-side and
supply-side forces can bring innovation to established consumption
patterns. The upswings in American heroin use in the 1940s and70 s
were in part stimulated by strong social and cultural elements, where
heroin use often conferred an outsider status, signaling the rejection of
mainstream values (Courtwright, 2001b). They also had strong supply-
side forces with the post-WW2 emergence of the Italian and French
connectionsupplying heroin to the US (Courtwright, 2001b) and new
sources of heroin imported from Southeast and Southwest Asia in the
1970s (McCoy, 2003). In the 1990s, a new form of heroin, produced by
Colombian transnational criminal organizations (TCOs), was brought
into the United States resulting in increased heroin use and adverse
https://doi.org/10.1016/j.drugpo.2019.01.010
International Journal of Drug Policy xxx (xxxx) xxx–xxx
0955-3959/ © 2019 Elsevier B.V. All rights reserved.
Please cite this article as: Ciccarone, D., International Journal of Drug Policy, https://doi.org/10.1016/j.drugpo.2019.01.010
consequences (Ciccarone, 2009;Ciccarone, Unick, & Kraus, 2009).
In sum, since the uptake of morphine and subsequent licit and illicit
opioids, the US has experienced multiple waves of opioid misuse and
their medical consequences caused by the forces of supply (iatrogenic
and new illicit sources) and demand (social, cultural and new tech-
nologies for use). In the current triple wave epidemic, we see both
forces at work again. On the supply side, we have witnessed the ia-
trogenic sourcing of opioid pills, a new source-form of rened heroin
and an illicit opioid sub-class, fentanyls, resurfacing from a new source.
On the demand side, there are social and structural root causes of
opioid use that have led to population dependency on opioids; starting
with pills, yet leading to spill-over eects driving heroin and subse-
quently fentanyl demand.
Wave one: prescription opioid pills
The supply side drivers underlying the rst wave of prescription
opioid overdose have been extensively discussed (Madras, 2017;Van
Zee, 2009). Wave one is often considered to have been driven ia-
trogenically with a tripling of opioid prescriptions starting in the 1990s
and peaking around 2011 (Kolodny et al., 2015). This increase in pre-
scriptions has been correlated to rising adverse consequences, particu-
larly opioid overdose (Centers for Disease Control & Prevention, 2011).
The introduction of extended release long-acting (ERLA) opioid for-
mulations support both supply-side and demand-side pressures. ERLAs
are a source of opioid in a novel form with a technological advance that
allowed higher, longer lasting doses in a single capsule. However, the
ease with which their delayed release mechanisms could by bypassed
and the whole dose discharged at once, for instance by crushing and
insuating (nasal snorting) or injecting, led to a wave of misuse
(Cicero, Ellis, & Surratt, 2012;Mars, Bourgois, Karandinos, Montero, &
Ciccarone, 2014).
A demand-side argument has been introduced examining the
structural factors that might be driving the epidemic. The most com-
pelling structural determinants include an aging population with rises
in reported pain and disability, economic distress, declining social co-
hesion and rising psychological malaise that may have led an at-risk
population to seek opioids in the rst place (Dasgupta, Beletsky, &
Ciccarone, 2018).
Wave two: heroin
Coincident with rising heroin-related deaths, the number of heroin
users, especially young heroin users, has been increasing since the mid-
2000s (Center for Behavioral Health Statistics and Quality, 2017;
Kilmer et al., 2014). The rst two overdose waves, from opioid pills and
heroin, have been termed intertwined epidemics(Unick, Rosenblum,
Mars, & Ciccarone, 2013). Young and new heroin users have described
transitioning to heroin from opioid pills as their growing dependence
required larger and more consistent pill supplies than they could obtain
either by prescription or on the street. The more ready availability of
high purity, low cost heroin made the switch to heroin economically
logical and dicult to resist (Mars et al., 2014).
Drug treatment data show that in successive cohorts from the 1960s
through the 2000s, patients admitted to treatment with heroin use
disorder increasingly reported starting their opioid dependency with
opioid pills (Cicero, Ellis, Surratt, & Kurtz, 2014). However, this has
begun to change as an increasing proportion of heroin use disorder
patients entering treatment report heroin as their rst experience of an
opioid (Cicero, Kasper, & Ellis, 2018). Overdoses due to heroin began to
accelerate in 2011. In late 2010 OxyContin, a brand name ERLA for-
mulation of oxycodone, was reformulated to be abuse-deterrent. The
reformulation of this popular diverted opioid pill may have had the
unintended consequence of driving a small proportion of the at-risk
population to heroin (Cicero et al., 2012).
Although overlapping and related, the rst and second opioid
overdose waves show some contrasts in age and regional distribution
that require explanation. Examining the years 20122014, the age
distribution of patients hospitalized for opioid pill overdose had its
largest peaks in the 50 to 64 year old group. Meanwhile, the peak age
group for heroin overdose admissions was 20 to 34 year-olds. In this
data we see possible evidence of population level transitions from
opioid pills to heroin use as the rates for overdose among 2034 year-
olds declined for opioid pills while, in the same time period, increased
for heroin (Unick & Ciccarone, 2017). In sum, we have seen elements of
demand-side drive in wave two, with rising numbers of heroin users
transitioning from opioid pill dependency followed more recently by
younger persons initiating rst with heroin.
Geographic disparities are also evident: opioid pill overdose is
Fig. 1. Opioid Overdose Deaths by Type of Opioid.
D. Ciccarone International Journal of Drug Policy xxx (xxxx) xxx–xxx
2
relatively even across the country whereas heroin overdose is much
higher in the US Northeast and Midwest regions, along with higher
rates of increase (Unick & Ciccarone, 2017). Some of this regional
disparity may be endemic, stemming from the 1970s, but there are also
signicant new supply-side forces shaping it. A dramatic transformation
in the US heroin supply, including changes in its country of origin, has
occurred in the last 10 years. Prior to 2000, heroin was imported from
four source regions/countries in the world, including Southeast Asia,
Southwest Asia, Mexico, and South America (Colombia). The 2000s
began an era in which most US heroin was transshipped by TCOs from
two countries: Colombia and Mexico (US Drug Enforcement
Administration, 2015). Regional heroin distribution became starkly
divided with Colombian-sourced heroin predominant in the eastern US
while black tarheroin from Mexico the major source-form in the
western US (Ciccarone, 2009;Ciccarone et al., 2009). Accelerating this
trend from oligopoly to monopoly, Mexican TCOs have increasingly
dominated the US heroin market with their market share increasing
from 50% in 2005 to 90% in 2016 (US Drug Enforcement
Administration, 2017b).
Mexican-sourced heroin is also becoming more rened. From 2005
to 2012, a growing and substantial proportion of analyzed heroin
samples obtained in eastern US cities by the US Drug Enforcement
Administration (DEA) for its Heroin Domestic Monitor Program were
from an unknown source and of unknown quality (Drug Enforcement
Administration, 2016). Subsequent DEA analyses have led to the con-
clusion that a more rened heroin has emerged from Mexican sources.
This so-called Mexican Whiteis a mimic of Colombian-sourced powder
heroin, replacing it in its traditional retail outlets of the Northeast and
Midwest (US Drug Enforcement Administration, 2015).
Wave three: synthetic opioids
Synthetic opioids in the heroin supply, chiey illicitly produced
fentanyl, are responsible for the third wave of overdose mortality
(Ciccarone, 2017;NIDA, 2018). Heroin, particularly in the Northeast
and Midwest, the regions with the greatest increases in wave two
overdose, currently exists as fentanyl-adulterated and/or fentanyl-sub-
stituted heroin (FASH) (Ciccarone, Ondocsin, & Mars, 2017). Illicitly
manufactured fentanyl is integrated into the illicit drug supply and sold
as heroinin powder form, or as counterfeit opioid or benzodiazepine
pills (Gladden, Martinez, & Seth, 2016).
Fentanyl is the main chemical in a growing family of chemical
analogues. These analogues come in a range of morphine-equivalent
potencies with some such as butyryl-fentanyl being less potent than
fentanyl by weight while others have much greater potency (Suzuki &
El-Haddad, 2017). In addition, there are other novel synthetic opioids
in circulation including U47700 and U48800. The greatest concern
arises from a branch of the fentanyl family that includes some ex-
ceedingly potent opioids including carfentanil, sufentanil and re-
mifentanil. It is unclear whether these extremely potent fentanyls will
become established elements in the opioid marketplace or if they are
just accidents or experiments in the rapidly evolving illicit opioid
supply.
According to the US Drug Enforcement Administration (DEA), the
main source of illicitly manufactured fentanyls is China. Fentanyls
sourced from China take a number of routes on their way into the US
including internet purchases, routing through Canada (typically pill
form), or through Mexico in powder or pill forms (US Drug Enforcement
Administration, 2016). Perhaps the most revealing aspect of the supply
that fuels the US fentanyl epidemic is its regional discreetness. Com-
paring drug seizure data with overdose death data one nds remarkable
geographical correlation between fentanyl seizures and synthetic opioid
overdoses (Gladden et al., 2016). These fentanyl events overlap in the
same regions as wave two heroin overdose: the Northeast and Midwest.
The reasons for this regional disparity are unclear. One possibility is
that fentanyl distribution is regionally orchestrated by a branch of the
Sinaloa TCO (US Drug Enforcement Administration, 2017b). Another
hypothesis is that source-forms of powder heroin, predominant in the
Northeast and Midwest, are more easily adulterated with powder fen-
tanyl than solid black tarheroin, which predominates in the western
US (Carroll, Marshall, Rich, & Green, 2017;Ciccarone, 2017). Such
stark regional disparities support the notion that the third wave is a
supply-side event (Mars, Rosenblum, & Ciccarone, 2018). A demand or
culturally driven event, such as through entrepreneurial or individual
internet purchases, would more likely have led to a more even geo-
graphic spread of fentanyl-related overdose or one that reected similar
social conditions in separate geographical locations.
Ethnographic research with persons who use heroin conrm that the
introduction of FASH has been unexpected and unsettling, that fentanyl
was not a demand-driven phenomenon and that there is a range of
desirability for FASH from abhorrence and avoidance through accep-
tance to enthusiasm (Carroll et al., 2017;Ciccarone et al., 2017;Mars,
Ondocsin, & Ciccarone, 2018). Those who favor fentanyl are never-
theless hampered from choosing it in the market place by its concealed
identity as heroinor counterfeit brand name pills (Ciccarone et al.,
2017;Mars, Ondocsin et al., 2018;Mars, Rosenblum et al., 2018). Im-
portantly, cultural idioms for fentanyl have been slow to emerge despite
four years of steady supply; slang terms have arisen for most desired
illicit drugs and their absence is evidence for a lack of strong demand.
Consequentially, emergence of slang can be seen as a marker for
growing acceptance of fentanyl.
In addition to the dangerous potency of fentanyl, ethnographic
observations support the notion of a possibly greater danger: rapid
changes in potency and purity, as well as varying mixtures of heroin,
fentanyl and its analogues (Ciccarone, 2017;Ciccarone et al., 2017;
Mars, Ondocsin et al., 2018;Mars, Rosenblum et al., 2018). Australian
research on heroin overdose has shown that uctuations within a wider
range of street heroin purity, particularly when around a higher mean
purity level, are an independent predictor of fatal overdose (Darke,
Hall, Weatherburn, & Lind, 1999). Vicissitudes in potency/purity/
mixture in the fentanyl street market may be discovered to have pro-
found eects on the overdose rate in a given location.
In summary, all three waves have impressive supply-side drivers
including excessive prescribing of medication, a new form of highly
rened Mexican-sourced heroin and a new illicit source of synthetic
opioids adulterating heroin and counterfeit pills. Demand for opioid
pills partially drove demand for heroin while demand for heroin un-
suspectingly feeds demand for synthetics-as-substitute. What is driving
increases in opioid mortality now are deaths due to FASH. The second
and third waves are regional, with the Northeast (including Mid-
Atlantic) and Midwest (including Appalachia), the most aected re-
gions.
There are other medical consequences, in addition to overdose, that
are growing in concern. The change from opioid pill misuse to heroin
involved, for many, a change in route of administration from oral in-
gestion to intravenous injection. While heroin can be smoked or in-
suated, it tends, in the US, to be injected (Ciccarone, 2019). This
raises concerns about the transmission of blood-borne viruses such as
hepatitis C and HIV. The US has recently had two documented injec-
tion-drug-related HIV outbreaks in Scott County, Indiana and eastern
Massachusetts (Peters et al., 2016;US Centers for Disease Control &
Prevention, 2018).
Addressing the fentanyl crisis
The triple-wave opioid overdose epidemic is an intertwined, three
drug sub-class epidemic. To comprehend and address it fully the drivers
of each wave need to be elucidated. Positive supply shocks have his-
torically led to drug epidemics and the same can be seen in the current
opioid crisis. Fentanyl, in particular, comes as a positive supply shock
leading to disastrous consequences. It is thus tempting to focus eorts
on controlling supply. There is evidence that supply-side interventions
D. Ciccarone International Journal of Drug Policy xxx (xxxx) xxx–xxx
3
can work if part of a comprehensive program that also includes demand
reduction (Caulkins, Reuter, Iguchi, & Chiesa, 2005). Unipolar supply-
side interventions however, may cause paradoxical unwanted results;
for example see (Ciccarone et al., 2009). These phenomena may be
occurring within the current crisis. Downward pressure on opioid pre-
scribing may be driving a portion of the at-risk population from opioid
pill misuse to heroin, thus exposing them to the even more dangerous
family of fentanyls. Another driver of unintended consequences may
have been the reformulation of ERLA opioids to abuse-deterrent for-
mulations, examples of which include OxyContin and Opana, with
misuse of the latter implicated in the Scott County Indiana HIV out-
break (Broz et al., 2018). The goals of curtailing excessive prescribing
practices or creating abuse-deterrent formulations may be reasonable,
but the untoward consequences must be recognized, monitored and
responded to accordingly.
The end of interdiction?
Regarding fentanyl, supply-side interventions include source control
and interdiction in the drug supply chain. Considering source control, it
is crucial to nd areas of cooperation between the United States and the
Government of China to improve monitoring, regulation and enforce-
ment of pharmaceutical and chemical manufacturing in order to deter
illicit suppliers (Pardo, 2018). Bilateral eorts by governmental agen-
cies in both countries have led to an expanding list of controlled psy-
choactive substances, including opioids and precursors, leading to dis-
cussions regarding scheduling fentanyl as a class (Knierim, 2018).
Interdiction will be challenging given the size of illicit fentanyl ows. In
2016, a mere 668 kg of fentanyl was seized in the US (Baum, 2017), a
fraction of the estimated 11 metric tons of cocaine seized in 2016 at the
US Southwest Border alone (US Drug Enforcement Administration,
2017a). Fentanyls high potency allows shipment in small volumes.
Considering a seizure to importation ratio of 1:4, a total of 2.6 metric
tons of fentanyl may have been distributed in the US in 2016. This
would t into approximately 10 industrial drum barrels a tiny volume
that if divided up over the huge trade that occurs across the Pacic Rim
constitutes a proverbial needle in a haystack.
The Iron Law of Prohibitionsuggests that highly potent-by-vo-
lume drugs like fentanyl are expected due to the honing eects of in-
terdiction (Beletsky & Davis, 2017). Following this is the concern that
constraining the mother chemical fentanyl too robustly and too rapidly
will foster the supply of fentanyl analogues. The number of known
fentanyl analogues exceeds 60; the number of potential fentanyl ana-
logues could exceed 600. Care must be taken not to foster the ingenuity
and creativity of the illicit drug manufacturers to push in even more
dangerous directions. Based on this concern, the DEA has imposed a
rst-ever class restriction on the family of fentanyls, the utility of which
is uncertain.
Surveillance of the drug supply
One supply-side intervention with potentially positive impact is
drug surveillance. Investments in drug monitoring, identication and
data collection could assist in interdicting supply (Pacula & Powell,
2018). US government ocials have called for greater public safety and
public health collaboration to address this crisis. One way for these two
domains to work together is by increasing local drug surveillance with
sharing of the data. Local criminal justice systems have a ready pool of
geo-located analyzable drug samples in their crime labs. Analysis of
drug samples and dissemination of the ndings could be achieved in
rapid cycles and enhance our understanding of the drugs in circulation
and especially how rapidly heroin, FASH and fentanyl analogue mix-
tures are changing.
Improved surveillance would benet not only the interdiction and
public safety side but also the public health side including rst re-
sponders, emergency and hospital clinicians as well as those who work
in community based programs serving the aected population
(Ciccarone, 2017). Point of use testing or drug checking is an intimate
form of surveillance that is emergent in the US because of the FASH
crisis. Evidence for its utilization is growing (Peiper et al., 2018), al-
though concerns have also been raised (McGowan, Harris, Platt, Hope,
& Rhodes, 2018).
Harm reduction
Considering the inadequate and paradoxical eects of current
opioid supply interventions, supply-side policies must be combined
with sucient investments in and expansion of eective prevention,
substance use treatment and harm reduction (Pacula & Powell, 2018).
Opioid use disorder has a number of medical treatment options that
have been shown to be medically ecacious as well as cost-eective
(Volkow, Frieden, Hyde, & Cha, 2014). The US Surgeon General has
called for greater distribution of naloxone, the opioid antagonist used to
treat an opioid pill, heroin or fentanyl overdose (US Surgeon General,
2018). Getting wider distribution of naloxone into the community is an
essential strategy in the current epidemic (Fairbairn, Con, & Walley,
2017;Wheeler, Jones, Gilbert, & Davidson, 2015). Sterile syringe pro-
vision must be greatly expanded to meet the increasing population at
risk. Drug surveillance, discussed above, can be utilized as a harm re-
duction strategy. Supervised consumption spaces can aid in prevention
of overdose and reduce HIV and HCV transmission risks (Dolan et al.,
2000;Marshall, Milloy, Wood, Montaner, & Kerr, 2011;Potier,
Laprévote, Dubois-Arber, Cottencin, & Rolland, 2014). These services
can act as a safety net or hub for persons at risk and provide them with
necessary resources and referrals to services (Kerr, Small, Moore, &
Wood, 2007).
Conclusion
A crisis level response is needed to address the triple wave epidemic.
In the 1990s, US government intervention, albeit slow to start, was
essential in curtailing the HIV epidemic. The Ryan White Care Act led to
a dramatic increase in funding for HIV prevention and treatment. That
coupled with medical progress led to a dramatic decrease in HIV in-
cidence, morbidity and mortality. The economic and social costs of the
opioid crisis are enormous, with estimates approaching $80 billion per
year. Estimates to address it range from $60 billion for treatment over
the next 5 years (Simmons, 2017) to $100 billion for a multi-pronged
approach to prevention, treatment and community resilience eorts
(Katz, 2018). The opioid epidemic is the latest phase of a multi-decade
increase in drug-related mortality (Jalal et al., 2018). With overdose
deaths increasing steadily since 1979, regardless of the primacy of any
particular drug, more resolve is needed to address the structural de-
terminants of this relentless epidemic.
Conicts of interest
Dr Ciccarone reports receiving consulting fees from Mallinckrodt
Pharmaceuticals and Nektar Therapeutics.
Acknowledgements
I gratefully acknowledge research funding from US National
Institutes of Health, National Institute of Drug Abuse Grant DA037820.
I thank Dr. Sarah Mars for extensive feedback and editing and Dr. Jay
Unick for creating Fig. 1.
References
Baum, R. J. (2017). Letter to Congress: Response to questions concerning fentanyl.
Washington DC: Oce of National Drug Control Policy.
Beletsky, L., & Davis, C. S. (2017). Todays fentanyl crisis: Prohibitions Iron Law,
D. Ciccarone International Journal of Drug Policy xxx (xxxx) xxx–xxx
4
revisited. The International Journal of Drug Policy, 46, 156159. https://doi.org/10.
1016/j.drugpo.2017.05.050.
Broz, D., Zibbell, J., Foote, C., Roseberry, J. C., Patel, M. R., Conrad, C., et al. (2018).
Multiple injections per injection episode: High-risk injection practice among people
who injected pills during the 2015 HIV outbreak in Indiana. The International Journal
of Drug Policy, 52,97101. https://doi.org/10.1016/j.drugpo.2017.12.003.
Carroll, J. J., Marshall, B. D. L., Rich, J. D., & Green, T. C. (2017). Exposure to fentanyl-
contaminated heroin and overdose risk among illicit opioid users in Rhode Island: A
mixed methods study. The International Journal of Drug Policy, 46, 136145. https://
doi.org/10.1016/j.drugpo.2017.05.023.
Caulkins, J. P., Reuter, P., Iguchi, M. Y., & Chiesa, J. (2005). How goes the war on drugs?
An assessment of U.S. drug problems and policy. Santa Monica, CA: RAND Corporation.
https://www.rand.org/pubs/occasional_papers/OP121.html.
Center for Behavioral Health Statistics and Quality (2017). 2016 National Survey on Drug
Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health
Services Administration.
Centers for Disease Control and Prevention (2011). Vital signs: Overdoses of prescription
opioid pain relievers United States, 19992008. Morbidity and Mortality Weekly
Report (MMWR), 60, 14871492.
Ciccarone, D. (2009). Heroin in brown, black and white: Structural factors and medical
consequences in the US heroin market. The International Journal of Drug Policy, 20(3),
277282. https://doi.org/10.1016/j.drugpo.2008.08.003.
Ciccarone, D. (2017). Fentanyl in the US heroin supply: A rapidly changing risk en-
vironment. The International Journal of Drug Policy, 46, 107111. https://doi.org/10.
1016/j.drugpo.2017.06.010.
Ciccarone, D. (2019). Heroin smoking is not common in the United States. JAMA
Neurology.https://doi.org/10.1001/jamaneurol.2019.0183.
Ciccarone, D., Unick, G. J., & Kraus, A. (2009). Impact of South American heroin on the
US heroin market 19932004. The International Journal of Drug Policy, 20(5),
392401. https://doi.org/10.1016/j.drugpo.2008.12.001.
Ciccarone, D., Ondocsin, J., & Mars, S. G. (2017). Heroin uncertainties: Exploring users
perceptions of fentanyl-adulterated and -substituted heroin.The International Journal
of Drug Policy, 46, 146155. https://doi.org/10.1016/j.drugpo.2017.06.004.
Cicero, T. J., Ellis, M. S., & Surratt, H. L. (2012). Eect of abuse-deterrent formulation of
OxyContin. The New England Journal of Medicine, 367(2), 187189. https://doi.org/
10.1056/NEJMc1204141.
Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The changing face of heroin
use in the United States: A retrospective analysis of the past 50 years. JAMA
Psychiatry, 71(7), 821826. https://doi.org/10.1001/jamapsychiatry.2014.366.
Cicero, T. J., Kasper, Z. A., & Ellis, M. S. (2018). Increased use of heroin as an initiating
opioid of abuse: Further considerations and policy implications. Addictive Behaviors,
87, 267271. https://doi.org/10.1016/j.addbeh.2018.05.030.
Courtwright, D. T. (2001a). Forces of habit. Drugs and the making of the modern world.
Cambridge, MA and London, UK: Harvard University Press.
Courtwright, D. T. (2001b). Dark paradise: A history of opiate addiction in America.
Cambridge, MA: Harvard University Press.
Darke, S., Hall, W., Weatherburn, D., & Lind, B. (1999). Fluctuations in heroin purity and
the incidence of fatal heroin overdose. Drug and Alcohol Dependence, 54(2), 155161.
Dasgupta, N., Beletsky, L., & Ciccarone, D. (2018). Opioid crisis: No easy x to its social
and economic determinants. American Journal of Public Health, 108(2), 182186.
https://doi.org/10.2105/AJPH.2017.304187.
Dolan, J. K., Fry, C., McDonald, D., Fitzgerald, J., Trautmann, F., & Kate (2000). Drug
consumption facilities in Europe and the establishment of supervised injecting centres
in Australia. Drug and Alcohol Review, 19(3), 337346.
Fairbairn, N., Con, P. O., & Walley, A. Y. (2017). Naloxone for heroin, prescription
opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding
to a dynamic epidemic. The International Journal of Drug Policy, 46, 172179. https://
doi.org/10.1016/j.drugpo.2017.06.005.
Gladden, R. M., Martinez, P., & Seth, P. (2016). Fentanyl law enforcement submissions
and increases in synthetic opioid-involved overdose deaths - 27 states, 20132014.
MMWR Morbidity and Mortality Weekly Report, 65(33), 837843. https://doi.org/10.
15585/mmwr.mm6533a2.
Hedegaard, H., Miniño, A. M., & Warner, M. (2018). Drug overdose deaths in the United
States, 1999-2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for
Health Statistics.
Jalal, H., Buchanich, J. M., Roberts, M. S., Balmert, L. C., Zhang, K., & Burke, D. S. (2018).
Changing dynamics of the drug overdose epidemic in the United States from 1979
through 2016. Science, 361(6408), https://doi.org/10.1126/science.aau1184
eaau1184.
Katz, J. (2017). Drug deaths in America are rising faster than ever. June 5th 2017New York
Timeshttps://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-
drug-overdose-deaths-are-rising-faster-than-ever.html.
Katz, J. (2018). How a police chief, a governor and a sociologist would spend $100 billion to
solve the opioid crisis. Feb 14, Retrieved fromThe Upshot, New York Timeshttps://
www.nytimes.com/interactive/2018/02/14/upshot/opioid-crisis-solutions.html.
Kerr, T., Small, W., Moore, D., & Wood, E. (2007). A micro-environmental intervention to
reduce the harms associated with drug-related overdose: Evidence from the evalua-
tion of Vancouvers safer injection facility. The International Journal of Drug Policy,
18(1), 3745. https://doi.org/10.1016/j.drugpo.2006.12.008.
Kilmer, Beau, Sohler Everingham, Susan S., Caulkins, Jonathan P., Midgette, Greg,
Liccardo Pacula, Rosalie, Reuter, Peter H., et al. (2014). What America's Users Spend
on Illegal Drugs: 20002010Santa Monica, CA: RAND Corporation. https://www.rand.
org/pubs/research_reports/RR534.html.
Knierim, P. E. (2018). Statement before the subcommittee on Africa, global health. Retrieved
fromGlobal Human Rights and International Organizations, Committee on Foreign
Aairs, U.S. House of Representativeshttps://docs.house.gov/meetings/FA/FA16/
20180906/108650/HHRG-115-FA16-Wstate-KnierimP-20180906.pdf.
Kochanek, K. D., Murphy, S. L., Xu, J. Q., & Arias, E. (2017). Mortality in the United States,
2016. NCHS Data Brief, no 293. Hyattsville, MD: National Center for Health Statistics.
Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., et al.
(2015). The prescription opioid and heroin crisis: A public health approach to an
epidemic of addiction. Annual Review of Public Health, 36, 559574.
Madras, B. K. (2017). The surge of opioid use, addiction, and overdoses: Responsibility
and response of the US health care system. JAMA Psychiatry, 74(5), 441442.
Mars, S. G., Bourgois, P., Karandinos, G., Montero, F., & Ciccarone, D. (2014). Every
neverI ever said came true": Transitions from opioid pills to heroin injecting. The
International Journal of Drug Policy, 25(2), 257266. https://doi.org/10.1016/j.
drugpo.2013.10.004.
Mars, S. G., Ondocsin, J., & Ciccarone, D. (2018). Sold as Heroin: Perceptions and Use of
an Evolving Drug in Baltimore, MD. Journal of Psychoactive Drugs, 50(2), 167176.
https://doi.org/10.1080/02791072.2017.1394508.
Mars, S. G., Rosenblum, D., & Ciccarone, D. (2018). Illicit fentanyls in the opioid street
market: Desired or imposed? epub 04 December Addiction.https://doi.org/10.1111/
add.14474 0(0).
Marshall, B. D., Milloy, M. J., Wood, E., Montaner, J. S., & Kerr, T. (2011). Reduction in
overdose mortality after the opening of North Americasrst medically supervised
safer injecting facility: A retrospective population-based study. The Lancet,
377(9775), 14291437.
McCoy, A. W. (2003). The politics of heroin. CIA complicity in the global drug trade. Chicago,
IL: Lawrence HIll Books.
McGowan, C. R., Harris, M., Platt, L., Hope, V., & Rhodes, T. (2018). Fentanyl self-testing
outside supervised injection settings to prevent opioid overdose: Do we know enough
to promote it? The International Journal of Drug Policy, 58,3136. https://doi.org/10.
1016/j.drugpo.2018.04.017.
Murphy, S. L., Xu, J. Q., Kochanek, K. D., & Arias, E. (2018). Mortality in the United States,
2017. NCHS Data Brief, no 328. Hyattsville, MD: National Center for Health Statistics.
Musto, D. F. (1999). The American disease: Origins of narcotic control (3rd ed.). New York:
Oxford University Press.
National Institute on Drug Abuse (2018). Overdose death rates. Retrieved fromhttps://
www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
Pacula, R. L., & Powell, D. (2018). A supply-side perspective on the opioid crisis. Journal
of Policy Analysis and Management, 37(2), 438446. https://doi.org/10.1002/pam.
22049.
Pardo, B. (2018). Evolution of the US overdose crisis: Understanding Chinas role in the
production and supply of synthetic opioids. CT-497. Testimony presented before the house
foreign aairs subcommittee on Africa, global health, global human rights, and interna-
tional organizations on tackling fentanyl: The China connection on September 6, 2018.
Retrieved from https://docs.house.gov/meetings/FA/FA16/20180906/108650/
HHRG-115-FA16-Wstate-PardoB-20180906-U2.pdf.
Peiper, N. C., Clarke, S. D., Vincent, L. B., Ciccarone, D., Kral, A. H., & Zibbell, J. E.
(2018). Fentanyl test strips as an opioid overdose prevention strategy: Findings from
a syringe services program in the Southeastern United States. The International Journal
of Drug Policy.https://doi.org/10.1016/j.drugpo.2018.08.007.
Peters, P. J., Pontones, P., Hoover, K. W., Patel, M. R., Galang, R. R., Shields, J., et al.
(2016). HIV infection linked to injection use of Oxymorphone in Indiana, 20142015.
The New England Journal of Medicine, 375(3), 229239. https://doi.org/10.1056/
NEJMoa1515195.
Potier, C., Laprévote, V., Dubois-Arber, F., Cottencin, O., & Rolland, B. (2014). Supervised
injection services: What has been demonstrated? A systematic literature review. Drug
and Alcohol Dependence, 145,4868.
Simmons, A. M. (2017). White House commission recommends president declare a national
emergency over the deadly opioid epidemicJuly 31, Retrieved from. Los Angeles
Timeshttp://www.latimes.com/nation/la-na-opioids-commission-report-20170731-
story.html.
Suzuki, J., & El-Haddad, S. (2017). A review: Fentanyl and non-pharmaceutical fentanyls.
Drug and Alcohol Dependence, 171, 107116. https://doi.org/10.1016/j.drugalcdep.
2016.11.033.
Tejada Vera, B., Bastian, B., & Arias, E. (2017). Mortality trends in the United States,
19002015. Retrieved fromNational Center for Health Statisticshttps://www.cdc.
gov/nchs/data-visualization/mortality-trends/.
Unick, G. J., & Ciccarone, D. (2017). US regional and demographic dierences in pre-
scription opioid and heroin-related overdose hospitalizations. The International
Journal of Drug Policy, 46, 112119. https://doi.org/10.1016/j.drugpo.2017.06.003.
Unick, G. J., Rosenblum, D., Mars, S., & Ciccarone, D. (2013). Intertwined epidemics:
National demographic trends in hospitalizations for heroin- and opioid-related
overdoses, 19932009. PloS One, 8(2), e54496.. https://doi.org/10.1371/journal.
pone.0054496.
US Centers for Disease Control and Prevention (2018). Undetermined risk factors and mode
of transmission for HIV infection among persons who inject drugs Massachusetts, 2018.
Epi-Aid Number: 2018-027.
US Drug Enforcement and Administration (2015). 2015 National Drug Threat Assessment
Summary. Washington, DC: Domestic Strategic Intelligence Unit, Special Strategic
Intelligence Section.
US Drug Enforcement and Administration (2016). 2016 National Drug Threat Assessment
Summary. Washington, DC: Domestic Strategic Intelligence Unit, Special Strategic
Intelligence Section.
US Drug Enforcement Administration (2017a). Colombian cocaine production expansion
contributes to rise in supply in the United States. (DEA intelligence brief, DEA-DCI-DIB-
014-17).
US Drug Enforcement Administration (2017b). National drug threat assessment. (DEA-DCT-
DIR-040-17). Retrieved fromhttps://www.dea.gov/documents/2017/10/01/2017-
national-drug-threat-assessment.
D. Ciccarone International Journal of Drug Policy xxx (xxxx) xxx–xxx
5
US Surgeon General (2018). Surgeon generals advisory on naloxone and opioid overdose.
Retrieved fromhttps://www.surgeongeneral.gov/priorities/opioid-overdose-
prevention/naloxone-advisory.html.
Van Zee, A. (2009). The promotion and marketing of oxycontin: Commercial triumph,
public health tragedy. American Journal of Public Health, 99(2), 221227.
Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted
therapies Tackling the opioid-overdose epidemic. The New England Journal of
Medicine, 370(22), 20632066. https://doi.org/10.1056/NEJMp1402780.
Wheeler, E., Jones, T. S., Gilbert, M. K., & Davidson, P. J. (2015). Opioid overdose pre-
vention programs providing naloxone to laypersons-United States, 2014. MMWR
Morbidity and Mortality Weekly Report, 64(23), 631635.
Xu, J. Q., Murphy, S. L., Kochanek, K. D., & Arias, E. (2016). Mortality in the United States,
2015. NCHS data brief, no 267. Hyattsville, MD: National Center for Health Statistics.
D. Ciccarone International Journal of Drug Policy xxx (xxxx) xxx–xxx
6
... Although earlier phases of the opioid crisis were characterized by the misuse of prescription opioids (first wave), recent trends reveal that heroin (second wave) and illicit synthetic opioids (third wave) have become crucial to characterizing the opioid epidemic. 2 Synthetic opioids such as fentanyl have been shown to be the most devastating contributors to the current rising opioidrelated cases due to its associated positive supply shock, allowing for its price to reduce significantly. 3 Predicted trends overlaying scatterplots. ...
Article
Full-text available
Introduction: Coronavirus 2019 (COVID-19) has had a devastating impact on mental health and access to addiction treatment in the United States, including in California, which resulted in the highest rates of emergency department visits (ED) for opioid poisoning in 2020. As California slowly returns to pre-pandemic normalcy, it remains uncertain whether the rates of opioid-related events have slowed down over time. We hypothesized that the number of opioid-related ED visits were exacerbated after the period of the COVID-19 pandemic and continue at a high rate in the present. Methods: In this analysis we searched the University of California (UC) Health Data Warehouse—a database of electronic health records from six UC health centers—for opioid-related ED visits, identifiying using the following International Classification of Diseases, 10th Ed, Clinical Modification codes: F11 codes, and T40.0*, T40.1*, T40.2*, T40.3*, T40.4*, T40.6*. Opioid overdose-associated visits were classified by types of opioids involved: heroin (T40.1*); prescription opioids (T40.2* or T40.3*); and synthetic opioids (T40.4*). We performed interrupted time analysis to estimate the immediate (level) change and change-in-time trend (trend change), from before (January 2018–October 2019) and during the pandemic (April 2020–December 2022). Monthly visit rates were evaluated with negative binomial regression adjusted for first-order autoregression and using all-cause ED counts as the offset. We present effect sizes as rate ratios (RR) and 95% confidence intervals (CI), tested at α = .05. Results: Before COVID-19, a steadily increasing trend in ED visit rates was observed for all outcomes (P < 0.05) except synthetic opioids. Total opioid-related ED visit rates increased by 15% (RR 1.15, 95%CI 1.02–1.29, P = 0.20) immediately after March 2020 before decreasing by 0.5% every month, albeit without statistical significance (RR .995, 95% CI .991–1.00, P = 0.06). Similar trends were observed with prescription opioid overdoses, with a step increase of 44% (RR 1.44, 95% CI 1.10–1.89, P = .008) before plateauing after March 2020 (RR 1.01, 95% CI .998–1.02, P = 0.12). After March 2020, ED visit rates for synthetic opioid overdoses were increasing steadily by 4% every month (RR 1.04, 95% CI 1.02–1.06, P = .001), unlike with heroin, which was observed with an 8% monthly reduction (RR .92, 95% CI .90–.93, P < .001). No immediate increase in visit rates was observed for either opioid. Conclusion: While opioid-related ED admissions among the UC health centers showed an overall decrease, prescription and synthetic opioid overdoses remained significantly higher than pre-pandemic trends as of December 2022. A multilevel approach to improve awareness of new opioid health policies could ameliorate these alarming rises in the post-pandemic era.
Preprint
Full-text available
Background The overdose epidemic is presently driven by polydrug use, sparking renewed interest in why people initiate use of certain drugs or drug combinations. Current research privileges the physiological ends of consumption, often ignoring the social and environmental context of use. Framed by social cognitive theory, the purpose of this study was to characterize factors precipitating substance initiation, transition, and combination beyond the immediate effects of the substance(s). Methods We conducted 30 semi-structured interviews with people who use drugs across North Carolina, exploring substance use history and risk and protective factors of polydrug use. Participants also completed a visual timeline activity. We used a staged analytic approach, beginning with deductive Structural Coding and ending with inductive Reflexive Thematic Analysis at both the transcript and excerpt levels. Results We conceptualized substance transitions as pragmatic processes within environments of constraints and opportunities. Socially, drug choices were often driven by a desire for interpersonal bonding, pressure to assimilate to practices in one’s social circles, and the ubiquity of use within one’s milieu. Transitions were also shaped by environmental context – which substances are locally available, the logistical convenience of competing substances, and the material costs of use. Conclusions Beyond the desire for new or enhanced physiological effects, substance transitions serve social and practical functions, like facilitating emotional closeness and ensuring stable supply. Interventions to reduce the risks of use should account for these contextual factors – for instance, by educating on strategies to avoid normative pressures and by promoting safe, affordable, and accessible supply.
Article
The opioid epidemic has devastated rural America, including adolescents that reside in these regions, yet studies on that focus on this population remain scarce. This study examined the relationship between various strains and substance use among rural adolescents in the United States, focusing on opioid use during the early stages of the opioid epidemic. Drawing on general strain theory (GST), the research examines the influence of different forms of victimization, homelessness, and poor health status on adolescent opioid use. Data were collected from 4529 adolescents in 27 different states who underwent evaluation for substance abuse treatment in non-metropolitan areas (population less than 250,000). Logistic regression analyses revealed significant associations between several forms of strain and opioid use, with physical victimization, anticipated victimization, emotional victimization, homelessness, and poor health emerging as predictors of opioid use. Additionally, depression and anxiety were found to mediate the relationship between certain strains and substance use. This research contributes to our understanding of the challenges faced by rural adolescents amidst the ongoing opioid crisis and highlight the need for targeted intervention.
Article
The use and misuse of opioids are a growing global problem. Although the effects of these drugs on the human endocrine system have been studied for decades, attention on their related clinical consequences, particularly on the hypothalamic-pituitary system and bone health, has intensified over recent years. This Statement appraises research data related to the impact of opioids on the gonadal and adrenal function. Whereas hypogonadism is well recognized as a side effect of opioids, the significance of their inhibitory actions on the hypothalamic-pituitary-adrenal system and the occurrence of clinically relevant adrenal insufficiency is not fully elucidated. The often-inconsistent results of studies investigating how opioids affect the secretion of GH, prolactin, arginine vasopressin, and oxytocin are assessed. The accumulating evidence of opioid actions on bone metabolism and their negative sequelae on bone mineral density and risk of fracture are also reviewed. In each section, available data on diagnostic and management approaches for opioid endocrine sequelae are described. This Statement highlights a plethora of gaps in research associated with the effects and clinical consequences of opioids on the endocrine system. It is anticipated that addressing these gaps will improve the care of people using or misusing opioids worldwide. The Statement is not intended to serve as a guideline or dictate treatment decisions.
Article
Introduction Psychological resilience has emerged as a key construct of interest in the study of substance use. However, very few studies have examined resilience among individuals who are actively using drugs. Furthermore, many studies of psychological resilience have focused on individual‐level factors. This study addresses the call for a more ‘ecological’ approach to the study of resilience by exploring how socio‐structural vulnerabilities may shape individuals' assessment of their own ability to cope. Methods The Peer Harm Reduction of Maryland Outreach Tiered Evaluation study conducted a cross‐sectional survey of people who used opioids in Baltimore, Maryland, USA ( n = 565). Resilience was measured using the 10‐item Connor‐Davidson Resilience Scale. We used linear regression to examine the association between resilience and stressors commonly encountered by individuals who use drugs, including both chronic, enduring stressors (e.g., homelessness, food insecurity) and discrete, event‐based stressors (e.g., overdose, arrest). Results We observed a negative relationship between self‐reported resilience and chronic stressors. Specifically, individuals who reported experiencing three ( β = −4.08; p = 0.002) or four ( β = −4.67; p = 0.008) types of chronic stress had significantly lower resilience scores. Additionally, we found that an unmet need for mental health treatment was associated with reduced resilience ( β = −1.74; p = 0.040) and greater educational attainment was associated with increased resilience ( β = 2.13; p = 0.005). Discussion and Conclusions Overlapping experiences of socio‐structural vulnerability, as well as access to mental health care, may influence how individuals who use drugs evaluate their own resilience. Interventions that seek to promote the resilience of this population should focus on addressing structural drivers of marginalisation and barriers to mental health treatment.
Article
Full-text available
Foregrounding the increasing global crisis of opioids as the “leading cause of deaths in fatal overdoses,” the World Drug Report 2023 , published by the United Nations Office on Drugs and Crime (UNODC), mentioned that in 2021 more than 80,000 people died due to opioid overdose in the United States of America. The Centers for Disease Control and Prevention (CDC), the national public health protection agency in the United States, has reported that “the predicted number of drug overdose deaths showed an increase of 0.5% from the 12 months ending in December 2021 to the 12 months ending in December 2022, from 109,179 to 179,680” (“Provisional Data”). Although the trajectory of opioid use disorders (OUDs) has affected different sociodemographic groups in the country since its first wave in the 1990s, teenagers in poverty-stricken rural areas are more vulnerable to such addiction (Keyes et al.). Poor parental guidance, impoverishment, troubled childhoods, detrimental familial structure, scarce opportunities, and accessibility to opioids are often considered to be the primary risk factors for unprivileged teenagers to develop a psychic reliance on opioids for engendering a perpetual sense of contentment. According to the incentive sensitization theory, the persistent desire to transcend physical and psychical limitations for a sense of relief, triggered by chronic drug misuse, often evokes a sense of “wanting” or incentive salience, a compulsive inclination towards drug-associated stimuli (Berridge and Robinson, “Drug Addiction” 22). This intense desire of “wanting” often generates a perpetual sensitization of the mesolimbic systems in the brain which is also activated by mental representations of drug-associated cues (Robinson and Berridge 3139). Focusing on drug-induced changes in the brain such as hypersensitization and neuroadaptation, this study analyzes Barbara Kingsolver’s Demon Copperhead , a modern reimagining of David Copperfield by Charles Dickens. The selected text addresses primarily some pertinent socio-political crises, such as the poor foster care system, poverty, and the engrossing opioid endemic in Southern Appalachia. However, this study attempts to analyze the precarious state of some characters, who become addicted to opioids seeking recognition from peer groups and perpetual psychic stability, in the selected text from a neuropsychological perspective.
Article
Context Drug checking, defined as the use of instruments (e.g. spectrometers), test strips, and other technologies to provide information on drug composition for harm reduction purposes, has emerged as a promising intervention to reduce harms of illicit drugs linked to overdose deaths. While demonstrating potential, these interventions remain limited in reach amid questions of how to reach the full population of people who use drugs and are at risk of overdose, including those outside urban areas. In response to these limitations, Substance, a drug checking project based in Victoria, Canada, developed a Distributed Model of Drug Checking and a concomitant training program. Program The Distributed Drug Checking Training program eliminates need for point-of-care spectrometry technicians, instead capacitating harm reduction workers to provide drug checking using software developed by the project, infrared spectrometers, and immunoassay test strips. The training includes 5 hours of group content that can be delivered virtually, and 2 hours of practice time per learner. Implementation Training and data collection took place between May 2022 and March 2024 with learners from 6 locations across Vancouver Island, Canada. We offered 13 training sessions, with evaluation data collected from 54 learners. Evaluation The training was evaluated across Kirkpatrick’s 4 levels of training evaluation. The training was highly acceptable to learners, attributable to intended changes in knowledge and skill related to drug checking, resulted in competence to deliver drug checking through the project’s Distributed Model, and facilitated expansion of drug checking services to 6 geographically distant locations. Discussion After completing the 7-hour training program, harm reduction workers were able to deliver drug checking without need for on-site drug checking technicians. The short duration of the training and its demonstrated success with the Distributed Model of Drug Checking make this a promising approach for expanding the reach of drug checking services.
Article
Full-text available
Deaths from drug overdose continue to be a public health burden in the United States (1-5). This report uses the most recent final mortality data from the National Vital Statistics System (NVSS) to update trends in drug overdose deaths, describe demographic and geographic patterns, and identify shifts in the types of drugs involved. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
Article
Full-text available
To the Editor The review by Alambyan and colleagues¹ is an excellent critical summary of the literature on leukoencephalopathy due to “chasing the dragon” (ie, heroin smoking). However, the review misrepresents the urgency of the situation by getting a few issues on heroin source forms and use incorrect, especially as they pertain to the US situation. There is no doubt that the United States is experiencing the consequences of an intertwined heroin and synthetic opioid epidemic of historic proportions²; however, there is no evidence that heroin smoking is rising in the United States. Different chemical forms of heroin lead to different medical consequences.³ The predominant form of heroin in the United States is a powdered hydrochloride salt, and thus it is not easily sublimated and instead burns with heating, destroying the active properties and discouraging this use pattern. The article conflates different forms of inhalation, such as nasal insufflation, which is readily done with heroin hydrochloride powders and vapor (pulmonary) inhalation (ie, smoking) which is much more feasible with base forms of heroin. Heroin base will vaporize before burning on gentle heating. Insufflating heroin is much more common in the United States than smoking. The data cited in the review on US heroin treatment admissions are correct in stating that 21% of admissions involved (nasal) inhalation; however, a deeper look at the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration Treatment Episode Data Set reveals that only 4.8% involved smoking heroin.⁴ The fact that insufflation is more common east of the Mississippi River is because of differences in distribution of heroin source forms, which include Colombian-sourced powdered heroin hydrochloride salt to the east and a Mexican-sourced heroin hydrochloride salt, a solid form called “black tar,” to the west.³ Heroin smoking is more common in Europe, which has base heroin sourced from Afghanistan, and most of the article’s cited literature on leukoencephalopathy is from Europe.
Article
Full-text available
Background Illicitly manufactured fentanyl and its analogues are appearing in countries throughout the world, often disguised as heroin or counterfeit prescription pills, with resulting high overdose mortality. Possible explanations for this phenomenon include reduced costs and risks to heroin suppliers, heroin shortages, user preferences for a strong, fast‐acting opioid and the emergence of Dark Web cryptomarkets. This paper addresses these potential causes and asks three questions: (1) can users identify fentanyl; (2) do users desire fentanyl; and (3) if users want fentanyl, can they express this demand in a way that influences the supply? Argument/analysis Existing evidence, while limited, suggests that some users can identify fentanyl, although not reliably, and some desire it, but because fentanyl is frequently marketed deceptively as other drugs, users lack information and choice to express demand effectively. Even when aware of fentanyl's presence, drug users may lack fentanyl‐free alternatives. Cryptomarkets, while difficult to quantify, appear to offer buyers greater information and competition than offline markets. However, access barriers and patterns of fentanyl‐related health consequences make cryptomarkets unlikely sources of user influence on the fentanyl supply. Market condition data indicate heroin supply shocks and shortages prior to the introduction of fentanyl in the United States and parts of Europe, but the much lower production cost of fentanyl compared with heroin may be a more significant factor Conclusion Current evidence points to a supply‐led addition of fentanyl to the drug market in response to heroin supply shocks and shortages, changing prescription opioid availability and/or reduced costs and risks to suppliers. Current drug users in affected regions of the United States, Canada and Europe appear largely to lack both concrete knowledge of fentanyl's presence in the drugs they buy and access to fentanyl‐free alternatives.
Article
Full-text available
Background: In 2016, the number of overdose deaths involving illicitly-manufactured fentanyl (IMF) surpassed heroin and prescription opioid deaths in the United States for the first time, with IMF-involved overdose deaths increasing more than 500% across 10 states from 2013 to 2016. IMF is an extremely potent synthetic opioid that is regularly mixed with heroin and often sold to unwitting consumers. Community-based organizations have started to distribute fentanyl test strips (FTS) as a strategy to identify IMF in street purchased products. We investigated the association between FTS use and changes in drug use behavior and perceived overdose safety among a community-based sample of people who inject drugs (PWID) in the United States. Methods: Between September-October 2017, a total of 125 PWID completed an online survey about their most recent FTS use in Greensboro, North Carolina. Our first outcome of interest included whether PWID engaged in any of the following changes in drug use behavior after using FTS: used less than usual, administered tester shot, pushed syringe plunger slower than usual, and snorted instead of injected. Our second outcome of interest was whether PWID felt that FTS use made them feel better able to protect themselves from overdose. We conducted bivariate and multivariate analyses to determine the association between FTS use and these two outcomes. Results: Overall, 63% of the sample reported a positive FTS test result and 81% reported using FTS prior to consuming their drugs. For the outcomes, 43% reported a change in drug use behavior and 77% indicated increased perceived overdose safety by using FTS. In multivariable models adjusting for demographic and FTS correlates, PWID with a positive FTS test result had five times the odds of reporting changes in drug use behavior compared to those with a negative result. PWID who used the FTS after drug consumption were 70% less likely to report behavioral changes at subsequent drug consumption compared to those who used it before consumption. PWID who were not existing clients of the syringe services program had four times higher odds than existing clients to report increased overdose safety from using FTS. Conclusions: We found that using FTS and receiving a positive test result was associated with changes in drug use behavior and perceptions of overdose safety. FTS may represent an effective addition to current overdose prevention efforts when included with other evidence-based strategies to prevent opioid overdose and related harm.
Article
Full-text available
Since 2013, North America has experienced a sharp increase in unintentional fatal overdoses: fentanyl, and its analogues, are believed to be primarily responsible. Currently, the most practical means for people who use drugs (PWUD) to avoid or mitigate risk of fentanyl-related overdose is to use drugs in the presence of someone who is in possession of, and experienced using, naloxone. Self-test strips which detect fentanyl, and some of its analogues, have been developed for off-label use allowing PWUD to test their drugs prior to consumption. We review the evidence on the off-label sensitivity and specificity of fentanyl test strips, and query whether the accuracy of fentanyl test strips might be mediated according to situated practices of use. We draw attention to the weak research evidence informing the use of fentanyl self-testing strips.
Article
Analyzing the drug abuse epidemic There is a developing drug epidemic in the United States. Jalal et al. analyzed nearly 600,000 unintentional drug overdoses over a 38-year period. Although the overall mortality rate closely followed an exponential growth curve, the pattern itself is a composite of several underlying subepidemics of different drugs. Geographic hotspots have developed over time, as well as drug-specific demographic differences. Science , this issue p. eaau1184
Article
Introduction: Previously, we reported a marked increase in the use of heroin as an initiating opioid in non-tolerant, first time opioid users. In the current paper, we sought to update and expand upon these results, with a discussion of the policy implications on the overall opioid epidemic. Methods: Opioid initiation data from the original study were updated to include surveys completed through 2017 (N = 8382) from a national sample of treatment-seeking opioid users. In addition, past month abuse of heroin and prescription were analyzed as raw numbers of treatment program entrant in the last five years (2013-2017), drawing from only those treatment centers that participated every year in that time frame. Results: The updated data confirm and extend the results of our original study: the use of heroin as an initiating opioid increased from 8.7% in 2005 to 31.6% in 2015, with increases in overall Ns per initiation year reflecting a narrowing of the "treatment gap", the time lag between opioid initiation from 2005 to 2015 and later treatment admission (up to 2017). Slight decreases were observed in treatment admissions, but this decline was totally confined to prescription opioid use, with heroin use continuing to increase in absolute numbers. Conclusions: Given that opioid novices have limited tolerance, the risk of fatal overdose for heroin initiates is elevated compared to prescription opioids, particularly given non-oral administration and often unknown purity/adulterants (i.e., fentanyl). Imprecision of titrating dose among opioid novices may explain observed increases opioid overdoses. Future policy decisions should note that prescription opioid-specific interventions may have little impact on a growing heroin epidemic.