Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore, MD

Abstract

Since 2001, heroin-related overdose deaths in the United States have risen six-fold, a rise unaccounted for by the expanding user population. Has heroin become a more dangerous drug? Reports of fentanyl and its analogs, often concealed in or sold as heroin, have also increased sharply. This paper investigates heroin injectors’ perceptions and experiences to changes in the heroin supply in the East Coast city of Baltimore, Maryland, currently experiencing an epidemic in heroin- and fentanyl-related overdose deaths. Unusually, Baltimore’s heroin market is divided between two types: ‘Raw’, believed to be Colombian in origin and relatively pure, and the more adulterated ‘Scramble’ (Raw heroin traditionally blended with quinine and lactose). Users reported that Scramble heroin, while gaining market share, has become a highly unstable product, varying dramatically in appearance, intensity of onset, duration of action and and effect. Some considered that scramble was no longer ‘heroin’ but heavily adulterated or even replaced, mentioning fentanyl, benzodiazepines and crushed opioid pills as additives. There was intense awareness of overdose as a present danger in users’ lives, which they linked to the recent adulteration of the heroin supply. Responses to this perceived adulteration varied, including information gathering, attraction, avoidance, taking precautions and acceptance.

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

“…Few disputed the dangers of overdosing from FASH and while some tried to avoid FASH, others sought it out similar to reports from Baltimore (Mars forthcoming). Even those who attempted to avoid FASH were not always able to make that choice when overcome by withdrawal symptoms: “I don’t like fentanyl.…”

“…The powder heroin in the eastern US is not smokable but can be insufflated (snorted) (Ciccarone 2009). The use of partial doses, while widely advocated for (Sorge 1998, Australian Injecting & Illicit Drug Users League 2013) and chronicled in some recent fieldwork among heroin users (Mars forthcoming), will require more real world exploration regarding their feasibility, acceptability and success.…”

“…It has a record of success in both domestic and international settings (Trotter et al 2001). The Heroin in Transition study (NIH/NIDA R01DA037820, PI: Ciccarone) uses a rapid assessment approach to specifically investigate reports of new and evolving heroin types, described in greater detail in Mars et al (Mars forthcoming). …”

“…These were used to compare responses across the interview data. The color range shown was based on previous ethnographic studies (Mars et al 2016, Mars forthcoming). …”

“…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 (Mars forthcoming). We relate here users’ experiences with and perceptions of fentanyl-adulterated and –substituted ‘heroin’ (FASH) and other heroin types in Massachusetts.…”