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Analyses of Substance Abuse and Treatment Need Issues 

Heroin Abuse in the United States

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2. Heroin Abuse in the United States

By Joan F. Epstein and Joseph C. Gfroerer

Numerous reports have suggested a rise in heroin use in recent years, which has been attributed to young people who are smoking or sniffing rather than injecting. The purity of heroin has increased to a level that makes smoking and sniffing feasible. The increased purity and concern about AIDS may be causing the shift from injecting to smoking and sniffing among heroin users. This paper examines these issues in addition to examining the prevalence of heroin use. It also describes the characteristics of heroin users and trends in heroin use.

The data presented here come from a variety of sources. One source is the Community Epidemiology Work Group (CEWG), a network of researchers from major metropolitan areas of the United States and selected foreign countries who meet semiannually to discuss the current epidemiology of drug abuse.1 It provides ongoing community level surveillance of drug abuse though the collection and analysis of epidemiologic and ethnographic research data. Another source is "Pulse Check", a series of qualitative interviews with ethnographers, treatment professionals and law enforcement agencies which provide a quick and subjective picture of what is happening in drug abuse across the country.2 The heroin retail price/purity system is a statistical system using information gathered by the Drug Enforcement Administration. Purchases and seizures meeting certain retail level criteria ranges are averaged each quarter to produce a national retail purity figure and a retail price figure.3 A computerized data base program is used to record, collate, and display the results of qualitative and quantitative chemical analysis of all drug evidence submitted to the Drug Enforcement Administration Lab. Purity data are based on printouts of average purities for the 1-to-10 gram, 1-to-10 ounce, and 1-to-10 kilogram ranges.5

The Drug Abuse Warning Network (DAWN) consists of two data collection efforts: data on drug abuse deaths reported by medical examiners in participating metropolitan areas and data collected on drug-related visits to a national probability sample of hospital emergency departments.5, 6 Data on client admissions to specialty substance abuse treatment programs are obtained from the Treatment Episode Data Set (TEDS).7 TEDS, which is compiled by SAMHSA from reports from states, covers primarily publicly-funded treatment facilities and accounts for about half of all public and private admissions to treatment in the U.S. All states do not participate. The National Household Survey on Drug Abuse (NHSDA) is an ongoing national probability survey that provides information on the use of illicit drugs, alcohol, and tobacco in the civilian noninstitutionalized population of the U.S., 12 years old and older.8 Monitoring the Future (MTF) is an annual survey by the University of Michigan’s Institute for Social Research under a grant from the National Institute on Drug Abuse (NIDA).9 Since 1975, it has surveyed a representative sample of all seniors in public and private schools in the coterminous United States. In 1991 MTF was expanded to include annual surveys of eighth and tenth graders. 

Description of Heroin and Effects of Use

A narcotic derived from the opium poppy, heroin was originally developed as a substitute for morphine in an effort to deal with morphine’s addiction problem. However, it was quickly recognized that heroin is even more addictive than morphine. As a result the drug was made illegal. Produced in Mexico and Asia, heroin is reported to be widely available throughout the U.S. At the street level, heroin is "cut" with a variety of substances, leading to variation in purity over time and in different areas. Estimates of the purity of heroin have shown substantial increases between 1984 and 1995.3, 4

When injected, sniffed or smoked, heroin binds with opiate receptors found in many regions of the brain. The result is intense euphoria, often referred to as a rush. The rush lasts only briefly and is followed by a couple of hours of a relaxed, contented state. In large doses, heroin can reduce or eliminate respiration. Withdrawal symptoms include: nausea, dysphoria, muscle aches, lacrimation or rhinorrhea, pupillary dilation, piloerection or sweating, diarrhea, yawning, fever, and insomnia. 

Prevalence of Heroin Use

Efforts to estimate the prevalence of heroin use have a long history with precise estimates remaining difficult to determine. Standard methods of measuring prevalence such as household surveys are not adequate. Since heroin use is rare in the general population, only a small number of users would be included in a household survey. Survey based estimates substantially underestimate prevalence because of difficulties in locating heroin abusers (e.g. many of them are not living in stable households). In addition, because heroin use is an illegal activity, heroin users may not accurately report their use.

Various studies using different methods for estimating the prevalence of heroin use have produced a range of estimates. Some of these studies combined data from more than one source. During the 1970s several studies combined data on heroin from admissions to federally funded drug treatment programs, hospital emergency room visits, heroin related deaths, retail price of heroin, and retail purity of heroin. These studies provided a range of estimates of the number of heroin addicts. The estimates range from 400,000 to 600,000 each year during the 1970s.10, 11 A recent study combining household survey and arrestee data estimated that there were 229,000 "casual" users and 500,000 "heavy" users in 1993.12

Data from the 1996 National Household Survey on Drug Abuse (NHSDA) conservatively show that there were approximately 2.4 million persons who used heroin at least once in their lifetime and approximately 455 thousand people who used heroin at least once in the past year.8 To partially account for underestimation due to underreporting and undercoverage, an adjustment based on counts of arrests and clients in treatment has been applied to NHSDA data, resulting in estimates of 2.9 million lifetime users and 663 thousand past year users.12 

Characteristics of Heroin Users

Data from the NHSDA for the combined years of 1995 and 1996 indicated that 67% of past year heroin users were male; 22% were 12-17 years old, and 21% were 35 years and older; 69% were white, 21% were black, and 9% were Hispanic; 39% lived in a large metropolitan area; 15% were college students 17-22 years of age. Among adult heroin users, 41% had less than a high school education, and 33% worked full time.13 (Table 1)

Rates of past year heroin use were 0.4% for persons 12-17 years of age, 0.6% for persons 18-25 years of age, 0.2% for persons 26-34 years of age, and 0.1% for persons 35 years and older. The rate of heroin use was 0.4% for blacks, 0.2% for whites, and 0.2% for Hispanics. Male use was 0.3%: three times that of female use. Use was reasonably constant by region: 0.2% for persons living in the Northeast, 0.2% for persons living in the North Central, 0.3% for persons living in the South, and 0.1% for persons living in the West. Use was also similar by population density: 0.2% for persons living in a large metropolitan area, 0.2% for persons living in a small metropolitan area and 0.2% for persons living outside a metropolitan area.

Use did vary by education: 0.4% for adults with less than a high school education, 0.1% for adult high school graduates, 0.2% for adults with some college, and 0.1% for adult college graduates. Among persons 17-22 years of age, the rate for college students was larger than the rate for persons who were not college students: 1.0% for persons who were college students and 0.7% for persons who were not college students. Use also varied with employment: 0.1% for adults employed full time, 0.3% for adults employed part time, 0.6% for the unemployed .03% for homemakers, 0.8% percent for students only, 0.2% for the retired, and 0.1% for disabled adults.13 (Table 2)

Next to cocaine, heroin was the most frequently occurring drug among deaths reported by medical examiners participating in DAWN. In 1995, heroin was mentioned in 4,178 deaths (45.3% of all deaths reported to DAWN in 1995).5 Among these heroin related deaths, 84% were males, 8% were persons less than 26 years of age, and 67% were persons age 35 years and older.14 (Table 4)

In 1995 heroin was mentioned in 72,217 emergency department visits (13.9% of all drug related visits to EDs in 1995).6 Of these heroin-related ED visits, 70% were male; 1.0% were less than 18 years of age, and 55% were 35 years of age or older; 38% were white, 39% were black and 14% were Hispanic.6 (Table 6) The most frequently reported reasons for visit were chronic effects (25%), seeking detoxification (23%) and overdose (23%).6 (Table 7)

Among persons admitted to publicly funded treatment programs for heroin abuse in 1995, 66% were male; 9% were less than 25 years of age and 55% were 35 years of age or older; 43% were white, 26% were black, and 28% were Hispanic.7 (Table 8)

Methadone programs designed to treat heroin addicts reported 112,000 clients in treatment in 1993 (on a single day). About 23 percent were in the state of New York and another 17 percent were in California.15 

Patterns of Use

There are some indications that a large proportion of heroin use involves heroin in combination with other drugs, especially cocaine and alcohol. Ethnographers have reported that "criss crossing" (lines of cocaine and heroin are alternately inhaled) is becoming more common and is gaining in popularity among cocaine users in New York City.1 They have also reported that some users are snorting heroin and smoking crack in combination. In this combination, it is believed that the primary drug is crack and heroin is used to ease agitation associated with crack.2 Among heroin-related drug abuse deaths reported to DAWN in 1995, most (90%) involved heroin in combination with other drugs. Cocaine was reported in combination with heroin in 1,933 deaths (46% of all heroin-related deaths). Alcohol was the next most frequently reported drug in combination with heroin among drug abuse deaths reported to DAWN. In 1995, 1,854 deaths (44% of all heroin-related deaths) involved heroin in combination with alcohol.5

Among persons admitted to EDs for heroin abuse in 1995, most (54%) were admitted for heroin in combination with other drugs. Cocaine was the most frequently reported drug in combination with heroin. Cocaine was mentioned in combination with heroin in 28% of all heroin-related ED visits. Alcohol was the next most frequently mentioned drug in combination with heroin. Alcohol was mentioned in combination with heroin in 27% of all heroin-related ED visits.6

Among the 191,000 persons admitted to publicly funded treatment programs for heroin in 1995, 61% reported using a secondary substance. The most frequently reported secondary substance was cocaine and the next most frequently reported secondary substance was alcohol. Cocaine was reported as a secondary substance in 40% of all primary heroin admissions and alcohol was reported as a secondary substance in 24% of all primary heroin-related admissions.7 (Table 8)

Estimates from some data sources suggest that persons who smoke or sniff heroin are younger than persons who inject heroin. Among persons admitted to publicly-funded treatment programs and hospital emergency departments (ED’s), those admitted for injecting heroin tend to be older than those persons admitted for inhaling or smoking heroin. In 1995, 64% of treatment admissions for injecting heroin were persons age 35 or older, while only 41% of admissions for smoking or inhaling heroin were persons age 35 or older.7 (Table 9) In 1995, 61% of ED visits for injecting heroin were persons age 35 or older and 33% of ED visits for sniffing or smoking heroin were persons age 35 or older.6 (Table 10) 

Trends in Heroin Use

Increases In Use and Consequences

Data suggest that there has been a rise in heroin use in recent years and that this rise has occurred among younger persons who are smoking or sniffing heroin rather than injecting. Some indicators exhibit an overall rise in heroin use, some display a rise in heroin use among youth, college students, and adolescents in small metropolitan areas and others suggest that new users tend to smoke or sniff rather than inject. In addition, there is some evidence that the time between first use of marijuana and first use of heroin is decreasing.

Data from the Monitoring the Future survey show a rise in heroin use among 8th, 10th and 12th graders. According to this survey, from 1991 to 1996 lifetime, annual and 30 day use of heroin increased among 8th, 10th and 12th graders. In 1991 annual prevalence of heroin use was 0.7% among 8th graders, 0.5% among 10th graders and 0.4% among 12th graders. Annual prevalences were 1.6%, 1.2% and 1.0%, respectively in 1996. The unusual pattern of younger students having a higher prevalence level may be due to the fact that heroin users are considerably more likely to have left school by senior year. It also could be due to the fact that "noise" level is higher in the earlier grades, with slightly more false reporting either intentionally or unintentionally.9 (Table 11)

Undisplayed Graphic

Data from the NHSDA have not shown any statistically significant long-term trends in the rate of past year and lifetime heroin use for persons 12 years of age and older. The lifetime rate of heroin use was 1.3% in 1979, 1.2% in 1995 and 1.2% in 1996. The annual rate of heroin use was0.2% in 1979, 0.2% in 1995, and 0.2% in 1996. However, between 1993 and 1996 there was a significant increase in the estimated number of current (past month) heroin users. The estimated number of current heroin users was 68,000 in 1993, 117,000 in 1994, 196,000 in 1995 and 216,000 in 1996 (Figure 1). (Using a ratio adjustment to partially account for underreporting and undercoverage results in estimates of 144,000 in 1993 and 342,000 in 1996.) From 1995 to 1996 there were also significant increases in both the rates and numbers of past year and past month heroin users, among males 15-44 years of age. From 1995 to 1996 the number of males 15-44 using heroin in the past year increased from 146,000 to 302,000 and the number of males using heroin in the past month increased from 43,000 to 125,000.8, 13

Between 1991-92 and 1995-96 there was a significant decrease in the rate of past year heroin use among persons in large MSAs (population greater than one million) and a significant increase in the rate of past year heroin use among persons in small MSAs (population less than one million). In 1991-92 the rate of past year heroin use among persons in large MSAs was 0.3%, while the corresponding rate was 0.2% in 1995-96. The rate of past year heroin use among persons in small MSAs was 0.1% in 1991-92, and 0.2% in 1995-96 (Table 2). For the same time periods, data from the NHSDA also indicate a significant increase in the rate of heroin use among college students 17-22 years of age. In 1991-92 0.2% of college students 17-22 years of age reported using heroin in the past year, while in 1995-96 1.0% reported using heroin in the past year. Between 1991-92 and 1995-96, among past year heroin users there has been a significant increase in the percent of heroin users with an education greater than high school. This increase was from 22.1% in 1991-92 to 33.3% in the 1995-96.13 (Table 1) These findings described above are quite consistent with reports indicating a growing number of new young heroin users who are fairly affluent, non urban dwellers who come to the city to buy their heroin.2

Between 1991 and 1995 the annual number of heroin-related ED visits increased from 36,000 to 72,217. (Table 6) Between the first half of 1995 and the first half of 1996, there was no significant change in the number of heroin related ED visits (36,000 and 32,700, respectively).6 Data reported by a consistent panel of medical examiners participating in the DAWN show that between 1992 and 1995 heroin-related deaths increased from 2,782 to 3,809.14 (Table 4)

Trends in heroin-related deaths and ED visits reported by DAWN don’t necessarily reflect trends in the number of users. Heroin-related deaths or ED visits may increase or decrease for many reasons other than changes in the number of users. These reasons include shifts in the purity and availability of drugs, patterns of use (e.g. drug combinations or route of administration), availability of treatment programs, and patient management practices. 

Increase In Snorting, Sniffing, and Smoking

Ethnographers for "Pulse Check" continue to report that the majority of new users are inhaling rather than injecting heroin.2 Data from other sources support their conclusion. The 1995 and 1996 NHSDA estimated that among persons who have smoked or sniffed heroin in the past three years, 57.3% had never injected heroin and 18.6% had injected heroin, but not within the past three years. Twenty-three percent had injected heroin within the past three years.13 The NHSDA estimated that among lifetime heroin users, the proportion who had ever smoked, sniffed, or snorted heroin increased from 55 percent in 1994 to 63 percent in 1995, and 82 percent in 1996, while the proportion who ever used heroin with a needle remained unchanged (49 percent in 1994, 47 percent in 1995 and 52 percent in 1996).9 (Figure 2) Among past year heroin users in 1991 and 1992, 38% had injected heroin in the past year while among past year heroin users in 1995 and 1996, only 25% injected heroin in the past year. (Table 1) Data from the NHSDA also indicated that among new users between 1989 and 1991, 56% had injected heroin, while among new users between 1993 and 1995 only 43% had injected heroin.13 (Table 12)

Among persons admitted to publicly-funded treatment programs and EDs for heroin, the proportion associated with injection of heroin has decreased. In 1981, nearly all heroin clients (95%) admitted to publicly funded treatment programs reported "intravenous" as their route of administration.16 In 1995, 69% of heroin clients admitted to publicly funded treatment programs reported "intravenous" as their route of administration.7 In 1981, 91% of persons admitted to EDs for heroin reported "intravenous" as their route of heroin administration, while in 1995 only 53% of persons admitted to ED’s reported "intravenous" as their route of heroin administration.6, 17 (Table 10).

The purity of heroin and the fear of AIDS may be responsible for the shift from injecting to smoking or sniffing heroin. The purity of heroin is much higher than it was 10 years ago. The National Narcotics Intelligence Consumers Committee reported that the purity of heroin at the retail level was less than 5% in 1984.4 The Drug Enforcement Administration reported the average purity of small (1-10 grams) heroin purchases was 37% in 1992 and 59% in 1995.3 This increase in the purity of heroin makes it possible to smoke or sniff heroin rather than inject it.

Since smoking or sniffing is less invasive than injecting heroin, it may be perceived as less risky. This may be a reason for the increase in new users of heroin, especially among the young, and a decrease in the time between first use of marijuana and first use of heroin (see below). 

Increasing Use Among Young People

The CEWG reported that a major trend in drug use is heroin’s growing popularity among a younger cohort of users, including teenagers, who snort rather than inject the drug.1 Among persons admitted to EDs who are 12-17 years of age, the percent associated with sniffing/inhaling or smoking was 15 in 1991 and 41 in 1995, while the percent associated with injecting was 30 in 1991 and 22 in 1995. (Table 10). The NHSDA estimated that the percent of persons 12-17 years of age smoking heroin in their lifetime was 0.2 in 1994, 0.5 in 1995 and 0.4 in 1996. The percent sniffing or snorting heroin in their lifetime was 0.1 in 1994, 0.3 in 1995 and 0.2 in 19968. Among new initiates of heroin there was a significant increase in the percent ofpersons 12-25 years of age from 1989 to 1995. Among new users between 1989 and 1991, 61% were 12-25 years of age while among new users between 1993 and 1995, 88% were 12-25 years of age. During 1991-92, 9 percent of past year heroin users were age 12-17, while during 1995-96, 22 percent of past year heroin users were age 12-17.13

Undisplayed Graphic

Trends In New Use (Incidence)

Estimates of incidence or initiation of heroin use from the NHSDA provide another measure of the Nation’s heroin problem. These estimates suggest that recent increases in new heroin use are comparable to the increases seen in the epidemic of the late 1960s. Although estimates of heroin incidence are subject to wide variability, there has been a statistically significant increasing trend in new heroin use since 1992. There were an estimated 141,000 new heroin users in 1995, which was more than estimates for prior years, since 1969. Except for 1994, when there was a slight increase, there has been a decreasing trend in the mean age of first use since 1988. In 1988 the mean age of first use was 27.3, while in 1995 the mean age of first use was only 19.3. The age specific rate of first use at age 12-17 increased from generally below 0.5 during the 1980s to 2.5 in 1995.

Undisplayed Graphic

The age-specific rate of first use at age 18-25 was 0.6 in 1993, 1.7 in 1994 and 2.4 in 1995. Age specific rates at age 26-34 did not display any clear long or short term trends. These age-specific rates of first use were based on combining 1994-1996 NHSDA data.8 (Table 13) When the 1991-1996 NHSDA data were combined to provide more stable estimates for assessing long term trends, the trend in age-specific rates showed that the recent increases in new heroin use are comparable to increases seen in the epidemic of the late 1960s (Figure 3).

Data from the NHSDA suggest that the time between first use of marijuana and first use of heroin may be decreasing. Among new users of heroin, this mean lag was 8.7 years among persons using heroin for the first time between 1989 and 1991 and only 5.6 years among persons using heroin for the first time between 1993 and 1995. Among persons using heroin for the first time between 1989 and 1991, 28.9% had a lag greater than 10 years, while among persons using heroin for the first time between 1993 and 1995 only 14.4% had a lag greater than 10 years.13 (Figure 4) (Table 12 )

Undisplayed Graphic

Despite the apparent increases among the younger persons, there still is an aging cohort of heroin users that is having an impact on emergency departments and treatment facilities. The percentage of heroin-related ED visits that were for persons 35 years of age and older has increased from 19% in 1980 to 48% in 1991 and 55% in 1995.6, 17 In 1995, 55% of primary heroin admissions to publicly funded specialty substance abuse facilities were 35 years of age and older.7

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