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The National Survey on Drug Use and Health is a comprehensive go-to source for information on drug use patterns and trends in the US. The following are key highlights from the 2013 survey’s report on heroin:
The National Institute on Drug Abuse has reported that from 2001-2013 there was a 500 percent increase in the number of fatalities resulting from heroin overdose. In 2013, in Texas alone, there were 319 heroin poisoning deaths.
Source: NIDA and Substance Abuse Trends in Texas: June 2014
A 2014 survey review of substance abuse patterns and trends revealed growing concern over the proliferation of black tar heroin. Due in part to sharing a border with Mexico, the most common form of heroin being abused in Texas is Mexican black tar heroin or powdered brown heroin (which is made from black tar heroin plus diphenhydramine or other chemicals).2
Although Afghanistan is the main source of the worldwide heroin supply, beginning in the 1990s, Central and South America became the dominant heroin suppliers for the US. Mexico is now a main supplier, especially for states west of Mississippi. Mexican heroin is typically a gummy and oily black tar, the result of a less complex process of refinement as compared to the Columbian process of making white powder heroin. Street heroin is not typically white because local dealers cut in additives that change the color.
Mexican black tar heroin can be diluted in water and then injected, which is the most common method of administration of this drug. Due to its consistency, black tar heroin is more likely to burn than to smolder when heated, making it an undesirable for smoking. Street dealers in Texas usually package black tar heroin in balloons or baggies under the nicknames Mud, Ace of Diamonds, Hearts, and Dog Food.3
Another concerning trend in Texas is the increase in heroin use among teenagers and young adults. A 2011 survey of students in participating secondary schools showed that 3.3 percent of this population had used heroin at least once in their lifetimes. This percentage was up from 2001 (3 percent), 2005 (3 percent), 2007 (2.4 percent), and 2009 (2.1 percent).
Student use of heroin is part of a larger trend of increasing demand for this drug in Texas. Access to heroin has increased by virtue of a reported drop in street prices for this opioid. Texas poison control centers reported that the number of calls involving heroin was 307 in 2013, up from 181 in 1998. In cases of fatal heroin poisoning/overdose, the average age of the victim was 36 in 2013 compared to 41 in 2005.4
Heroin is classified as an opioid. Street heroin can be traced back to the poppy plant, most commonly cultivated in Southeast Asia, Southwest Asia, and Latin America. Approximately three months after being planted, the poppy plant develops flowers. These flowers can be removed to reveal a bulbous seedpod. Farmers slice the pods, which contain creamy white sap and leave them to air out. The white sap soon turns to brown and gummy, which is raw opium that contains approximately 10 percent morphine. At this point, farmers/producers will scrape this substance off the bulbs and roll it into balls or bricks.
These packages will then be sold to black market morphine and/or heroin refineries. To make heroin, illicit laboratories add chemical compounds (from the acetyl group) that change the structure of morphine in the opium. The change in morphine’s structure helps to expedite this drug’s travel time to the brain, which is part of the reason heroin is so potent and fast-acting.
Source: Frontline PBS
Heroin seizures in Texas provide another layer of information about this drug. Overall, heroin makes up a small percentage of all reported drug seizures in Texas (in 2013, 4 percent).5In terms of pounds, according to law enforcement information (based on EPIC data), in 2011, heroin seizures amounted to 636 kilograms, which was similar to the 641 kilograms seized in 2012.
Seizures also provide insight into the geographic availability of heroin. Seizure reports indicate that black tar heroin was the most common type of heroin found in the Dallas area. In El Paso, heroin is considered moderately available, but more available in 2013 compared to 2012. In the Houston area, law enforcement consider heroin to be moderately available.6
Research indicates both Mexican black tar heroin and Mexican brown heroin are moderately priced, though prices vary depending on the city. Black tar heroin is sold by balloon/paper/capsule, gram, ounce, or kilogram. On average, in 2013, black tar heroin cost $5-20 per balloon/paper/capsule, $50-150 per gram, $800-3,000 per ounce, and $19,000-60,000 per kilogram. Mexican brown heroin (again, black tar that has been cut with additives that makes it injectable or snortable) cost an average of $50-500 per gram and $500-3,000 per ounce.7
As USA Today reports, there is a national uptick in the use of heroin across the US. In 2003, government surveys revealed that heroin use had hit a decade low with 119,000 estimated users.8 But in 2014, that number had spiked to about 330,000. Only a decade later, and it’s a callback to the heroin epidemic of the mid-1970s.
Different theories have emerged from researchers, governmental authorities, and clinicians, but there is a general consensus that the prescription painkillers epidemic has contributed to the resurgence in heroin use. Heroin and prescription painkillers (including generic drugs like hydrocodone and oxycodone, and branded drugs like Opana) have separate pathways of development (the former illegal, the latter legal when used according to prescription) but both are opioids.
The opioid class of drugs is semisynthetic or entirely synthetic laboratory-made drugs that replicate the chemical structure of morphine. As with morphine, these drugs have a pain-relieving effect but can also induce euphoria.
In response to prescription opioid abuse, governmental officials and manufacturers have increased regulations, such as clamping down on doctor prescriptions, which caused a decrease in the street supply and a rise in price for pills that are available. As a result, some who were abusing prescription painkillers turned to heroin as a low-cost alternative.9 However unintended, this chain of events is harrowing from a public health and drug control standpoint.
A 2013 review of treatment admissions for heroin opens a window into the circumstances around abuse of this drug, such as whether it is part of poly-drug use and methods of heroin administration. Heroin was the primary drug of abuse in 13 percent of all admissions to Texas rehab centers.10 Of these individuals, 36 percent only abused heroin (i.e., they were not poly-drug users) and 16 percent reported problematic use of cocaine, which may reflect the speedballing (combining heroin and cocaine) process). This trend was also witnessed in terms of autopsy results. Of all the heroin-involved deaths in 2013, 61 percent indicated heroin only, and 14 percent indicated the presence of cocaine and heroin.11
Among those in treatment for heroin abuse, inhalation was the least common method of use. However, it appears that individuals who inhale are more likely to seek treatment earlier in their abuse compared to those who inject heroin. In the inhaler group, on average, there was a period of eight years between first use of heroin and seeking treatment, compared to 12 years on average for the injection group.12 This statistic directly challenges the myth that injection use causes greater dependence than inhalation use. Individuals who inhale heroin are at a high risk for becoming addicted, and they tend to recognize the need for treatment sooner than their counterparts who inject this drug. Some who initially inhale heroin may cross over to injecting it, thus increasing the likelihood that it will take them longer to seek treatment.
Overall, there was an increase in the number of young people who were being admitted for treatment in Texas rehab centers. Among those seeking heroin addiction treatment in 2013, those who were under 30 years old increased from 40 percent in 2005 to 52 percent in 2013.13 When this statistic is compared to data on how long it typically takes people who abuse heroin to seek treatment, it becomes clear that many of the people who were admitted in their 20s had started using heroin in their teenage years. Additional evidence of this trend can be derived from the average age of death in heroin-involved fatalities. In 2005, 41 was the average age, but in 2012, it dropped to 36 years of age.14
In Texas, and across the nation, drug rehab programs begin with medical detox, which is immediately followed by intensive therapy. Detox can occur onsite at the rehab center, if such services are available, or offsite at a hospital or detox clinic. In the case of heroin abuse, the term detox may not be entirely accurate. Typically, it is safer for individuals to be tapered off heroin rather than have all opioids completely removed from the body.
To that end, during medical detox, individuals may be tapered off heroin with use of FDA-approved targeted medications: methadone, buprenorphine (branded names Suboxone and Subutex), and naltrexone. At an early point in the weaning period, the attending physician will establish the proper dosage of the targeted medication that needs to be used (whether it’s methadone, buprenorphine, or naltrexone). The weaning process revolves around the dynamic between the client’s physiology and the drugs involved. Once stabilized on the medication, the client will enter the abstinence maintenance phase of treatment.
The two main components of available treatment for a person recovering from opioid abuse are medication and therapy. If methadone is used as an abstinence maintenance therapy, a main benefit is that once individuals are stabilized on this drug, they should not experience cravings for heroin.15 It is well established in addiction treatment literature that cravings are a main contributor to relapse. If taken strictly in accordance with the attending physician’s treatment plan, methadone should not produce euphoria or any other psychoactive effects.
Methadone can be administered in tablet, powder, or liquid form at the rehab center, and a dose can last 24-36 hours. During an inpatient or outpatient program, staff members will administer the drug. After completion of the rehab program, by law, the recovering person must go to an approved clinic to receive maintenance dosages. In rural areas, where transportation is limited, or if the recovering person has a disability, the requirement to go to a methadone provider may present a considerable inconvenience and even a barrier to ongoing recovery.
Like methadone, buprenorphine can be administered in rehab programs as a method of heroin abstinence maintenance. But unlike methadone, after program graduation, buprenorphine can be taken by prescription, which makes it a more convenient option for many recovering individuals. Individuals who continue to take buprenorphine after completion of a rehab program will make periodic visits to a local doctor’s office or clinic, tested to ensure opioids or other drugs are not present, and given a prescription for Suboxone and Subutex.16
To preempt the potential for Suboxone abuse, the formulation of this drug includes naloxone. When individuals take Suboxone and then consume heroin (or another opioid), the naloxone in Suboxone will cause them to experience withdrawal symptoms. In other words, naloxone creates a chemically based disincentive for people who are on Suboxone to abuse heroin. As an additional safeguard against abuse, Suboxone comes in a sublingual pill form that will not be effective if chewed or swallowed. Note that Subutex does not contain naloxone.
Naltrexone is a non-narcotic option that can be used as part of a heroin abstinence maintenance program.17It is sold under the tradenames ReVia and Vivitrol. Since naltrexone-based medications are non-narcotic, they do not operate in the brain to diminish heroin or other opioid cravings. However, naltrexone-based medications have shown to be effective in stopping a person who uses heroin form experiencing euphoric effects.
There is a unanimous consensus in the drug abuse treatment community that the use of medications alone is not sufficient to achieve recovery during rehab or to maintain abstinence after program graduation. Therapy is an essential part of the recovery process. Medications can address the biological component of heroin abuse but not the psychological aspects. Research shows that a combination of medication and therapy are effective for the treatment of heroin abuse.
Within the field of psychology, there are numerous different theoretical and clinical approaches to mental health treatment, including substance abuse recovery. These different approaches provide a host of options to rehab centers in Texas across the US. Typically, a rehab center will have an overarching treatment philosophy and favor the use of therapy approaches that are most complementary while at the same time effective. Although specific therapy approaches may vary among centers, therapy – in both an individual and group setting – is a mainstay of any treatment regime.
Joining a recovery group is a informal but effective component of drug rehab programs as well as aftercare programs. The group members operate the meetings, which helps individuals to own their recovery processes. Recovery groups are historically based on Alcoholics Anonymous, a 12-Step fellowship. Today, there are numerous recovery groups, some of which observe the 12-Step model while others do not.
According Heroin Anonymous Worldwide Services, the organizational touchpoint for HA meetings nationally and internationally, the only requirement for membership is a desire to stop using heroin. All meetings are free, and there are never any hidden or express fees to participate. The fellowship’s official website makes the following resources available to the public:
Source: Heroin Anonymous
The Anonymous fellowships, all legacies of Alcoholics Anonymous, include Narcotics Anonymous as well as more specialized groups, such as Heroin Anonymous (HA). These groups are all inclusive; for instance a person in recovery for heroin abuse would be as welcome at an AA meeting as at an HA meeting. The crossover potential helps to ensure that anytime individuals want to find a meeting, they will be able to do so.
Heroin abuse in Texas is part of a larger national epidemic. Despite troubling statistics, such as the number of younger individuals initiating into use of this dangerous opioid, treatment is available, and it can be effective.
Drug recovery is always a reactive and proactive process. Rehab services address the immediate biological and psychological issues associated with heroin abuse, and they help to prevent an escalation of the harms that can arise from heroin abuse.