Heroin Holding More and More People Under Its Spell

From the WebMD Archives

July 20, 2000 -- Singer Lou Reed described a heroin high as feeling like Jesus' son. But more and more, the drug is apt to instead act like one of it's many slang names: Judas. According to a new government report, the drug is killing more people by overdose in the Portland and Seattle areas every year, and the problem, according to one expert, is nationwide.

The CDC reports heroin overdose deaths in Multnomah County, Ore., (of which 75% of the population lives in Portland) rose from 46 in 1993 to 111 in 1999. The majority was men, and almost half of the people were 45 to 54 years old. During six years of investigation, almost 400 people were known to die from heroin overdose. Among men 25 to 54 in this area, overdose causes about as many deaths as cancer, AIDS, or heart disease.

That may be just the tip of the iceberg. Another CDC report on King County, Wash., -- which includes Seattle -- shows opiate overdose deaths increased 134% from 1990 to 1999, peaking in 1998 at 140.

Gary Oxman, MD, MPH, the chief health officer of the Multnomah County Health Department, says one reason for the spike in heroin deaths is access. Interstate 5 runs from Los Angeles up to Seattle, and Oxman tells WebMD it's a key passageway for a type of heroin called "black tar," which comes from Mexico and South and Central America.

The problem may not just be I-5 related, though, says Oxman, who claims many communities do not actively look for this problem. Heroin overdoses may get lost among the broad category of drug-related deaths, a "laundry basket" term. "It may be occurring in lots of other communities that simply aren't aware or aren't tracking the data carefully," Oxman says.

Glenn Backes, MSW, MPH, would likely agree. Backes tells WebMD the system nationwide to track drug overdoses is very poor, so the data is very incomplete. But it is known, for instance, that heroin overdose is the No. 1 cause of death for men aged 15 to 44 in Utah. The same goes for several cities in New Mexico. San Francisco has a "huge problem," and presumably other West Coast cities do, too. Backes is director of the health and harm reduction program for the Lindesmith Center, a drug policy think tank in New York City.

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"I have the sense that we've maintained a high level, in New York state, ranging form 600 to 1,000, a year in the New York City area, and what's interesting is no mayor has ever stood up and screamed his head off about this," Backes says.

The Drug Abuse Warning Network (DAWN) has compiled some data from 25 U.S. cities, according to Backes, who says, "there's definitely been an increase nationwide in overdose deaths. In 1998, from that report, there was over 6,500 overdoses in the top 25 cities followed, and as I said, it's an underestimation of those 25 cities."

Backes put the numbers in perspective by comparing them to alcohol-related auto fatalities in the U.S. "There's 16,000 a year alcohol-related auto fatalities, so comparatively, we're talking about a huge public health problem related to drugs that's not being addressed. So if it rounds up to maybe 10,000 in the U.S., we're talking comparatively, a massive problem of which there's been very little attention [paid]."

Of course, it just makes sense that if that many people are overdosing, many more are using the drug who aren't. Oxman says it's estimated there are about 10,000 active heroin users in the community around Portland. Backes says a "standing estimate" for injection drug use in New York state over the last 10 years has run up to 250,000 and there's large injecting populations in Baltimore, Philadelphia, Newark, and Boston, to name a few.

And these people come from all walks of life; they're not all street urchins and criminals. "There's the popular image of the heroin user as being very down and out, a homeless criminal type ... what we're talking about is people who use heroin and represent a very wide cross section of the community. These folks are not monsters, they're human beings and they're struggling with a horrible addiction that they can't drop," Oxman says.

No longer is it necessary to be a full-time criminal to afford heroin, although many users can obviously fall into crime as their habit progresses. Many people work minimum wage jobs and maintain a heroin habit, Oxman says.

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The drug dealers in Portland, for instance, have a very sophisticated distribution network that reacts to change very quickly, according to Oxman. The heroin is easily found, and usually is sold in a "balloon" or packet, consisting of one-eighth of a gram, for $20.

That is not the only reason for all the overdoses, though, Oxman says. In local interviews of heroin users, he says many long-term, 15- to 20-year users admitted to having lived through two to six overdoses.

So "they don't believe they're at a huge risk for overdose. Indeed, their experience suggests that," Oxman tells WebMD.

What finally gets the addicts is a mix of factors. The black tar is "fairly potent stuff," but has a tremendous variability. Oxman says "it's always a guessing game as to how strong it's going to be." For some people who don't "test" the dose, the drug may prove lethally potent.

Another problem is sometimes people try to kick the habit, or perhaps get thrown in jail for a week. During that time, their tolerance level changes, but they shoot the same amount of heroin as they used to, causing an overdose.

It typically takes a person one to three hours to die from an overdose after their most recent shot. The majority of the deaths are witnessed, according to Backes, and most of the other witnesses are drug users. They may have an outstanding warrant, or they might just fear arrest. They might simply not want to get locked up in a drug-free jail. The causes of overdose are many.

"It's the variability, it's increased number of people using, and, unfortunately, in the drug war environment, in which all of our emphasis has been on law enforcement, people don't feel free to call 911 if they witness a fatal overdose," Backes tells WebMD.

So what can be done to turn the tide? Oxman says they have an active outreach program in Portland with needle exchange, and general education for active users stressing an overdose reduction message, such as "don't shoot alone; if somebody 'crashes,' call 911; use a tester dose; try to get drugs from a consistent dealer," he says.

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And there are efforts to increase drug treatment slots, something both Oxman and Backes claim is a good start. Seattle alone, for instance, recently has increased its licensed treatment slots from 2,100 to about 3,150.

In Salt Lake City, Backes says the community has worked with law enforcement to lower drug users' fear over calling 911. And a more controversial plan is to make available and train drug users in the use of naloxone, a drug that can counteract an overdose. Available over the counter in parts of Europe, the drug is prescription here, and no communities have touched that political hot potato yet.

But whatever happens, Backes tells WebMD, the solution will be community-based. "Treatment, primary prevention, and law enforcement is part of the picture, but in an era when we spent more resources on law enforcement than any other, we've seen an increase in heroin use, and so we also have to have interventions which work with heroin-using communities to reduce the rate of fatalities."

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