Heroin-related overdose: The unexplored influences of markets, marketing and source-types in the United States

Abstract

Heroin overdose, more accurately termed ‘heroin-related overdose’ due to the frequent involvement of other drugs, is the leading cause of mortality among regular heroin users. (Degenhardt et al., 2010) Heroin injectors are at greater risk of hospital admission for heroin-related overdose (HOD) in the eastern United States where Colombian-sourced powder heroin is sold than in the western US where black ‘tar’ heroin predominates. (Unick et al., 2014) This paper examines under-researched influences on HOD, both fatal and non-fatal, using data from a qualitative study of injecting drug users of black tar heroin in San Francisco and powder heroin in Philadelphia Data were collected through in-depth, semi-structured interviews carried out in 2012 that were conducted against a background of longer-term participant-observation, ethnographic studies of drug users and dealers in Philadelphia (2007–12) and of users in San Francisco (1994–2007, 2012). Our findings suggest three types of previously unconsidered influences on overdose risk that arise both from structural socio-economic factors and from the physical properties of the heroin source-types: 1) retail market structure including information flow between users; 2) marketing techniques such as branding, free samples and pricing and 3) differences in the physical characteristics of the two major heroin source forms and how they affect injecting techniques and vascular health. Although chosen for their contrasting source-forms, we found that the two cities have contrasting dominant models of drug retailing: San Francisco respondents tended to buy through private dealers and Philadelphia respondents frequented an open-air street market where heroin is branded and free samples are distributed, although each city included both types of drug sales. These market structures and marketing techniques shape the availability of information regarding heroin potency and its dissemination among users who tend to seek out the strongest heroin available on a given day. The physical characteristics of these two source-types, the way they are prepared for injecting and their effects on vein health also differ markedly. The purpose of this paper is to examine some of the unexplored factors that may lead to heroin-related overdose in the United States and to generate hypotheses for further study.

The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland

“…Batches of street heroin that have been linked to overdose risk have also been documented as being more popular among some groups of PWID due to the 'better' euphoric effects (Mars, et al, 2015;Singer, 2006). However, these effects are usually at the brink of overdose.…”

“…However, these effects are usually at the brink of overdose. Tolerance to respiratory depression in people who inject heroin can develop quickly with chronic use, but can be lost quickly in withdrawal, making the judgement of lethal doses hard to predict (Mars, et al, 2015;Strang, et al, 2003). Street heroin with variable purity levels and price due to the variances of supply, make it harder to identify a lethal dosage, particularly after heroin shortages when the 'normal' quality resumes (Darke, Hall, Weatherburn, & Lind, 1999;Travis, 2011;Unick, Rosenblum, Mars, & Ciccarone, 2014).…”

An ethnographic exploration of drug markets in Kisumu, Kenya

“…Several other interviewees and injectors with whom we spoke in the field admitted they knew peddlers who adulterated their products to boost profits, but declined to share specifics. Importantly, the lack of information on the street about the cut can result in overdose deaths and other adverse health outcomes, as evidenced in some U.S. heroin markets (Denton, Donoghue, McReynolds, & Kalelkar, 2008; Mars et al, 2015). Low-level users who inject adulterated, lower quality, and therefore more dangerous drugs often have less access to public health services to contend with the health consequences.…”

Systematic review of surveillance by social media platforms for illicit drug use

“…synthetic cathinones 'bath salts') or unique drug combinations intended to entice more users. 38 Established in 1972 in the USA, Drug Abuse Warning Network (DAWN) was operated by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Department of Health and Human Services (HHS). DAWN collected data on substance use and abuse from non-federal hospital EDs' from 37 metropolitan states.…”