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

Abstract

Background The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30–50× more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as ‘heroin’ and to observe the drugs and their use. Methods A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin. Results 1) The composition and appearance of heroin changed in the last four years; 2) heroin is cheaper and more widely available than before; and 3) heroin ‘types’ have proliferated with several products being sold as ‘heroin’. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl’s presence, followed by taste, solution appearance and powder color. This paper presents a new ‘heroin’ typology based on users’ reports. Conclusion Massachusetts’ heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users’ discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.

Fentanyl in the US heroin supply: A rapidly changing risk environment

“…Fentanyl adulteration of heroin represents a significant change in the structural risk environment for users of heroin (Ciccarone, Ondocsin, and Mars 2017). Ciccarone and colleagues report on qualitative findings from Massachusetts, a CDC “high-burden” state for synthetic overdose deaths, and point out their respondents’ discernment and mixed opinions regarding the desirability of fentanyl.…”

“…Ciccarone et al’s participants report increased availability of heroin and changes in heroin characteristics and form since 2013 (Ciccarone, Ondocsin, and Mars 2017). The authors identify a possible heroin and fentanyl typology based on participant’s responses and call for its empiric testing.…”

“…The challenges in the synthetic era include erratic drug potency, naloxone dosing quandaries and a narrower overdose response window. Ciccarone, Ondocsin and Mars also discuss the overdose risk due to vicissitudes in drug potency, now magnified when potent opioids are combined (Ciccarone, Ondocsin, and Mars 2017). Fairbairn et al call for scaling up naloxone distribution into new venues and improving post-overdose care, drug checking services and advanced opioid substitution including heroin prescription (Nadia, Coffin, and Walley 2017).…”

“…Carroll et al and Ciccarone et al discuss the effect that controlled consumption of drug, aka a “tester shot”, “taste” or insufflation (aka snorting) prior to or in lieu of injection might have in reducing overdose risk (Carroll et al 2017, Ciccarone, Ondocsin, and Mars 2017). Point-of-use testing or “drug checking” has been used especially in Europe, to inform and engage persons who consume drugs as well as provide a potential surveillance platform (Hondebrink et al 2015, Caudevilla et al 2016, Brunt et al 2017).…”

“…Point-of-use testing or “drug checking” has been used especially in Europe, to inform and engage persons who consume drugs as well as provide a potential surveillance platform (Hondebrink et al 2015, Caudevilla et al 2016, Brunt et al 2017). Rapid testing exists for some of the fentanyls and several contributors point out the positives and the challenges of this harm reduction strategy (Ciccarone, Ondocsin, and Mars 2017, Nadia, Coffin, and Walley 2017, Gilbert and Dasgupta 2017). …”