Heroin in Brown, Black and White: Heroin in Brown, Black and White: Geographic Risk Environments inGeographic Risk Environments inGeographic Risk Environments in Geographic Risk Environments in

the US Heroin Marketthe US Heroin Market

Dan Ciccarone, MD, MPHDan Ciccarone, MD, MPHFamily and Community MedicineFamily and Community MedicineFamily and Community Medicine Family and Community Medicine Anthropology, History and Social Anthropology, History and Social MedicineMedicineUCSFUCSF

Obj tiObj tiObjectivesObjectives

►►Characterize trends in US retail heroin Characterize trends in US retail heroin markets frommarkets from 19901990 –– 20022002markets from markets from 1990 1990 20022002

Political economy of changing heroin sourcesPolitical economy of changing heroin sourcesE i ff t f h i i d itE i ff t f h i i d it►►Examine effects of heroin price and purity Examine effects of heroin price and purity on heroinon heroin--related deaths nationallyrelated deaths nationally

►►Explore specific heroin types and Explore specific heroin types and consequencesconsequencesqq

►►Discuss policy implicationsDiscuss policy implications

M ltiM lti th d l i l R hth d l i l R hMultiMulti--methodological Researchmethodological Research

►► EpidemiologicalEpidemiologicalUS governmental data:US governmental data:US governmental data: US governmental data: ►►Drug Enforcement Agency; Centers for Disease ControlDrug Enforcement Agency; Centers for Disease Control►►19901990--20022002; ; 19 19 US citiesUS cities

►► EthnographicEthnographicMultiMulti--city participant observationcity participant observationClinical work in syringe exchangesClinical work in syringe exchanges

►►Historical Historical US and international documents US and international documents academic worksacademic works

H i SH i SHeroin SourcesHeroin Sources

►►Global heroin sources:Global heroin sources:South West Asia (Afghanistan/Pakistan)South West Asia (Afghanistan/Pakistan)South East Asia (Golden triangle: MyanmarSouth East Asia (Golden triangle: MyanmarSouth East Asia (Golden triangle: Myanmar, South East Asia (Golden triangle: Myanmar, Thailand, Laos)Thailand, Laos)Colombia (Colombia (55% of world’s opium/heroin)% of world’s opium/heroin)Colombia (Colombia (55% of world s opium/heroin)% of world s opium/heroin)Mexico (Mexico (22% of world’s opium/heroin)% of world’s opium/heroin)

►►US heroinUS heroin►►US heroinUS heroin

Heroin Trafficking RoutesHeroin Trafficking Routesgg

“Golden Crescent”“Golden Triangle”

Geographic Origin of HeroinGeographic Origin of HeroinGeographic Origin of HeroinGeographic Origin of Heroin

Results: Heroin Price and PurityResults: Heroin Price and PurityResults: Heroin Price and PurityResults: Heroin Price and Purity

Ch i i k iCh i i k iChanges in Risk Environment: Part Changes in Risk Environment: Part 11

►► Introduction of new heroin source: ColombiaIntroduction of new heroin source: ColombiaRapid dominance due to product quality and costRapid dominance due to product quality and costRapid dominance due to product quality and costRapid dominance due to product quality and costCompetition drives out two heroin sourcesCompetition drives out two heroin sources

►►Historic changes in heroin supply:Historic changes in heroin supply:►►Historic changes in heroin supply:Historic changes in heroin supply:Purity: Purity: 220220% increase between % increase between 1990 1990 (min) and (min) and 1998 1998 (max)(max)(max)(max)Declines slightly after Declines slightly after 19981998P iceP ice 7373% decline in p ice to histo ic lo s% decline in p ice to histo ic lo sPrice: Price: 7373% decline in price to historic lows% decline in price to historic lows

ColombiaColombiaColombiaColombia

►►Brief political historyBrief political historyInternal conflictsInternal conflicts►►Separation from Ecuador and Venezuela in Separation from Ecuador and Venezuela in 18301830►►> > 8 8 civil wars over next civil wars over next 70 70 yearsyearsyy

►►Help establish the twin traditions of violence and Help establish the twin traditions of violence and distrust of the governmentdistrust of the government

►►Intertwined conflicts over political rule geographyIntertwined conflicts over political rule geography►►Intertwined conflicts over political rule, geography Intertwined conflicts over political rule, geography and drug tradeand drug trade

22ndnd worldwide in internally displaced peopleworldwide in internally displaced people►►Drug trade fuels conflict and conflict fuels drug Drug trade fuels conflict and conflict fuels drug

tradetrade

Colombian Drug TradeColombian Drug TradeColombian Drug TradeColombian Drug Trade

►►Marijuana trade > US; flourished Marijuana trade > US; flourished 19601960ssTrade route through Caribbean Trade route through Caribbean Preliminary instruction in drug traffickingPreliminary instruction in drug trafficking

►►CocaineCocaineDemand rises in US, Demand rises in US, 19701970ssMore lucrative than marijuana More lucrative than marijuana

S i d f l i iS i d f l i i►►Savvier and more powerful organizations Savvier and more powerful organizations ►►Industry embraced by the local populaceIndustry embraced by the local populace

Provided otherwise scarce opportunities for social mobilityProvided otherwise scarce opportunities for social mobilitypp ypp yCartels provided basic infrastructure Cartels provided basic infrastructure –– schools and healthcare schools and healthcare ––that the government had not that the government had not

Colombian HeroinColombian HeroinColombian HeroinColombian Heroin

►► 19801980ssMedellin & Cali cartels ran the enormous US cocaine marketMedellin & Cali cartels ran the enormous US cocaine market►► Weaken government controlWeaken government control►► Weaken government controlWeaken government control

19861986: first poppy plants detected in Colombia: first poppy plants detected in ColombiaLate Late 19801980s: US demand for cocaine was flattenings: US demand for cocaine was flattening

►► EarlyEarly 19901990ss►► Early Early 19901990ssThe big cartels were significantly weakenedThe big cartels were significantly weakened►► “Cartelitos,” smaller low profile drug organizations, flourish“Cartelitos,” smaller low profile drug organizations, flourish►► Political rebel groups also take advantagePolitical rebel groups also take advantage►► Size was conducive to the heroin trade: smaller US demand by Size was conducive to the heroin trade: smaller US demand by

volume; higher selling price / weightvolume; higher selling price / weight

MidMid l tl t 19901990►►Mid Mid -- late late 19901990ssThe big cartels had dissolvedThe big cartels had dissolvedCooperation with Mexican org: routes and productCooperation with Mexican org: routes and productCooperation with Mexican org: routes and productCooperation with Mexican org: routes and productColombia becomes biggest heroin supplier to the USColombia becomes biggest heroin supplier to the US

“War on Drugs”“War on Drugs”War on DrugsWar on Drugs

►►US “war on drugs” in its fourth decade:US “war on drugs” in its fourth decade:ExpendituresExpendituresExpendituresExpenditures►►2 2 billion USD in billion USD in 1991 1991 ►►1919 billion USD inbillion USD in 20032003►►19 19 billion USD in billion USD in 20032003

25 25 -- 3535% for substance treatment% for substance treatment

►►Supply reductionSupply reduction►►Supply reductionSupply reductionInterdiction and source country control Interdiction and source country control Poor results despite upbeat government reportsPoor results despite upbeat government reports

Paradoxes of InterdictionParadoxes of InterdictionParadoxes of InterdictionParadoxes of Interdiction

I t di ti f f B li i d PI t di ti f f B li i d P►► Interdiction of coca from Bolivia and Peru Interdiction of coca from Bolivia and Peru concentrated cocaine production and power in concentrated cocaine production and power in ColombiaColombiaColombiaColombia

►►Governments ignored early poppy cropsGovernments ignored early poppy crops►►Weakening the major cocaine cartels allowedWeakening the major cocaine cartels allowed►►Weakening the major cocaine cartels allowed Weakening the major cocaine cartels allowed

smaller players to promote a new drug (drug smaller players to promote a new drug (drug diversification)diversification)

►► Interruption of Caribbean trade routes leads Interruption of Caribbean trade routes leads Colombian and Mexican smugglers to cooperate Colombian and Mexican smugglers to cooperate (trade route diversification)(trade route diversification)(trade route diversification)(trade route diversification)

NAFTA (NAFTA (19941994))

ConsequencesConsequencesConsequencesConsequences

►►Deaths: OpiateDeaths: Opiate--related overdoserelated overdose

Heroin Purity and OverdosesHeroin Purity and OverdosesHeroin Purity and OverdosesHeroin Purity and Overdoses

Ch i i k iCh i i k i 22Changes in Risk Environment: Part Changes in Risk Environment: Part 22

►►Heroin market dynamics correlate with rise Heroin market dynamics correlate with rise in heroin overdose deathsin heroin overdose deathsin heroin overdose deathsin heroin overdose deaths

Average overdoses in MSA increased Average overdoses in MSA increased 217217% % between between 1990 1990 (min) and (min) and 1999 1999 (max)(max)Statistically significant increase in overdoses Statistically significant increase in overdoses y gy gassociated with heroin purity after controlling associated with heroin purity after controlling for time and MSA characteristicsfor time and MSA characteristics

Heroin Types: SourcesHeroin Types: SourcesHeroin Types: SourcesHeroin Types: SourcesBlack Tar Heroin: MexicanBlack Tar Heroin: Mexican

Brown powder Heroin:Brown powder Heroin: Colombian/SWA

White powder Heroin: SEA

“Tar” Heroin Distribution“Tar” Heroin DistributionTar Heroin DistributionTar Heroin Distribution

►► NYC (NYC (19911991--19931993))BTH samples/ all BTH samples/ all p /p /DEA heroin DEA heroin samples: samples: 00%%

►► Los AngelesLos Angeles►► Los AngelesLos AngelesBTH: BTH: 9393%%

►► DenverDenver►► DenverDenverBTH: BTH: 100100%%

Black Tar Heroin HypothesisBlack Tar Heroin HypothesisBlack Tar Heroin HypothesisBlack Tar Heroin Hypothesis

►►Chemical properties of BTH oblige IDUs to modify Chemical properties of BTH oblige IDUs to modify their behavior:their behavior:t e be a ot e be a o

Heating of drug solutionHeating of drug solutionHabitual and thorough rinsing Habitual and thorough rinsing

►►Clinical complications:Clinical complications:Venous sclerosis > intramuscular injection > abscessesVenous sclerosis > intramuscular injection > abscesses

►► Structural effects:Structural effects:Increased syringe turnover?Increased syringe turnover?Shorter injection careers?Shorter injection careers?

►►BTH specific:BTH specific:ddGreater acidity?Greater acidity?

Strong Correlation between BTH and Strong Correlation between BTH and L HIV P lL HIV P lLower HIV PrevalenceLower HIV Prevalence

►► Bivariate regression analysisBivariate regression analysis►► Bivariate regression analysisBivariate regression analysisThe percentage of BTH samples in all DEA samples explained The percentage of BTH samples in all DEA samples explained 7575% of the variance in the natural log of IDU/MSM HIV % of the variance in the natural log of IDU/MSM HIV prevalence by cityprevalence by cityprevalence by city. prevalence by city. The ratio was used to control for MSM HIV prevalenceThe ratio was used to control for MSM HIV prevalence

Botulism in CaliforniaBotulism in California 19511951––9898Botulism in California, Botulism in California, 19511951––9898

BTH has market dominance (BTH has market dominance (9595%) %) BTH has market dominance (BTH has market dominance (9595%) %) in California since in California since 19931993

Werner SB et al. CID 2000;31:1018-24.

Ch i i k iCh i i k i 33Changes in Risk Environment: Part Changes in Risk Environment: Part 33

►►Heroin Type (Source):Heroin Type (Source):Bl k T H i i lBl k T H i i lBlack Tar Heroin use appears inversely Black Tar Heroin use appears inversely correlated to HIV correlated to HIV The trouble with Tar:The trouble with Tar:►►Abscess and other bacterial infectionsAbscess and other bacterial infections

ConclusionConclusionConclusionConclusion

►►Paradox of interdiction & “war on drugs:”Paradox of interdiction & “war on drugs:”F til t t fl i f l b li ti dF til t t fl i f l b li ti dFutile to stop flow in era of globalization and Futile to stop flow in era of globalization and neoliberal economic policiesneoliberal economic policiesColombia successfully marketed a new drug Colombia successfully marketed a new drug ––heroin heroin –– in the US during the in the US during the 19901990’s’sDramatic upswing in heroin qualityDramatic upswing in heroin quality►►AND MEDICAL CONSEQUENCESAND MEDICAL CONSEQUENCESQQ

Worldwide supply exceeding demandWorldwide supply exceeding demand►►“Back flush” of export quality heroin seen in“Back flush” of export quality heroin seen in►► Back flush of export quality heroin seen in Back flush of export quality heroin seen in

producing regionsproducing regions

ConclusionConclusionConclusionConclusion

►►Structural factors in the risk environment of Structural factors in the risk environment of heroin users:heroin users:heroin users:heroin users:

Source: dictates distributionSource: dictates distributionType: predicts practiceType: predicts practice

►►Risk is therefore distributed geographicallyRisk is therefore distributed geographically►►Risk is therefore distributed geographicallyRisk is therefore distributed geographically

Di iDi iDiscussionDiscussion

►►Structural problems >> structural solutionsStructural problems >> structural solutionsO d iO d i►►Overdose preventionOverdose prevention

Naloxone distributionNaloxone distributionSafe injection facilitiesSafe injection facilities

Overdose PreventionOverdose PreventionOverdose PreventionOverdose Prevention

A k l d tA k l d tAcknowledgementsAcknowledgements

Alli Kraus Alli Kraus –– research assistantresearch assistantJay Unick, PhD, UCSFJay Unick, PhD, UCSFPhilippe Bourgois PhD U PennPhilippe Bourgois PhD U PennPhilippe Bourgois, PhD, U PennPhilippe Bourgois, PhD, U PennJeff Schonberg Jeff Schonberg –– PhotographerPhotographergg g pg pUS Drug Enforcement AdministrationUS Drug Enforcement AdministrationNIH/NIDA funding: KNIH/NIDA funding: K2323DADA1616516165

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M th d D t SM th d D t SMethods: Data SourcesMethods: Data Sources

►►Heroin data Heroin data U S Drug Enforcement Administration (DEA)U S Drug Enforcement Administration (DEA)U.S. Drug Enforcement Administration (DEA), U.S. Drug Enforcement Administration (DEA), Domestic Monitoring Program (DMP)Domestic Monitoring Program (DMP)►►19901990 20022002►►19901990--20022002►►19 19 US citiesUS cities

St t ( t il) l f h i NSt t ( t il) l f h i N 48034803►►Street (retail) samples of heroin, N= Street (retail) samples of heroin, N= 48034803DEA lab analyzed for heroin purity DEA lab analyzed for heroin purity Chemical “signature” of source countryChemical “signature” of source countryChemical signature of source countryChemical signature of source countryRetail price recorded; standardized for price/mg pure heroinRetail price recorded; standardized for price/mg pure heroin

M th d D t SM th d D t SMethods: Data SourcesMethods: Data Sources

►►Medical examiner dataMedical examiner dataD Ab W i N t k (DAWN)D Ab W i N t k (DAWN)Drug Abuse Warning Network (DAWN)Drug Abuse Warning Network (DAWN)All reported drugAll reported drug--induced deathsinduced deathsHeroin/morphine documented by lab testingHeroin/morphine documented by lab testing►►Includes heroinIncludes heroin--related deaths with multiple causes; related deaths with multiple causes; p ;p ;

multiple drugsmultiple drugs►►Excludes: HIV/AIDS, violent deathsExcludes: HIV/AIDS, violent deaths

M th d A l iM th d A l iMethods: AnalysisMethods: Analysis

►►Collapsed all data in a given year and in a Collapsed all data in a given year and in a given Metropolitan Statistical Area (MSA)given Metropolitan Statistical Area (MSA)given Metropolitan Statistical Area (MSA).given Metropolitan Statistical Area (MSA).

19 19 MSAsMSAsYears Years 19901990--20022002

►►Used bootstrap resampling to account forUsed bootstrap resampling to account for►►Used bootstrap resampling to account for Used bootstrap resampling to account for skewed OD data and random effects to skewed OD data and random effects to account for clustering within MSAaccount for clustering within MSAaccount for clustering within MSA.account for clustering within MSA.