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International Journal of Drug Policy 25 (2014) 257–266

Contents lists available at ScienceDirect

International Journal of Drug Policy

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o

esearch paper

Every ‘Never’ I Ever Said Came True”: Transitions from opioid pills to eroin injecting

arah G. Mars a,∗, Philippe Bourgois b, George Karandinos c, ernando Montero d, Daniel Ciccarone a

University of California, San Francisco, United States University of Pennsylvania, United States Harvard Medical School, United States Columbia University, United States

r t i c l e i n f o

rticle history: eceived 6 March 2013 eceived in revised form 2 October 2013 ccepted 8 October 2013

eywords: eroin

njection drug use on-injection drug use rug transitions oung people pioid analgesics

Gateway’ hypothesis

a b s t r a c t

This qualitative study documents the pathways to injecting heroin by users in Philadelphia and San Francisco before and during a pharmaceutical opioid pill epidemic. Data was collected through in-depth, semi-structured interviews (conducted between 2010 and 2012) that were, conducted against a back- ground of longer-term participant-observation, ethnographic studies of street-based drug users and dealers in Philadelphia (2007–12) and San Francisco (1994–2007, 2012). Philadelphia and San Francisco were selected for their contrasting political economies, immigration patterns and source type of heroin. In Philadelphia the ethnographers found heroin injectors, usually white users, who had started their opiate using careers with prescription opioids rather than transitioning from other drugs. In both Philadelphia and San Francisco, most of the young heroin injectors interviewed began, their drug-use trajectories with opioid pills – usually Percocet (oxycodone and acetaminophen), generic short acting oxycodone or, OxyContin (long-acting oxycodone) – before transitioning to heroin, usually by nasal inhalation (sniff- ing) or smoking at first, followed by injecting. While most of the Philadelphia users were born in the city or its suburbs and had started using both opioid pills and heroin there, many of the San Francisco users had initiated their pill and sometimes heroin use elsewhere and had migrated to the city from around the country. Nevertheless, patterns of transition of younger injectors were similar in both cities suggesting an evolving national pattern. In contrast, older users in both Philadelphia and San Francisco were more likely to have graduated to heroin injection from non-opiate drugs such as cannabis, metham- phetamine and cocaine. Pharmaceutical opioid initiates typically reported switching to heroin for reasons of cost and ease-of-access to supply after becoming physically and emotionally dependent on opioid pills. Many expressed surprise and dismay at their progression to sniffing and subsequently to inject- ing heroin. Historically and structurally these users found themselves caught at the intersection of two

major developments in the opiate supply: (1) an over 500% increase in opiate pill prescription from 1997 to 2005 resulting in easy access to diverted supplies of less stigmatized opiates than heroin and (2) a heroin supply glut, following the US entry of Colombian-sourced, heroin in the early 1990s, that decreased cost and increased purity at the retail level. A nationwide up-cycle of heroin use may be occurring among young inner city, suburban and rural youth fueled by widespread prescription opioid pill use.

© 2013 Elsevier B.V. All rights reserved.

ackground

Historians and social scientists have long pondered the extent o which individuals choose their own paths or are acted upon y wider forces. The entrée of Colombian-sourced heroin into

∗ Corresponding author. Tel.: +1 4154205667. E-mail address: [email protected] (S.G. Mars).

955-3959/$ – see front matter © 2013 Elsevier B.V. All rights reserved. ttp://dx.doi.org/10.1016/j.drugpo.2013.10.004

the eastern US heroin market in the 1990s led to a rise in purity and fall in prices nationwide followed by a leveling out of prices in the early 2000s (Ciccarone, Kraus, & Unick, 2009a; Rosenblum, Unick, & Ciccarone, 2013). As well as offering cheap- ness and potency, Colombian heroin was inserted into the existing

crack cocaine distribution network which allowed it to reach a new population of users (Agar & Reisinger, 2001). Over the same time frame, an enormous increase in the prescription of opioid analgesics formed a second major source in the opiate

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upply.1 Opioid pill prescribing grew 533% from 1997 to 2005 ith hydrocodone becoming the leading prescribed medication

nd oxycodone the top retailed opioid by weight in the United tates (Manchikanti, 2007). In 2009 an estimated 201.9 million pioid prescriptions were dispensed (Volkow, McLellan, & Cotto, 011).

The case of the brand name extended release formulation of xycodone is particularly noteworthy. OxyContin was federally pproved in 1995 at a time when prescribing opioids for the relief f chronic pain was becoming more acceptable within US medical ractice and tolerated by regulatory bodies. Manufacturer Pur- ue Pharma aggressively promoted its product as less likely to be bused or cause dependence than other opioid analgesics, spend- ng $200 million on marketing in one year alone, including the argeting of primary care physicians who were less likely to be rained in pain management or addiction (Van Zee, 2009). Purdue’s ctivities aroused concern from the US Drug Enforcement Admin- stration (US DEA) (United States General Accounting Office, 2003) nd in a 2007 court case the company pleaded guilty to falsely isrepresenting the addictive qualities of the drug compared with

ther pain medications (Webster, 2012). OxyContin’s sales contin- ed to rise, however, and by 2010 it ranked 5th in all brand-name S retail drug sales and number one in brand-name controlled rugs, earning $3.5 billion that year (Mack, Weinrich, Vitaku, & jardarson, 2010). Ultimately Purdue Pharma reconstituted its xtended release oxycodone tablets to prevent them from being hewed or crushed for sniffing, smoking or injecting, techniques sed to circumvent their time-release action. The new ‘OP’ marked ablets replaced the ‘OC’ marked originals in late 2010–2011 and his change may have encouraged some OxyContin dependent users o switch to heroin (Cicero, Ellis, & Surratt, 2012). The OP formula- ion effectively extended patent protection for Oxycontin, ensuring urdue’s monopoly as no extended release generic can be currently pproved based on the original patent approval (Meier, 2013).

Since prescription opioids are close pharmaceutical relatives of eroin – a prohibited yet highly sought-after commodity – it is nsurprising that around the prescribed supply lies a large shadow

and of borrowed, bought, fraudulently obtained and stolen pills. iversion of these pharmaceuticals from their sanctioned channels ccurs in many forms at every stage of the supply chain through- ut North America (Roy, Arruda, & Bourgois 2011) and ‘nonmedical se’ climbed alongside sales.

The incidence rate for nonmedical use of pain relievers stayed elatively low and stable for 12–25 year olds from 1979 to the arly 1990s. Around 1994, the rates rose to approximately 12–13 er 1000 persons for this age group and then sharply thereafter to early 50 per 1000 among 12–17 year olds and to over 30 per 1000

or 18–25 year olds in 2001 (CEWG, 2004) From 2002 to 2004 use pread westwards across the nation from initial high concentra- ions in the Northeast and Appalachia (Cicero, Inciardi, & Munoz, 005) It has been found to be highest in populations outside of

arge metropolitan areas (Cicero et al., 2005) and to be more com- on among men than women (SAMHDA, 2012). Extended release

xycodone was estimated to have had the highest rate of nonmed- cal use among opioid analgesics when accounting for the number f people filling prescriptions (Cicero, Surratt, Inciardi, & Munoz,

007). Treatment admissions for oxycodone misuse rose in both hiladelphia and the San Francisco area between 2009 and 2011 CEWG, 2011, 2012).

1 ‘Opiate’ refers here to drugs extracted from the opium poppy, such as morphine r codeine, or derived from one of these, such as heroin, as well as similar synthetic ubstances which bind with opiate receptors. ‘Opioid’ is a subset of ‘opiates’, used ere to denote the more synthetic and semi-synthetic substances such as oxycodone, ydrocodone and methadone but excluding heroin.

f Drug Policy 25 (2014) 257–266

From 1997, opioid related overdose hospitalizations began to climb geometrically nationwide, with rates rising from 2 per 100,000 US population that year to 15 per 100,000 in 2009 (Unick, Rosenblum, Mars, & Ciccarone, 2013) and concerns have been raised about an intertwining relationship between this epi- demic in prescription opioid overdose and an incipient nationwide heroin-related overdose trend especially among 20–34 year olds (Unick et al., 2013). Early reports from local drug monitoring systems around the country have reported a pathway between prescription opioid use and heroin (Clark & Elliott, 2001; Ohio Substance Abuse Monitoring Network, 2002; Siegal et al., 2003; U.S. Department of Justice, 2001). Regional studies have sug- gested that some prescription opioid users are transitioning to heroin after becoming dependent on OxyContin (Daniulaityte, Carlson, & Kenne, 2006) and other prescription opioid pill s which serve as a ‘gateway’ to heroin (Inciardi, Surratt, Cicero, & Beard, 2009) and/or to injecting (Lankenau et al., 2012; Young & Havens, 2011). However, there is a lack of scholarly publications that examine these transitions in greater detail (Lankenau et al., 2012).

Many studies have examined how people become involved in heroin use. The large literature on the ‘gateway hypothesis’ cites tobacco, alcohol and cannabis as the first drugs typically used prior to progression to harder drugs, either singly or sequentially, but does not prove a causal link (e.g. Fergusson, Boden, & Horwood, 2005; Kandel, 2002). Transition to injecting drug use has been asso- ciated with having a family member who uses drugs or drinks alcohol problematically, stressful family situations, earlier expo- sure to other injectors, and having friends who think it is acceptable to inject (Sherman, Smith, Laney, & Strathdee, 2002).

The purpose of this qualitative study was to understand the process by which heroin injectors in two contrasting cities had ini- tiated heroin use and injecting prior to and during a pharmaceutical opioid pill epidemic. Philadelphia and San Francisco were chosen for their distinct political economies and contrasting heroin sup- plies. Philadelphia is highly segregated and the poorest large city in the United States, losing population to outmigration every year from 1959 to 2010 and containing large tracts of de-industrialized, abandoned buildings. San Francisco is a more integrated, global city that attracts immigrants and has been undergoing a long process of gentrification. Philadelphia is primarily supplied with white/beige powder heroin sourced from Colombia while San Francisco mainly receives “black tar” heroin originating in Mexico; each heroin source-form has unique chemical properties, use patterns and medical consequences (Ciccarone and Bourgois, 2003; Ciccarone, 2009b).

Methods

This investigation arose from the Heroin Price and Purity Out- comes study (HPPO) (PI: Ciccarone) funded by the US National Institutes of Health, National Institute of Drug Abuse (NIH/NIDA) which aims to place local understandings of heroin injectors’ drug use, beliefs, behavior and health within a regional and national US structural context. In the two contrasting cities of Philadelphia and San Francisco it uses ethnography and qualitative interview- ing which are then set against a wider picture derived from national epidemiological datasets. The ethnographic project in Philadelphia (2007–2012) and San Francisco (1994–2007, 2012) (Bourgois & Hart, 2011; Bourgois et al., 2006; Bourgois, Prince, & Moss, 2004) provided a privileged insertion into networks of users and gener-

ated the preliminary guiding hypothesis of this interview-based study concerning the changing demography and drug-use trajec- tory of the contemporary heroin-using population. It informed the preparation of the interview guide and the recruitment priorities

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S.G. Mars et al. / International Jou

nd sites. The ethnographic methodology is discussed in further etail in the book Righteous Dopefiend (Bourgois & Schonberg, 009). Some ethnographic observations are provided here as a con- extual backdrop but were not all pursued in the interviews.

For the interviews a targeted sampling strategy was used, largely nformed by the ethnographic work, with purposive recruitment nd some snowballing; sampling techniques often used to access idden populations (Barendregt, van der Poel, & van de Mheen, 005). To be eligible for the study interviewees had to be at least 8 years old and self-reported current heroin injectors living in ither San Francisco or Philadelphia. Interviewees were recruited n areas of known open drug markets in both cities and through nee- le exchanges. Particular effort was made to recruit women given hat they are less prevalent among this population and to balance ampling of longer-term users (more than 3 years’ use) with more ecent users (up to 3 years’ use). Respondents were offered small ash sums of $15–20 per interview, or for taking the researchers on

‘tour’ of the local heroin scene, to compensate for their time. All articipants were interviewed once in 2012.

Consistent with participant-observation techniques, the semi- tructured interviews were conducted by the ethnographers (FM, K and PB) and PI (DC) at the moment of recruitment in the atural environment of the users. Interviews, for example, were onducted near syringe exchanges, in shooting galleries, parks, on orners where users purchase drugs, in cars on the way to and rom purchasing drugs, and in transiently occupied apartments. his anthropologically informed qualitative strategy reduced social esirability bias. Interviews usually lasted 1–1.5 h each. Although he interviews were open-ended, an interview guide was used hich included questions on the respondent’s involvement in drug se, their initiation into opiates and injecting, experience of obtain-

ng drugs, methods of administration, history of drug-related health vents and contact with clinical services and criminal justice. At the nd of the interviews participants were asked if they wanted infor- ation on treatment options and needle exchange. Some shorter

nterviews were conducted towards the end of the research, once he patterns of pills-to-heroin had emerged so starkly from the ata, focusing on heroin initiation experiences and any relation- hip with opioid pills. Recruitment of new interviewees ceased after saturation’ was reached determined by new subjects consistently roviding redundant information. All the interviews were audio ecorded and transcribed verbatim. Transcriptions were verified gainst the audio recordings for accuracy.

Twenty-two current heroin injectors were interviewed in hiladelphia and 19 in San Francisco. NVivo software was used o assist with data organization and retrieval (QSR International, 012). Hypotheses generated from the ethnography were tested

n the interviews and were revised iteratively as the interviews nd coding progressed. The first author (SGM) carried out all of the oding which was reviewed by the senior author (DC). ‘Open cod- ng’, described by Strauss and Corbin, was carried out to identify oncepts and categories and systematically apply them through- ut the transcripts (Strauss & Corbin, 1990). The study protocol as approved by UCSF and University of Pennsylvania IRBs and the ata (and its collection) are protected by two Federal Certificates f Confidentiality issued by NIH/NIDA.

esults

arly ethnographic observations

The ethnographers in Philadelphia witnessed an influx of young eroin users, generally from nearby poor white working class eighborhoods and declining suburbs, but also from more afflu- nt areas. They and the PI were alerted to the opioid pills-to-heroin

f Drug Policy 25 (2014) 257–266 259

transition phenomenon on a tour of outdoor shooting galleries in Philadelphia on September 29, 2011. The following is an excerpt from their fieldnote:

On the way back, two middle-aged white running partners approach us and strike up a conversation about what we are doing. When we explain that we are conducting public health research on heroin use one of the men begins telling us, exas- perated that he only started using when he was 44 years old. I think he says he is 52 now. The two of them launch into an angry tirade blaming doctors for getting people hooked on opiates and then cutting off their patients forcing them into injecting heroin. They both say they were first prescribed pills before eventually turning to heroin. The skinnier man is more vehement in his crit- icism of doctor’s liberal prescription of opiates while the other man says that his experience was that he turned to heroin once he was cut off from Oxycontin.2

This encounter stimulated the inclusion of interview questions about previous experience with opioid pills. Subsequently the ethnographers met younger users who had transitioned to heroin from prescribed and diverted pills. We term this use of opioids ‘extra-medical use’ rather than ‘non-medical use’ as it includes unsupervised self-medication for pain relief as well as use for hedo- nistic purposes and for the relief of withdrawal symptoms.

In Philadelphia, the ethnographers noted a racialized demo- graphic transition pattern in which whites of all ages and older African Americans traveled every day into the Puerto Rican neigh- borhood to purchase heroin. This regular migration pattern was unambiguous and dramatically visible because of the city’s clearly delineated neighborhood segregation. Despite seeking exceptions to this demographic pattern, the ethnographers were only able to locate a few young African American or Latino heroin injectors and they were all outcasts from their ethnic social networks and neighborhoods whereas older African American and Latino injec- tors were numerous and lived in segregated ethnic neighborhoods. These ethnic differences cannot be explained by access to heroin: most of the heroin sellers in the ethnographic sample in Philadel- phia were young African Americans or Latinos (almost all Puerto Rican) and most consumed opioid pills either recreationally or chronically. Only a handful of these pill users transitioned to heroin or injection and those who did represented distinct exceptions. The few young Puerto Ricans who transitioned to injection were sub- ject to physical and verbal abuse and shaming from neighbors and friends. One Puerto Rican neighbor of the primary ethnographers in Philadelphia, for example, was chased out of the neighborhood when he suddenly openly transitioned from pill consumption to heroin injection.

The San Francisco neighborhoods frequented by heroin injec- tors were more subject to gentrification and more ethnically diverse than those of Philadelphia. There was a large pres- ence of older African American heroin injectors in the longer term ethnographic study whose first opiate experience was heroin and they were fully integrated into their ethnic social networks that often proudly or aggressively differentiated them- selves from other ethnicities. The few young injectors sampled in San Francisco who were African American maintained almost

2 The use of brand names to refer to prescription opioids in this paper reflects the interviewees’ descriptors rather than any preference of the authors. The drug with the street name “Perc 30” is not in fact Percocet (short acting oxycodone and acetaminophen) but refers to short acting oxycodone products eg Roxycodone.

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ymbols). Similarly the young Latino injectors in San Francisco’s ong-term ethnographic samples either adopted a white ethnic elf-representation or only incidentally referred to one of their arents being of Latino origin. We did not focus on ethnicity or ocio-economic status in the interview questions given that these emographic questions are more suited to exploration using survey ethods.

haracteristics of the interview study participants

Among the Philadelphia sample, 8 were women and 14 were en. Sixteen had used for more than 3 years and 6 for 3 years

r less. In the San Francisco sample, 12 were women and 7 were en, among whom 15 had used for more than 3 years and 4 for 3

ears or less. Most were unemployed and either homeless or inse- urely housed. Some had completed high school but few had any ollege education. In Philadelphia, users commonly participated in he peripheral economy around drug markets selling syringes or howing users from outside the neighborhood where to buy high uality heroin. In San Francisco, several users sold cannabis to sup- ort themselves. Other sources of income across the cities included orking in construction, benefits and sex work. The Philadelphia

njectors had almost all grown up in and around that city and begun heir drug using careers there, while many (14 out of 19) of the San rancisco users were migrants from around the country.

ge differences and heroin initiation

The interview study found a stark contrast in the patterns of eroin initiation between younger (aged 20–29) and older (aged 0 and over) heroin injectors on both coasts. In Philadelphia, all 0 and in San Francisco 8 of the 9 younger heroin injectors had rogressed to heroin from opioid pills, termed here ‘pill initiates’. ll the younger users in Philadelphia and San Francisco (n = 19) had tarted using heroin within the last 10 years, with a mean of age of 5 years and 4.4 mean years using heroin.

Across the two cities there were 10 ‘recent’ users, defined as sing heroin for up to 3 years, with nine of them transitioning to eroin from opioid pill dependency. With the exception of the one ecent user who had progressed straight to heroin without using ills first, all the recent users were under 30 years old and pill ini- iates. The initiation of younger users into heroin through opioid ills coincided with the past decade and a half of high levels of opi- id pill prescribing; among younger pill initiates in both cities, the ean year of initiating opioid pill use was 2005 and the mean year

f starting heroin use was 2008. Older users primarily transitioned o heroin from other drugs such as cannabis, cocaine or metham- hetamine before the profusion of opioid pills in medicine cabinets nd on the streets. These straight-to-heroin users are termed here

heroin initiates’. When discussing pills used before their heroin nitiation, a few older users reported taking barbiturates or speed ut only one had used an opioid pill (Dilaudid – hydromorphone), nd on a single occasion. Only one pill initiate had injected any drug efore heroin (Dilaudid) but four of the heroin initiates were already

njectors (methamphetamine or cocaine) when they started heroin. he heroin initiates had often used opioid pills in an opportunistic ashion but only after they had started heroin injection.

In Philadelphia, 14 of the 22 participants were pill initiates with mean age of 31 and 7 mean years’ use. Among the eight heroin nitiates, the mean age was 44 and their mean years’ use was 23. n San Francisco, 11 of the 19 heroin injectors were pill initiates,

ith a mean age of 29 and mean years’ use of 5.8. The eight heroin

nitiates had a mean age of 50 years and their mean years’ use was 0.

We also found an interesting division between patterns of pill se among older and younger pill initiates prior to heroin. While

f Drug Policy 25 (2014) 257–266

almost all of the younger pill initiates described transitioning to heroin after becoming dependent on (usually diverted) opioids, most of the older pill initiates had either developed a dependence on opioids prescribed to them for injury/pain, like the two users encountered in the ethnographic segment above, or they had used opioid pills only occasionally prior to heroin without reporting dependence. All of these older pill initiates were longer-term heroin injectors and were not part of the widespread social initiation into frequent opioid use characteristic of the younger generation pill initiates.

In the twentieth century the use of pills of various kinds, including barbiturates, benzodiazepines or amphetamines, prior to initiating heroin was not unusual (Kandel, 2002). The key difference in this study’s finding is that virtually all of the young/recent heroin injectors in our sample considered themselves already opiate- dependent before they initiated heroin injection. While our sample is small and not representative, the numbers are striking nonethe- less.

Prescription opioid pill sources and distribution

A few users, both heroin and pill initiates, had been prescribed opioid pills for pain relief, usually short-acting oxycodone with acetaminophen (e.g. Percocet) or extended release oxycodone, at least initially, until their physically required or emotionally desired use outpaced their prescribed supply. The rest reported most of the same pill sources described in national survey data, with the excep- tion of the rarer method of buying on the internet (SAMHSA, 2012): some received them (given or sold) from a friend or relative (both with and without prescriptions) and others took them without ask- ing from friends or relatives; some bought them on the street or at bars from acquaintances and small scale suppliers.

Several users referred to purchasing pills from larger scale sup- pliers who engaged in “doctor-shopping” and one user had actively doctor-shopped himself. This 25 year old man had started his heroin use as a teenager and, unusually for this age group, was a heroin initiate but started injecting pills afterwards. He described the process of obtaining pills in Florida, a state well-known for its easy access to opioid analgesics, for both personal use and income generation (Vanguard, 2009):

[. . .] I used to go to Florida and go to the pain clinics you know and go to like 4 different clinics with the same MRI [Magnetic Resonance Imaging scan] of 5 other people and we’d come back to [his home state] with like 10,000 pills and cut them in half you know. Like a lot of people were doing it you know it was really easy for a long time.

Significantly, however, he also mentioned that he kept a sup- ply of heroin to offer clients in case he could not obtain pills for them, remarking “that’s actually how I’ve gotten a lot of people acci- dentally hooked on heroin.” Similarly, many interviewees reported that their street pill supplier usually also offered them heroin – an entrepreneurial merging of the opiate supply that facilitated the transition from pill use to heroin. This 51 year old man in Philadel- phia was originally prescribed Percocet for a knee injury and despite initially resolving not to use heroin had started 5–6 years earlier:

. . .I guess like a lot of people, you start on the pills, and then the doctor gives you some and some more [. . .] I took what he gave me, plus whatever – buy[ing more] on the street, and at

some point in time, just the pills aren’t doin’ it, and they’re a little harder to find. [. . .] Every morning we would go to the one place and they had both things [heroin and pills] but [. . .] they never were out of heroin, but once in a while – well, three

S.G. Mars et al. / International Journal of Drug Policy 25 (2014) 257–266 261

Table 1 US price and purity of heroin, 2000–2008.

Price per gram retailed (USD) Price per gram pure (USD) Heroin purity as % by volume

San Francisco Philadelphia San Francisco Philadelphia San Francisco Philadelphia

2000 114.91 294.62 603.02 399.61 19.05 73 2005 87.05 269.37 755.41 503.04 11.58 53.55

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2008 89.82 261.03 1058.12

ource: Drug Enforcement Administration System to Retrieve Information from Dru

times a week probably, they didn’t have the pills. So I’d have to scramble around, and then I finally had enough and said “Fuck. The hell with this, give me a bag [of heroin]!” and was off to the races.

ontrasting cities and drug markets

Ethnographic findings showed very different drug markets cross the two cities. Philadelphia’s drug market, where cocaine, eroin, pills and syringes could be bought, was out in the open on treet corners or in abandoned buildings (often disused factories) nd located in racially hyper-segregated Puerto Rican and African- merican areas. San Francisco’s high value real estate has shaped a ifferent dynamic. A fieldnote from June 2012 describes an area of an Francisco formerly known for its open drug dealing.

The streets are lively with bar goers drinking in bars that are far hipper, shinier and more in-your-face than the drinking holes of the past. And of course the patrons are whiter and seemingly more affluent. The drug scene is subdued and we see or hear only a bit of dealing. We are offered a variety of pills while working, especially in [San Francisco neighbor- hood]: roxys (Roxycodone/short acting oxycodone), OPs (new OxyContin formula), Vicodin (hydrocodone and acetaminophen), Suboxone (buprenorphine and naloxone) . . ..Gentrification has forced down the number of heroin users and also forced the heroin out of SF. We hear repeatedly that Oakland is the only good place to score dope [heroin] these days.

This observation regarding the quality of heroin in San Francisco as confirmed in the interviews and by data from the US DEA’s

TRIDE database, which showed that over the first decade of he twenty-first century, the purity of San Francisco’s black tar eroin has been low and the price high, especially in comparison ith Philadelphia’s Colombian-sourced powder (Table 1). (STRIDE

ncludes data from undercover purchases and seizures). Opioid pills ere found to be much more readily available in San Francisco’s iminished open-air drug market than heroin, with correspond-

ngly low prices. The 80 mg oxycodone was available for $20 $0.25 mg–1). In Philadelphia, it was usually priced at $1 per mg. his made it much more cost-effective to buy Colombian heroin n Philadelphia, with a mean street-price of $0.56 per mg-pure Ciccarone et al., 2009a), particularly considering that the par- nteral equianalgesic dose of heroin is 1/2 to 1/3 that of oxycodone.

San Francisco attracts a higher proportion of its population from cross the US than does Philadelphia (2010 American Community urvey). While most of the Philadelphia users were born in the city r its suburbs and had started using both opioid pills and heroin here, many of the San Francisco users had initiated their pill and ometimes heroin use elsewhere and had migrated to the city from round the country (8 of 11 pill initiates and 4 of 8 heroin initiates). ost of the pill initiates (6 out of 8) and heroin initiates (4 out

f 6) who had moved to San Francisco were already using heroin hen they arrived. Among San Francisco natives, most of the pill

nitiates (2 of 3) and both heroin initiates had started heroin in an Francisco.

435.41 8.49 59.95

dence (STRIDE).

A wide variety of reasons for migrating to San Francisco were given, some drug-related and others not. Significantly, however, none of these migrants mentioned the quality of its heroin as a pos- itive draw. In fact one 26 year old pill initiate who had quit heroin use before moving to the San Francisco had hoped to maintain absti- nence: “when I got out here [I] stayed off of it for a good 3 years and then after I found out where to get good heroin again out here I started doing it again.” Another 26 year old San Francisco migrant and pill initiate, who had been using for 7 years, thought that she would be able to avoid using heroin in San Francisco because of its low quality. She did so for 2 years until she found a contact who was able to supply her with a much higher priced, higher purity white powder heroin unavailable in the open street market.

The contrasting heroin distribution mechanisms, quality and price in San Francisco and Philadelphia may have influenced the likelihood of transition from opioid pills to heroin in each city and relapse among former heroin users. In Philadelphia, with its open drug market, it was easy even for those without contacts among existing users or dealers to obtain high potency and relatively inex- pensive heroin. In San Francisco, however, buying higher quality heroin required greater local knowledge and a trip to the nearby city of Oakland or a connection to a dealer who would deliver.

Progression from pills: crossing thresholds

The typical progression for pill initiates began with chewing pills or crushing them to a powder and sniffing or smoking them. This was often followed by sniffing or smoking heroin and then by injecting it. For most pill initiates, heroin was their first expe- rience of injecting any drug and those who injected the crushed pills only did so after they had already started injecting heroin. Their accounts, which involved crossing thresholds of stigmatized behavior at each stage, attributed this progression to their growing dependence and tolerance, the rising cost of their pill habit coupled with their need to avoid withdrawal symptoms and heroin’s easy availability and comparatively lower cost. Depending on local mar- kets, interviewees and published sources have reported pill prices varying considerably across the country (e.g. Poitras, 2012).

This account of a transition to heroin after four months using OxyContin is from a 28-year old Philadelphia man who had been injecting heroin for 5 years at interview. It typifies many of the younger heroin injectors’ experiences:

A: My buddy [. . .], the one that introduced me to Oxies was actually doing dope [heroin] at the time. And I came over his house and I was sick [in withdrawal] and I asked him if he could get me an Oxy for ten bucks, which I needed an 80 [mg], which they were [$]20 and I only had [$]10. So he basically convinced me and started talking about how Oxies and dope there is no difference.

Q: So is that the first time you’d heard that, that there’s no difference between Oxies and dope?

A:[. . .] No it wasn’t the first time I heard that you know[. . .]

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Q: Did you ever think you were going to become a heroin user?

A: No, I didn’t[. . .] My father is in recovery, he’s been sober for like 6 years and he was a heroin user so I swore that I would never touch it because of like him you know but obviously I did.

Older heroin initiates typically described their first use as a social rocess, offered by a friend, sexual partner or family member, some entioning curiosity as their motive and a few seeking to ‘come

own’ from stimulant use. Only one interviewee, a heroin initiate, eported seeking out the drug without knowing any other heroin sers. More typically, this 56 year old female heroin initiate had een injecting heroin for several decades after transitioning from lcohol, cannabis and crack cocaine:

Q: Okay. So how did you get started; what happened?

A: I was always a curious person. I always hung around grown people, you know, at 14 I was hanging with my first boyfriend [. . .] So I started going to clubs and stuff like that and the people I hung around did it so I was just curious [. . .]

Pill initiates’ introduction to opiates was facilitated by the lesser tigma and perceived lower risk of opioid pills and many give the mpression that they would never have considered trying heroin ad they not first become dependent on these pills. Despite the

act that many of the pill initiates were aware of the chemical imilarity of opioids and heroin, they perceived pills to be more cceptable and safer than heroin, consistent with the existing lit- rature on non-dependent pill consumers (Daniulaityte, Falck, & arlson, 2012). A 25 year old man, who had injected heroin for 7–8 ears in Philadelphia explained:

[. . .] there was always people in my neighborhood like the older guys who already did heroin. I was that type that said, “I’ll never do Oxies”. I was the type that said “I’ll never” and every “never” I ever said came true. “I’ll never shoot heroin” and you know so yeah the older guys were already doing heroin and I was like, “Dude no way, I’d rather eat a pill.”

Some research studies have shown that drug users with vary- ng degrees of experience with illicit drugs perceive Percocets nd Vicodin to be much less dangerous than OxyContin, which in urn they considered less dangerous than crack cocaine or heroin Daniulaityte, Carlson, & Kenne, 2007; Daniulaityte et al., 2012). It as common in our study for pill initiates to have used Percocets and

ometimes short-acting oxycodone street-termed ‘Perc 30s’ first nd then to progress to OxyContin. However, this may have simply eflected users’ increasing tolerance rather than different percep- ions of risk, given the fact that these oxycodone formulations are old in different dosages: Percocet in 2.5–10 mg tablets, short-acting xycodone in 5, 15 and 30 mg and OxyContin in 10–80 mg tablets. hile some users, like the 25 year old male quoted directly above,

tigmatized OxyContin, and breaking through that taboo may have ncreased the likelihood of transitioning to heroin, other users did ot mention any greater risks from OxyContin than from Percocet r other less powerful opioids.

Crossing the second threshold from opioid pills to heroin may ave been eased by not having to transition straight to injecting. As

n the post-HIV 1990s (Chitwood, Comerford, & Weatherby, 1998), ome new heroin users reported finding sniffing a more accept- ble transition before they had started injecting. In Philadelphia the

owder heroin can be sniffed and on the West Coast black tar heroin an be smoked on foil (‘chased’) or sniffed from a nasal inhaler bot- le in which it has been dissolved in a small amount of water. A 21

f Drug Policy 25 (2014) 257–266

year old pill initiate interviewed in San Francisco who had switched to heroin use five years earlier when his wholesale supplier of pills, a ‘crooked doctor’, was raided reported that the street prices for opioid pills were unaffordable yet he remained reluctant to initiate injection.

I went to pick up Oxies from one of my connects and he was like, “Oh, I’m out of Oxies but I have black tar.” And at the time I was smoking Oxies. And so I was just like I didn’t want to inject at that time in my life so I was just like, “I don’t want to shoot anything up.” And he was just like, “No, you can smoke them the same way. Just put it on foil and smoke it the same way.” And I was like, “Oh.” I was like, “Well how much can I get for forty bucks?” And he was like, “Half of a gram.” And I was like, “Sure.” And so that lasted me a hell of a lot – that forty bucks went way longer than like if I would have spent it on a pill, which would have lasted me like 25 minutes. It lasted me two days almost.

For most of these pill initiates, by the time they tried heroin there was a sense of physical compulsion and even desperation in their choice. Many of them seemed shocked to have found themselves injecting heroin but for some, even after transitioning to this stage, a new hierarchy of corporeal risk emerged delineated by their pre- ferred location of injection. Most users reported initiating injecting in their arms or legs before resorting to the perceived higher risk or taboo areas of the neck or groin. There was some variation in opin- ions over which injection sites should be avoided. A 28 year old male pill initiate interviewed in San Francisco had been surprised to find himself injecting heroin a year earlier after previously look- ing down on injectors. He described how his addiction continued to drive his risk-taking practices:

[. . .] My neck was kind of one of those places that I kinda thought I never would but I did. I’d say that my femoral [groin] would be another place that I [will avoid] – I mean it’s all a matter of desperation I guess you know when you’re desperate enough and you get to that point.

While users explain their ongoing transitions pragmatically as a response to increasing addiction, tolerance levels and loss of venous access, these decisions take place in changing contexts. As maintenance of their opiate supply becomes an increasing focus of their lives, they may spend more time with other drug users whose norms make otherwise taboo behavior more acceptable, while becoming more isolated from non-drug-using friends and family. One 23 year old female heroin injector in San Francisco explained:

Doing opiates it’s kind of like[. . .] you flock together [her empha- sis] [. . .] I’d been using the OCs [original formulation Oxycontin] not really getting high, just staying not sick, I dunno friends around me have used heroin, it just kinda became a less and less scary and taboo thing.

As Paula Mayock notes, “the type of calculus involved in the making of drug journeys is fluid and relational, socially contingent rather than static” (Mayock, 2005). Not only do the norms change with a changing peer group but once a threshold has been crossed the range of choices look different from the new vantage point.

While some appear to have changed peer group as they pro- gressed, several pill initiates described how friends they had known

before their opiate use had guided them along the same path, using opioids first and then heroin, leading them to new sources and modes of administration as they followed in their wake. Others

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escribed taking this lead role themselves. This 25 year old man in hiladelphia explained:

A: Pretty much 80% of the friends that I grew up with are using [heroin].

Q: So what’s that all about? How’d that happen?

A: Honestly once Oxycontin hit the Northeast [of Philadelphia] it was a wrap, that was it. Once Oxycontins came around and everybody started doing Oxies and then when you’re paying 40 dollars a pill and then you hear you can pay ten dollars for the same effect of course you’re going to do it.

Incarceration and institutional contexts, including substance reatment, provided some users with peer influences encourag- ng their transition to heroin injecting. A 26 year old woman who ad been using heroin in Philadelphia for seven years learnt about eroin while in a rehabilitation facility after becoming dependent n Percocet and OxyContin: “Rehab made me sicker every time. It ave me new connects; new places to find things; new ways to do hings.”

hemical connections

Given the surprise many users expressed about their escalating ddiction and their graduation to heroin, we added questions about heir awareness of the chemical similarity between opioid anal- esics and heroin at the time they began using pills. Many knew that xycodone and other opioids were related to heroin but some did ot. One 21 year old male who had been using heroin for approxi- ately 2 years in Philadelphia described the apparent contradiction

n his knowledge:

Q: Did you realize that all of these things, Percocets and short acting Percocets, 30s, the OxyContins and heroin are also in the same chemical family?

A: I mean at the time you know obviously you know when you’re snorting Perc 30s you’re saying to yourself I’ll never go do Oxy- contin and then you start doing Oxycontin and like I’ll never go do dope and then you’re snorting dope, well I’ll never shoot it. Yeah I mean you know but like in your head it’s just such a differ- ent world. But like I’ll tell you what like after I started shooting dope it’s so different. Like every other drug like it’s such a – it becomes such a lifestyle when you start shooting dope [emphasis added].

One 17 year old male who sold heroin on the Philadelphia treet corner where the two primary ethnographers lived (FM, GK) rgued, while he was high on Percocets, “There is no f–king way that ercocets could be the same thing as dope [heroin]. I know because

use them. . . I mean like maybe Xanies [Xanax, a benzodiazepine] ight be more like dope [heroin]. . . but not Percocets. . . Nah!”

upply-side changes

In 2009 Purdue Pharma gained approval from the Food and Drug dministration for its tamper-resistant formulation of OxyContin

FDA, 2009). Although many of the pill initiates in this study had ransitioned to heroin before the new gel form replaced the old ablets in late 2010/2011, one 29 year old heroin injector explained

ow the change had prompted his switch to injecting.

I was big into Oxycontin at first. . .and I still used heroin a lit- tle bit when OxyContin was crushable, but at that point I only

f Drug Policy 25 (2014) 257–266 263

sniffed, and I only did it when I had problems finding Oxycontin. It wasn’t until the Oxycontin switched from OC to OP, and the non-tamper-proof versions [sic], that I really just went straight to heroin and immediately started shooting it, which I guess was a little over a year ago.

This outcome of the reformulation in shifting users away from pharmaceuticals and into heroin was not quite as unanticipated as assumed by some commentators (e.g. Cicero et al., 2012), at least within the state structures of drug control. The US DEA sent out warnings to various health care organizations at the time of the reformulation, stating that OxyContin users switching to heroin was a potential consequence (ODLL, Drug Enforcement Administration, 2010). Supply-side changes also impacted some OxyContin users when their sources were cut off following the arrest of prescribers, prompting their switch to heroin. In 2011, a new law in Washington State brought in a raft of controls on doctors managing pain patients with opioids, the results of which will be closely watched (Okie, 2010).

Discussion

Although the epidemic of extra-medical opioid use and its links with heroin injecting have been reported, (e.g. OSAM, 2002; U.S. Department of Justice, 2001) there have been very few in- depth studies of the experiences of users transitioning between these drugs, their modes of administration and the contexts in which these developments take place (see Daniulaityte et al., 2006; Lankenau et al., 2012). To our knowledge, this is the first qualitative paper to compare the contexts of initiation into prescription opioid use and transitions to heroin injection across two generations of current heroin injectors in two distinct US cities.

We found a dramatic contrast between paths of initiation among older and younger heroin injectors. Across both cities, younger heroin injectors (aged 20–29) had almost exclusively progressed to heroin from opioid pills while older heroin injectors (30 years and above) typically exemplified the heroin-first trajectory. All of the recent heroin injectors were under thirty and most were pill initiates. The impression that opioid dependence prior to heroin is a social phenomenon particularly affecting young people was strengthened by the differences we found between younger and older pill initiates. Younger pill initiates were more likely to report dependence on diverted opioid pills prior to heroin initiation whereas the smaller group of older pill initiates had either devel- oped dependence on a prescribed supply or had used pills only occasionally prior to heroin without developing a habit. These changes in patterns of initiation reflect important developments in the heroin and opioid pill markets since the late twentieth century.

Pill initiates’ typical pathway of chewing or snorting pharma- ceuticals first, followed by non-injecting heroin use and then heroin injecting corresponded with findings from a sample of extra- medical opioid users in Ohio. Likewise, none of the younger users in this study or Ohio had injected pills before injecting heroin (Daniulaityte et al., 2006). Younger pill initiates who did inject pills started doing so only after initiating injection with heroin when heroin was unavailable. This contrasts with a study of young IDUs in which a number, mainly from Los Angeles, had injected opioids prior to heroin, possibly pointing to variations in different cities’ opiate markets (Lankenau et al., 2012) or local taboos around inject- ing opioid pills. Pill initiates in our study usually reported heroin as being more easily available than opioid pills, a major consideration

in their transitions.

Reflecting wider migration patterns, many of the San Francisco heroin injectors had moved to the city from across the country or state, often initiating opioid and heroin use before their arrival,

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hile most of the East Coast group had been born and raised n or around Philadelphia. Philadelphia’s high potency, low cost olombian heroin was therefore more significant in pill initiates’ ransition from opioids to heroin than the low quality, higher priced eroin available in San Francisco was to the San Francisco group.

n fact, this paper found suggestions of a protective effect in the ow quality and high price of San Francisco’s black tar heroin, help- ng some recovering heroin users to remain abstinent for several ears. Additionally, black tar heroin has been blamed for causing n epidemic of soft tissue infections (Ciccarone et al., 2001). Spec- latively, users suffering venous sclerosis and soft tissue infections ay end their injection careers earlier. This possible protective effect related not only to the price and

uality of the heroin available in San Francisco but the ease of ccess through which users could obtain a desirable product. Rapid entrification of former drug dealing areas has constricted San rancisco’s open street market in heroin, widely acknowledged to upply low quality, high price heroin. San Francisco users required ore savvy local knowledge and networks to locate higher qual-

ty heroin. Philadelphia’s easily accessible street market did not equire such contacts or local knowledge. The potential of these ifferent structures of retail market to affect opiate user’s patterns f initiation, abstinence and relapse are important early findings equiring further inquiry.

Many pill initiates mentioned that their usual suppliers offered hem heroin when they were unable to obtain opioid pills for their riends or customers. Several described their initial reluctance to try eroin, requiring persuasion regarding the equivalence of opioids nd heroin or reassurance that they would not have to inject. Others eported simply giving in to the frustration of trying to maintain or fford a regular pill supply. This entrepreneurial merging of heroin nd opioid supplies by dealers is a novel finding which helps to xplain the process of transition among pill initiates.

This paper posits an unfolding process of transition during hich pill initiates’ perspectives on risk and taboo continued to

hange and initiation into heroin injection was not the end point ut another threshold into a new set of corporeal risks around injec- ion sites. Among these pill initiates there was a pervasive sense f shock and surprise at finding themselves injecting heroin. The otives of curiosity about the effects of heroin and seeking peer

pproval described in the heroin epidemics of past eras (Chitwood t al., 1998; Finestone, 1957; Stephens, 1991; Sutter, 1966) did not ypically describe the experiences of these pill initiates when first onsidering trying heroin. As reported elsewhere, their escalating isk was propelled by increasing dependence and economic consid- rations (Lankenau et al., 2012). These driving forces were the same s those reported by heroin initiates transitioning from sniffing or moking to injecting heroin in this study and elsewhere (Sherman t al., 2002).

Drug users’ perceptions around the relative risks of opioid pills nd other drugs have been studied (Daniulaityte et al., 2007, 2012) ut there is little known about their understanding of the chemical elationship between different forms of prescription and illicit opi- tes. A number of interviewees mentioned that they were aware hat heroin and opioid pills were related or chemically equivalent efore they had transitioned to heroin while others were not. Those ho were aware of the similarity still seemed to consider heroin

he most stigmatized opiate. Further exploration is needed of the mplications for decision-making of different levels of knowledge bout the chemical relationship between opiates.

Data from the ethnographic research suggest that pill initiate eroin injectors are predominantly white in the two cities stud-

ed. Survey data suggest that this is typical of the wider using opulation over the last two decades, with white heroin injectors aking up a larger proportion of those seeking treatment and a

4% decline in African-American heroin injectors seeking treatment

f Drug Policy 25 (2014) 257–266

from 1992 to 2004 (Broz & Ouellet, 2008). This pattern has also been found in regional studies, where injecting continued to be the most prevalent mode of administration among young white heroin using arrestees while young African-American and Hispanic arrestees were less likely to use heroin and those who did were more likely to sniff than inject (Golub and Johnson, 2005).

Opioid pill use is more common among whites and Hispan- ics than African-Americans with 4.6% of whites, 4.5% of Hispanics and 3.8% of African-Americans nationally reporting nonmedical use of prescription pain relievers in the previous year (SAMHSA, 2012). Given the frequency with which users reported acquir- ing pills from friends’ or family members’ prescriptions or their own, the higher prevalence of extra-medical use among whites may reflect the greater likelihood of whites to receive patient pre- scriptions for opioid analgesics than African Americans but does not explain the equally high prevalence in the Hispanic popula- tion who are also less likely to receive opioid prescriptions for pain relief (Pletcher, Kertesz, Kohn, & Gonzales, 2008). Golub et al. reported regional ethnic variations in opioid pill use among a national sample of arrestees but unfortunately their data source did not distinguish between legitimately prescribed and diverted opi- oids (Golub, Elliott, & Brownstein, 2013) and may therefore reflect, at least in part, variations in access to healthcare. The relationship between ethnicity and opioid use and transitions to heroin has not been studied in depth and further research is therefore needed to explore the effects of ethnicity, segregation, socio-economic status and geography on those paths taken and not taken.

Our paper is the first to report the US DEA’s warning to health care organizations that an increase in heroin use was a potential consequence of the reformulation of OxyContin; a warning that seems to have been largely ignored. The reformulation occurred after most pill initiates in this study had switched to heroin so its impact on such transitions is not addressed here. However, research on opioid users in treatment has shown a move from OxyContin to heroin following this change (Cicero et al., 2012). The decision- making process around OxyContin’s reformulation and the ensuing public health consequences require further investigation.

Conclusion

From the accounts of younger/recent heroin injectors in this study, it is evident that since the rise of the opioid pill epidemic, the barriers to heroin use and to injection have been reduced by the normalized pervasiveness of these pharmaceuticals. The widespread availability of opioid analgesics outside sanctioned channels and, paradoxically, medical and regulatory attempts to curb this through monitoring and limiting prescribing, appear to be drawing a new generation into higher risk heroin injecting. Unlike those substances previously labeled ‘gateway drugs’, opioid pills seem to have a direct relationship with progression to heroin initi- ation.

It is ironic that heroin, one of the few drugs entirely prohibited under US drug control laws, remains so widely available and rel- atively inexpensive that even those opioid-dependent users who are reluctant at first to try it are ultimately persuaded by market forces when their pill of choice becomes unavailable or unafford- able. These pill initiates for the most part did not seek out heroin, in fact many initially stigmatized heroin, but as they tried to resist each stage of their transitions, their membership of a particular generation and a historical era in specific regions put them at par- ticular risk of transition to opiate dependence and injecting. We do

not know whether the pathways through heroin dependency are the same for those starting on opioid pills as for those who do not, or what influenced those users who exited pill dependency rather than progress to heroin. These questions require further study.

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The importance of the racialized ethnic dynamic in shaping the merging pills-to-heroin-injection epidemic, which emerged from he ethnography, needs to be further studied in future years in order or public health to develop better upstream structural interven- ion strategies to diminish the long-term harms of drug use among ulnerable populations.

Changes in the macro level opiate markets, both licit and illicit, learly have major implications for young people’s involvement ith opiates and their transition to injecting drug use. Policies

ttempting to control the flow of heroin, pursued for a century, ppear to be failing while commercial interests and concern to elieve patient suffering have resulted in a second substantial opi- te supply line. Awareness already exists within government of the otential effects on existing opioid users of efforts to curb the pill upply. Future policy approaches need to be carefully thought out n advance to take into account the potential impact of changes in upply on populations at risk.

Public health measures that can address and reduce the onsequences of a nascent heroin sub-epidemic need urgent imple- entation. Surveillance on the numbers of active heroin users is

necessary starting point. Harm reduction services, e.g. overdose revention, especially peer distribution of naloxone, and syringe istribution/exchange, need to prepare for a rise in clients and their eeds. Substance use treatment services similarly need additional cale-up and funding to help stem the coming tide.

imitations

The limitations of our study are the usual ones for qualitative esearch. Ethnographic and qualitative research is subject to a num- er of biases including subjective sampling and response biases. iven that the events reported often occurred some years before

he interview, the possibility of recall bias is important to bear n mind. These are lessened somewhat by the length of immer- ion in the study sites and interview styles grown out of extensive xperience.

cknowledgements

We thank our Heroin Price and Purity Outcomes study col- eagues Jay Unick and Daniel Rosenblum, the interviewees and also ason Fessel, Galen Joseph and Kimberly Koester for helpful com-

ents on earlier drafts. We would also like to thank Mary Howe for er help in arranging interviews in San Francisco and Paul Yabor for is work conducting interviews in Philadelphia. Finally the authors ould like to acknowledge the helpful comments provided by

wo anonymous peer reviewers. Funding: NIH/NIDA/NIAID, Grant A27599 (PI: Ciccarone) and DA10164 (PI: Bourgois).

onflict of interest

None declared.

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