Prevalence Of Heroin Use Research Articles

PERSONALITY DISORDERS IN PATIENTS ON HEROIN SUBSTITUTION THERAPY

Introduction: The prevalence of heroin use in Morocco was 0.02%. These figures were higher in the northern region of Morocco. The personality disorder represented a difficulty in the management of the heroin addicted patient. The aim of this study was to show that personality disorders were often comorbid with heroin addiction and to specify the predominant pathological personalities in the Moroccan population. Material and methods:A descriptive cross-sectional study in a population of 171 subjects.Collection of sociodemographic and clinical data by form.Scale:Personality Diagnostic Questionnaire (PDQ - 4+)Statistical analysis: Excel 2016, SPSS 2021: Student test, ANOVA and CHI-2 Results:Sample of 171 patients with 97.7% of male patients and average age of 43,59.Half of the population (48.5%) had only primary education80.7% never received psychiatric care.The average number of incarcerations in our population was 3,96The predominant personality disorders were borderline and antisocial personality disorder respectively.Statistically significant relationship between borderline personality disorder and psychiatric history and the number of hospitalizations in psychiatric units.Statistically significant relationship between the number of incarcerations and antisocial personality disorder. Conclusion: Heroin addicts in Morocco suffered from social instability, strong cannabis dependence, delinquency and frequent judicial recidivism. The most frequent personality disorders were borderline and antisocial. However, the causal link between the personality disorder and the addiction remained to be defined.

Trends in heroin use and injection drug use among high school students in five urban school districts in the US (2005–2017)

Background. We describe the prevalence of and changes in heroin use and injection drug use (IDU) among high school students in five large, urban school districts in the US (2005–2017); nearly three-fourths of the students were Black and/or Hispanic/Latino. Methods. Data are from the Centers for Disease Control and Prevention’s “Youth Risk Behavior Survey” program, which includes biennial surveys in urban school districts. We pooled data across districts and survey years, and then generated weighted prevalence estimates (and 95% CIs) for any lifetime heroin use and IDU. Joinpoint regression modeling was used to estimate changes in prevalence over the study period. Results. Biennial prevalence estimates (2005–2017) for heroin use and IDU were above 1.8% for all seven timepoints. In 2017, prevalence of heroin use and IDU were 2.9% and 2.5%, respectively. Both heroin use and IDU were higher among boys than girls. There were statistically significant increases in heroin use and IDU among girls from 2005–2009, whereas changes over time were stable among boys. Conclusions. High school students in large, urban school districts may have higher rates of heroin use and IDU than US high school students in general, and there is little evidence of increases since 2009. This study suggests that adolescence may be a critical period for initiation of heroin use among adolescents in large urban school districts, the majority of whom are Black and/or Latino. Supplemental data for this article is available online at https://doi.org/10.1080/15332640.2021.1992327 .

Trends in heroin use among women of reproductive age in the United States, 2004–2017

Opioid use during pregnancy has been linked to several adverse outcomes including stillbirth, preterm birth and neonatal abstinence syndrome. Recent data suggest that heroin use has increased in the United States (US) whereas prescription opioid use has decreased. Prevalence estimates for reproductive age women combine heroin and non-medical prescription opioid use, which might mask the increasing heroin trend. The aim of the current study is to estimate the prevalence of heroin use among US women of reproductive age, stratified by pregnancy status. For each year, a representative sample of the US civilian non-institutionalized population is recruited for the National Survey on Drug Use and Health (NSDUH). Pregnancy status and heroin use were assessed in women 15–44 years of age (n = 277,333) using audio computerized-assisted self-interviews. From 2004 to 2017, the prevalence of past 30-day heroin use was 12 per 10,000 reproductive age women (95% confidence interval [CI] = 11, 14). Heroin use has increased from 6 per 10,000 women in 2004–05 to 18 per 10,000 women in 2016–17 (Average percent change = 20.8; 95% 11.2, 31.2). The increase was evident among non-pregnant women, but not among pregnant women. Heroin use remains uncommon among women of reproductive age, yet its prevalence has increased over time. Screening for heroin use might be needed at multiple time points including prior to pregnancy to mitigate adverse outcomes associated with use during pregnancy.

Trends in Adolescent Heroin and Injection Drug Use in Nine Urban Centers in the U.S., 1999–2017

PurposeAlthough estimates of heroin and injection drug use (IDU) among U.S. adolescents have remained low and stable, national data may mask local variation in use. Adolescent use may be higher in urban areas, many of which have historically high rates of heroin use and IDU. We investigate trends in heroin use and IDU among 9th–12th grade students in major urban centers in the U.S. MethodsWe used local Youth Risk Behavior Survey data from all large, urban school districts (n = 9) with at least 5 years of weighted, publicly available data. We used time series mean estimation to estimate the prevalence of heroin use and IDU among high school students from 1999 to 2017 and used logistic regression to test for linear and quadratic trends. ResultsWe observed statistically significant linear increases in (1) lifetime heroin use in New York (β = .43, 1%–3.9%), Chicago (β = .15, 3.1%–4.6%), and Milwaukee (β = .35, 2.8%–7.4%); and (2) lifetime IDU in New York (β = .34, .8%–2.7%), Orange County (β = .17, 2.2%–3.5%), and Miami-Dade County (β = .16, 2.7%–3.9%). Only San Bernardino experienced significant decreases in heroin use (β = −.34, 4.6%–1.6%) and IDU (β = −.20, 2.5%–1.9%) over the time period. ConclusionsIn contrast to national trends, the prevalence of heroin use is increasing among adolescents in certain urban centers in the U.S. Our results illustrate that national averages mask local variation in adolescent heroin use. Further research with locally representative samples is needed to inform public health policy and practice, especially in cities where heroin problems have been historically endemic and continue to rise.

Adolescent prescription opioid misuse, illicit opioid use and overdose

Adolescent prescription opioid misuse, illicit opioid use and overdose

Estimating Prevalence of Illicit Drug Use in Yunnan, China, 2011-15.

Background and Aims: Yunnan has been one of the provinces most afflicted by illicit drug use in China. However, there have been few systematic studies on the prevalence of illicit drug use in the area.Method: Using data on illicit drug users registered in the police system, this study aims to estimate the population size of illicit drug users and the annual prevalence of drug use in Yunnan from 2011 to 2015 using Zelterman's capture-recapture method.Results: In the 15–64 year-old population, the estimated prevalence rate of any illicit drug use was 0.81% (0.76–0.86%) in 2011 and 0.94% (0.90–0.98%) in 2014, representing a significant increase. The prevalence rate of heroin use decreased from 0.67% (0.63–0.73%) in 2011 to 0.57% (0.53–0.61%) in 2015, while the prevalence rate of methamphetamine use doubled from 0.20% (0.17–0.24%) in 2011 to 0.48% (0.46–0.50%) in 2015. The mean age of the 141,702 identified illicit drug users in Yunnan from 2011 to 2015 was 32.2 years, and the majority were male, low educated, and peasants; nearly half were single and ethnic minorities. The ratio of the number of identified illicit drug users to the number of hidden users increased from 1:12 in 2011 to 1:5 in 2015.Conclusion: The prevalence of illicit drug use in Yunnan has been increasing. Although the prevalence of heroin use decreased, methamphetamine use increased dramatically from 2011 to 2015. Preventive strategies that are more effective in reducing illicit drug use are urgently needed in Yunnan.

Racial/Ethnic Differences in Prevalence Trends for Heroin use and Non-Medical use of Prescription Opioids Among Entrants to Opioid Treatment Programs, 2005–2016

ABSTRACTRecent data suggest an increase in use of heroin and non-medical use of prescription opioids (POs) in the United States, but it is unclear if these trends are consistent across racial/ethnic groups. In a nationwide prevalence study, 69,140 patients newly admitted to an opioid treatment program (OTP) completed a brief self-administered survey of past month heroin use and PO misuse from January 2005 through September 2016. We calculated heroin use and PO misuse prevalence rates, and prevalence rate ratios of Black and Latino OTP entrants compared to White entrants over time. Initially, Black and Latino respondents reported much higher prevalence of heroin use and much lower prevalence of PO misuse than White respondents. Heroin use increased among White respondents, while it decreased among Black respondents, resulting in rates that were no longer significantly different. PO misuse prevalence decreased among White respondents while it increased among Black respondents, but remained significantly higher among White respondents. Heroin use decreased and PO misuse increased among Latino respondents during the late 2000s, but these trends largely reversed in more recent years. Among OTP entrants, racially/ethnically disparate rates of heroin use, and to a lesser extent, of PO misuse have become more similar over time. These trends were stronger when analysis was restricted to OTP entrants who either had no previous OTP history or were younger. To understand potential impacts of interventions to deter PO misuse and to maximize the effectiveness of OTPs it is important to consider potential changes in opioid use across racial/ethnic groups.

Changes in US Lifetime Heroin Use and Heroin Use Disorder

Heroin use is an urgent concern in the United States. Little is know about the course of heroin use, heroin use disorder, and associated factors. To examine changes in the lifetime prevalence, patterns, and associated demographics of heroin use and use disorder from 2001-2002 to 2012-2013 in 2 nationally representative samples of the US adult general population. This survey study included data from 43 093 respondents of the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and 36 309 respondents of the 2012-2013 NESARC-III. Data were analyzed from February 2 to September 15, 2016. Lifetime heroin use and DSM-IV heroin use disorder. Among the 79 402 respondents (43.3% men; 56.7% women; mean [SD] age, 46.1 [17.9] years), prevalence of heroin use and heroin use disorder significantly increased from 2001-2002 to 2012-2013 (use: 0.33% [SE, 0.03%] vs 1.6% [SE, 0.08%]; disorder: 0.21% [SE, 0.03%] vs 0.69% [SE, 0.06%]; P < .001). The increase in the prevalence of heroin use was significantly pronounced among white (0.34% [SE, 0.04%] in 2001-2002 vs 1.90% [SE, 0.12%] in 2012-2013) compared with nonwhite (0.32% [SE, 0.05%] in 2001-2002 vs 1.05% [SE, 0.10%] in 2012-2013; P < .001) individuals. The increase in the prevalence of heroin use disorder was more pronounced among white individuals (0.19% [SE, 0.03%] in 2001-2002 vs 0.82% [SE, 0.08%] in 2012-2013; P < .001) and those aged 18 to 29 (0.21% [SE, 0.06%] in 2001-2002 vs 1.0% [0.17%] in 2012-2013; P = .01) and 30 to 44 (0.20% [SE, 0.04%] in 2001-2002 vs 0.77% [0.10%] in 2012-2013; P = .03) years than among nonwhite individuals (0.25% [SE, 0.04%] in 2001-2002 vs 0.43% [0.07%] in 2012-2013) and older adults (0.22% [SE, 0.04%] in 2001-2002 vs 0.51% [SE, 0.07%] in 2012-2013). Among users, significant differences were found across time in the proportion of respondents meeting DSM-IV heroin use disorder criteria (63.35% [SE, 4.79%] in 2001-2001 vs 42.69% [SE, 2.87%] in 2012-2013; P < .001). DSM-IV heroin abuse was significantly more prevalent among users in 2001-2002 (37.02% [SE, 4.67%]) than in 2012-2013 (19.19% [SE, 2.34%]; P = .001). DSM-IV heroin dependence among users was similar in 2001-2002 (28.22% [SE, 3.95%]) and in 2012-2013 (25.02% [SE, 2.20%]; P = .48). The proportion of those reporting initiation of nonmedical use of prescription opioids before initiating heroin use increased across time among white individuals (35.83% [SE, 6.03%] in 2001-2002 to 52.83% [SE, 2.88%] in 2012-2013; P = .01). The prevalence of heroin use and heroin use disorder increased significantly, with greater increases among white individuals. The nonmedical use of prescription opioids preceding heroin use increased among white individuals, supporting a link between the prescription opioid epidemic and heroin use in this population. Findings highlight the need for educational campaigns regarding harms related to heroin use and the need to expand access to treatment in populations at increased risk for heroin use and heroin use disorder.

Evidence of slow-release morphine sulfate abuse and diversion: epidemiological approaches in a French administrative area.

Slow-release oral morphine sulfate (SM) is one of the most abused prescription opioids in France. However, the regional feature of the abuse of morphine is poorly documented. To investigate the abuse of SM in a French administrative region, a multisource approach was applied. The first approach was based on SM exposition at national and regional level using the OPPIDUM survey. In a second approach, we analyzed a drug reimbursement database to assess the magnitude of SM abuse in Languedoc-Roussillon (LR) region. A clustering method was applied to classify patients and to describe the profile of deviant patients. The third approach was based on a self-administered anonymous questionnaire, proposed to patients seen in addiction care centers in the LR region and consuming oral SM. The OPPIDUM study showed that in most regions, where the prevalence of heroin use is higher than the national average of 9.1%, SM consumers were fewer. With the clustering method, three subgroups were identified. One of them gathered 35 users (3.2%) with a deviant behavior characterized by significantly more dispensations, dispensing pharmacies, and prescribers. These subjects were mainly men, younger, and more consumers of benzodiazepines and opioid maintenance therapy than the others. The third study allowed specifying that SM was mainly injected (93.7%), bought in the street (80%), and used because of unavailability and the poor quality of heroin (33.9%). The three proposed approaches are complementary and help to clarify the abuse of oral SM, while assessing the motivations of this abuse.

Perceived risk of heroin use among nonmedical prescription opioid users

AimsThe prevalence of heroin use among nonmedical prescription opioid (NMPO) users has increased in recent years. Identifying characteristics associated with heroin use in this population can help inform efforts to prevent heroin initiation and maintenance. The aim of this study was to evaluate differences in perceived risk of heroin among NMPO users with and without histories of heroin use, and to examine temporal trends in perceived risk of heroin among this population. MethodsData are from the 2002–2013 National Survey on Drug Use and Health, and included all past-year NMPO users (N=49,045). Participants reported perceived risk of trying heroin once or twice and regular heroin use. Responses were coded dichotomously (great risk vs. other risk) and logistic regression analyses were used to evaluate the association between lifetime heroin use and perceived risk of heroin, and to determine temporal changes in perceived risk. ResultsResults indicated a significant association between lifetime heroin use and lower likelihood of reporting great risk of trying heroin (OR=0.38, 95% CI: 0.33, 0.44, p<0.001), and of regular use of heroin (OR=0.39, 95% CI: 0.32, 0.48, p<0.001). There was a significant, yet modest, trend toward decreasing perception of great risk from 2002 to 2013. ConclusionsFindings from this analysis of nationally representative data indicate that NMPO users with a history of heroin use perceive heroin to be less risky than those without heroin use. Perception of risk has decreased from 2002 to 2013 in this population, consistent with increasing rates of heroin initiation.

Prevalence, correlates and patterns of heroin use among young adults in the United States

IntroductionThe prevalence of heroin use, abuse, and dependence has increased considerably over the past decade. This increase has largely been driven by young adults (18–25years). This study aims to improve the understanding of heroin use among young adults by determining the prevalence, correlates, patterns and attitude of heroin use among young adults in the US. MethodsThe 2011–2013 National Survey on Drug Use and Health was analyzed. Study population included 55,940 young adults with valid interviews. Self-reported lifetime, past-year and past-month use of heroin were examined. Descriptive statistics and adjusted odds ratios were estimated in accordance with the complex survey design. ResultsOf the respondents, 18.4 per 1000 (95% CI=16.8–20.0) used heroin at some time in their lives, and 7.3 per 1000 (95% CI=6.3–8.3) and 3.3 per 1000 (95% CI=2.6–4.0) used heroin in the past year and past month, respectively. The single most common route of heroin use was by sniffing. Majority of young adults reported using heroin in combination with other substances. Users of non-prescribed opioid pain relievers, cigarette smokers, illicit drug users and those arrested and booked for breaking the law, had higher odds of using heroin during their lifetime, in the past-year and past-month. ConclusionFewer than 2% reported ever using heroin, and 82% of those reported no use in the past month. Majority were polysubstance users and sniffed heroin in combination with other routes of use. Comprehensive programs that target young adult heroin users and address important risk factors for heroin use are needed.

Circumstances and contexts of heroin initiation following non-medical opioid analgesic use in New York City

BackgroundAs the prevalence of opioid analgesic (OA) misuse and associated harms have increased in the United States, the prevalence of heroin use and rates of unintentional overdose have concurrently risen. Research has begun to identify connections between OA misuse and heroin use, although this relationship remains under explored. The present study explores the context of heroin initiation among persons with histories of OA misuse in New York City. MethodsIn-depth interviews were conducted with 31 individuals with histories of OA misuse who initiated heroin use within the past five years. Data were collected between August 2013 and January 2015. All participants’ OA misuse temporally preceded their heroin use. Interviews were coded and analyzed utilizing thematic qualitative methods. ResultsParticipants ranged in age from 18 to 44 years; 25 identified as male and 30 identified as non-Hispanic white and heterosexual. All participants had stable housing at the time of interview and all were high school graduates. Participants described several key points of transition along their trajectories from OA misuse to heroin initiation: dual- to single-entity OAs; oral to intranasal OA administration; and the development of physical opioid dependence. Participants described the breaking down of heroin-related stigma across social networks as new drug use permeated social groups. ConclusionSeveral points of transition were identified in participants’ trajectories from OA misuse to heroin initiation. In particular the development of physical dependence was a critical factor as existing heroin stigma was rapidly overcome in the face of opioid withdrawal. The relatively short time to heroin initiation documented among new user groups serves as an added challenge to the development of interventions.

Prevalence of heroin markers in urine for pain management patients

Surveys of current trends indicate heroin abuse is associated with nonmedical use of pain relievers. Consequently, there is an interest in evaluating the presence of heroin-specific markers in chronic pain patients who are prescribed controlled substances. A total of 926,084 urine specimens from chronic pain patients were tested for heroin/diacetylmorphine (DAM), 6-acetylmorphine (6AM), 6-acetylcodeine (6AC), codeine (COD), and morphine (MOR). Heroin and markers were analyzed using liquid chromatography tandem mass spectrometry (LC–MS–MS). Opiates were analyzed following hydrolysis using LC–MS–MS. The prevalence of heroin use was 0.31%, as 2871 were positive for one or more heroin-specific markers including DAM, 6AM, or 6AC (a known contaminant of illicit heroin). Of these, 1884 were additionally tested for the following markers of illicit drug use: 3,4-methylenedioxymethamphetamine (MDMA), 3,4-methylenedioxyamphetamine (MDA), methamphetamine (MAMP), 11-nor-9-carboxy-Δ9-tetracannabinol (THCCOOH), and benzoylecgonine (BZE); 654 (34.7%) had positive findings for one or more of these analytes. The overall prevalence of heroin markers were as follows: DAM 1203 (41.9%), 6AM 2570 (89.5%), 6AC 1082 (37.7%). MOR was present in 2194 (76.4%) and absent (<LOQ) in 677 (23.6%) of the heroin-positive specimens. COD was present in 1218 (42.4%) specimens. Prevalence of combinations for specimens containing MOR were as follows: DAM only 13 (0.59%), 6AM only 1140 (52.0%), 6AC only 24 (1.1%), DAM/6AM/6AC 710 (32.4%), 6AM/6AC 188 (8.6%), DAM/6AM 113 (5.2%), DAM/6AC 6 (0.27%). Importantly, the prevalence of combinations for specimens without MOR were as follows: DAM only 161 (23.8%), 6AM only 217 (32.1%), 6AC only 92 (13.6%), DAM/6AM/6AC 50 (7.4%), 6AM/6AC 7 (1.0%), DAM/6AM 145 (21.4%), DAM/6AC 5 (0.74%). Unexpected patterns of excretion were observed, such as the presence of DAM and 6AC in the absence of 6AM and MOR; therefore, multiple heroin markers may be useful to assess for heroin use.

Efforts to Reduce Overdose Deaths

The recent article by Schwartz et al. addresses the intersection of two important public health issues: opiate substitution therapy and fatal heroin overdose.1 In the United States, drug overdose is responsible for more than 36 000 deaths annually2 and is the leading cause of death among illicit drug users. Baltimore, Maryland, has one of the highest per capita heroin addiction rates in the nation, with an estimated prevalence of heroin use in 10% of the population.3 Schwartz et al. conducted a 15-year ecological analysis in Baltimore and found that increases in buprenorphine and methadone treatment with concurrent decreases in overdose deaths, controlling for heroin purity. Along with previous research,4 this study demonstrates the far-reaching benefits of opiate agonist treatment. In Baltimore, an estimated 34% of 68 000 drug users were in drug treatment in 2011, with heroin being the primary drug of abuse.5 The magnitude of out-of-treatment drug users in Baltimore and in the United States underscores the need for overdose prevention efforts targeting this population. Furthermore, out-of-treatment, long-term injection drug users (IDUs) are at greatest risk for overdose.6,7 As Schwartz et al. noted, periods of abstinence resulting from recent incarceration or drug treatment are chief overdose risk factors, given associated decreases in tolerance.8,9 These facts speak to the importance of overdose prevention among active IDUs. Capital City Care, a medical marijuana dispensary, is shown in Washington, DC, on April 15, 2013, prior to the store's opening. Three years after Washington, DC, legalized medical marijuana, three stores are set to open, allowing patients with HIV/AIDS, ... As of 2012, there were an estimated 188 overdose prevention education and naloxone distribution programs (OPEND) in the United States.2 OPEND programs train peer drug users how to prevent overdoses and administer naloxone in the event of an overdose. Naloxone is a short-acting opiate antagonist that reverses the effects of respiratory depression commonly caused by opiate overdose.7 Since 2004, Baltimore’s OPEND program, Staying Alive, has reached 35 000 individuals including an estimated 10 000 IDUs, 1200 medical and drug treatment providers, and 8500 jail inmates. Staying Alive has distributed 4000 vials of naloxone, and 250 reversals have been reported. Between 2003 and 2009 (half of the study period examined in Schwartz et al.), Staying Alive distributed 1263 naloxone vials and 196 reversals were reported. We commend Schwartz et al. for their study, which highlighted important public health programs that appear to reduce overdose mortality. We believe that both OPEND and increased availability of opiate substitution therapy have contributed to decreases in overdose mortality in Baltimore. We think that both are necessary for a holistic approach to the issue of overdose.

Patrones de consumo de heroína en una muestra de consumidores de Medellín - Colombia

In Colombia, there are no specific studies on the prevalence of heroin use. This paper reviews the patterns of substance use in a consumer group in the city of Medellín and its metropolitan area, showing that consumption is becoming a threat to public health due to the particular forms of consumption, among which risk practices are included. To evaluate the use of heroin in the city of Medellín and its metropolitan area. The study took a mixed approach using multiple-case study to cover each of the variables and categories proposed; 42 heroin users of treatment centers in the city of Medellín and its metropolitan area were accessed between July and September 2008, using the "snowball", technique. Information was collected by a structured, face to face interview, asking about the type of heroin consumed, routes of administration, frequency of consumption, equipment used, consumption practices and rituals that accompany these practices. Quantitative data were analyzed using the EPI-Info statistical package 2,000 and Atlas ti qualitative, version 5.5, for Windows. Consumers were predominantly male, single, aged between 18 and 23 years, childless and many had not completed college. Most respondents were in the middle socioeconomic stratum, had a family history of psychoactive substance use and had started heroin use between 15 and 17 years. There are special forms to name heroine, consumers, and rituals to consume the substance. The article gives details of the heroin consumed, the paraphernalia and associated practices. The use of heroin is an emerging reality in Colombia. Qualitative-quantitative studies are necessary to allow us to acknowledge and understand more about this phenomenon in order to decrease the impact on public health.

Combined effects of law enforcement and substitution treatment on heroin mortality

To explore the combined effects of street-level law enforcement and substitution treatment programs on drug-related mortality, taking into account prevalence of heroin use and changes in injecting behaviour. Time trend analysis using annual police reports and case register data of opioid substitution treatments in Switzerland, 1975-2007. Drug-related mortality increased during times of more intense street-level law enforcement [odds ratio (OR) 1.32, 95% confidence interval (95% CI) 1.15-1.51], and the number of drug-related deaths predicted the number of heroin possession offences 2 years later (r = 0.97, P < 0.001). Substitution treatment had a protective effect on drug-related mortality (OR 0.23, 95% CI 0.18-0.30). Surprisingly, the number of drug-related deaths was substantially biased by an oscillation period of 14 years (OR 1.24, 95% CI 1.17-1.32). Our analysis revealed that the amount of police resources allocated to law enforcement was determined rationally, however, on biased grounds and with untoward consequences. Substitution treatment of heroin users reduced drug-related mortality in the long run, but different factors masked its impact for several years. Therefore, the introduction-or the expansion-of opioid substitution treatment programs should not be promoted with the argument of an immediate reduction of drug-related deaths in a country.

Reflexive Practice as Ethics and Political Position

The following article deals with the ethical implications of reflexive practice in an ethnographic study of heroin use in a neighbourhood of the city of Barcelona (Spain). The fieldwork was carried out during a period of historically high prevalence of heroin use (1994—5) and the analysis was extended to the year 2000. Various situations experienced during the fieldwork were analysed, and the `positions' of the ethnographer or author of the text were explored in two ways: (1) based on intersubjective components of the informant-ethnographer relationship (social categories, emotions, decision making, authority, etc.); and (2) based on the tension of `enunciative positions' (of the discourse) within the text. Among the results I can highlight are: (1) building awareness of the `enunciative positions' shown in the text; (2) the possible transformations of the subjects involved that is, of the informants, the ethnographer and the readers, and the multiple subjectivities that emerge and stand out in the specific contexts of interaction, and (3) the ethical implications of these positions.

Chronic Nephropathies of Cocaine and Heroin Abuse

Renal disease in cocaine and heroin users is associated with the nephrotic syndrome, acute glomerulonephritis, amyloidosis, interstitial nephritis, and rhabdomyolysis. The pathophysiologic basis of cocaine-related renal injury involves renal hemodynamic changes, glomerular matrix synthesis and degradation, and oxidative stress and induction of renal atherogenesis. Heroin is the most commonly abused opiate in the United States. Previous studies identified a spectrum of renal diseases in heroin users. The predominant renal lesion in black heroin users is focal segmental glomerulosclerosis and in white heroin users is membranoproliferative glomerulonephritis. Although the prevalence of heroin use in the United States has increased, the incidence of "heroin nephropathy" has declined. Because reports of heroin nephropathy predated the surveillance of hepatitis C virus and HIV, the varied findings might be related to the spectrum of viral illnesses that are encountered in injection drug users. Socioeconomic conditions, cultural and behavioral practices, or differences in genetic susceptibilities may be more associated with the development of nephropathy in heroin users than the drug's pharmacologic properties. Administration of cocaine in animal models results in nonspecific glomerular, interstitial, and tubular cell lesions, but there is no animal model of heroin-associated renal disease. The heterogeneity of responses that are associated with heroin is not consistent with a single or simple notion of nephropathogenesis. There are no well-designed, prospective, epidemiologic studies to assess the incidence and the prevalence of renal disease in populations of opiate users and to establish the validity of a syndrome such as heroin nephropathy. It is concluded although there is a paucity of evidence to support a heroin-associated nephropathy, the evidence from in vitro cellular and animal studies to support the existence of cocaine-induced renal changes is more convincing.

The "lessons" of the Australian "heroin shortage".

Heroin use causes considerable harm to individual users including dependence, fatal and nonfatal overdose, mental health problems, and blood borne virus transmission. It also adversely affects the community through drug dealing, property crime and reduced public amenity. During the mid to late 1990s in Australia the prevalence of heroin use increased as reflected in steeply rising overdose deaths. In January 2001, there were reports of an unpredicted and unprecedented reduction in heroin supply with an abrupt onset in all Australian jurisdictions. The shortage was most marked in New South Wales, the State with the largest heroin market, which saw increases in price, dramatic decreases in purity at the street level, and reductions in the ease with which injecting drug users reported being able to obtain the drug. The abrupt onset of the shortage and a subsequent dramatic reduction in overdose deaths prompted national debate about the causes of the shortage and later international debate about the policy significance of what has come to be called the "Australian heroin shortage". In this paper we summarise insights from four years' research into the causes, consequences and policy implications of the "heroin shortage".

The New Heroin Users Among Manhattan Arrestees: Variations by Race/Ethnicity and Mode of Consumption

The incidence of heroin use among Manhattan arrestees interviewed by the Arrestee Drug Abuse Monitoring (ADAM) program remained around 20% from 1987 through 2001. However, the authors had expected a decline because the heroin injection epidemic peaked back in the 1960s and early 1970s. A detailed analysis found differences across race/ethnicity. Black arrestees born since 1955 (who came of age since the heroin injection epidemic) were much less likely to use heroin than those born between 1945 and 1954 (who came of age during the epidemic). Hispanic arrestees born since 1970 (but not those born between 1955 and 1969) were also less likely to use heroin, suggesting that the decline in heroin use started among Blacks before Hispanics. During the 1990s, sniffing replaced injecting as the predominant mode of heroin consumption for Black and Hispanic arrestees, even among older arrestees. In strong contrast, the prevalence of heroin use among White arrestees did not decline in the 1990s and injection was still their most popular method of consumption. The discussion highlights implications for fu rther research and drug treatment.