Heroin use is associated with significant medical and social problems. In addition to HIV and other blood-borne infections there is concern about mounting heroin-related overdose (HOD) and bacterial skin and soft tissue infections (SSTI) including methicillin-resistant staphylococcus aureus (MRSA) infections. Social concerns include trafficking-related violence and societal costs of heroin use eg incarceration and healthcare utilization. US heroin and illicit opioid supply and consumption are changing: in the past 20 years, as Colombian- sourced heroin gained dominance, heroin prices have decreased and purity increased to record levels; prescription opioid pill misuse has drawn in new populations that are younger, more rural, white and female. Nationwide heroin use is increasing dramatically due to robust availability of high quality heroin and a wave of dependent opioid pill users switching to this cheaper, more reliable supply. In addition the heroin supply is in flux wit evidence of sharply increased production in Mexico and a diversity of heroin products hitting US streets. What are the health and behavioral implications of use of these novel heroin source-forms? Different source-forms of heroin are chemically distinct leading to different use patterns and medical consequences. Distribution of Colombian-sourced powder heroin (PH), a cold-water soluble heroin, is associated with greater HIV and HOD. New forms of powdered heroin are emerging regionally eg chocomil, gunpowder, fentanyl-laced heroin and cheese heroin; all are cold water soluble raising concerns about increased HIV and HOD risk. In addition, some market characteristics, eg branding, maybe associated with higher quality heroin and more negative consequences than others. How are changes in heroin supply, heroin market structure and quality affecting populations at risk and healthcare utilization and costs? The Heroin in Transition study will investigate the rapidly evolving risk environment for heroin users in the US utilizing integrated micro- to macro-level anthropological, economic and epidemiological approaches.
Specific Aim 1 : To assess, through qualitative inquiry, the micro-personal risk behaviors of heroin IDUs related to their use of specific major and variant types of heroin in 2 sentinel and 12 rapid assessment sites.
Specific Aim 2 : To examine the structure of heroin markets and retail heroin price/purity in 27 US MSAs, 1993-2014, relating them to changes in populations at risk, healthcare utilization and societal costs.
Specific Aim 3 : To develop longitudinal and agent-based models linking heroin and opioid market conditions, ie structure, availability and quality, to individuals' patterns of heroin-related medical outcomes eg HIV, HOD, SSTI and MRSA.

Public Health Relevance

The Heroin in Transition study uses multiple methods to study the rising use of novel forms of heroin, changing drug markets and the resultant medical problems and social costs. Achieving its objectives will advance understanding of drug epidemics and morbidities; help tailor public health interventions and provide community level tools for better monitoring and allocation of scarce resources.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Research Project (R01)
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Study Section
Special Emphasis Panel (ZRG1-AARR-G (02))
Program Officer
Obrien, Moira
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University of California San Francisco
Family Medicine
Schools of Medicine
San Francisco
United States
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Bourgois, Philippe; Holmes, Seth M; Sue, Kim et al. (2017) Structural Vulnerability: Operationalizing the Concept to Address Health Disparities in Clinical Care. Acad Med 92:299-307
Bluthenthal, Ricky N; Wenger, Lynn; Chu, Daniel et al. (2017) Drug use generations and patterns of injection drug use: Birth cohort differences among people who inject drugs in Los Angeles and San Francisco, California. Drug Alcohol Depend 175:210-218
Ciccarone, Daniel (2017) Fentanyl in the US heroin supply: A rapidly changing risk environment. Int J Drug Policy 46:107-111
Ciccarone, Daniel; Ondocsin, Jeff; Mars, Sarah G (2017) Heroin uncertainties: Exploring users' perceptions of fentanyl-adulterated and -substituted 'heroin'. Int J Drug Policy 46:146-155
Unick, George Jay; Ciccarone, Daniel (2017) US regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations. Int J Drug Policy 46:112-119
Mars, Sarah G; Ondocsin, Jeff; Ciccarone, Daniel (2017) Sold as Heroin: Perceptions and Use of an Evolving Drug in Baltimore, MD. J Psychoactive Drugs :1-10
Mars, Sarah G; Bourgois, Philippe; Karandinos, George et al. (2016) The Textures of Heroin: User Perspectives on ""Black Tar"" and Powder Heroin in Two U.S. Cities. J Psychoactive Drugs 48:270-8
Ciccarone, Daniel; Bourgois, Philippe (2016) Injecting drugs in tight spaces: HIV, cocaine and collinearity in the Downtown Eastside, Vancouver, Canada. Int J Drug Policy 33:36-43
Ciccarone, Daniel; Unick, George Jay; Cohen, Jenny K et al. (2016) Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions. Drug Alcohol Depend 163:126-33
Ciccarone, Daniel; Harris, Magdalena (2015) Fire in the vein: Heroin acidity and its proximal effect on users' health. Int J Drug Policy 26:1103-10

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