Buying Heroin online in Montero

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Buying Heroin online in Montero

Background Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since In , study participants described the arrival of new, unusually potent tablets sold as ostensibly controlled substances, without a prescription, directly from pharmacies that cater to US tourists. Concurrently, fentanyl- and methamphetamine-based counterfeit prescription drugs have driven escalating overdose death rates in the US, however their presence in Mexico has not been assessed. Aims To characterize the availability of counterfeit and authentic controlled substances at pharmacies in Northern Mexico available to English-speaking tourists without a prescription. Methods We employed an iterative, exploratory, mixed methods design. We employed immunoassay-based testing strips to check each pill for the presence of fentanyls, benzodiazepines, amphetamines, and methamphetamines. We used Fourier-Transform Infrared Spectroscopy to further characterize drug contents. Results Of 40 pharmacies, these controlled substances could be obtained in any form with no prescription at Pharmacy employees occasionally expressed concern about overdose risk and provided harm reduction guidance. Discussion The availability of fentanyl-, heroin-, and methamphetamine-based counterfeit medications in Northern Mexico represents a public health risk, and occurs in the context of 1 the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2 plummeting rates of opioid prescription in the US, affecting both chronic pain patients and the availability of legitimate pharmaceuticals on the unregulated market, 3 the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It is not possible to distinguish counterfeit medications based on appearance, because identically-appearing authentic and counterfeit versions are often sold in close geographic proximity. Nevertheless, US tourist drug consumers may be more trusting of controlled substances purchased directly from pharmacies. Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 1 — 4. In , study participants—especially those who were US citizens that frequently visited in or stayed in Mexico to consume illicit drugs—began describing new, unusually potent medications, sold ostensibly as controlled substances, from pharmacies that cater to US tourists. This raised suspicion for the proliferation of counterfeit prescription drugs in brick-and-mortar pharmacies 5. Counterfeit pharmaceutical drugs—especially those containing illicitly manufactured fentanyls IMF — are playing an increasing important role in the United States US overdose crisis 5 — 7. IMF and other synthetic opioids have transformed the risk environment for people who use drugs PWUD given their much higher potency and shorter half-life compared to other opioids. Although reports of counterfeit prescription opioids containing IMF surfaced as early as the early s, 8 in recent years they have become commonplace across the US 9 , IMF-based pills e. They have also been driving a large relative increase in the overdose death rate of adolescents 7 , who are more likely to experiment with drugs they perceive as prescription pharmaceuticals relative to powders sold as heroin, or other drugs that are more stigmatized For the general population, there is a profound added risk of counterfeit prescription medications relative to other fentanyl-based illicit drug formulations, as pills purporting to be pharmaceuticals may be perceived as a lower-risk category of recreational drugs 6 , despite currently representing one of the most potentially lethal options for illicit drug use, especially because they may be more likely to be used by individuals with no tolerance to opioids. Although counterfeit prescriptions are described in the US illicit drug market—and it is well-known that a large portion of the IMF and methamphetamine that are pressed into counterfeit prescription drugs sold in the US originate in Mexico 15 , 16 —the prevalence of their consumption among PWUD in Mexico is not well-described in academic literature. Previous drug checking and ethnographic studies have characterized the arrival of IMF to Tijuana and elsewhere in Mexico, especially in the form of China White ostensibly powder heroin, often found containing fentanyl , which has increased in prevalence in recent years 3 , However, previous ethnographic literature describing illicit drug supply chains in Mexico indicate that a complicated and varying set of cartel politics and on-the-ground dynamics limit which products are sold in Mexico versus those exclusively earmarked for export to the US 3 , It should therefore not be assumed that illicit drug products produced in Mexico for export to the US—including counterfeit pills—are consumed by PWUD in Mexico. Given the potential public health risks associated with IMF-based counterfeit prescriptions sold from pharmacies, we sought to characterize the availability and composition of pills sold as ostensibly controlled substances in pharmacies across Northern Mexico. Ethnographic data were collected as part of a wider study investigating shifting risk environments of PWUD in Mexico. Sampling dynamics and methodology have been described extensively elsewhere 1 — 4. Briefly, we targeted initial fieldwork towards the immediate surroundings of drug- and sex-tourism micro-neighborhoods. The largest fraction of participants in the initial ethnographic work were deported individuals who had spent significant time in the US but could not return at-will. However, a sizeable minority of key ethnographic informants consisted of US citizens and residents intentionally visiting or residing in Mexico for the purpose of purchasing and consuming illicit drugs at far cheaper prices than those seen in proximate parts of the US. Ethnographers accompanied and informally interviewed participants as they engaged in routine daily activities, including the acquisition, preparation, and consumption of illicit drugs, and the generation of funds. With IRB approvals, we employed a conversational interview format, frequently using audio recording with participant permission. Over time, most key informants were formally and informally interviewed on dozens of occasions during the research process. All ethnographers were bilingual, and textual data were translated to English for presentation. Study protocols were approved by the institutional review board at the University of California, Los Angeles, in the United States, and the institutional review board at Prevencasa, A. C, in Baja California, Mexico. During the process of accompanying key informants, visits to pharmacies were commonplace, especially among US citizen participating in cross-border drug use visiting for short periods or living in Mexico for the purpose of drug use , who would occasionally purchase one-off benzodiazepine pills, bottles of tramadol for use in heroin cessation, or boxes of syringes at pharmacies proximate to drug and sex tourism microneighborhoods. Given the existing information available, pharmacies were chosen strategically to be geographically broad—both within and between cities—maximizing the probability of discovering counterfeit prescriptions in at least one area, should they exist. This was accomplished by sampling various pharmacies in distinct types of micro-neighborhoods within several cities e. Therefore the study sought to be hypothesis generating and exploratory, not assessing prevalence in a representative fashion. Based on initial ethnographic insights, all pharmacies appeared to be independent entities, not part one of the many popular national pharmacy chains. All pharmacies were located in areas frequented or transited by US-based tourists. Generic names e. Immediately after each encounter, metadata was recorded, indicating if controlled substances were available in any form including full bottles , and if single pills could be obtained which were universally requested when full bottles were offered. Only single pill samples were obtained and analyzed. After each encounter, detailed ethnographic accounts were recorded, transcribed, added to the existing corpus of data, and coded. Data from prior to were drawn from the pre-existing corpus of ethnographic information, whereas novel ethnographic data were collected in for this study. All qualitative data were entered into NVivo and analyzed for emergent themes. Of particular relevance for this analysis, all encounters occurring in pharmacies were analyzed separately to track the evolving use of pharmacies by PWUD over time to Narratives from pharmacy staff and key informants with detailed relevant knowledge regarding medication quality, safety, contents, and origin, were also specifically assessed. All samples were processed in a standardized fashion see supplement for step-by-step details. Briefly, the entire pill was pulverized using a glass instrument in a single-use plastic receptacle, and pill contents were mixed thoroughly to minimize heterogeneity. A small sub-sample was then selected—the smallest quantity that completely covered the crystal window of the Fourier-Transform Infrared FTIR Spectroscopy window. Subsequently, the same sample was added to 1. We then employed 4 immunoassay-based testing strips from BTNX laboratories for each sample, to check each pill for the presence of 1 fentanyls, 2 benzodiazepines, 3 amphetamines, and 4 methamphetamines. Each strip was inserted into the dissolved solution for ten seconds, and the result was read after 5 minutes by two trained investigators. In the rare case of disagreement between investigators, or an inconclusive or invalid result, a second strip was employed, providing a definitive result in all cases. For samples sold as Adderall, we further diluted the solution using mL of water for fentanyl testing, to avoid the known issue of false positives at high concentrations of certain stimulants See the supplement for more details of the drug checking analysis, including the logic employed to reach each final read. Pharmacy-level statistics are shown, depicting the availability of controlled substances, as well as counterfeit status as determined with immunoassay and FTIR spectroscopy. None of the pills sold as Xanax were found to be counterfeit. A wide variety of presumptively authentic controlled substances based on fentanyl and methamphetamine negative status with immunoassay strips, and FTIR confirmation were available see Figure 3. A variety of phenotypes of counterfeit medications were also observed Figure 3. See the supplement for more details on how final drug checking designations were determined. Pill-level data are shown, with one row per sample analyzed. The labs on the far left show the prompt used to obtain each pill, i. FTIR results are shown in free text, with up to 3 results separated by semi-colons. Photos front and back are shown of example pills, by what the sample was sold as, as well as presumed authentic or counterfeit status. Despite intensive fieldwork employed in concert with drug checking technologies, the ethnographic team determined that it was not possible to distinguish counterfeit medications from their authentic counterparts based on appearance, as identically-appearing authentic and counterfeit versions were often sold in close geographic proximity. Geographic context was also helpful—with substances sold in specific microneighborhoods found to be more likely to be counterfeit—but provided no guarantee of authenticity. Only the use of several concurrent drug checking technologies provide a reasonable measure of confidence in medication composition. Of note, heroin-based counterfeits were not initially detected by immunoassay strip testing and were only identified by FTIR spectroscopy—a level of drug checking sophistication currently unavailable in many settings where illicit drugs are purchased and consumed. In her early 30s, she has been dependent on injection opioids for nearly a decade. She is excited to show me a dizzying array of drug consumption spaces in the city. One of the stops is a somewhat formal looking brick-and-mortar pharmacy. And then you can even take it in the back and use it back there. We go into this pharmacy, which I had never taken a second look at, despite passing by it frequently. She greets the pharmacist, who is wearing a white coat, and is visibly covered in tattoos on all exposed parts of his hands, arms, and neck. He barely notices me, which I imagine is because Linda is a charismatic force of nature, who frequently can be seen pulling male clients around in her orbit as she traverses the urban landscape. She hands over 50 pesos and asks for a Valium. He gives her a single pill and 20 pesos in change, and we go into the back room so she can snort it. After she crushes up the pill with a plastic card, and snorts the white powder, she tells me that with the remaining twenty pesos she can show me a shooting gallery right across the street; if we can find five more pesos we can get a 25 peso bag of meth. We leave the pharmacy, cross the street, and duck into an alleyway …. The ethnographic passage above—from the pre-existing ethnographic corpus—details a pharmacy-based drug acquisition encounter occurring in Single tablets of controlled substances—especially benzodiazepines—could be routinely obtained at affordable prices from specific pharmacies known to PWUD. Most were proximate to drug- and sex-tourism microneighborhoods catering to US tourists and heroin- and methamphetamine-dependent Mexican nationals. On rare occasions, the ethnographic team also observed methamphetamine and heroin purchased directly from white coat-clad pharmacy employees. More central to the lives of most PWUD was the acquisition of individual sterile syringes a legal practice ; PWUD often shared details with one another from a complicated taxonomy of which pharmacies would sell syringes to tourists, which ones were open to individuals who appear to have a homeless habitus, and if a cover story was required e. Oxycontin was not routinely pursued at pharmacies by most ethnographic study participants, and most opioid users used peso 2. In , ethnographic participants began describing new, unusually potent controlled substance tablets sold from pharmacies that cater to US tourists:. So I started doing a bunch of em, like 7 a day if I had the money. But they felt different, the oxys felt like heroin to me, but these new ones, are like fentanyl or some shit. It used to be more than a dollar per milligram, like 35 dollars for an M30, but all the sudden they were 20 dollars. And then all the pharmacies in this area were selling them. In these instances, a broad variety of taxonomies were used to describe the various options available. The full one might be too dangerous. He goes under the counter and pulls out a cardboard box full of syringes. He reaches underneath the needles, and pulls up this false bottom on the box, and the bottom is full of these little blue pills, just loose in the box. He takes one out of the pile and puts it in a little plastic bag for us. As he hands it to me. Then we ask about Mexican Adderall. He shows us the bottle and it says methylphenidate Ritalin. On rare instances, pharmacy employees were more forthcoming about what they suspected were the contents of their medications. I asked for Oxy, and one of them pulled out this plastic case from beneath the counter, with lots of little boxes, like for fishing tackle. It was transparent, so we could see all these different looking pills in little bags. They had two different colors of pills that looked like oxy M30s, one blue and one green. They also had a bunch of white and yellow pills of various sizes and shapes, that looked like Percocet, Norco, etc. One spoke better English and relayed the question to the other in Spanish. These pharmacies tended to be larger, with more employees working at a given time, and located in areas catering to more formal kinds of tourism i. However, it was not possible for investigators to reliably predict with certainty which pharmacies would sell controlled substances or counterfeit products. On numerous occasions, two pharmacies directly adjacent to one another would provide highly discordant products. Further complicating these dynamics, some pharmacies sold a mixture of counterfeit and authentic oxycodone products. One-off counterfeit and authentic controlled substance tablets in pharmacies were observed to be stored and accessed in a variety of fashions. However, the degree of discretion employed by pharmacy staff did not appear to be predictive of product authenticity. Tablets were typically stored inside of small plastic bags, kept inside metal breath mint containers in fanny packs, in small cardboard boxes previously containing electronics, in plastic organizer boxes with numerous compartments, or occasionally loose in drawers. At times these boxes were transparent and were left out on pharmacy counters for extended periods of time, as pharmacy staff attended to other patrons seeking medications that were not controlled substances. On other instances, pharmacy staff appeared distinctly concerned about security and employed maneuvers to minimize risk:. When I asked about Xanax, he was only going to sell by the bottle, minimum 30 pills. He did the math and took the money for everything I had asked for. But after he took the money, he just kind of stood behind the counter, counted the money and just like leaned on the wall, like nothing was going to happen. In hindsight, that was probably because there were quite a few police cars right outside in that area. It was at least two full minutes of just standing around, and then someone from the outside finally came in, and the guy moved around me to the back of the store in this really awkward way and pulled the little baggie with two pills out of his pocket and handed it to me and I left. It felt like way more precautions were taken than other encounters, which I attributed to it being in a part of town with more formal tourism in the area, so they took more precautions than pharmacies in the part of town where people go for sex tourism, where things were a bit more out in the open. Additionally, on several occasions, pharmacy employees selling exclusively authentic oxycodone products would counsel caution purchasing products elsewhere, implying risk of overdose or adverse drug reactions:. And look, we want you to have a good time, but if you take one of those, you are not coming back. But I have the real thing. Always ask to see the package, OK? I only have 20 milligrams. But you guys are gonna be happy. Key informants also confirmed that consumption of counterfeit IMF-based tablets, often pressed to look like blue Oxycodone M30s, was subjectively associated with an increased risk of overdose:. But one of my homies did almost, yeah, he was smoking the blues and he nodded real hard, actually right over here, and the girl from the pharmacy had to keep pushing on his chest like this motions doing chest compressions. A distinct phenotype of tourist-oriented pharmacies—focused on selling controlled substances exclusively in bottles and blister packs of quantities ranging from 10 to tablets—was noted in several locations. Pharmacy employees offered various strategies for successful importation of the medications to the US on return flights, and some offered to facilitate international shipping for an additional fee. At a subset of these pharmacies, single pills could be obtained in a similar fashion to other locales, but only after considerable insistence that a large quantity was not of interest. Leveraging recent improvements in point-of-use drug checking technologies, we provide the first characterization—to our knowledge—of the contents of medications sold at pharmacies in tourist-serving areas of Northern Mexico, in single pill form, to English-speaking tourists without a prescription. We find a high rate of counterfeit products, with widespread fentanyl and methamphetamine prevalence in numerous sites. The availability of fentanyl, methamphetamine, and heroin-based counterfeit medications in Northern Mexican pharmacies that are oriented towards serving tourists represents a distinct public health threat. These medications have been implicated in large increases in overdose risk in the United States, especially among subpopulations of individuals that are willing to experiment with prescription pills but not more stigmatized formulations like powder heroin 6 — Although IMF-based pills represent a very high-risk category of illicit drug product, drug consumers may be more trusting of controlled substances purchased directly from pharmacies. Critically, it is not possible to distinguish counterfeit medications based on appearance or geography, as identically-appearing authentic and counterfeit versions are often sold in close geographic proximity. Harm reduction logic would dictate that a person consuming purported controlled substances purchased at pharmacies in these micro-neighborhoods should test each pill on each occasion that drugs are consumed, to ensure IMF and methamphetamine contamination has not occurred. Ethnographic data suggest that the phenomenon of counterfeit controlled substances in pharmacies of northern Mexican cities is likely recent. Nevertheless, it occurs in the context of a long history of drug and medical tourism to Mexico by US residents and citizens 22 — This demand in large part reflects the extremely expensive, unaffordable, confusing, and exploitative nature of the US healthcare system, where many individuals fear that even simple healthcare encounters may result in financially catastrophic outcomes Additionally, it is well-described in the literature that many prescription drugs are dozens to hundreds of times more expensive in the US than in other countries, including Mexico Legally, this does not apply to controlled substances—such as opioids, benzodiazepines, or stimulants—which Mexican law dictates do require a special kind of prescription from a licensed physician authorized to prescribe psychoactive drugs 29 — However, in specific locations we observed a widespread practice wherein certain kinds of controlled substances, especially alprazolam, were readily available with no prescription, at pharmacies that visibly cater to English-speaking tourists. Indeed, in 0 of the 40 small, non-corporate pharmacies included in the sample were prescriptions required; controlled substances were either available or unavailable, regardless of prescription status. In some of these pharmacies, employees routinely offered advice to US tourists on how they can smuggle controlled substances back into the US and avoid detection. In this context, it could be especially difficult to recognize the threat of possibly counterfeit controlled substances—which can contain potentially lethal quantities of IMF 32 —because a mix of counterfeit and authentic controlled substances are illegally sold either by the lack of a legally-required prescription, or by being illicit drugs from the same locales. For a US tourist with a poor level of knowledge of the Mexican legal landscape, it may not be immediately apparent that the sale of any controlled substance without a special prescription constitutes an illegal act. These decreases have been shown to have affected many patients with known painful chronic conditions, including terminal cancer, and other palliative care patients Many patients have been rapidly tapered off opioid regimens, which has been associated with increased rates of suicide and drug overdose 35 , A large unmet demand for diverted and legitimate prescription opioids has led to widespread consumption of counterfeit opioids in the US by witting and unwitting consumers. Similarly, recent shortages of Adderall have led to substantial unmet demand for amphetamine among US patients and diverted medication consumers, which some drug policy experts have hypothesized may lead to increased use of counterfeit methamphetamine-based Adderall tablets This study is exploratory in nature, and the results should be considered hypothesis-generating and limited, requiring validation. Importantly, we did not seek to characterize or represent the prevalence of counterfeit medications across all pharmacies at the four cities of interest. Instead, we used ethnographic data to guide a purposive sampling approach that we believed was most likely to document the presence of counterfeit medications if they were present in any one of an array of intentionally selected micro-neighborhoods. This study also leverages several drug checking methodologies that are relatively new, and which require validation. Although we took extensive efforts to reduce false positives and negatives see supplement , we cannot rule them out, and all results should be interpreted in light of the inherent uncertainties of modern drug checking methodologies. We also did not seek to characterize the full population of individuals that may be purchasing these drugs, relying on a convenience sample of known informants. There is a lack of drug mortality surveillance data in Mexico, largely stemming from limitations on epidemiological and drug checking data sources. A number of qualitative and drug checking studies have indicated that fentanyl has arrived to Tijuana and other northern Mexican border cities 3 , 4 , Yet the quantitative epidemiological impact of these shifts, and any further implications from the availability of counterfeit medications, has not been adequately characterized. The availability of fentanyl-, heroin- and methamphetamine-based counterfeit medications in Northern Mexico represents a public health risk to Mexican residents and tourists, and occurs in the context of 1 the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2 plummeting rates of opioid prescription in the US, affecting both legitimate pain patients and the availability of legitimate pharmaceuticals on the black market, 3 the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. It is not possible to distinguish counterfeit medications based on appearance, because authentic and counterfeit versions are often sold in close geographic proximity and are visually and otherwise indistinguishable from one another. Nevertheless, US tourists may be more trusting of controlled substances purchased directly from pharmacies. We gratefully acknowledge the contributions of Dr. Pamina Gorbach and Dr. Steven Shoptaw to earlier drafts of this manuscript, as well as those of several collaborators at Mexican institutions who chose to remain anonymous. Pendleton Charitable Trust. CLS was supported by the U. AB was supported by the U. DGM was supported by the U. View the discussion thread. Supplementary Material. Skip to main content. Joseph Friedman. Abstract Background Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since Introduction Our ethnographic team has conducted longitudinal research focused on illicit drug markets in Northern Mexico since 1 — 4. Drug Checking Methods All samples were processed in a standardized fashion see supplement for step-by-step details. Figure 1. Figure 2. Figure 3. Examples of Known Counterfeit and Presumed Authentic Samples Photos front and back are shown of example pills, by what the sample was sold as, as well as presumed authentic or counterfeit status. We leave the pharmacy, cross the street, and duck into an alleyway … The ethnographic passage above—from the pre-existing ethnographic corpus—details a pharmacy-based drug acquisition encounter occurring in Discussion Leveraging recent improvements in point-of-use drug checking technologies, we provide the first characterization—to our knowledge—of the contents of medications sold at pharmacies in tourist-serving areas of Northern Mexico, in single pill form, to English-speaking tourists without a prescription. Limitations This study is exploratory in nature, and the results should be considered hypothesis-generating and limited, requiring validation. Conclusions The availability of fentanyl-, heroin- and methamphetamine-based counterfeit medications in Northern Mexico represents a public health risk to Mexican residents and tourists, and occurs in the context of 1 the normalization of medical tourism as a response to rising unaffordability of healthcare in the US, 2 plummeting rates of opioid prescription in the US, affecting both legitimate pain patients and the availability of legitimate pharmaceuticals on the black market, 3 the rise of fentanyl-based counterfeit opioids as a key driver of the fourth, and deadliest-to-date, wave of the opioid crisis. Data Availability All data used in the paper are contained in the manuscript's supplement. Acknowledgements We gratefully acknowledge the contributions of Dr. References 1. Am J Public Health. OpenUrl CrossRef. Deported, homeless, and into the canal: Environmental structural violence in the binational Tijuana River. The introduction of fentanyl on the US—Mexico border: An ethnographic account triangulated with drug checking data from Tijuana. International Journal of Drug Policy. In Press. Green TC , Gilbert M. Counterfeit Medications and Fentanyl. Harm Reduct J. Morbidity and Mortality Weekly Report. Steep increases in fentanyl-related mortality west of the Mississippi River: Recent evidence from county and state surveillance. Drug Alcohol Depend. Trends in seizures of powders and pills containing illicit fentanyl in the United States, through University of Michigan Accessed February 7, Accessed January 25, The Last Harvest? Journal of Illicit Economies and Development. Gilmour S , Allum F. Accessed January 26, Assessing the limit of detection of Fourier-transform infrared spectroscopy and immunoassay strips for fentanyl in a real-world setting. Drug and Alcohol Review. High concentrations of illicit stimulants and cutting agents cause false positives on fentanyl test strips. Harm Reduction Journal. Bustamante AV. Connell J. Contemporary medical tourism: Conceptualisation, culture and commodification. Tourism Management. Contreras TC. Eurasia Border Review. Gan LL , Oviedo N. Social Science Research Network ; Judkins G. Persistence of the U. Journal of Latin American Geography. Rosenthal E. Penguin Press ; Homedes N , Ugalde A. South Med Rev. Geographical and socioeconomic disparities in opioid access in Mexico, — a retrospective analysis of surveillance data. The Lancet Public Health. Ciccarone D. Fentanyl in the US heroin supply: A rapidly changing risk environment. Published October 19, Accessed January 17, J Clin Oncol. Patient outcomes after opioid dose reduction among patients with chronic opioid therapy. Knibbs K. Drugs, discipline and death: Causes and predictors of mortality among people who inject drugs in Tijuana, Int J Drug Policy. Traffic Injury Prevention. Back to top. Previous Next. Posted January 28, Download PDF. 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The Textures of Heroin: User Perspectives on “Black Tar” and Powder Heroin in Two US Cities

Buying Heroin online in Montero

Official websites use. Share sensitive information only on official, secure websites. Corresponding Author: Sarah G. The strict division of heroin markets may be changing with novel forms of powder heroin appearing in San Francisco. Our researchers and interviewees perceived vein loss stemming from the injection of heroin alone to be a particular problem of BTH while among the Philadelphia sample, those who avoided the temptations of nearby cocaine sales displayed healthier injecting sites and reported few vein problems. Abscesses were common across both sites, the Philadelphia sample generally blaming missing a vein when injecting cocaine and the San Francisco group finding several explanations, including the properties of BTH. We discuss the reasons that their tastes take this narrow form and its relationship to the structural constraints of the heroin market. Keywords: heroin, drug markets, injection drug use, heroin purity, USA, connoisseurship. Street heroin is well known to vary in purity and adulterants Akhgari et al. Regional monopolies separate most US heroin consumers from the full range of heroin source-types sold in their country Ciccarone Since the s, consumers on the East Coast have been almost exclusively offered Colombian-sourced powder heroin PH. In the mids the sources of heroin shifted from four international regions to these two countries Ciccarone In the middle of the US, more competition exists between each source Rosenblum, Unick, and Ciccarone Strang et al first raised the significance of these differences, specifically in relation to their comparative health risks in the United Kingdom. In the US, Ciccarone and Bourgois hypothesized that injection preparation practices associated with these specific heroin source-types explain the higher prevalence of HIV among injection drug users IDUs in cities with PH market dominance relative to cities with BTH market dominance. In addition, BTH appears to induce venous scarring rapidly causing users to migrate to subcutaneous or intramuscular injection routes, with lower HIV transmission risks Bourgois and Schonberg , Rich et al. Other public health risks have also been linked to particular source-types. BTH is also associated with specific infections: wound botulism Passaro et al. Ciccarone , Binswanger et al. Recently, the Heroin Price and Purity Outcomes HPPO study has found that relative to BTH, PH is associated with particular risks of overdose independent of purity; the percentage of powder heroin sold by metropolitan statistical area was an independent predictor of overdose controlling for purity Unick et al. Qualitative research suggests that this may result from regional differences in retail market models, marketing techniques and the heroin source-types themselves Mars a. A quantitative analysis of hospitalizations for injection-related SSTIs carried out by our team found that cities where the dominant heroin type was Mexican-sourced i. A doubling in SSTI rates nationally between and was a particularly worrying finding. Adulteration by dealers could be seen as negative diluting or positive in the enhancement of the high and potency was not considered analogous with purity Bancroft and Scott Reid This study used ethnography and qualitative interviewing in Philadelphia and San Francisco. The ethnographic insertion of the same anthropological team in both cities provided privileged access to observational and interview data in the natural environment of street-based users and allowed comparative observations. It informed the preparation of the interview guide and the recruitment priorities and sites for cross-regional comparison. For the qualitative interviews, the ethnographic work enabled a targeted sampling strategy, with purposive recruitment augmented by the snowball convenience sampling techniques generally used to access hidden populations. Interviewees over 18 who were current heroin injectors and living in either San Francisco or Philadelphia were recruited in areas of known open-air drug markets in both cities and through needle exchanges. When it became clear that the effects of heroin on vein health was complicated by the injection of cocaine powder, we recruited additional users who injected only heroin. All participants were interviewed once in and several were accompanied on multiple occasions. All the interviews were audio recorded and transcribed verbatim. Transcriptions were verified against the audio recordings for accuracy. Twenty-two current heroin injectors were interviewed in Philadelphia and 19 in San Francisco. Details of the methods have been reported previously Rosenblum et al. Philadelphia is highly ethnically segregated and has suffered for many years from the effects of de-industrialization Rosenblum et al. The Census was the first since the — census to report a population increase Mackun after decades of outmigration. San Francisco is a more integrated, prosperous global city that attracts immigrants worldwide and within the US. It has been undergoing an intensifying process of gentrification and population increase. Among the Philadelphia sample interviewed, 8 were women and 14 were men. Sixteen had used for more than 3 years and 6 for 3 years or less. In the San Francisco sample, 12 were women and 7 were men, among whom 15 had used for more than 3 years and 4 for 3 years or less. Across both groups, some had completed high school but few referred to experience of college education; unemployment and either homeless or insecure housing were common. In San Francisco, some users sold marijuana to support themselves. Other sources of income across the cities included working in construction, social service benefits, acquisitive crime and sex work. The Philadelphia injectors had mostly grown up in and around that city 17 out of 22 and begun their drug using careers there, while the majority 14 out of 19 of the San Francisco users were migrants from around the country. It is poorly vaporizable smokeable but can be effectively insufflated snorted although injecting is the most efficient route of administration. On rare occasions BTH was said to be available in limited amounts but in five years of observations the ethnographers never saw any being sold or used. No Philadelphia users reported seeing GPH. In Philadelphia it is further packed inside tiny ziplock bags see Figure 2. Although the price was constant, purity by volume varied and it is on purity that Philadelphia heroin sellers compete against each other Mars b. Users in both cities reported family members selling heroin to them for considerably less. Philadelphia users interviewed typically bought one to three bags of heroin at a time, a sign of its easy availability and possibly greater impoverishment than their San Francisco counterparts. Buying only a bag or two at a time also allowed users to monitor the quality of competing brands, returning only if they deemed it worthy of repeat custom. In San Francisco, BTH is a comparatively less refined substance which includes a mixture of alkaloids. It can require a knife to cut, be brittle enough to shatter or soft enough to stretch and tear apart when warmed to body temperature, perhaps in a pocket. Some speculated that it was cut with molasses, sugar, lactose or shoe polish but few had direct experience of the cutting process. Among many of the interviewees it had gained popularity as a higher potency alternative to the longer established product. Some of the interviewees mentioned that it clumped together and became tar with small amounts of moisture, as when breathed on. Like tar, it needed heat to dissolve quickly but tended to be more soluble than BTH. A more refined powder heroin of widely varying purity was also reported on sale in San Francisco. This was apparently limited to private dealers who arrange sales by cell phone rather than selling on the streets. There is speculation among analysts that this white powder is the result of Mexican chemists using production processes borrowed from Colombian drug producers ONDCP ; another possibility is that it is the synthetic opiate fentanyl, sold under the guise of high quality heroin. According to the interviewees, cocaine powder was hard to find and of poor quality in San Francisco. Methamphetamine, by contrast, was more widely available but not popular among this group. For the injectors interviewed the condition of their veins, the portals through which pain could be assuaged and pleasure accessed, was of considerable significance. A consensus emerged across the Philadelphia group that cocaine was more damaging to veins than PH. Only three of the Philadelphia sample used heroin but no cocaine at the time of the interview. However, others who had formerly injected only PH observed that they too had experienced few vein problems until they had added cocaine to their repertoire. In their wider observations, the ethnographers witnessed no devastating vein loss among heroin injectors in Philadelphia except among those who also injected cocaine powder. Users in the Philadelphia group who had lost venous access elsewhere often transitioned to injecting in their neck jugular vein but most drew the line at the groin femoral vein. Some, like this 29 year old man, considered injecting into their neck particularly pleasurable:. It hits you a lot quicker, a lot more — it seems like it takes less and it just hits you better. Both skin popping heroin and injecting speedballs have been linked to abscesses at injection sites Murphy et al. However, they generally attributed this to missing veins with cocaine and rarely to PH alone. In San Francisco six of the sample injected powder cocaine as well as heroin at the time of interview; five had done so in the past but had given up using it, with remarks that it was difficult to obtain and of poor quality. Seven had either never or only very rarely injected cocaine in the past or present. Most thought cocaine more destructive to their veins than BTH but some considered BTH equally damaging and several attributed the loss of many usable veins to black tar alone. Some San Francisco users avoided intentionally muscling or skin popping BTH because, they said, it was painful or led to abscesses. The longer term use of more than one heroin source-type, enabling users to observe their comparative vascular effects was rare among the Philadelphia group, only one of whom had traveled extensively in her drug using career, sampling heroin across the US. When asked to compare the different source-types, she was skeptical of differences between them aside from their injecting implications, saying:. People here want tar. I personally prefer China White honestly because the tar tears up your veins. Such comparative experience was more common in San Francisco not only because of the high proportion of migrants from across the country but also the wider range of heroin products reportedly available. Limbs of San Francisco long-term injectors of black tar heroin with scarred injecting sites. Vein loss, resorting to or preferring inaccessible neck veins, inexperience injecting, withdrawal symptoms and hands shaking from the effects of stimulants were commonly mentioned as reasons they might seek help with a shot. The skill required to inject intravenously and the need to be injected, whether among injecting initiates or veterans, produced a form of exchange both for utilitarian motives and symbolic significance Bourgois and Schonberg , Epele The ethnographers noted that in Philadelphia some older, often male, heroin users could afford their large habits thanks to younger, especially female, users who ask them to inject them in exchange for a bag of heroin. Interviewees in both cities considered potency and duration of effect as the chief attributes of high quality heroin. That was fentanyl cut. Users interviewed in both cities equated high quality with potency and the potential for overdose, like this 29 year old man in San Francisco, using for 6 years:. Appearance, texture and odor, important in the appreciation and selection of other drugs such as alcohol, tobacco and marijuana, were generally only noted in relation to what they might indicate about the potency of heroin. Among heroin injectors in Philadelphia some had tried tastes of BTH when it appeared briefly on the market as a fluke and others knew it only by reputation. Those with direct experience and those without tended to describe it as more potent than PH and as lasting longer but these were mostly fleeting impressions, often vaguely remembered. Migration could be a way to overcome this problem but most of the migrants in our study had moved to generally less desired BTH-dominant San Francisco rather than PH-Philadelphia. While most of the Philadelphia interviewees had grown up there, some had moved from nearby towns or suburbs. Although this did not involve changing heroin source-types, some reported moving into the area of the main open street market where heroin is known to be plentiful, cheap and good quality. While some of our findings show contrasting effects of the two main heroin source-types, others transcended these divisions, being common to heroin injectors studied in both cities. Ethnographic and qualitative research is subject to a number of biases including subjective sampling and response biases. Given that some of events reported often occurred years before the interview, the possibility of recall bias is important to bear in mind. These are lessened somewhat by the length of immersion in the study sites and interview styles grown out of extensive experience. As with much qualitative research, the samples are small and non-random. However, the qualitatively generated hypotheses regarding the risks of SSTIs from contrasting source-types has been tested in quantitative models by our team Ciccarone The loss of venous access was perceived to be a major problem among heroin injectors. In San Francisco, where there was agreement about the low quality and scarcity of cocaine powder, users displayed and described severe vein loss and trauma they experienced as the result of injecting BTH. In Philadelphia, PH injectors who reported avoiding the temptations of nearby cocaine sales suffered less vein loss or scarring. The reasons for the severe vein loss perceived by both the interviewees and the ethnographers as associated with BTH rather than PH needs further exploration; one commentary suggests drug acidity levels are a proximal etiology Ciccarone and Harris Vein loss had also prompted some to transition to major veins in the neck and groin, more commonly in Philadelphia with concurrent cocaine injecting. Among the San Francisco group, the neck was a more taboo injecting location. The persistence of cocaine powder in Philadelphia, which users considered unsuitable for intramuscular and subcutaneous injection, may have encouraged a more extreme culture of intravenous injection. With drugs such as alcohol, tobacco and marijuana, a culture of taste or connoisseurship has grown up in which smell, appearance, taste, plant variety and country of origin are often important parts of the experience of consumption. However, in this study smell and appearance were generally only noted in terms of what they indicated about potency. With the choice of heroin limited by duopoly, there is little opportunity for consumer comparisons between heroin types. However, in San Francisco, interviewees reported a wide price range determined by anticipated and perceived potency and some users were able and willing to pay more for the higher priced products. It differs in form from the upper class wine connoisseurship, which overtly disfavors intoxication, sometimes to the exclusion of actual consumption spitting wine out at tastings, for instance. The connoisseurship among these heroin injectors takes the narrower form of a search for potency because it is shaped by the necessity of dependence, the mode of drug administration injecting removes the oral taste experience , lack of resources of these users who consume the drug soon after purchase, their often precarious living situations, stigmatized status and the constraints of the US heroin market in which accurate information on sources and methods of cultivation and production are hidden. On the West Coast, heroin types are diversifying with the appearance of reportedly higher potency source-types after many years of typically low purity and the addition of fentanyl to the supply. The drivers of this change are as yet unclear but are most likely structural DEA As new forms of the drug appear to be proliferating, it will be interesting to observe what might be the implications for patterns of consumption and health. As a library, NLM provides access to scientific literature. J Psychoactive Drugs. Published in final edited form as: J Psychoactive Drugs. Find articles by Sarah G Mars. Philippe Bourgois , Ph. Find articles by Philippe Bourgois. George Karandinos , B. Find articles by George Karandinos. Fernando Montero , M. Find articles by Fernando Montero. Daniel Ciccarone , M. Find articles by Daniel Ciccarone. Fernando Montero : M. Issue date Sep-Oct. PMC Copyright notice. The publisher's version of this article is available at J Psychoactive Drugs. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Buying Heroin online in Montero