HEROIN

OFFICIAL NAMES: Heroin (diacetylmorphine)

STREET NAMES: H, horse, boy, smack, stuff, mud, dope, tar, black tar, dragon fire, king kong, cat woman, hat man, TNT, white skull, body bag, creeper, shake, treat, cap, spoon, slag, dragon, mac, heron, chiva, china white, monkey, magic, lady, tammy, manteca, diesel, turkey

DRUG CLASSIFICATIONS: Schedule I, narcotic

OVERVIEW

According to the U.S. Central Intelligence Agency, worldwide production of opium has doubled since the mid-1980s. The result has been easier and cheaper access to the drug and worsening social problems, such as crime, associated with its abuse. Derived from opium, heroin is a highly addictive drug, and its use is a serious and growing problem. Rising purity levels and lower prices have fueled heroin's popularity.

The widely held misconception that snorting or smoking it is "less addictive" than intravenous injection lures new young users. Any ingestion of heroin promotes tolerance and drug cravings that can, and frequently do, lead to addiction. Teens and young adults across the country are learning the hard way that heroin addiction can come just as easily in a pipe as a needle.

Opium production occurs in three source regions—Southeast Asia, Southwest Asia, and Latin America. While an undetermined amount of the opium is consumed in the producing regions, a significant amount of the drug is converted to heroin and sent to its major markets in Europe and North America.

Origin and production

Heroin is a narcotic derived from the opium poppy plant (Papaver somniferum). Opium poppy is grown primarily by destitute farmers in what is known as the Golden Crescent in Southwest Asia (encompassing Turkey, Iran, Afghanistan, and Pakistan) and the Golden Triangle in Southeast Asia (Burma, Thailand, Laos, and Vietnam). In the Americas, Columbia and Mexico are chief producers.

The poppy plant produces raw opium. Crude refineries modify the opium into a brown paste that is molded and dried into bricks. More sophisticated laboratories are found in Bangkok, Karachi, and Hong Kong. These labs change opium into what is known as number three heroin, a smokeable form. Purification of heroin to the "injectable" fourth stage (number four heroin) involves a volatile chemical combination that can result in catastrophic explosions.

History

The history of opium usage stretches back to 3400 b.c., where it was first cultivated in lower Mesopotamia. The Sumerians called the poppy Hul Gil or the "joy plant." The art of poppy cultivation spread from the Sumerians to the Assyrians, and from the Assyrians to the Babylonians and Egyptians.

The Egyptians applied proven agricultural methods to growing opium poppies, and the trade flourished throughout the ancient world. For the next 3,000 years, opium was an important trade item among civilizations clustered around the Mediterranean. Prized by merchants and traders, opium would find its way into markets in Greece, Carthage, India, Persia, and China.

As Europe began its slow emergence from the Dark Ages in the sixteenth century, opium began to reappear in medical journals on the continent. A century later, an English apothecary named Thomas Sydenham introduced "Sydenham's Laudanum," pills made from opium, sherry, and herbs. They were popular remedies for a variety of ills.

Portugese traders with routes to the East China Sea smoked opium with tobacco in long-stemmed pipes. They reintroduced the practice to the Chinese who had frowned on its use. The British East India Company assumed control of poppy-producing fields in India and dominated the opium trade. By the late 1700s, the East India Company had established a monopoly on its import into China, Europe, and the United States.

Opium had long been used by the Chinese to stop diarrhea, but in the seventeenth and eighteenth centuries, its recreational use exploded. In 1800, the Imperial government of Kia King banned its import and trade completely, but could not effectively enforce the ban. Opium dens flourished in the port cities and spread inward.

With its officials routinely bribed, China quickly became a haven for corruption, lawlessness, and addiction. In desperation, the imperial government made opium illegal in 1836 and took action against Chinese merchants and Western traders who continued to traffic in the drug. This and other trade disputes with the British led to the first of two Opium Wars.

By the time opium was banned by the U.S. Congress in 1905, the abuse of black market heroin had already taken hold. In 1910, Britain signed an agreement with China to dismantle the opium trade. But the profits made from its cultivation, manufacture, and sale were so enormous that no serious interruption would be felt until World War II closed supply routes throughout Asia. And although Bayer ended the manufacture of heroin for medicinal use in 1913, illicit importation and distribution networks in New York and San Francisco were already well established.

U.S. military involvement in Vietnam was credited with the next major surge in heroin smuggling into the United States. Political and economic turmoil in the region led to a surge in production from Southeast Asia's Golden Triangle. By the end of the U.S. war in Vietnam, there were some 750,000 heroin addicts on American streets.

Despite the billions of dollars spent to keep heroin off its streets, America's efforts have been unsuccessful. Heroin is not only more plentiful in the United States than it was 30 years ago, but it is also cheaper and at its point of sale almost 10 times as pure.

CHEMICAL/ORGANIC COMPOSITION

All drugs derived from opium poppy are called opiates. Of the opiates, heroin (diacetylmorphine) is the most potent and fast-acting. Though heroin is no longer used in medical settings, its less potent cousins—codeine, liquid morphine, pethidine, and methadone—are found in clinics and hospitals all over the world. But it wasn't until the early 1970s that scientists began to understand the real reasons behind heroin's propensity for abuse and addiction.

The chemical composition of opiates are remarkably similar to endorphins, chemicals produced by the brain in times of distress or injury to relieve pain or ease fear. There are three major types of endorphins: beta endorphins, located in the brain; and enkephalins and dynorphin, which are distributed throughout the brain and body.

These natural chemicals are small chain peptides that bind to opiate receptors distributed throughout the brain—including the limbic system, where their activation produces feelings of happiness, euphoria, serenity, and fearlessness.

The endorphins enkephalin and dynorphin possess natural analgesic (pain-relieving) qualities. When they bind to opiate receptors in the spinal cord, they suppress the ability of the brain to register pain. Heroin binds to these same opiate receptors in the brain and body.

Types of heroin

Most heroin is packaged and shipped in bricks of powder. Pure heroin is white, but the color when it reaches the user can vary from yellow to dark brown, owing either to impurities during the manufacturing process, the presence of powdered additives, or both.

Heroin is usually cut with baking soda, powdered milk, baby powder, sugar, starch, or quinine, but has also known to be cut with lidocaine, curry powder, strychi-nine, and even laundry detergent. Law enforcement officials in New York report the existence of heroin cut with a rat poison from Santa Domingo called Tres Pasos(meaning "three steps"). Three is the number of steps the mice take before dying after exposure to the poison.

Another form of heroin commonly distributed in the western and southwestern regions of the United States is called Black Tar or Mexican Brown. These varieties are produced in Mexico and—because they're manufactured crudely—have an either hard black coal or sticky, tar-like consistency. Purity rates range from 20–80%.

In 1980, the purity of heroin was somewhere in the 4% range. In 2002, the average bag sold by dealers in the United States was almost 40% pure, and sold for less than one-fifth the 1980 price.

INGESTION METHODS

Until very recently, the most common means of administering heroin was injection with a hypodermic needle, either intravenously (into a vein; called "mainlining"), subcutaneously (just under the skin; called "skin-popping") or intramuscularly (injected into muscle rather than a vein). Injection by regular users and addicts was preferred because the street drug was so diluted with fillers that injection was the most efficient way to get high.

Many first-time intravenous users of heroin have intensely negative reactions to the drug, including nausea and vomiting. For many, this is enough to turn them off heroin for good, but for others, social pressures and other factors compel them to keep trying until they find the high they anticipated.

With purity levels of packaged heroin increasing, the drug can now be snorted or smoked, severing for many people the negative associations heroin has with intravenous drug use. This has greatly expanded heroin's

pool of potential users and addicts, especially among young people.

According to a recent study by the National Institute on Drug Abuse (NIDA), smoking produces lower levels of heroin in the blood than injection, but the effects on the user are roughly similar. Smoking heroin also gives users more control over their intake of the drug without the burden of preparing another intravenous dose.

Snorting heroin is probably the least efficient means of taking the drug and has several immediate drawbacks, including strong stomach cramps and a constantly running nose. Many regular users of heroin began by snorting the drug on occasion. This kind of early heroin use is called "chipping." A high percentage of chippers eventually turn to injection of the drug before realizing they are hooked.

THERAPEUTIC USE

Because of its analgesic (painkilling) properties, opium and its derivatives have long been used for the treatment of ailments. Throughout the nineteenth century in England and the United States, opium was administered in plasters, pills, cough drops, lozenges, and many other applications dispensed by physicians and pharmacists.

In 1895, while working for the Bayer Company in Germany, Heinrich Dreser produced a drug he thought was as effective an analgesic as morphine, but without its harmful side effects. Bayer began mass production of diacetylmorphine, and in 1898 began marketing the new drug under the brand name "heroin" as a cough sedative.

Pharmacists in France, England, and the United States regularly marketed heroin as an excellent pain killer and a cure for disease, including respiratory ailments and diarrhea.

Several medical societies in the United States at that time offered heroin as a safe means of treating morphine addiction. Articles appearing in American medical journals early in the twentieth century spoke highly of heroin's ability to soothe the painful aches, shakes, and vomiting experienced by recovering morphine addicts, and it was widely used as a "step down" cure.

Within a decade, doctors realized they were merely substituting one opiate addiction for an even more powerful one.

Internationally, heroin's use as a medicine wasn't regulated until 1925 when the League of Nations adopted strict rules governing international heroin trade. The same body later stipulated that heroin producers could only manufacture quantities sufficient for medical use, though these guidelines were unenforceable and largely ignored.

USAGE TRENDS

Every government agency that has sought to quantify usage trends of heroin in the United States over the last several years has come to one inescapable conclusion: heroin use across the country is climbing dramatically, especially among young people.

In 2000, heroin was second only to cocaine in the number of drug-related emergency room episodes reported to a national registry run by the Drug Abuse Warning Network. Heroin, listed as a principal agent in respiratory and cardiac emergencies, went from 33,884 episodes nationwide in 1990 to 94,804 in 2000—an increase of nearly 180%.

Locally the numbers are even more dramatic. In a similar eight-year period (between 1991 and 1998), the rate of heroin-related incidents at area hospitals increased by 413% in Miami, 288% in Chicago, and 238% in St. Louis.

Scope and severity

The Office of National Drug Control Policy's (ONDCP) study of 21 major metropolitan areas in the United States revealed that the most likely user of heroin is over 30 years old. However, younger adults (18–30) comprise a substantial portion of those believed to be experimenting with heroin use. In the South, younger adults are more likely than adults over 30 to be regular users of the drug.

Figures compiled by the U.S. Department of Health and Human Services National Household Survey on Drug Abuse (NHSDA) estimate that there were approximately 104,000 new heroin users in 1999. Among these new users, 87,000 were between the ages of 12 and 25 and 34,000 of them were under age 18. The average age at first use among these new heroin users was 19.8 years.

The same study found that the number of people who had used heroin in the last month, an indication of more regular use, had climbed from 68,000 in 1993 to 208,000 in 1999.

Nationwide, the NHSDA released estimates in 1999 that said approximately 2.7 million Americans (1.2% of the population) are thought to have used heroin at least once in their lifetimes.

Age, ethnic, and gender trends

According to the National Institute on Drug Abuse (NIDA), among high-school-age teens, rates of heroin use remained relatively stable and low from the late 1970s until the start of 1990s.

After 1991, however, use began to rise among tenth-and twelfth-graders, and after 1993, among eighth-graders as well. In 1999, prevalence of heroin use was roughly the same for all three grade levels. Although the number of students who reported using heroin in the last year remain under 2% in 1999, the rates are about two to three times higher than those reported in 1991.

The NIDA released figures showing 1.7% of eighth graders, 1.7% of tenth graders, and 1.8% of high school seniors (twelfth graders) reported using heroin at least once. The results are remarkably static as respondents leave school and enter college, suggesting a strong adolescent culture of drug experimentation. Among college students, 1.7% reported using heroin at least once in their lifetime, while 1.8% of young adults aged 19–28 reported lifetime heroin use.

When asked about heroin use in the last 30 days,0.6% of eighth graders, 0.3% of tenth graders, and 0.4% of twelfth graders reported using heroin at least once, compared to 0.2% of college students and 0.1% of young adults.

In a separate report issued by the Centers for Disease Control (CDC), the indications of heroin experimentation among teens in high school were even higher. In the CDC report, 2.4% of sampled high school students reported having tried heroin at least once.

Drawing on data supplied by individual states, estimates of teen use varied between a low of 1.7% to a high of 5.2%. The CDC report also looked at specific metropolitan areas and these estimates mirrored state data; surveys pegged teen prevalence with a low of 1.0% and a high of 5.3%.

In a 2001 study entitled Epidemiologic Trends in Drug Abuse conducted by the Community Epidemiology Work Group (CEWG), a branch of NIDA, the number of men who abused heroin strongly outweighed the number of female users.

These trends appear to be established early on. Male high school students who report trying heroin, for example, outnumber female students in the CDC study by a ratio of almost three to one.

According to the ONDCP, which conducts in-depth drug usage profiles in 21 American cities, heroin users are most likely to be white and male. Whites and blacks are equally represented among heroin users in Birmingham, Alabama, and Columbia, South Carolina; and Hispanics are the dominant user group in El Paso, Texas, and Los Angeles, California. In Denver and Philadelphia, white users predominate, but Hispanics are overrepresented relative to their percentage of the general population. Similarly, in Boston, whites are more numerous among heroin users, but blacks are overrepresented.

MENTAL EFFECTS

The force of heroin's initial impact on the user, and the duration and intensity of the high, depends on the method of ingestion. If injected directly into the bloodstream, the euphoric "rush" hits the user in less than 10 seconds. Intramuscular or subcutaneous injection produces a much more gradual response as the drug takes longer (six to eight minutes) to filter into the bloodstream. Smoking heroin also produces less of an initial rush and a more gradual response to the dose, anywhere from 10 to 15 minutes.

It is the drug's sudden entry into the brain that accounts for the initial surge of energy. The rush is thought to last as long as it takes the brain and body to break heroin down into morphine, which is then absorbed by the body's opioid receptors. This stage finds the user going "on the nod," an alternatively wakeful and pleasurably drowsy state that lasts four to six hours.

Given that the morphine is artificially dosing the brain's opiate receptors, it is not surprising to hear users describe a powerful state of complete fulfillment and a tremendous sense of self-satisfaction while under the influence of the drug. Over time, because of the development of tolerance (needing higher doses more frequently to achieve the same effects felt at first use), heavy users and addicts lose the ability to get high and use the drug solely to counteract the effects of withdrawal.

PHYSIOLOGICAL EFFECTS

Heroin is a central nervous system depressant. The drug slows heart and breathing rates dramatically. During the "nod off" phase, consciousness may be lost. Any one of these effects is dangerous to the user; in combination, they are potentially life-threatening. Given the high incidence of nausea and vomiting associated with heroin use, for example, users who lose consciousness and then become sick are at risk of choking to death.

As is the case with other opiates, regular ingestion of heroin creates rapid tolerance in the user. Even over a relatively short period, weekend users may find themselves taking larger doses of the drug to achieve the same high. As many recovering addicts will attest, this is the often the first addictive hook heroin gets into recreational users.

The mechanics of tolerance are still not fully understood. One hypothesis suggests that when habitual heroin ingestion upsets the body's natural chemical equilibrium, the body attempts to compensate for it. More of the drug is then needed to overwhelm the body's attempt to suppress the drug's influence. This kind of tolerance is found with regular use of nearly all psychoactive substances.

Tolerance to heroin can vary greatly among individuals. A "regular" or "safe" dose for an experienced user can kill someone who has never tried it before. Even occasional users who build up some tolerance and take several weeks off from the drug can suffer an over-dose from their "usual" dose.

Depending on tolerance, and the amount and purity of the drug consumed, a lethal dose of heroin can range anywhere from 200 to 500 mg. Hardened addicts have survived doses three times that high.

The growing purity level of street heroin sold in American cities and suburbs is one of the most worrisome aspects of the drug's resurgence. Users accustomed to 25% purity can easily overdose if they use the same amount of the drug that is 50% or 70% pure.

A 2001 study conducted by the ONDCP found that Colombian heroin purity ranges from as low as 7% to as high as 95%. Purity of Mexican black heroin sold in South and West ranged from 14% to 58%—with both extremes reported in Seattle. These kinds of fluctuations can have deadly consequences for the user.

Harmful side effects

Heroin use can cause tragic complications during pregnancy, greatly increasing the chances of spontaneous miscarriage, breech deliveries, premature birth, or stillbirth. Research conducted by NIDA suggests that babies born to heroin-addicted mothers are at higher risk for sudden infant death syndrome (SIDS). Infants who do survive the pregnancy are often born addicted to heroin and exhibit severe withdrawal symptoms for a period of weeks and even months.

Heroin addicts are at a much higher risk for contracting HIV, hepatitis C, and bloodborne pathogens through the sharing and reuse of hypodermic syringes and other "works" associated with injection drug use. Government studies suggest that one-third of all HIV and more than half of all hepatitis C cases are the result of injection drug use.

Long-term health effects

Of course, one of the most debilitating effects of heroin use is dependence and addiction. Dependence follows the same trajectory as tolerance.

Eight to twelve hours after the addict's last dose, the user begins to experience the onset of flu-like symptoms: watery eyes, sneezing, muscle aches, weakness, and vomiting. The symptoms increase in severity over the next two to three days and include shivering, muscle spasms, paranoia, fear, hallucinations, and debilitating cramps in the stomach and extremities. Within a week, the body has corrected the imbalance created by the regular ingestion of heroin, and the symptoms subside. However, intense cravings for the drug last for a much longer period of time and often contribute to relapse.

Health consequences of chronic heroin abuse include scarred and collapsed veins, bacterial infections of the blood vessels and heart valves, boils, a variety of soft-tissue infections, kidney problems, and liver disease. Pneumonia, tuberculosis, and other lung diseases are also common among long-term users, which can be attributed to either poor nutrition and depressed respiratory function or both. Many of the additives heroin is cut with do not dissolve in the body and can block blood vessels, translating into higher risk of sudden death from stroke or heart attack.

Recovering heroin addicts often endure years of corrective dental work due to neglect and the side effects of regular drug use. Heroin addicts often have cavities along the gum-line and gum disease, because the drug causes a marked decrease in the production of saliva. Saliva protects the mouth by neutralizing acids that cause cavities and providing lubrication that reduces the retention of food debris.

A NIDA-supported study conducted by the University of Southern California Los Angeles examined the lives of some 587 heroin addicts admitted to criminals' addiction programs in the early 1960s. The researchers found their lives were marked by cycles of abstinence, relapse, crime, incarceration, chronic disease, and early death. By 1997, nearly half of the group had died. A full 40% of the survivors were still struggling with their addiction and reported using heroin in the last year. Fewer then 10% were in a working addiction program.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

Even experienced users caution mixing heroin with anything else: alcohol, amphetamines, and especially cocaine all greatly increase the dangers of using heroin by itself.

Ingesting heroin along while consuming alcohol is considered especially dangerous. Drinking alcohol increases the likelihood of vomiting and the dangers of choking. Also, both heroin and alcohol are central nervous system depressants and could slow the heart rate and breathing to dangerously low levels.

Combining cocaine and heroin, regardless of the ingestion method, is called "speedballing." Speedballing is extremely dangerous. For reasons that are not completely understood, the drugs enhance each other's effectiveness. Heroin enhances the electric high produced by cocaine, while cocaine elevates the mellowing aspects of heroin.

Physiologically, cocaine is a powerful stimulant that quickens the heartbeat, but it wears off much faster than heroin, which works to depress the heart rate. The stimulant effect of the cocaine and the depressant effect of heroin wreak havoc on the heart, which can lose its rhythm. Cocaine frequently masks how much heroin has been consumed, and when the cocaine's effects dissipate, heart failure can result. John Belushi and River Pheonix both died this way after taking speedballs.

In some parts of the western United States, particularly California where methamphetamine (crystal) is plentiful, speedballing a mix of heroin and methamphetamine, whether they are inhaled or injected, is increasing in popularity. In addition to methamphetamine, some heroin users take benzodiazepines—types of tranquilizers—to increase the effect of the opiate. Sources report that the use of MDMA (ecstasy) is increasing among heroin users, and that Rohypnol, a sleeping aid, is being taken to "soften the fall" when the effects of the drug combination begin to wear off.

TREATMENT AND REHABILITATION

A variety of treatments and treatment programs that are available to people addicted to heroin, though the treatment options available and the quality of the care provided greatly increase with the ability to pay. In a recent Rolling Stone interview, one anonymous addict said it cost his parents $150,000 for his two-year stay in a drug treatment center. Publicly subsidized treatment programs frequently have waiting lists and are forced to turn people away. The cold realities of drug treatment are even more troubling.

Despite progress, most studies post the failure rate of most treatment programs at or near 80%. Most addicts who try to abstain relapse at least once, and often several times before successfully kicking their drug addiction.

A common first step of treating heroin addiction is detoxification. The objective is to relieve withdrawal symptoms while allowing patients to adjust to life without heroin. "Detox," as it is sometimes called, is not an end in itself but a beginning that must also include broad therapeutic programs. Most successful programs of this type are in-patient residential regimens lasting three to six months.

Because any opiate derivative will suffice to soothe heroin cravings associated with withdrawal, methadone, a synthetic opiate that has no sedating side effects, has been an effective treatment for heroin and morphine addiction for more than 30 years. The medication is taken orally and suppresses narcotic withdrawal for a period of 24 to 36 hours. Methadone can be taken continuously for 10 years or longer with no harmful side effects.

Like methadone, LAAM (levo-alpha-acetylmethadol) is a synthetic opiate used to treat heroin addiction. LAAM can block the effects of heroin for up to 72 hours. This makes outpatient treatment much more convenient, given that patients need to dose only two to three times a week. Naloxone and naltrexone are new medications that are also effective at blocking the pleasurable effects of heroin, helping motivated individuals to abstain.

Buprenorphine (Temgesic, Subutex) is a new medication that has been shown to be even more effective in blocking the effects of heroin than methadone. Recent preclinical studies have shown that buprenorphine may also significantly reduce cravings associated with cocaine addiction.

Though drug-based treatment regimens can be helpful in conquering heroin addiction, integrating them with behavioral and therapeutic programs (both individual and group counseling) have consistently proven more effective at preventing relapse over the long term.

PERSONAL AND SOCIAL CONSEQUENCES

There is nothing glamorous, cool, or chic about heroin use. It is a personally and socially destructive compound that in imperceptible stages can reorient the user's priorities around its consumption.

Few, if any, heroin addicts set out to sacrifice their families, friends, and futures in service of their next fix, but that is what often happens. Heroin gradually sinks its hooks deeper into the user's psyche. What starts out as very occasional use can evolve in small steps to more frequent use. Monthly use can soon become weekly use. Before long, it is the drug that is dictating when it is consumed.

Heroin addiction is not easy or cheap to overcome. Many heroin addicts face a life of continual relapse, declining economic opportunity, broken families, and failing health. In a Rolling Stone interview, one user who failed in her attempt to stay clean likened the experience of sobriety to wanting to tear the muscle off her bones.

Heroin abuse has repercussions that extend far beyond the individual user and his or her family. The consequences of drug abuse and addiction carry a social price in festering criminality, violence, and disruptions to the workplace and educational environments that cost billions of dollars each year.

LEGAL CONSEQUENCES

Strict penalties are provided for drug convictions, including mandatory prison terms for many offenses. Federal law states that any conviction for possession, use, or distribution of illicit substances can result in loss of federal benefits, confiscation of property, fines, and jail sentences.

Persons convicted on federal charges of possessing any controlled substance face penalties of up to one year in prison and a mandatory fine of no less than $1,000 up to a maximum of $100,000. Second convictions are punishable by not less than 15 days but not more than two years in prison and a minimum fine of $2,500. Subsequent convictions are punishable by not less than 90 days but not more than three years in prison and a minimum fine of $5,000.

If death or serious bodily injury results from the use of an illegally distributed controlled substance, the person convicted of distributing that substance faces a mandatory life sentence and fines of up to $8 million.

Persons convicted on federal charges of drug trafficking within 1,000 feet of a university face penalties of prison terms and fines that are twice as high as the regular penalties for the offense, with a mandatory prison sentence of at least one year.

See also Cocaine; Methadone; Opium

RESOURCES

Books

Berridge, Virginia, and Griffith Edwards. Heroin, Opium and the People: Opiate Use in Nineteenth-Century England. New York: St. Martins Press, 1981.

Fernandez, Humberto. Heroin. Center City, NY: Hazelden Information Education, 1998.

Inciardi, James. The War on Drugs II: The Continuing Epic of Heroin, Cocaine, Crack, Crime, AIDS and Public Policy. Mountain View, CA: Mayfield Publishing Company, 1991.

Periodicals

European Union. European Monitoring Center for Drugs and Drug Addiction. Report on the Risk Assessment of Ketamine in the Framework of the Joint Action on New Synthetic Drugs. September 25, 2000.

U.S. Department of Health and Human Services. 2001 Monitoring the Future: National Results of Adolescent Drug Use. Washington, DC: U.S. Dept. of Health and Human Services, January 2002.

U.S. Department of Health and Human Services. National Institute on Drug Abuse. "Buprenorphine Proves Effective, Expands Options For Treatment of Heroin Addiction." NIDA Notes (May 2001).

U.S. Department of Health and Human Services. National Institute on Drug Abuse. "Heroin Snorters Risk Transition To Injection Drug Use And Infectious Disease." NIDA Notes (August 1999).

U.S. Department of Health and Human Services. National Institute on Drug Abuse. Heroin Update: Smoking, Injecting Cause Similar Effects; Usage Patterns May be Shifting. Washington, DC: U.S. Dept. of Health and Human Services, July/August 1995.

U.S. Department of Health and Human Services. National Institute on Drug Abuse. "33-Year Study Finds Lifelong Lethal Consequences of Heroin Addiction." NIDA Notes (October 2001).

U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. National Clearinghouse for Alcohol and Drug Information. Heroin Treatment Admissions Increase: 1993-1999. Washington, DC: U.S. Dept. of Health and Human Services, January 2002.

U.S. Department of Justice. National Drug Intelligence Center. National Drug Threat Assessment 2002. Washington, DC: U.S. Dept. of Justice, December 2001.

U.S. Office of National Drug Control Policy. "Pulse Check: Trends in Drug Abuse: Heroin." November 2001.

Other

U. S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. July 8, 2002. <http://www.samhsa.gov>. Accessed July 8, 2002.

U.S. Department of Justice. Drug Enforcement Administration. <http://www.usdoj.gov/dea>. Accessed July 8, 2002.

U.S. National Institute on Drug Abuse. June 27, 2002. <http://www.nida.nih.gov>. Accessed July 8, 2002.

U.S. Office of the National Drug Control Policy. July 5, 2002. <http://www.whitehousedrugpolicy.org>. Accessed July 8, 2002.

Christopher V.G. Barillas