Pubdate: Sun, 19 May 2019
Source: New York Times (NY)
Copyright: 2019 The New York Times Company
Author: Abby Goodnough


BALTIMORE - Heroin has ravaged this city since the early 1960s,
fueling desperation and crime that remain endemic in many
neighborhoods. But lately, despite heroin's long, deep history here,
users say it has become nearly impossible to find.

Heroin's presence is fading up and down the Eastern Seaboard, from New
England mill towns to rural Appalachia, and in parts of the Midwest
that were overwhelmed by it a few years back. It remains prevalent in
many Western states, but even New York City, the nation's biggest
distribution hub for the drug, has seen less of it this year.

The diminishing supply should be a victory for public health and law
enforcement alike. Instead, in cities like Baltimore, longtime users
who managed to survive decades injecting heroin are now at far higher
risk of dying from an overdose. That is because synthetic fentanyl, a
deadlier drug that is much cheaper to produce and distribute than
heroin, has all but replaced it.

The dramatic rise of fentanyl, which can be 50 times stronger than
heroin, has been well documented. But its effect on many older, urban
users of heroin, who had been able to manage their addiction for
years, has been less noticed. The shift from heroin to fentanyl in
cities has contributed to surging overdose deaths among older people
and African-Americans and deeply unnerved many like William Glen
Miller Sr., who first tried heroin as a 13-year-old in West Baltimore.

"It doesn't take a second for it to hit you," said Mr. Miller, 64,
describing the unfamiliar punch of fentanyl. "All I remember is
pushing in the needle, and three hours later I am getting up off the
ground." He was speaking from a nursing home bed in northern
Baltimore, where he spent several recent months recovering from
pneumonia and contemplating addiction treatment in another state.
Heroin had a lulling effect, he and others said, but fentanyl is
killing many of their peers. The claim is backed by federal data
showing that the rate of overdose deaths involving fentanyl increased
by nearly 54 percent in 2017 for people ages 55 to 64 - more than for
any other age group.

"Clients we've known for years are dying," said Derrick Hunt, director
of the Baltimore City Needle Exchange Program, which has two vans that
serve 17 locations around the city. "Everywhere I go, this person
passed, that person passed."

The reason fentanyl is everywhere is economic: Dealers and traffickers
can make far more money from it than from heroin. Instead of waiting
months for poppy fields to grow in Mexico and farmers to harvest the
brownish-black gum, which then gets refined into powder and shipped
north, traffickers here and in Mexico can order fentanyl from China,
or precursor chemicals to make it in clandestine labs, generating far
more doses with far less labor.

This is not an elegy for heroin, a dangerous drug in its own right
that spread from cities into suburbs and rural areas about a decade
ago, when addictive prescription painkillers became harder to get. But
for longtime urban users like Mr. Miller, many of them
African-American, its disappearance is taking a particular toll. From
2016 to 2017, the fatal overdose rate from fentanyl and other
synthetic opioids increased by 61 percent among black Americans,
compared with a 45 percent increase for whites.

The number of overdose deaths involving heroin has been dropping, even
as overdose deaths over all have kept climbing because of fentanyl. In
Maryland, deaths involving heroin fell by 38 percent from 2016 through
2018, according to preliminary data. In Massachusetts, heroin or
likely heroin was present in 71 percent of opioid-related deaths in
2014; in the third quarter of 2018, it was present in only 34 percent.

And in New Hampshire, which did not have a robust heroin market until
the painkiller-fueled crisis of the past decade, the drug has almost
completely vanished. Only four of the 397 opioid deaths in New
Hampshire last year involved heroin, according to preliminary data;
363 involved fentanyl.

"In this situation, heroin looks protective compared to the fentanyl,"
said Dr. Daniel Ciccarone, a family physician and researcher at the
University of California, San Francisco, who has studied both drugs.

Nationally, there were 7 percent fewer deaths involving heroin in the
year ending in September 2018 than there were in the previous year,
according to preliminary data from the Centers for Disease Control and
Prevention. The smaller overall decline may be a reflection of
heroin's continued strong presence in Western states like California
and Arizona.

Data on drug seizures similarly suggest a diminishing of heroin. Here
in Baltimore, Todd C. Edwards, a spokesman for the Drug Enforcement
Administration's local district office, said law enforcement was now
seizing more fentanyl than heroin. And in a Philadelphia neighborhood
called Kensington, which has been hit particularly hard by opioid
addiction, users report that "they can't find heroin anymore," said
Patrick Trainor, a spokesman for the D.E.A. there. "It's pretty much
been replaced."

On a street corner in East Baltimore one recent morning, a van
distributed clean needles to about 25 clients, most of them older
black men. Some leaned on canes or walkers; all said they missed
heroin and its relative predictability. On the front of the van was a
sticker showing a needle aimed at an arm and the words "GO SLOW," a
warning to inject only a little fentanyl at a time.

Each person took a paper bag full of needles and Narcan, the overdose
reversal drug. The vans now also offer test strips, which people can
use to check their drugs, including cocaine, for fentanyl. But some
clients don't see the point.

"Most people, they're not using no test strips," said Mr. Miller, who
helped start a local group that hands out fentanyl strips and
naloxone. "Because fentanyl is in daggone everything now."

Fentanyl may still be mixed with heroin or other drugs, but
increasingly, it arrives pure - either as powder or pressed into
counterfeit pills resembling Percocet or Xanax. It can be diluted with
more filler than heroin can, because it takes far less fentanyl to
have a powerful effect.

"At the dealer level right now, fentanyl is like a magic dust - it's a
moneymaker," said Jon DeLena, the associate special agent in charge of
the D.E.A.'s New England field division.

"We were hearing people start to say, 'I want the old stuff again, I
want the brown,' meaning heroin," he continued. "But traffickers just
started mixing fentanyl with something that had a brown tinge to it.
They're never, ever, ever going to go back to selling heroin around
here again."

Mexican poppy cultivation reached a high in 2017, according to the
D.E.A. But several news outlets have reported that the price of opium
paste - the part of the poppy that gets turned into heroin - has
dropped sharply over the last year, a sign that criminal organizations
are increasingly focused on fentanyl.

Ray Donovan, who leads the D.E.A.'s New York office, said he believed
China's recent decision to ban all variants of fentanyl as a class
could ultimately force traffickers to refocus on heroin. But because
China has not banned many of the precursor chemicals needed to make
fentanyl, others believe the effect could be minimal.

Tino Fuentes, a former heroin user who teaches people how to test
their drugs for fentanyl, said only half of the samples he tests in
New York these days are positive for heroin - much less than even a
year ago.

"I have people telling me all the time, 'If you find something that's
heroin, let me know,'" Mr. Fuentes said.

Still, law enforcement officials are continuing to seize heroin coming
across the border. From January through April, Customs and Border
Protection officers seized 1,585 pounds of heroin at official ports of
entry, along with 921 pounds of fentanyl.

"The notion that heroin is disappearing altogether is false," said
Katherine Pfaff, a spokeswoman for the D.E.A., adding that the drop in
heroin-related deaths could be a result of Narcan saving more heroin
users. Still, she said, there is definitely more demand now for
fentanyl than heroin in some regions, including New England.

That could be because most users in those regions took up heroin only
after crackdowns on prescribing opioids took hold, and were just as
happy with fentanyl, Mr. DeLena said.

Not so for Mr. Miller and many other longtime heroin

"I'd rather have the straight heroin from back in the day," said Duane
Coleman, 67, who was among those seeking needles from the health
department van. "The fentanyl comes on you too strong. Thank God I'm
still holding on."

Even if heroin were to proliferate again, Mr. Miller said, the high it
provided would not suffice for most users because the fentanyl they
have gotten used to is so much more potent. Mr. Miller said he had had
to use fentanyl 10 times a day to avoid withdrawal, up from two or
three times a day for heroin.

At the Baltimore needle exchange, Wayne Hall, 65, accepted a handful
of strips to test his drugs for fentanyl, along with his batch of
clean needles. He had gone to the emergency room recently, he said,
after injecting what he assumes was fentanyl. He had woken up
trembling, with his heart racing.

"When I was doing heroin I never shook like that," he said, leaning on
a cane, his paper bag of supplies tucked under his arm. "I do miss
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