Epidemic: Rise in
The first sign of trouble was an overdosed drug user in
cardiac arrest rushed in by ambulance. Resuscitation efforts
failed to get his heart beating again.
Drug overdose deaths are not an extraordinary occurrence at Hopkins Hospital, especially on a Friday night. "You see them," said Gabor Kelen, professor of emergency medicine in the School of Medicine and director of the hospital's emergency department, "but you don't see them every day."
When a second overdose patient arrived--this time still living--and then a third, the medical team on duty began to wonder what was going on.
"At about this time we started getting calls from other emergency departments asking us if we were seeing an unusual number of overdose cases," said Kelen, who was managing the department that evening. "Then it was like the floodgates opened and every intravenous drug user in the city was going to area hospitals."
Many of the patients were manifesting psychotic behavior in reaction to the drugs they had injected. "They were agitated, acting crazy and combative and totally out of their minds," Kelen said. "Some had severe physiological reactions that caused lasting damage to their hearts, kidneys or other organs. A few died from it."
The culprit was a bad batch of heroin that hit the streets earlier that day containing significant amounts of scopolamine, an anticholinergic used for seasickness. A belladonna-like alkaloid, injected scopolamine has what treatment specialists call the "Alice in Wonderland" effect: victims, it is said, will appear mad as a hatter, dry as a bone, red as a beet, hot as a hare and blind as a bat.
The outbreak of bad heroin in Baltimore created a mini-epidemic of drug-related emergency department admissions. Many of the users may have received the drugs as a free sample from dealers anxious to find new clients or market a new product. The next morning, Kelen joined Baltimore mayor Kurt Schmoke, Hopkins medical professor Donald Jasinski and Richard Zane, another emergency specialist at Hopkins in a hastily arranged press conference to urge drug users to avoid the lethal mixture.
This summer's cluster of overdoses followed similar occurrences in New York, Boston and Philadelphia. It--and another, smaller outbreak only weeks later--culminated in a press conference, national news exposure and even an article in the Center for Disease Control's Morbidity and Mortality Weekly Report, the nation's official record of disease and death.
What most of the news media missed, however, is the underlying story that Kelen has been gathering data on for several years now. Heroin is back. Addiction to the opiate is resurging through America's cities and spreading to their suburbs.
"Heroin usage and addiction is growing significantly, there is no doubt about it," Kelen said. Pinpointing precisely how many people use the drug is difficult. Drug Abuse Warning Network, a publication of the U.S. Public Health Service, relies on the numbers of emergency department cases known to be drug-related to come up with a rough estimate of the incidence of drug usage.
And those numbers, said Kelen, are growing at an alarming rate: "In 1990 there were 33,000 emergency department visits nationally where heroin use was noted," he said. "By 1995 that number had grown to 76,000, a more than doubling in five years."
In Baltimore, data shows the number of emergency department visits rising from 1,600 to 8,500 in the same period. At Hopkins Hospital alone, reported cases rose from less than 700 to more than 3,000 during this time.
In a separate study, Kelen surveyed Hopkins' emergency department patients for intravenous drug use, regardless of the cause of admission. His data suggests that in the mid-1980s about 10 percent of the patient population could be identified as engaged in IV drug use. Now, he said, that number is almost doubled.
"Baltimore has always had a significant heroin problem, and my gut feeling is that we are seeing an increase in use," agreed Peter Beilenson, Baltimore city health commissioner and associate in Maternal and Child Health at the School of Public Health. His office estimates there are currently 30,000 injection drug users in Baltimore City alone.
One of the reasons heroin use has increased may have to do with the economics of supply and demand. Previously, heroin was quite costly in relation to other drugs. "The result was that it was harder to get and what was on the streets you had to inject because it had been repeatedly cut," Kelen said. In the 1960s and '70s street heroin was often no more than 5 to 10 percent pure. "Now the price has plummeted and street samples will often be 60 to as high as 90 percent pure."
Government reports have suggested a new source for the drug, a morphine derivative obtained from the opium poppy. "It appears that up to 90 percent of the heroin is now coming from Burma, which is one of the few countries we have no influence over whatsoever," Kelen said. Many countries in Europe are experiencing similar influxes of cheap and potent supplies of the drug.
At the current levels of purity, a new danger arises because the drug can be taken without the need to inject it.
"There are some drug users who are put off by the culture of injection, but who may become addicted to heroin through other means," Kelen said. "College students and recreational drug users, for instance, might try snorting heroin when they wouldn't think of injecting it." Although there is no statistical evidence to suggest an increase in heroin use in these populations, he said there is "anecdotal evidence" suggesting that the drug is making inroads in high schools and college campuses.
"It seems to be becoming more acceptable to use," he said.
Unfortunately, the drug's addictive qualities are every bit as potent in this seemingly more benign form of ingestion.
"Heroin is one of the most addictive drugs known," Kelen said. "The images of a junkie becoming violently ill because of the need for a fix are literally true. Coming off of a heroin addiction is something that is best attempted under medical supervision."
In September, Kelen was called to testify before the congressional subcommittees for national security, international affairs and criminal justice about the national rise in heroin use. The increase in drug use is an issue presidential candidate Bob Dole has tried repeatedly to tie to the Clinton administration, and some members of Congress agree.
As yet, however, there is no clear scientific evidence suggesting what policy or combination of programs is most effective against illicit addictive drugs.
"Some would say it's Bill Clinton's fault, or not his fault, but the fact of the matter is we have had a major problem with the abuse of opiate drugs for over 100 years now," said Jasinski, who heads the Bayview Center for Chemical Dependency. "The abuse of opiates has tended to alternate with the abuse of stimulants. Heroin use will give way to cocaine use and then back and forth. It's nothing new, but that doesn't make it any less costly to society, or any easier to live with."
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