Pulse Check: National Trends in Drug Abuse. Spring 1996 Table of Contents. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 1 Description of Sources . . . . . . . . . . . . . . . . . . . . .2 Summary of Findings. . . . . . . . . . . . . . . . . . . . . . .3 Trends in Drug Use . . . . . . . . . . . . . . . . . . . . . . .6 Heroin .. . . . . . . . . . . . . . . . . . . . . . . . . .6 Ethnographers . . . . . . . . . . . . . . . . . . . .6 Police . . . . . . . . . . . . . . . . . . . . . . . .8 Treatment providers . . . . . . . . . . . . . . . . .8 Cocaine . . . . . . . . . . . . . . . . . . . . . . . . . .9 Ethnographers . . . . . . . . . . . . . . . . . . . .9 Police . . . . . . . . . . . . . . . . . . . . . . . 10 Treatment providers . . . . . . . . . . . . . . . . 11 Marijuana . . . . . . . . . . . . . . . . . . . . . . . . 12 Ethnographers. . . . . . . . . . . . . . . . . . . . 12 Police . . . . . . . . . . . . . . . . . . . . . . . 13 Treatment Providers . . . . . . . . . . . . . . . . 14 Emerging Drugs . . . . . . . . . . . . . . . . . . . . . . . . 14 Developments in the Heroin Trade . . . . . . . . . . . . . . . 15 Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Introduction The Pulse Check, published by the Office of National Drug Control Policy (ONDCP), is a series of reports on drug use across the nation. Its name captures its purpose: to provide a quick sense of what is happening with regard to drug abuse and drug markets across the country. In the four years the Pulse Check has been conducted, it has provided valuable descriptions of the drug scene that inform researchers and policy makers in a timely manner. However, Pulse Check is not a population-based survey and should not be considered a substitute for such surveys. The Pulse Check is conducted periodically by Dr. Dana Hunt of Abt Associates. Data are collected through telephone conversations with 15-20 drug ethnographers and epidemiologists, 10-20 law enforcement agents, and 40-50 drug treatment providers all over the country. The ethnographic and law enforcement sources are chosen to represent various areas of the country, and are generally the same for each round of calls. Treatment providers are drawn randomly from a national listing of small and large treatment programs. Thus, the Pulse Check provides a blend of information and perspectives on the state of drug abuse in America. The following sections present the findings of Pulse Check calls made in April, 1996. Information is summarized in the text, and is presented in table form at the end of the report. This issue also includes a special section on developments in the heroin trade. Description of Sources Ethnographic Sources Seventeen ethnographers, epidemiologists, and other ethnographic sources from urban areas were interviewed for this issue of Pulse Check. Ethnography is a qualitative research technique which, unlike highly structured observation methods, observes and records activity þon its own terms,þ that is, without predetermined ideas. Ethnography is not undercover work. Rather, the ethnographer, who is fully revealed as a social science researcher, enters the drug userþs world to record and describe it. The ethnographic sources contacted by Pulse Check this quarter include some of the best known drug researchers in the country. In some cases, they are trained ethnographers; in other cases, they are epidemiologists with access to ethnographic information; a few are social researchers working in a field site collecting ethnographic data. Police Sources Police sources are drawn from the Abt staffþs existing contacts within law enforcement and from contacts developed through the recommendations of law enforcement agencies. These sources are typically officers working on special squads, narcotics task forces, and DEA agents. This round of calls reached police sources in ten cities. Treatment Providers The sample of treatment providers is derived from the directory of programs compiled by the National Institute on Drug Abuse (NIDA). The NIDA listings are divided into four regions that have a similar number of treatment programs and are treated equally for sampling. The original sample based on the 1991 National Drug Abuse Treatment Unit Survey has been updated using the more recent NIDA files. From each region, 20 to 25 programs are identified, 10 are contacted, and the remainder serve as replacements. The samples are stratified to include equal numbers of small (under 100 clients) and large programs. This round of calls reached 50 treatment providers. The states in each region are listed below. þ Region I: Connecticut, Maine, Massachusetts, New York, New Jersey, Rhode Island, New Hampshire, Vermont, Pennsylvania þ Region II: Alabama, Florida, Georgia, Kentucky, Mississippi, Texas, North Carolina, South Carolina, Tennessee, Arkansas, Louisiana, Oklahoma, Maryland, Delaware, Virginia, Washington, D.C., West Virginia þ Region III: Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin, Iowa, Kansas, Missouri, Nebraska, North Dakota, South Dakota þ Region IV: Colorado, Montana, Utah, Wyoming, Nevada, Arizona, California, Idaho, New Mexico, Washington, Oregon Summary of Findings Heroin þ Heroinþs popularity continues to rise in many areas of the country. Most heroin users are older, long-term drug abusers, but sources report that more teenagers, young adults, middle and working class people, and suburban residents are using heroin. þ Purity is high everywhere except the South. Prices for heroin are variable, but in general, they remain low. Heroinþs high purity and low price has driven new demand and drawn some former addicts back into use. þ Last winter, many treatment providers reported a fairly even split between clients who inhaled and clients who injected heroin. Providers in most areas now report approximately a three- fourths/one-fourth split favoring injection. This may show that inhalation is a transition phase that switches to injection after a few years of use. þ In some areas, cocaine dealers are also selling heroin, a practice called þdouble-breastedþ dealing or þone on oneþ sales. Distributors of South American cocaine are offering or even pressuring lower level dealers to sell South American heroin. As a result, cocaine/crack dealers who are inexperienced at þcuttingþ or diluting heroin are using harmful adulterants and selling dangerous mixtures. Also, there are reports that more South American heroin is available in street markets. þ The illicit market for methadone, a narcotic used to treat heroin addiction, is growing. This suggests that more heroin users are becoming addicted and searching for ways to control or reduce their use. Cocaine þ Cocaine and crack use are stable in most areas even though availability is still high. Ethnographic sources in New York, Colorado, and Southern California say that use may even be declining. þ However, in Texas, cocaine use has increased in some middle income communities. In Delaware and Washington, D.C., there are reports of more new female cocaine users. The ethnographer in Atlanta reports that crack use has become more common in some nearby suburbs. þ Crack users appear to be an þagingþ population with fewer young people entering the crack culture. However, sources report that there is a steady cohort of older users who use crack compulsively. þ Cocaine prices have remained stable. They range from approximately $60-$120/gram for cocaine powder (HCl), and $5-$20/unit of crack. þ Treatment providers now see more clients who also have a diagnosed mental illness, known as þdual diagnosisþ or þmentally ill chemical abuseþ (MICA) clients. Providers state that MICA clients strain limited resources because of their complex social and medical needs. Marijuana þ All but five ethnographic sources report that marijuana use is up in their area. It is reported as stable in parts of the West and New York. þ In general, users are young and represent all ethnic and socioeconomic groups. Marijuana users may also consume LSD, MDMA, Ketamine, and a number of other organic and synthetic drugs. þ In all areas except California, high quality marijuana is widely available. Prices vary with quality and range from $60-$300/ounce. Marijuana cigarettes or cigars laced with crack or PCP command higher prices. þ In general, marijuana sellers continue to be young users who sell to a network of friends and associates. Marijuana sellers usually do not deal heroin or cocaine. Emerging Drugs þ Methamphetamine use continues to rise in the West and Northwest, and has made inroads into new areas. Its most popular form appears to be in þcrystalsþ which are snorted or injected, and it is often used as a cocaine substitute. þ In Southern California, police report that cocaine, particularly crack, now has a þlowlifeþ image, while methamphetamine is considered þhip.þ In California, many users ingest a mix of heroin and methamphetamine, a process called þspeedballing.þ þ Rohypnol, a powerful sedative, is increasingly prevalent in the Southwest and in the Mid-Atlantic region. Ethnographers report that it was formerly one of several þclub drugsþ used by young people, but it has now reached a wider audience and is becoming a street drug. þ Other þclub drugs,þ including Ketamine, Quaaludes, Xanax, MDMA, and LSD, continue to rise in popularity among young adults. þ There is increased interest in þnatural productsþ found in health food stores and mail order catalogs. Many of these products contain ephedrine, a drug that reportedly mimics methamphetamine. These products are currently legal, and in most areas, uncontrolled. They are often marketed as energy enhancers or weight loss aids. Trends in Drug Use HEROIN Ethnographers (Table 1) The popularity of heroin, which has been high for at least two years, has risen in Connecticut, Georgia, Colorado, Delaware, Maryland, parts of Texas (Houston/Austin), and Northern California. Ethnographers report that heroinþs popularity is beginning to stabilize, albeit at a high level, in New York, New Jersey, Washington, D.C., Southern California, and along the Texas border. As in previous issues of Pulse Check, reporters in Florida find that there is a relatively low incidence of heroin use. However, sources report that Customs and law enforcement officials seize large amounts of heroin at airports, in the mails, and in warehouses. Clearly, most of these supplies are intended for other cities. The Miami source notes that some heroin is making its way into local markets, particularly in the southern part of the state, since there has been a marked increase in recent heroin related deaths. The appearance of new, young heroin users continues in many areas of the country. Eight of the seventeen sources report that many heroin users are in their late teens and early twenties. In areas where high purity heroin is available (New York, New Jersey, Connecticut, Delaware, Maryland), new users are likely to inhale, rather than inject the drug. The ethnographer from Baltimore noted that many young users are þsecond generationþ -- teenage/young adult children of an older cohort of heroin users. In addition, there are increases in two types of older users: older methadone clients (þold timersþ) returning to heroin use (Georgia) and low dose methadone clients who use heroin as well (Colorado). Some areas also report the presence of crack users who have switched to heroin (Georgia). In areas where lower purity black tar heroin is common (Colorado, Florida, Texas, Southern California), the majority of users are still older injectors. Sources in Washington, D.C. and Delaware report an increase in female heroin users. In many areas, heroin users combine heroin with cocaine powder (HCl) or with crack and inject the mix. This practice is known as þspeedballing.þ Heroin inhalers, in particular, often choose to use heroin and crack simultaneously. In California, where methamphetamine is plentiful, speedballing a mix of heroin and methamphetamine, through both injection and inhalation, is increasing in popularity. In addition to methamphetamine, sources report that the use of MDMA and Rohypnol is increasing in the heroin community. Some sources report that heroin is used in combination with alcohol (Washington, D.C., Colorado, New Jersey). For the first time, in some areas (Colorado, Maryland), reporters mention a growing market for methadone. Methadone, which is used to treat heroin addiction, has always had some black market value, but it is rarely a primary drug of abuse. An ethnographer in Baltimore commented on the increased presence of methadone in that area: þPeople are using it for habit management when their habit is out of control -- not as the drug of choice.þ However, with more heroin users becoming addicted due to increased availability of high purity heroin, the use of illegally diverted methadone may indeed become more of a choice; that is, addicts may turn to street methadone to help deal with or reduce their heroin habit. Notably, ethnographers report significant changes in the distribution market for heroin in some areas, particularly those where high purity heroin has been available for some time. In the past, street level markets have operated as separate entities for trade in heroin and trade in cocaine/crack. Recently, however, dealers are selling both drugs in joint sales markets. This practice is referred to in some areas as þdouble breasted dealingþ or þone on oneþ sales. While this may not seem surprising, it is anomalous for street sales in most of the country. Street dealers for heroin and cocaine/crack in New York, for example, have traditionally operated þon their own corners,þ selling to different clientele. However, there has been an increase in joint sales in New York, which may stem from pressure put on middle and lower- level cocaine/crack dealers to sell bags of heroin. As þone on oneþ sales become more prevalent, market borders are blurring. These developments are discussed in greater detail in a section devoted specifically to the heroin trade at the end of this report. Sources report a wide variety of street level dealers, including Hispanics (Texas, California, Colorado), Whites (Georgia), and African Americans (California, Georgia). Sellers are usually males in their twenties, and some belong to gangs. In Austin, sources report that West Africans sell Southeast Asian heroin, while Hispanics sell Mexican heroin. Prices of heroin remain stable. At the street level, heroin is sold in $5, $10 and $15 bags that contain approximately 1/8 ounce of heroin and adulterant. Sources in California and Colorado report slightly higher prices. One notable exception is in Baltimore, where prices have dropped significantly since the last Pulse Check. In fact, the Baltimore ethnographer comments that þit is hard to imagine prices falling any lower, and there is no size or purity difference between a $6 and a $10 capsule -- just the time of day the sale is made.þ Purchase amounts vary somewhat; heroin is sold in glassine bags, capsules or þpills,þ or balloons. Purity varies as well; in many areas it is high (over 50% in Connecticut, New York, New Jersey, Washington, D.C., Maryland) and in others it is quite poor (Texas, Florida). Police (Table 2) Of the ten police sources contacted, six report that heroin use is increasing in their areas. Like the ethnographers, police report that heroin use is concentrated in older, urban populations. However, there are signs that use is increasing in younger, middle income suburban populations in several areas (Colorado, Washington, D.C., Massachusetts, Maryland). Colorado and Oregon law enforcement sources both note increased sales of heroin to working and middle class white males. Maryland State Police concur that heroin's popularity is rising as evidenced by an increase in the number of times it is found in cars during highway stops. According to police sources, middle to upper-level heroin distributors vary across regions. In the West and along the Southwest border, Mexican nationals are sources for large quantities of heroin. In other areas, source dealers include Pakistanis, Lebanese, Nigerians, Dominicans, and Colombians. As is discussed later in this report, law enforcement sources in New York, Maryland, Massachusetts, and Washington, D.C. report an increase in cocaine traffickers and dealers who add heroin to their product line. These sources report that there is more South American heroin in their areas. In addition, sources report that street-level dealers and the neighborhoods where they sell have similar demographic characteristics. Prices vary according to the type of the heroin. Sources in Denver state that high quality Mexican black tar heroin sells for $600-$800/gram, while prices for heroin powder in most areas is as low as $100- $200/gram. Highly adulterated (poorer quality) heroin, most often destined for injectors, can sell for as low as $65-$70/gram according to the Maryland State Police, a price consistent with the Baltimore ethnographer's comment that þit can't drop any lower!þ Purity varies across sites; it is generally above 50 percent except for small sales at the street level. Treatment providers (Table 3) Over half of the treatment providers surveyed report that the number of clients who enter treatment with heroin as their primary drug problem remains stable (between 7-26%). However, in the Mid-Atlantic and Southern states (Region II), a substantial number of treatment providers (38%) report increases in heroin clients. In the West (Region IV), thirty percent of respondents state that the number of clients entering treatment with heroin as their primary drug of abuse is decreasing. This may be related to the substantial rise in clients demanding methamphetamine treatment in this region, which is discussed in the section on emerging drugs. The majority of people in treatment for heroin addiction are older, experienced drug users. In all regions, 65 percent or over are in their thirties, and over 70 percent of them have been in drug treatment before. While several providers said they noticed more women in treatment, males still outnumber females two to one. One provider in a large New York methadone program commented that the increase in female addicts is placing a decided strain on resources, because it adds more complicated service needs related to pregnancy and child care. Two programs (California and Washington, D.C.) report that they are enrolling more working class and middle class heroin users. The proportion of clients injecting versus inhaling increased in this round of interviews. Last winter, treatment providers in the Northeast and in the Mid-Atlantic and Southern states (Regions I and II) reported a fairly even split between clients who inhaled and clients who injected heroin. In contrast, providers in most areas now report approximately a three-fourths/one-fourth split favoring injection. Though the bias towards injection has been reported previously in the South and the West, in the Northeast, the number of heroin inhalers entering treatment had been growing, not shrinking. However, providers of large treatment programs in both Newark and Baltimore now report that 75 percent of their clientele are injecting. Injection is not limited to inner city users; providers in suburban California, Georgia, and North Carolina report that the number of working class addicts who inject is rising. The return of high proportions of injectors entering treatment does not imply that inhaling heroin was a fad. More likely, it indicates that inhalation is a transition phase that changes to injection when addiction is established. Providers state that while there may be more new young users experimenting with inhalation, most heroin users are older addicts or returning users who still prefer to inject. COCAINE Ethnographers (Table 4) Sources in all areas of the country report that both cocaine powder ( HC1) and crack are readily available though many areas, including New York, have seen recent large seizures. However, in most areas , the demand for cocaine has stabilized or even declined. Eleven of the seventeen ethnographers describe cocaine use as þstableþ or þstable at a high levelþ in their area; reporters in Los Angeles, New York, and Denver report that use has declined slightly. Heavy cocaine and crack use is becoming more concentrated in a core of older, regular users. Several sources (Texas, California, Colorado, Florida) characterize the population as older, established drug users who live mainly in inner city areas. In Los Angeles, cocaine and crack users are described as þan aging population.þ Notably, few new users are surfacing in emergency rooms or in similar settings that would imply a growing population. Only Baltimore reports a continuous rise in new users. However, there are some pockets of change. In Texas, cocaine use has increased in some middle income communities, and in Delaware and Washington, D.C., there are more new female cocaine users. The ethnographer in Atlanta reports that while crack is found primarily in inner city areas, it has become more common in some nearby suburbs. Drugs that are used in combination with cocaine include heroin (in a speedball), alcohol, and marijuana. In Los Angeles, methamphetamine, a popular stimulant, is also used with or as a substitute for cocaine. In Austin and Miami, sources report increased popularity of Rohypnol, Ketamine, and MDMA among cocaine users. Ethnographers report that high-level distributors include Mexicans, Colombians, and Dominicans. In some areas, all three groups supply the street markets (Texas, Florida, Washington, D.C.) while in others, suppliers are predominantly Colombian (New York, New Jersey, Connecticut). At the street level, cocaine and crack are sold by young non-users. These entrepreneurs may invest a small amount of capital for cocaine HCl, which they cook into crack to be packaged and sold at a profit. In some areas, like New York and New Jersey, they sell cocaine powder since users there prefer to cook their own crack. In some Southern areas (Texas, Georgia), African Americans and Hispanics dominate street level sales. Three areas (Connecticut, Colorado, Illinois) report that cocaine sellers are organized in gangs. Prices and purchase amounts vary. In some areas in the East (Connecticut, New York, and Delaware), cocaine is sold in $10 to $20 bags. In Florida, Southern California, and Washington, D.C., rocks, vials, or bags of crack are sold for $5 to $10. Grams of cocaine powder range in price from $75 (Washington, D.C.) to $125 (St. Petersburg, FL). Sources report that the purity of cocaine is variable or high; only three sources report that purity is below 50 percent. In New York, heightened enforcement of bans on crack paraphernalia (stems, pipes, screens) has led users to improvise modes of ingestion. Typically, water pipes used for smoking crack have two glass stems connected to a round chamber; one is thick and heat resistant and the user inhales from the other one, which is thin and more fragile. Some area stores were selling only the thin pipe, which is hazardous because it can shatter when used as the lighting end of the pipe. In addition, law enforcement officials have focused on cocaine sales from small food markets (bodegas), which has increased the number of sales from private apartments and home deliveries of cocaine HCl, known as þhome sales.þ Police (Table 5) Police sources in some areas (Alabama, Colorado, Ohio, Oregon) report increases in the availability of cocaine, though most sources report that the market is stable or declining. In Denver, seizures of cocaine in powdered form are up 200 percent from last year and crack seizures are up over 100 percent. Sources in Oregon and Washington both note that there has been a rise in cocaine use in their area, but say it is directly linked to a recent shortage of the stimulant methamphetamine; many users switched to cocaine as a substitute. In many areas, cocaine/crack use is stable or declining. While the market for cocaine in powdered form is still active, most buyers are purchasing it to make crack. In Cleveland, police sources describe the use of cocaine HCl as þvirtually going away,þ though crack is still popular. In Boston and Washington, D.C., sources report that cocaine use is down. Police in Washington, D.C. also describe crack use as þbottoming out.þ They report that over the last year, crack has developed an image as a drug that makes users particularly volatile and irrational. In addition, crack markets may be viewed as inherently dangerous. The D.C. source comments that þyou see hard-using heroin users afraid of crack. There have been too many casualties in the war.þ Police sources in some areas (Maryland, Washington, D.C.) confirm ethnographers' reports of dealers selling both heroin and cocaine. Sources identify Colombian, Dominican, Jamaican and Mexican primary suppliers. Street-level dealers are often young males who are ethnically matched to the neighborhoods where they sell. Sources in Western areas report that Mexican and other Hispanic sellers are common. Cocaine prices seem to vary considerably across the country, though they have remained stable in general. Massachusetts and Oregon sources report that an ounce of cocaine powder costs approximately $800 while an ounce in Washington or Colorado runs from $1000-$1800. Prices of crack rocks are between $15-$20 for 1/10 gram in Alabama; in Colorado, a larger 1/4 gram rock costs the same amount. Purity in general is described as good (over 50%). Treatment providers (Table 6) The proportion of clients in treatment with cocaine as the primary drug problem differs little from what was reported in Pulse Check last winter. Approximately half of clients in the Northeast (Region I) and a third in the Mid-Atlantic/Southern states and the Mid-Western states (Regions II and III) are in treatment for cocaine abuse. There are considerably fewer clients entering treatment with cocaine as their primary drug of abuse in the West (Region IV) because methamphetamine, marijuana and an assortment of other drugs are prevalent in that area. Most users who enter treatment for cocaine abuse are smoking crack rather than using powdered cocaine. In all regions, alcohol abuse is a major problem for cocaine treatment clients. Treatment providers report that cocaine users are a diverse group. Some people in treatment are quite young (under 20), though the majority are young adults (20-30 years) or older. The rise in the number of people in treatment for cocaine abuse over age 30 corresponds with ethnographic sources who describe an þagingþ population. In addition, many people in treatment for cocaine abuse have had prior treatment; with the exception of the Western region, more than 60 percent of clients have been in treatment before. Ten treatment providers mention a noticeable increase in the number of clients who have concurrent problems of drug use (particularly cocaine) and mental illness. They are often called þmentally ill chemical abuseþ (MICA) or þdual diagnosisþ clients. MICA clientsþ mental health problems (depression, general anxiety disorder, schizophrenia) may or may not be related to substance abuse. Theseclients pose problems for drug treatment providers because they may need specialized services and/or medication for their mental illness that are not available through drug treatment programs. Dual diagnosis clients are described as older users who have been using cocaine or crack for several years and have several family, medical, legal, housing, and employment problems. One treatment provider comments that þwe want to help, but they (dual diagnosis clients) strain an already strained situation because they need and use so many of our limited resources.þ MARIJUANA Ethnographers (Table 7) All but five ethnographic sources report that marijuana use is up in their area. As one Texas ethnographer described the market, þit is plentiful and potent.þ In other places (Los Angeles, Washington, D.C., New York, and Colorado) marijuana use is described as stable, and in San Francisco, use is characterized as low due to recent scarcity. While a wide variety of people are using marijuana, the majority of users are teens and young adults. One exception is Texas where there is a substantial population of adult users. In general, the user population has stayed the same since the last Pulse Check report, though New York and Delaware report an increase in female users. Marijuana is smoked in cigarette papers, rolled in cigar paper as þblunts,þ and in pipes or þbongs.þ The reappearance of bongs and water pipe paraphernalia, which were popular in the 1960s and 70s, was mentioned in San Francisco and Washington, D.C. Several sources also mentioned the appearance of a wide variety of cigarette rolling papers marketed in convenience and video stores. These papers are typically used by cigarette smokers who roll their own cigarettes from loose tobacco, but their increased availability may be an indicator of a growing marijuana market. In Atlanta, the majority of marijuana is home grown, and the ethnographer reports that marijuana sellers are preparing for the Olympics, anticipating that visitors will provide an additional market. Marijuana is used both alone and in combination with a number of other drugs -- most commonly alcohol, and in some areas, crack or PCP. In New York, a variety of Indian marijuana laced with PCP (þbeadiesþ) has gained popularity. Both crack and PCP may be sprinkled on marijuana; a marijuana cigarette or cigar may also be dipped in a liquid solution of PCP, dried and then smoked. The ethnographer at the Texas border reports that the teens who are smoking crack mixed with marijuana often disparage those who smoke crack alone (in a pipe) as þdopers,þ defining their own crack use as benign. Two areas (Texas and Delaware) report the practice of dipping blunts in embalming fluid, producing what in Texas is called a þswisher.þ Three sources (Georgia, Florida, New Jersey) report that the use of MDMA is appearing in their areas. In general, sales of marijuana are separate from the sales of other drugs, and they are conducted through networks of users. Since a large portion of the supply is grown domestically or even locally, there are diverse supply sources. For example, many small local growers can supply an area through an informal system of acquaintance distribution. In Florida, there were recently 23 arrests in a local high school for sales among a network of friends and acquaintances in a class of 200 teenagers; teens who were interviewed reported that twice as many students were actually selling. In general, there is a wide variety of sellers, which reflects the diversity of the user population. Marijuana prices vary somewhat by region, though small units (bags) costing $5-$15 are common everywhere. Each small bag of marijuana can be made into approximately 2-4 cigarettes or fewer blunts. In New York, marijuana may also be sold in glass vials. Prices range from $30 per ounce for poor grade marijuana (Florida) to $100-$300 per ounce for a higher quality grade in other areas (Georgia, California). Individual cigarettes sell for $1-$3, though ones in which marijuana is mixed with crack are more expensive ($10-$15 each). One Florida ethnographer reports that poor quality marijuana does not sell well, even though it is widely available, because users value the appearance and smell of the product. Police (Table 8) Seven of the ten police sources report that marijuana use and availability is up in their area. In Colorado, seizures of marijuana are up almost 300 percent over last year. Only the Massachusetts area reports stable use. Police say that marijuana attracts a wide range of users, but most are teens or young adults. Changes include more young users in Florida and in Washington, D.C., where users are as young as middle school children. In Washington, D.C., young marijuana users may also be experimenting with snorting household products to get high. Sources in three areas (Alabama, Washington, D.C., Ohio) report that smoking marijuana in þbluntsþ is a popular method of ingestion, and two sources (Alabama, Maryland) report the emergence of MDMA. Police sources concur with ethnographers in reporting that the most common method of distribution is through established networks of users who know each other and handle fairly small transactions. In Cleveland, sources report an increase in older users as well as more suburban users/distributors. This is echoed by the Birmingham law enforcement source who describes marijuana as a white, rural/suburban problem; it is sold primarily through networks in þyuppieþ neighborhoods. Marijuana may be purchased by the gram ($10-$15), by the ounce ( $90- $250), or by the pound ($2000- $5000). Prices depend on quality, with hydroponically grown products commanding top dollar due to their high THC content. In Boston, the appearance of small packaging units that cost between ten and forty dollars has made marijuana more accessible to younger users with limited funds. In areas like Washington state, where there is a considerable amount of local marijuana growing, larger organized groups export to other areas. In Florida, for example, a recent raid of a large estate uncovered $35 million of high quality, hydroponically grown marijuana that was undoubtedly intended for export. In addition to local supplies, most areas report that Mexican marijuana is available, though it is generally of poor quality. Treatment Providers (Table 9) Less than a quarter of persons entering treatment in all regions have marijuana as their primary drug of abuse. This proportion is about the same as reported in Pulse Check last winter. Alcohol is the drug most commonly combined with marijuana, though tranquilizers and amphetamines are reported in the Mid-Atlantic and Southern states, and in the Mid-West (Regions II and IV). In general, marijuana treatment clients are younger than those in treatment for heroin or cocaine abuse; sources report that approximately a quarter of their clients are under 20 years old, though a third to a half of them are over 30 years old. Most marijuana treatment clients in all areas are white, and there is a greater proportion of males. Many treatment providers comment that persons in treatment for marijuana abuse are novice users of illegal substances, and even though they may have serious problems with alcohol, most do not have prior treatment experience. EMERGING DRUGS Methamphetamine continues to be a rapidly growing problem in many areas of the country. In Alabama, a household survey found that the number of state residents in need of treatment for methamphetamine abuse nearly equals that for cocaine and exceeds that for heroin. Treatment providers in California, Oregon, Georgia, Arizona and North Carolina report significant increases in clients entering treatment with methamphetamine problems. One clinical director in Arizona reported that 70-80 percent of clients are methamphetamine abusers, and in Washington state, methamphetamine admissions are up 20 percent over last winter. Ethnographers in California and Colorado report a steady climb in the numbers of methamphetamine users in their areas. The Colorado ethnographer comments that as recently as a year ago methamphetamine was considered a þbikerþ drug, but it is now gaining in popularity and þmoving into new groups.þ Some new users are former cocaine users who have switched to methamphetamine. As a drug which can be injected, inhaled, or made into pills, methamphetamine attracts a wide variety of users. In San Francisco it is popular among young club goers, suburbanites, and heroin users. Some heroin users in that area þspeedballþ with heroin and methamphetamine rather than the more common speedball combination of heroin and cocaine. Police sources in Seattle report that methamphetamine is the þdrug of choice.þ It enters the area in large quantities from Mexico and is incorporated into the distribution networks for heroin and cocaine. Methamphetamine is also one of the few drugs reported as more or equally prevalent as other illicit drugs in areas outside the inner city (Colorado, California, Washington, D.C.). Police sources in Washington, D.C. report that it is used heavily in the suburbs, especially on college and university campuses. In that area, it is most commonly found in granular form and snorted. Police contacts in Southern California report that cocaine, particularly crack, has acquired a þlowlifeþ reputation, while methamphetamine has gained a reputation as a þhip drug.þ Use in Southern California appears to be pervasive -- from Mexican immigrants to high school students to Hollywood club goers. Many methamphetamine users are former cocaine users. A Georgia treatment provider described methamphetamine as þredneck cocaine,þ referring to its popularity among white working class users who may have formerly used cocaine. Rohypnol, a powerful benzodiazepine tranquilizer, is also cited widely as an emerging drug. Ethnographers in Delaware and Florida state that Rohypnol was formerly one of several þclub drugsþ used by young club and rave goers, but it has now reached a wider audience and is emerging as a street drug of abuse. Sources in the South and along the Mexican border report its prevalence, and it also appears in reports from Washington, D.C. and the Mid-Atlantic area. In addition, sources report that other þclub drugsþ such as Xanax, Ketamine, Clonipin, and Quaaludes are also increasingly popular, especially among younger drug users. Ephedrine is a rising problem in many areas. There is increased interest in þnatural productsþ that contain ephedrine or pseudoephedrine, which reportedly act like methamphetamine or MDMA. These products are legal, and they are often marketed as energy enhancers or weight loss aids in health food stores and mail order catalogs. In Texas, sources report that consumers are trying to buy large quantities of these products in pharmacies. DEVELOPMENTS IN THE HEROIN TRADE For the last two or three rounds of the Pulse Check, ethnographers and law enforcement officials have reported an increase in dealers at all levels who sell both heroin and cocaine. This is a significant development because joint marketing has not been the norm in the drug trade. In high trafficking areas where both drugs are available, they are dealt on different corners, by different dealers. Occasionally, a heroin seller may have a small amount of cocaine to sell to customers who speedball, but it is not likely to be a regular part of his trade. In most areas, the demographics of heroin sellers at the street level match those of the areas where they sell. In addition, street level sellers are often addicts who are paid in drugs; that is, they take 10-20 bags of heroin from a distributor and can either keep a specified number of bags for their own use or are þpaidþ in a few bags of heroin when they return with the money. Sellers market to other users, who are often friends or acquaintances. Similarly, a cocaine or crack dealer is not likely to deal heroin routinely. Unlike heroin sellers, successful cocaine and crack sellers are typically not users themselves. They are more likely to be members of informal groups or more organized crews who coordinate packaging and sales. These groups avoid recruiting crack users because of their unreliability and their notorious inability to control their own drug use. For example, the New Jersey source describes a crack house operator who distributed crack and HCl extensively through his familyþs network, but was immediately removed from the family business when he became a user. In general, cocaine/crack sales at the street level are business-like, and sellers are more often paid with money than drugs. In addition, unlike marijuana and heroin sellers, cocaine and crack sellers tend to associate with non-users, and their cocaine sales are usually to strangers. However, sources in several areas (Connecticut, New York, Delaware) report that street sales are becoming increasingly managed by young non-users who sell both heroin and cocaine. As described earlier, this practice is known as þdouble breastingþ or þone on oneþ sales. One consequence of this new marketing structure is that cocaine/crack sellers who have no experience in þcuttingþ or diluting heroin may be using poor cuts or combining heroin with unusual adulterants. Powerful mixtures (heroin þcocktailsþ) of heroin with substances like cocaine, dextramorphin and scopolamine (a motion sickness drug) are appearing in street markets; in February, 43 users in Philadelphia were hospitalized when they suffered a loss of consciousness followed by violent delirium after ingesting a combination of high purity heroin and scopolamine. In addition, heroin cocktails sent over 100 users in Philadelphia and another 20 users in Baltimore into emergency rooms in May. DEA sources report that þdouble breastedþ dealing of heroin and cocaine started about two years ago in New York, parts of Florida, and Chicago, where it was noticed in seizures and in raids on stash houses. In some areas, middle-level dealers of South American cocaine are now offering or even pressuring lower level distributors to sell South American heroin. Dealers may even þfrontþ heroin for their distributors, that is, not require payment in advance for the supplies they take to sell. This was seen in the very competitive markets of the Northeast. DEA sources describe this tactic to break into the heroin market as unusually aggressive, and the increased competition has brought higher quality and lower prices. Double breasted dealers are described as the þboldest group out there.þ For example, when a recent New York police action pushed more established heroin dealers indoors, these new sellers remained in open air locations. DEA accounts concur with ethnographic sources in New York, who report that dealers describe pressure from Colombian cocaine distributors to take heroin. Though the emergence of double breasting implies that more South American heroin is on the street, seizures of South American heroin are small (averaging 800 grams). Routes of entry into the country, which include body cavity packing, commercial airlines (80-90% of seizures), and the mails, suggest that there are a number of small independent operators. Traffickers vary the routes of entry and run continuous couriers to bring in enough quantities to stay competitive. While the DEA finds far less heroin than cocaine under cultivation in South America, sources say that it is an important market to watch.