Heroin from hell

"I've been off and on methadone since 1983, and in the past, you could do 10 bags of heroin [while taking methadone] and you couldn't get high," says Steve, a self-described "dope fiend" who sports a pair of wide, mirrored sunglasses that make his face look like a housefly's. "But not this stuff out there today. It's a real diabolical drug."

Some authorities think that addicts like Steve are just buying better dope. According to the Drug Enforcement Agency (DEA), the heroin in Boston ranks among the nation's strongest, usually hovering between 30 and 50 percent pure heroin -- up from 5 to 10 percent a decade ago. This rise, which began in earnest in the early 1990s, has been well documented by both the medical community and the media.

But for some time, the buzz on the street has been that something else -- specifically, additives such as the pharmaceuticals procaine and lidocaine -- is being mixed with high-purity heroin, resulting in a new, extremely powerful designer drug. People in the know call it "P-dope," and though the drug has been making inroads on the East Coast for more than a decade, addicts in the city say that it's exploded in Boston within the past three years -- even though many users still don't know it by name.

"People think they are just getting good old-fashioned heroin. But they aren't," says Artie, a 43-year-old addict from Woburn.

Junkies, of course, are prone to hyperbole. But the DEA's New England field office confirms that procaine and lidocaine are routinely found in Boston-area heroin. And if there's a designer heroin out there so potent that even small doses can override methadone, it represents a grim challenge to this country's most proven and most frequently used weapon against heroin abuse. Furthermore, the new drug is surfacing at a time when the Boston heroin trade has blossomed; while cocaine- and crack-related crimes have leveled off, heroin arrests in the city have increased annually since 1992.

To date, there's been no formal study of how a mixture like P-dope might change heroin's effects. But authorities acknowledge the potential dangers, especially for addicts going through methadone treatment. "You get 50 percent pure heroin and an addition of lidocaine and procaine to give it a rush, and in most circumstances, that heroin would cut through the methadone," says Howard Lotsof, a New York-based researcher of alternative addiction treatments.

Yet the discussion of P-dope in Boston remains almost totally confined to the street. Says Joe, a soft-spoken, articulate Boston addict originally from New York: "There's a gap between what the medical and law-enforcement communities know and what addicts already know."

"Addicts want this drug more, and dealers want it more," says Stuen-Parker. "And it's pushed regular heroin right out."

Not everyone shares Stuen-Parker's passion or conviction about P-dope. Many experts continue to argue that high-purity heroin is a much bigger problem than heroin mixtures. But addicts say that something different is out there on the street, and Stuen-Parker is determined to let people know about it. An indefatigable rabble-rouser, he decided to draw attention to his cause by having himself arrested. He called police last year in New Haven -- where he attended Yale -- with enough P-dope in his pockets to get him locked away for 20 years. And he's not about to stop making noise up in Boston.

"P-dope heroin is a national emergency," Stuen-Parker says. "It's really bad. But right now, no one's paying much attention."

More than 30 years after its introduction, methadone remains the cornerstone of heroin-addiction treatment in the United States. Though the drug has its drawbacks (methadone itself is addictive), it continues to be largely well-regarded in addiction-therapy circles, and there's a high demand for methadone treatment. Currently, there are roughly 120,000 methadone patients in the US. Last fall, a National Institutes of Health (NIH) panel recommended that the rigid federal methadone regulations be loosened to allow the drug to be dispensed more widely, even prescribed by ordinary doctors.

Methadone is a synthetic "opiate agonist." It relieves withdrawal symptoms and eases the craving for heroin, essentially by dulling a recipient's ability to get high. Used for both detoxification and longer-term therapy ("maintenance"), it has undoubtedly helped many heroin addicts. But quitting heroin is often a lengthy struggle. Some users will relapse again and again -- even addicts who are eager to get clean, and who are enrolled in maintenance programs that require regular urine testing for drugs. In recent years, the burgeoning supply of high-grade heroin has led some experts to reconsider how much methadone is necessary for addicts to see results.

J. Peter Stein, a drug-treatment specialist at the North Charles Institute for Addictions, in Somerville, says the minimum effective methadone dose appears to be creeping upward. "There's a concept we call a `blocking dose.' That means we give people enough methadone that any reasonable attempt to break through it is going to be prevented. But some of these drugs today seem to be [breaking through]," Stein says.

So far, however, drug-abuse specialists have blamed breaking through on the purity of the heroin. "It's easier to end up using more pure opiate than it used to be, and what that means is that people can break through on methadone," says Roger Weiss, clinical director of the alcohol- and drug-abuse treatment program at McLean Hospital, in Belmont. "What we see here is that there are a lot of people who require more methadone for detoxification purposes."

"If you're on methadone, and you shoot good, pure heroin, you're going to feel it," says Norma Reppucci, general manager of the Habit Management Institute, a mobile methadone clinic in the Boston area. And Alan Wartenberg, director of the addiction-recovery program at Boston's Faulkner Hospital, says there have always been addicts who successfully undercut their methadone treatment. "People can always use an amount of heroin that is enough to get high on top of methadone," he says.

But Jon Stuen-Parker thinks -- insists -- that it's not just a matter of strength and purity. Based on what he's heard from addicts in Boston, New Haven, New York, and beyond, he's convinced that there is something distinct and troubling about the way today's heroin is made. "It's different stuff," Stuen-Parker says. "It's a new kind of drug."

Of course, heroin has always been mixed with additives. Some of them -- lactose, mannitol, and starch, for example -- are used simply to dilute the heroin and allow dealers to maximize profits. But other additives, called "adulterants," aim to give the drug an extra narcotic punch -- often a sharp rush to accompany the warm, extended euphoria of heroin's opiate high. (Many adulterated drugs strive to mimic the high of a "speedball," a combination of cocaine and heroin.)

There have been hundreds, if not thousands, of heroin adulterants -- ranging from caffeine to quinine to scopalomine, a motion-sickness drug that resulted in a rash of heroin overdoses a few years back. (In the 1980s and early 1990s, there were also overdoses caused by the pharmaceutical fentanyl, but that was a synthetic designer drug, known as an "opiate analogue," that in most cases contained no heroin.)

But for the past two or three years, according to New England DEA regional director George Festa, two of the most common heroin adulterants found in Boston have been procaine and lidocaine. Both are anesthetics. Sometimes they are found individually in heroin, but often they are found together.

Lotsof stresses that P-dope hasn't been studied thoroughly enough to reach any conclusions, but he believes the combination could produce an effect both physiologically and psychologically different from that of heroin -- essentially creating a new drug, he says. As an example of a similar effect, he notes that researchers found an unusual compound, cocaethylene, being metabolized in the livers of addicts who mixed large amounts of cocaine and alcohol.

"What is metabolized when heroin is mixed with procaine and lidocaine? That's an unknown," Lotsof says. "That's the kind of thing that could be determined from research. "

But as little as experts know about them, P-dope and other high-purity heroin combinations are already major topics of conversation on the streets of Boston, and have been for some time. Addicts will tell you about people they know with 40-bag-a-day P-dope habits. They'll talk about friends who have overdosed in recent months. They'll talk about needle sharing, the spread of HIV among users, and their own difficulties going straight, even if they are enrolled in treatment.

These addicts, many of whom have been using for more than a decade, believe they can tell the difference between "straight" heroin and mixtures like P-dope. Whereas heroin is generally associated with a dreary, sleeplike high, P-dopers describe a quicker-acting drug that produces pins-and-needles sensations and strong adrenaline-like rushes immediately after shooting up. "Regular heroin, you use it and you'll get real low, real mellow," says Artie, the addict from Woburn. "But P-dope will keep you up all night."

Accounts of P-dope's arrival in Boston vary. Some addicts say it's been available off and on since the late 1980s, when P-dope started becoming a fixture in the drug scenes of East Coast cities like New York, New Haven, and Newark. But there is general agreement that its availability and potency here in Boston have increased dramatically.

"This stuff has just shown up in the past couple of years," says Steve P., an addict who, like many of his peers, is HIV-positive. "It's real powerful. The first time I did it, I did like three bags -- and I fell down, smash, on the carpet."

Indeed, P-dope is also proving to be a powerful temptation even to users who are pursuing treatment. Steve P. says that just a few years back, using heroin while enrolled in methadone maintenance was like "throwing money down the toilet" because the methadone blocked the high. But that isn't case anymore, he says; with P-dope, the highs come quickly and powerfully.

"All you need is, like, two bags of this stuff," says Ellen, a Gloucester native in her 40s, who says she takes a daily 90-milligram methadone dose. "The first time I did it, I didn't think I'd feel anything, but I did."

But by mixing P-dope with her methadone maintenance, Ellen -- like other addicts in the city -- risks ending up even worse off than she was before she started treatment.

"The drug is so strong, you have people who are struggling to stay straight who wind up double-addicted -- they have both a methadone habit and a heroin habit," says Doug, another Boston addict. "And that's really horrible."

Of course, not every addict who enters a methadone program keeps trying to find a way to get high on heroin. Many have made substantial progress on methadone maintenance.

But it's also true that addicts are often drawn to the most potent and powerful of narcotics, no matter what the cost. Of the use of heroin among methadone patients, Edward Bernstein, associate professor of emergency medicine at Boston Medical Center, says: "It shows how much people want to get high."

Several users even testify that whenever news gets around about a strain of heroin causing overdoses or even deaths, demand goes through the roof, and the pagers of local dealers start beeping. "If someone dies, everyone's going to want it," says Joe.

One Boston-area heroin dealer, an addict himself, knows how powerful the demand is. Most mornings, he says, he sells large amounts of P-dope to addicts who are outpatients at the city's various methadone clinics. They are a captive, reliable audience, he says. And his selling technique is simple.

"You tell them it cuts right through methadone, and they want it right away," he says.

Addicts say that P-dope has already crippled lives, families, careers. But that story remains mostly hidden on these streets. Much of the current heroin hype has focused on the drug's appeal to the young, vibrant, and beautiful: models, musicians, and the like. Less is said about the drug's impact on chronic, aging users, who are finding it harder than ever to kick. "You want to know what it's like to live with P-dope?" asks Artie. "It's fuckin' hell, believe me. Fuckin' hell."

For decades, the heroin on the streets of Boston almost always came from Southeast Asia, originating in places like Thailand, Burma, and Vietnam. It was largely controlled by Asian criminal groups, which had replaced the Mob and other organized-crime outfits as the drug's principal suppliers. But about four years ago, the market changed abruptly. According to the DEA's Festa, Boston was flooded by an unparalleled surge of heroin produced in South America, delivered via New York, and sold primarily by Colombian and Dominican dealers. In a smart but sinister marketing maneuver, Festa says, these dealers often handed out free samples of their heroin to crack addicts and other drug users.

This South American dope was exceptionally high-grade -- usually 30 to 40 percent pure, Festa says. Sometimes, agents found heroin with purities of 90 percent and above. Not only was this pure heroin more prevalent and, therefore, cheaper -- ranging from $4 to $10 a bag -- but it could be snorted or smoked instead of injected, luring a whole new group of users who had been turned off by needles. "The one thing that is certain is we're seeing a lot more middle-class and upper-middle-class heroin use," says Faulkner Hospital's Wartenberg.

Given this trend, it's not surprising that the chief concern for the DEA has been the growing accessibility of this high-purity form of the drug. "To me, that's the biggest change," says Festa. It's the same in Worcester, Lowell, Lawrence, Springfield, and Providence. "What's scary is when you go up to Maine and see heroin for $6 a bag," he adds.

Less public attention has been devoted to mixtures -- "designer" drugs. But that doesn't mean that local law-enforcement agencies aren't familiar with them. Like Stuen-Parker, the DEA -- which routinely sends out field agents and street sources to collect samples of the local stock -- traces the arrival of heroin laced with procaine and lidocaine back about two or three years. And Lieutenant John Gallagher, the head of the Boston Police Department's drug division, says the city's officers have picked up on the street discussion of P-dope. "I have heard about it," Gallagher says.

In fact, both the BPD and the DEA say they routinely send representatives out into the street to warn addicts when a particularly potent strain of heroin has arrived in the city. (Stuen-Parker often travels around Boston posting signs that read, in part: PLEASE WARN HEROIN USERS ABOUT DEADLY P-DOPE.)

Still, the vast majority of people in the Boston are unfamiliar with the dangers of designer heroin. Part of the problem, again, is the absence of a formal medical study. Another issue is the uniquely varied terminology of the drug culture, where one slang word can have different definitions from city to city, even from street corner to street corner. Understandably, this creates confusion. The White House Drug Policy Office, for example, defines P-dope as "20 to 30 percent pure heroin," not a heroin-procaine-lidocaine mixture. The term has also been used to describe fentanyl synthetic heroin.

And, of course, accounts on the street can vary widely depending on which addicts you talk to -- and, more important, on where they're getting their drugs. Wartenberg, in fact, challenges claims that Boston's heroin purity is rising. In his experience, purity has dipped somewhat in recent years, a trend he measures by the number of addicts who come to clinics seeking methadone treatment and counseling. "I'm not downplaying the quality of heroin in New England, which is better than New York's, but I don't think it's as [pure] as it was two or three years ago," he says.

This lack of consensus frustrates Stuen-Parker, who believes P-dope is a crisis hovering below the public's radar. Every once in a while, it will get a mention -- last year, Stuen-Parker talked about P-dope in a Globe story about a rash of heroin overdoses in South Boston, and there have been stories in the Quincy Patriot-Ledger and Lynn's Daily Evening Item -- but for the most part, he is waging a lonely battle, stymied by limited funds. Stuen-Parker has sent samples of Boston heroin to a New York physician for lab analysis, but he needs to come up with $1500 or so to fund the study. Likewise, the National AIDS Brigade is in debt; Stuen-Parker is pinning his hopes on a Boston-New York bicycle ride to raise money.

But in the meantime, P-dope continues to do damage, Stuen-Parker says. "We've tried telling everyone, but no one seems to care," he says.

What may bring relief to the P-dope situation are alternative treatments for heroin addiction. One longer-acting medication, LAAM (levomethadyl acetate hydrochloride), has proven a worthy alternative to methadone and is already in use in Boston clinics. Another, buprenorphine, is on the verge of Food and Drug Administration approval; trials have shown the drug suppresses heroin craving but isn't as addictive as methadone, and those who use it can gradually be weaned off.

New choices, of course, will be welcome news to users who find themselves addicted to both heroin and methadone. But too often, good treatment is a question of access. Last fall's NIH panel called for the expansion of substance-abuse treatment programs in the US, noting that fewer than 20 percent of heroin addicts nationwide are enrolled in methadone maintenance.

Also uncertain is the status of such alternative treatments as ibogaine, an alkaloid derived from the iboga plant in the rain forests of West Africa. Ibogaine proponents say the drug triggers an intense, psychedelic-like reaction in a patient that often produces therapeutic visions of childhood and of earlier drug episodes. Howard Lotsof -- who is president of NDA international, a company that promotes ibogaine -- is one of the nation's biggest ibogaine supporters. He claims that the drug "appears effective for a broad spectrum of chemical dependencies, including opiates."

Though ibogaine has been administered successfully overseas, skepticism among federal regulators has prevented its extensive use in this country. Likewise, a radical treatment called rapid opiate detoxification -- in which the heroin is "flushed" out of an anesthetized user's body -- has yet to win mainstream acceptance in the US, despite promising results in other countries.

Still, many drug-abuse specialists are finding solid success with a more mainstream approach that combines methadone treatment with in-depth counseling and other techniques. Inventive touches abound. J. Peter Stein, of the North Charles Institute for Addictions, for example, promotes hatha yoga for addicts, along with methadone and intensive group therapy. Betsy Smith, of the Fenway Community Health Center, uses acupuncture.

In essence, the medical community's attitude toward addiction is evolving from an aggressive search for quick, permanent solutions to a more realistic, long-term concept of "harm reduction" -- the idea that a drug user in treatment is causing less trouble, committing fewer crimes, and endangering others less, even if he or she relapses now and again.

"We want to think of treatment as something that is short-term -- we want it to be effective, and we don't want to include the idea of relapse. But treatment is characterized by relapse," says Stein.

Even with new treatment options, it's certain that heroin is here to stay in Boston. But given the kinds of drugs that are on the streets today, whether addicts themselves will be sticking around is another question.

"People are dying, and I can't relax," says Jon Stuen-Parker. "How can I relax when there's a drug out there like this one? How can anyone?"

Jason Gay can be reached at jgay[a]phx.com.