On September 11, 1973, President Richard Nixon announced to a White House conference on the heroin problem that “we have turned the corner on drug addiction in the United States.” At the time, some evidence suggested that he was correct. For about a year, the government had watched various indicators of heroin use decline: admissions to treatment programs in many cities were down, the prevalence of serum hepatitis (a disease that, among young adults, is strongly related to intravenous drug use) had dropped, and fewer persons arrested were found to have heroin traces in their urine or to require detoxification in jail. Narcotics agents on the streets of the large Eastern cities were finding it harder and harder to make undercover buys of heroin or arrests of major heroin traffickers. In fact, cocaine had become, without anyone’s intending it, the major object of law-enforcement efforts in many cities.
Now, a year and a half later, it is no longer so clear that we have turned the corner. In retrospect, the decline in heroin use was real, but it was limited to a few large Eastern cities and was not characteristic of the nation as a whole. What is worse, those Eastern cities in which a combination of law enforcement and medical treatment seemed to have improved matters now hover ominously on the brink of what may be a new upsurge in usage. Finally, communities that had never experienced a serious heroin problem before are now finding that they have heroin problems as alarming as those found in the older, larger cities.
In the time since Mr. Nixon’s optimistic statement, much has changed; not the least change has been a substantial improvement in the quality of data and the sophistication of analysis in the area of addiction. Various researchers in and out of government have achieved some brilliant successes in identifying the sources of heroin entering the country, in plotting changes in the price of heroin, in using various public-health and hospital reports to measure the incidence of drug abuse, and in devising mathematical models to explain—and perhaps predict—how heroin use spreads. The two federal agencies concerned with drug abuse—the Drug Enforcement Administration (DEA) and the National Institute of Drug Abuse (NIDA)—are now monitoring and further refining a set of indicators of drug use based on this research. These indicators provide a retrospective picture of heroin use in the past and a method for understanding future patterns of use.
For some time, experts have been aware that heroin use spreads as if it were an epidemic. That is, an initial user will, during his first few months of use, induce his friends to experiment with it; out of the initial group of users, one or more will induce friends to try it, and in a rather short period of time a very large population of young persons will be exposed to the drug and a large but unknown fraction of those exposed will become regular users. Each initial user is “infectious”—that is, able and willing to enlist his acquaintances into heroin use—for about a year; after that, he seldom produces new users, because either he has stopped using it himself or he has become so confirmed a user that he associates only with other confirmed users who share his way of life and can help him “connect” with a regular supplier. Leon Gibson Hunt of the Drug Abuse Council, a private organization in Washington, D.C., has developed an elegant mathematical model of how this process operates.
It was once assumed that these epidemics would be confined to the large cities where there were large numbers of potential users, many overlapping friendship networks, and readily available supplies of the drug. For this and other reasons, many supposed that the heroin problem was and would remain primarily a big-city problem.
Now Hunt and others have shown that this is not the case. Heroin use can and will spread to smaller communities following a pattern observed with many diseases, with urban riots, and even with the usage of television. The “diffusion” of narcotics occurs this way: after the peak incidence year of an epidemic has passed, which for most Eastern cities occurred around 1969-70, new epidemics on a smaller scale begin to break out in Middle Western cities and in smaller communities. This does not mean that the heroin problem in the Eastern cities is “over” and now is to be found elsewhere: it still remains serious in the East because, although the rate at which new users are being recruited has leveled off, that rate remains high and a vast pool of addicts remains in existence. The size of the addict population (i.e., the “prevalence” of heroin) will not decrease until the rate at which new addicts are created (i.e., the “incidence” of heroin) drops below the rate at which old users are giving up the habit (i.e., “maturing out”). For a brief while, old users on the East coast were maturing out faster than new users were being recruited, but that is no longer the case.
It is the incidence of new heroin users that is going up rapidly in smaller communities. There are now identifiable heroin addiction problems in Racine, Wisconsin, Des Moines, Iowa, and Boulder, Colorado. The problem has even entered some rural areas. It appears that the most rapid growth in heroin may be occurring in cities thought to be strongholds of Middle America and thus immune to such problems as addiction.
This diffusion of heroin from the big cities to the small ones is graphic though tragic evidence of the extent to which we have become one nation, one culture. At one time, it was conceivable that many parts of the country—the South, the Middle West, small communities—could quarantine themselves from the real and imagined evils of big-city life. Indeed, it was once possible within the big cities to quarantine certain activities by confining them to specialized parts of the city. Hence red-light districts, skid row, Chinatown, the “other side of the tracks.” Personal mobility, urban growth, the national media, and mass merchandising have changed all that.
No one knows how big the problem may become in the smaller communities, but Hunt estimates that as many as 200,000 new addicts could be recruited in these areas during the next few years. If that is true, then treatment facilities as well as some law-enforcement efforts will have to be allocated to areas long thought to have no need for such programs.
Concomitant with the shift in the locus of heroin epidemics has been a change in the composition of the addict population. The most rapidly growing part of that population is white, both male and female. Indeed, in the United States it would appear that there are more white than black addicts, though the rate for blacks is higher than for whites. Furthermore, whereas the size of the black component is stable, the size of the white component is increasing. This is, of course, exactly what one would expect as epidemics begin to occur in communities without large black ghettos.
One of the best indicators of the incidence of intravenous drug abuse (most of which involves heroin) is the extent of serum hepatitis. Unlike infectious hepatitis, which can be contracted without sticking a needle in your arm and which tends to be most prevalent among the very young (ten years of age or even younger), serum hepatitis is most easily transmitted through an infection of the bloodstream (as from a dirty needle) and is most prevalent among young adults (ages 15 to 30). Most of these cases, it can be shown, are the result of drug abuse. Hepatitis is reported to the Public Health Service and this provides data on the extent of drug use independent of police and other sources. Furthermore, serum hepatitis is a good measure of the rate at which new drug users are being created because, once the disease is contracted, the body usually develops an immunity to its recurrence. Older, established addicts are, as a result, less vulnerable to hepatitis than younger, novice users.
After mid-1972, when the number of cases of serum hepatitis was declining in the Eastern industrial states with a recognized problem—states such as Illinois, Massachusetts, New York, and Pennsylvania—the number of cases was beginning to rise, though no one noticed it at the time, in states such as Florida, Kansas, Wisconsin, Indiana, and even New Hampshire.
Whatever the hepatitis figures may tell us about the recruitment of new addicts, other data already suggest that the older, existing addicts in the Eastern cities are beginning to increase their consumption. Urine tests performed on prisoners in the District of Columbia jail show an increase in heroin signs after a long period of decline. Requests for admission into treatment programs are once again rising.
Facts confirming this trend are available from still another source. The Drug Abuse Warning Network (DAWN) is a nationwide system, devised and paid for by the federal government and operated by a private contractor, that systematically collects and processes into a computer information about admissions to hospital emergency rooms, drug clinics, and drug-crisis centers. The number of patients entering these facilities mentioning drug use is tabulated, anonymously, and sent to Washington. While one must be cautious in using these data, they suggest that over the last year or so—in fact, regularly since Mr. Nixon’s 1973 speech—there has been a more or less steady increase in the frequency with which heroin is mentioned in the DAWN system.
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The nationalization of the heroin problem—its first engulfing black communities, then its spreading to white areas adjacent to ghettos, and now its appearance in smaller communities—may be only the inevitable, albeit tragic, working out of an epidemiological phenomenon that began in the 1960’s in the big cities. But what can explain the serious possibility of a new increase in heroin consumption in the Eastern United States? There are a number of possibilities, but one dramatic factor—perhaps the dominant one—is readily apparent: the East coast heroin shortage, that existed in 1972-73, is ending.
The fact of the shortage was beyond dispute. Beginning in mid-1972, street buys of heroin became harder to make. Intelligence reports suggested the influx of major shipments was down. And perhaps most revealing, the price of heroin on the street went up substantially. Between mid-1972 and mid-1973, the cost of heroin, per pure milligram, rose on the East coast from about $1 to nearly $3. The actual price to the addict of a “bag” of heroin was, of course, much higher—around $20—because each bag contained several milligrams of the narcotic. At the same time, the purity of the drug in the typical bag declined, from about 8 to only 2 or 3 per-cent pure.
For some, this price increase was bad news. Many experts believed that addiction was so compulsive and uncontrollable that users would continue to buy the drug in the same amounts whatever the price and, since the price was often beyond their means, would have to steal more and more in order to “teed their habits.” In fact, for a variety of reasons, heroin consumption declined as price increased. For one thing, there were by 1972 sufficient drug-treatment programs in most Eastern cities so that a feasible alternative to heroin use existed. The primary form of treatment, methadone, is controversial, and early claims for it were exaggerated, but it has proved to be a remarkably effective way of stabilizing many thousands of addicts well enough to permit them to lead reasonably normal lives while undergoing various forms of counseling and treatment. For another, some heroin users find it possible to substitute other drugs—barbiturates, illegally diverted methadone, amphetamines, alcohol—for heroin when the latter becomes too scarce or too costly. And many addicts who had acquired a habit with bags that were only 2 per-cent pure had become so mildly addicted that they could detoxify themselves, reducing or abandoning their heroin consumption with relative ease.
Whatever the precise combination of explanatory factors, the central fact seems clear: the demand for heroin is not, in economic language, entirely inelastic; rather, it is price-elastic to the degree that if price goes up sharply, consumption will decrease.
Beginning in late 1973 and early 1974, the purity of East-coast heroin began to increase and by mid-1974 the price per pure milligram began to go down. If shortages and high prices had led to reduced consumption, there was every reason to believe that enhanced purity and lower prices would lead to increased consumption. And that, apparently, is exactly what is happening.
East-coast suppliers are not yet back to their pre-1973 levels, if current prices are any indication. But they are moving in that direction. From February to September 1974, purity doubled (from 3.5 to 7 per cent) and price per pure milligram fell from $2.90 to $2.00.
The facts in the rest of the country are consistent with the theory that heroin consumption is powerfully affected by the amount of the drug available and its price. California, and the West coast generally, experienced no heroin shortage. During the last few years, the purity of heroin available in California has remained relatively high (10 to 12 per cent, and in a few cities even higher) and the price, though it has risen, has remained much lower than the levels reached in New York: less than $1 per pure milligram. And during this period, heroin consumption remained high as measured by every available indicator. From 1969 through 1973, the rate of serum hepatitis was higher than it was on the East coast and remained about constant, without the big dip that in the East accompanied the shortage. Demand for treatment facilities remained high. At the very time that Mr. Nixon was telling the nation that we had turned the corner, police chiefs, treatment physicians, and hospital administrators on the West coast were grumbling loudly about what they saw as the inadequate level of federal support for their burgeoning heroin problem.
The reason that West-coast heroin supplies remained abundant can be given in one word: Mexico. Widespread opium poppy cultivation in many of the western provinces of Mexico has supplied a large number of clandestine laboratories located in the same region which in turn provided a sizable supply of heroin that encountered relatively little resistance in crossing the 1600-mile border between Mexico and the United States. Furthermore, the Mexican heroin is not managed by a monopoly distributor or by a few tightly-organized “connections.” Free enterprise reigns, with a host of distributional networks ranging from the casual “mule” (a person carrying a small quantity of the drug on his person) to well-financed organizations operating boats and airplanes.
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For a long time no one knew exactly how large a share of the American market was taken up by Mexican heroin. In fact, some thought that much of what came from Mexico was actually transshipped through there from sources in France or Southeast Asia. And almost everybody believed that the Mexican operation, if that is in fact what it was, represented a recent development stimulated by the closing down of the Turkish poppy fields and the disruption of many heroin laboratories in Marseilles. Some went so far as to say that the advent of the Mexican problem was a sure sign of the failure of our Turkish policy since Mexico has “proved” how easily and quickly new sources of heroin can be brought into production.
It is now possible to make some fairly confident statements about many of these speculations and at least to cast doubt on some of the inferences. By the development of an elaborate process for relating chemical analyses and intelligence on drug origins, it can be said with some assurance that the vast bulk of heroin entering from Mexico is in fact produced there and now constitutes one half or more of the entire U.S. heroin market. Furthermore, Mexican heroin is not a recent innovation. A study of DEA files reveals that Mexico has been a significant producer and exporter of heroin since at least World War II. The Mexican heroin may have partially filled the void created by the shortage of French heroin, but it was by no means created in response to the disruption of the France-Turkey production systems and might have developed to its present level whether or not the Turkish poppy fields had been plowed under.
One deep puzzle remains, however. For two years or more, there has been in existence a sharp price differential between West-coast and East-coast heroin. In June 1972, for example, a user in Los Angeles could buy 12 per-cent pure heroin for 32 cents a pure milligram whereas his cousin in New York City would have had to pay 80 cents per milligram for a bag that was only 6 per-cent pure. In 1974, the absolute price levels in both cities were higher, but the differential persisted—what cost less than $1 per pure milligram in Los Angeles cost nearly $3 in New York.
If such a differential existed with respect to color television sets, tickets to the Super Bowl, or uncut diamonds, there would immediately arise a good deal of transcontinental buying and selling until the differential disappeared or was much reduced. Nothing of the sort happened in the heroin market.
The explanation is apparently linked to the fact that Mexican heroin did not enter the big East-coast markets in substantial amounts. When white “French” heroin became hard to find, brown Mexican heroin did not immediately fill the void even though it was relatively abundant in the rest of the country. One reason may be that big-city East-coast addicts have an aversion to “Mexican brown,” perhaps because it is brown (or beige, depending on how it is cut).
Another possibility is that the highly organized East-coast heroin distribution system has had sufficient monopoly power to exclude the cheaper Mexican heroin and to maintain the high prices charged for white heroin. Or perhaps ethnic rivalries made it difficult for those handling Mexican heroin to establish good working relations with the Italians and blacks who are important in Eastern-drug trafficking.
Whatever the reasons, Mexican heroin as late as December 1973 accounted for only 10 per cent of the retail purchases by law-enforcement agencies in New York City at a time when it made up 80 per cent of the purchases in the central part of the United States and 60 per cent of those in California. By September 1974, there was more Mexican heroin in New York but it still accounted for only 20 per cent of the total there and only 30 per cent of the total in other Eastern seaboard cities.
In the long run, it is hard to believe the price differential will persist or that Mexican heroin will not find adequate distributional channels throughout the country. If that happens, and if at the same time there is a renewed supply of French-Turkish heroin, heroin supplies in the East will once again be abundant, prices will fall even lower, the consumption by addicts will probably rise, and the recruitment of new addicts may also increase.
And French-Turkish heroin is reappearing in substantial quantities. In August 1974, DEA agents in New York seized 75 kilograms (about 160 pounds) of pure French heroin and there are good grounds for suspecting that this was not an isolated shipment. In addition, a new group of manufacturers and traffickers based in Lebanon has begun to enter the U.S. market: 1.7 kilograms of high-quality Lebanese heroin were seized in Detroit in April 1974.
DEA officials speculate that the raw materials for this French and Lebanese heroin were stored in Europe and Turkey at the same time the Turks ceased producing poppies. Now that the Turks have resumed cultivation of the poppy, these stockpiles are being used to make heroin in anticipation of their replenishment within the year from fresh Turkish supplies.
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These developments strongly suggest that it is premature to relax federal and local efforts to deal with the problem. The differing experiences of the East and West coasts over the last few years are consistent with the theory that a combination of vigorous law enforcement and ample treatment facilities employing a variety of techniques can make a difference in the total level of heroin consumption and in the recruitment of new addicts. No program can “eliminate” the heroin problem or “stamp out” heroin—not, at least, without unacceptable costs in money and personal liberties. It is not even clear how many addicts can be permanently cured, but it does seem that substantial reductions in the use of the drug for significant periods of time can be achieved.
The East-coast heroin shortage was the result of vigorous law enforcement combined with the Turkish poppy ban. That no similar shortage was produced on the West coast is due not only to the decentralized nature of the delivery systems from Mexico, making it harder to immobilize many traffickers with a few key arrests, but also to the fact that DEA is stretched very thin. Though state and local narcotics agents are important, international trafficking and the major national and regional distributors are the special responsibility of DEA. Yet to deal with the countless suppliers of several hundred thousand heroin addicts, DEA has only two thousand agents. As John R. Bartels, Jr., administrator of DEA, puts it: “We have only two-thirds the number of officers that the New York Transit Authority employs and whereas they need only cover three subway lines, we must fight a three-front war overseas [Turkey, Mexico, and Southeast Asia] and a sixty-city war in the United States.” He might also have added that DEA employs one-third the number of field officers of the Environmental Protection Agency.
Of highest priority, perhaps, must be efforts to bring Mexican production under control. Key officials of the Mexican government have worked energetically on this, but the problem is vast: thousands of acres of poppies are cultivated on small sites in remote regions of the country. With persistence and sufficient resources, however, there is no inherent reason that poppy cultivation cannot be substantially reduced and clandestine laboratories disrupted.
Once the narcotic leaves Mexico, it becomes harder to stop. It is easy to suppose that blanketing the border region with investigators and detection equipment is the appropriate strategy, but though closer controls at the border may be valuable, the largest shipments skip over the border by plane and go directly to the big cities: Los Angeles, Chicago, St. Louis, Montreal, and so forth. The investigative effort will have to emphasize these cities and breaking up the distributional organizations located there rather than the utopian ideal of “sealing off” the border. (The disaster that was “Operation Intercept” of former Attorney General John Mitchell suggests the problems of concentrating on the border.)
Treatment facilities will require expansion, primarily in middle-sized and smaller cities. If the 1974 serum hepatitis data bear out the apparent increase in big-city heroin consumption, and the revived demand for space in big-city treatment facilities continues, more funds may have to be spent in these areas as well.
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Finally, it may be necessary to place drug abuse once again higher on the national political agenda. From 1969 through 1973, there was close Presidential attention to the matter. This had both desirable and undesirable results. Things were made to happen in the bureaucracy, appropriations rose, and coordination of law-enforcement and treatment efforts improved. But at the same time, there was a tendency to play politics with drugs and some persons associated with the drug effort later were found to be implicated in Watergate and other sordid affairs. In a fragmented governmental structure such as ours, energetic executive leadership often can occur only at some risk of political gamesmanship. These risks can be minimized by insisting on integrity and public accountability in the White House, but they cannot be eliminated. And the costs of failing to provide Presidential leadership are even graver: law enforcement will continue to be muddled by bitter jurisdictional quarrels, the support and direction of treatment programs will sink down into obscure, business-as-usual bureaucratic niches, and our foreign-policy objectives will not be sufficiently sensitive to our domestic drug concerns.
It would be a pity, for in the last few years we have learned a great deal about drug abuse, above all how to think about it systematically. There is absolutely no reason to return to the years when we were caught unawares by the great heroin epidemic of the 60’s and so paid a higher price, in tragically wasted lives, than was necessary.
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