Magister Artium (Social Work) - MA(SW) / Heroin usage is on the increase in the Western Cape province of South Africa owing to globalization and to increased access to the drug in this province. The goal of this study is to explore the experiences of coloured heroin users in the Metro South area of Cape Town, which stretches from Simons Town and Muizenberg to Retreat, Lavender Hill, Grassy Park, Parkwood and Wynberg. These individuals have been found to congregate in the Wynberg CBD. The overarching theoretical framework for the purpose of this research is social constructionism and symbolic interactionism, using a qualitative means of inquiry. Snowball sampling was used to recruit prospective participants and data was collected by means of in-depth interviews, with a semi structures interviewing schedule. The questions informed the subsequent themes and categories that arise from the data collection process. Snowball sampling was employed in this case, a non-probability sample, in which participants were recruited via key informants. The sample distribution included 13 participants, 10 of which were heroin users (5 female, 5 male) and the remaining 3 were key informants which contributed to triangulation of the data. In terms of the findings, participants spoke of mostly being involved in intimate relationships, which according to participants had dual benefits. For female participants intimate relationships offered a form of protection on the often dangerous streets of Wynberg and for certain males, intimate relationships offered an opportunity to fund their habit, by trading their female partners to perform sexual favors for money to acquire heroin. While the study found females were mainly involved in trading sexual favors for money, heterosexual males were also implicated in having sexual relations with homosexual men for money. Furthermore, the study found that heroin users in Wynberg represented a surrogate family, where, because of their lifestyle, they were disconnected from their own family. This family surrogate was found to be supportive, caring to a large extent, shared a living space, protective of each other and shared a common language and understanding.

abstract: Opioid use in the United States is skyrocketing. Overdose deaths have increased 433% in the last decade and will continue climbing. In addition to the mortality caused by illicit opioid misuse, morbidity rates have also risen. People Who Inject Drugs (PWID) demonstrate higher rates of Human Immunodeficiency Virus (HIV), Hepatitis C Virus (HCV), Endocarditis, Persistent Abscesses, Staphylococcus Aureus (S. aureus, Staph) and other skin infections. This thesis serves as (1) a systematic review of the differences in health conditions experienced by PWID and (2) an examination of the trends in skin and soft tissue infection from a small sample in Phoenix, Arizona. The author argues that PWID suffer from an increased rate of comorbid conditions associated with substance use. Targeted social work interventions could be useful in reducing the rates of disease and their impact on the individual and community. / Dissertation/Thesis / Masters Thesis Social Work 2019

The increase in heroin use is one factor contributing to the current opioid epidemic in the United States. There are three Food and Drug Administration (FDA) approved medications for the treatment of opioid use disorder (OUD), and these include agonist (i.e. methadone and buprenorphine) and antagonist (i.e. naltrexone) therapies. Although these medications are effective for some patients, regulatory constraints for agonist therapies limit access and patient compliance for naltrexone is poor. The development of new therapies, such as immunopharmacotherapies, for the treatment of OUD is a priority for the National Institute of Drug Abuse. A heroin immunopharmacotherapy, or vaccine, produces heroin selective antibodies that bind to and sequester heroin in the periphery. One formulation of a heroin-tetanus toxoid (TT) conjugate vaccine has shown promise in preclinical studies in mice in monkeys but has not been fully assessed to determine independent variables that might impact vaccine effectiveness such as heroin route of administration, species of animal or abuse-related behavioral endpoints. Chapter II of this dissertation aimed to determine effectiveness and selectivity of the heroin-TT conjugate vaccine to alter the antinociceptive effects of subcutaneous and intravenous heroin in male and female rats. In addition, maximal vaccine effects were compared to effects of a positive control naltrexone. Vaccine effectiveness to reduce heroin antinociception was selective, but effectiveness did not depend on route of administration. Furthermore, maximum effects were less than those seen with a clinically meaningful dose of naltrexone. Combining the vaccine with naltrexone enhanced the effectiveness of naltrexone to block the antinociceptive effects of heroin. Chapter III determined vaccine effectiveness and selectivity to block heroin’s discriminative-stimulus effects in nonhuman primates and compared maximal effects produced by vaccine and naltrexone. The heroin vaccine weakly but selectively reduced the abuse-related subjective-like effects of heroin in one of two monkeys. However, chronic naltrexone treatment nonselectively antagonized the abuse-related effects of both heroin and fentanyl, and naltrexone effects were more robust than those of the vaccine. Chapter IV established a translational procedure to assess candidate medication effects on the reinforcing effectiveness of heroin in a heroin versus food choice procedure in rats. In the procedure, rats choose between a liquid food reinforcer and ascending doses of heroin in a 5-component choice procedure. Heroin versus food choice was found to be sensitive to an environmental manipulation of altering response requirement for both reinforcers. Chronic buprenorphine decreased heroin choice, consistent with its FDA-approved indication for treating OUD. Collectively, these data suggest that the current formulation of the heroin-TT conjugate vaccine may not be as effective as naltrexone at decreasing heroin use. However, one potential indication the vaccine may be useful for is as an adjunctive therapy to clinically available agonist or antagonist medications and a heroin versus food choice procedure in rodents would be one way to full assess this preclinically.

Heroin addiction is a growing epidemic in the United States. The need for proper treatment programs accessible by heroin users who wish to or are mandated to participate in recovery programs is a growing need, and pathways to sobriety for ex-offenders have presented in literature as understudied. The purpose of this study was to examine heroin-addicted offenders' experiences prior to and after release on their paths to sobriety. This study followed a qualitative phenomenological approach based on the theory of personal causation, which posits that individuals see events in life as either driven by themselves or caused by others, both of which affect internal motivation. An empirical phenomenological approach was used to explore how this group of individuals perceived or experienced heroin addiction and their subsequent attempts at sobriety A purposeful sample of 15 heroin-addicted offenders were interviewed in a jail in a rural county of Wisconsin. Upon re-entry, 4 participants completed follow- up interviews. The results showed that external motivators such as social and treatment factors were separate from internal factors, although external motivators could influence the way a person makes internal choices. Results were obtained by performing coding on the semi-structured interviews both by hand and within the Atlas-ti analysis program. The theory of personal causation supports and is supported by the findings of this study. Implications for positive social change include a better understanding of the needs of heroin-addicted offenders moving from incarceration to release in treatment program development, thereby reducing harm to the heroin user, family members, and communities by decreasing relapse, recidivism, and chances of overdose and death.

The goal of this research was to aid in the fight against the heroin and opioid epidemic by developing new methodology for heroin provenance determination and forensic sample comparison. Over 400 illicit heroin powder samples were analyzed using quadrupole and high-resolution inductively-coupled plasma mass spectrometry (Q-ICP-MS and HR-ICP-MS) in order to measure and identify elemental contaminants useful for associating heroin samples of common origin and differentiating heroin of different geographic origins. Additionally, 198 heroin samples were analyzed by multi-collector ICP-MS (MC-ICP-MS) to measure radiogenic strontium isotope ratios (87Sr/86Sr) with high-precision for heroin provenance determination, for the first time. Supervised discriminant analysis models were constructed to predict heroin origin using elemental composition. The model was able to correctly associate 88% of the samples to their region of origin. When 87Sr/86Sr data were combined with Q-ICP-MS elemental data, the correct association of heroin samples improved to ≥90% for all groups with an average of 93% correct classification. For forensic sample comparisons, quantitative elemental data (11 elements measured) from 120 samples, 30 from each of the four regions, were compared in order to assess the rate of discrimination (5400 total comparisons). Using a match criterion of ±3 standard deviations about the mean, only 14 of the 5400 possible comparison pairs were not discriminated resulting in a discrimination rate of 99.7%. For determining the rate of correct associations, 3 replicates of 24 duplicate samples were prepared and analyzed on separate days. Only 1 of the 24 correct pairs were not associated for a correct association rate of 95.8%. New methods for provenance determination and sample comparison are expected to be incredibly useful to intelligence agencies and law enforcement working to reduce the proliferation of heroin.

The prefrontal cortex (PFC) is considered a critical node in the neural circuitry underlying drug-seeking behaviors. However, the mechanisms by which this region influences drug seeking and whether or not the lateral PFC mediates cocaine or heroin seeking are questions that have yet to be answered. To expand on the role of the PFC in drug seeking, rats were trained on either heroin or cocaine self-administration for a minimum of 12 days before undergoing extinction training and subsequent reinstatement tests (cued and drug-prime). All pharmacological manipulations were delivered immediately prior to reinstatement testing and were targeted at either the ventral region of the medial PFC, the infralimbic cortex (IL), the anterior portion of the medial PFC, the medial orbitofrontal cortex (mOFC), the anterior region of the insular cortex, the dorsal agranular insular cortex (AId), or the posterior region of the insular cortex, the posterior insular cortex (PIc). In chapter 1, D1 and D2 antagonists were administered into the IL and mOFC prior to cued and cocaine-prime reinstatement. Although previous studies found that the IL inhibits cocaine seeking, blocking D1 receptor activity in this region reduced cued reinstatement and had no effect on cocaine-prime reinstatement, indicating that the IL can promote cocaine seeking under certain circumstances. In contrast, blocking D1 receptors in the mOFC reduced all forms of reinstatement that were examined. Blocking D2 receptors in either region had no effect on cocaine seeking. Our data are the first to demonstrate a role for the mOFC in cocaine seeking and suggest that although the IL and mOFC lie immediately adjacent to one another, they play distinct roles in mediating cocaine seeking. In chapter 2, we pharmacologically inactivated the AId and PIc via a GABA agonist administered immediately prior to both cocaine and food seeking. Reversible inactivation of the AId reduced cued reinstatement but had no effect on cocaine-prime reinstatement. In contrast, inactivating the PIc had no effect on any form of cocaine seeking. Additionally, blocking the AId during cued and food-prime reinstatement had no effect on food seeking, indicating the role of the AId in reinstatement is specific to cocaine seeking and not general motivated behavior. Additionally, blocking CRF1 receptors in the AId blocked cued reinstatement, suggesting a possible mechanism whereby the AId is influencing cocaine seeking. These data are the first to establish a role for the AId in cocaine seeking and demonstrate that although the PIc influences alcohol and nicotine seeking, it does not mediate cocaine seeking. Chapter 3 further examined the role of the AId in cocaine seeking and expanded the influence of the insular cortex in drug seeking to heroin. AId D1 receptor blockade reduced both cued and cocaine-prime reinstatement following extinction training, whereas D2 receptor blockade had no effect on cocaine seeking. These results establish a role for the AId in cocaine-prime reinstatement, as pharmacological inactivation showed no role for the AId in cocaine-induced drug seeking. Additionally, blocking the AId during heroin seeking potentiated cued reinstatement whereas blocking the PIc during heroin seeking reduced cued reinstatement. These results demonstrate a role for the insular cortex in heroin seeking that has never been shown before and further explain how the AId may be influencing cocaine seeking.

Does Nimbin have a drug problem? This tiny village in north-eastern NSW has an international reputation for its alternative community and its street drug market. Ever since the Aquarius Festival thirty years ago Nimbin has fascinated the media, and recurrent headlines about the village's (undefined) 'drug problem' suggested my research topic. My research aim was to investigate the meaning/s of Nimbin's 'drug problem' in the context of Nimbin's 'alternative' culture. Because the topic of illicit drugs is both ethically challenging and highly sensitive, my research design was strongly participant-focused, with an emphasis on confidentiality balanced by a mixed methodology to cross-validate results. My methods included an anonymous household (door-to-door) survey based on a national household survey; an anonymous mailed-back survey of Nimbin and Lismore drug injectors; taped interviews with health and legal professionals, cannabis activists and drug dealers; semi-structured interviews with 'professional' cannabis crop growers; and participant observation over several years. I found the multi-method research design to be particularly effective for investigating illegal drug marketing and use, and the design provided me with multiple perspectives on a complex issue. Superficially, there appeared to be two drug 'problems' in Nimbin — one was the (largely cannabis) street market, and the other revolved around heroin users, and included complaints about scruffy-looking people hanging around the main street, or overdosing in the public toilet. However, my research suggested that these issues, while immediately comprehensible as 'drug problems', obscured more complex issues. For example, the village's street drug market was intertwined with the local economy and with the alternative community's values and drug use, while close to half of the drug injectors lacked secure housing (which creates problems that are not related to heroin), and all heroin users were blamed for the actions of few. Many factors influence the creation and maintenance of what we might call 'problems', and drugs are frequently blamed for broader social problems. What is Nimbin’s drug problem? The answer depends, in part, on the drug of interest, but more importantly it depends on your definition of a ‘problem’. Some useful and meaningful perspectives on this important social issue include quantified indicators such as death, injury, arrest rates, the economics of black markets, the demographics of drug use, and estimates of ‘social costs’. Qualitative perspectives include people’s opinions about drugs, media-generated moral panics, the effects of social marginalisation, and the role of drug cultures. A number of ‘drug problems’ arise as a direct result of drug illegality. They include black markets, corruption, drug-related violence, theft, stronger forms of the drug, and more dangerous using practices (with the risk drug overdoses and HIV/AIDS), as well as public nuisance issues. Government policy, judicial sentencing and public opinion are moving towards the social reintegration of illicit drug users, but this is almost invariably counter-balanced by a toughening of legal sanctions against supply of the same drug. Most discussions about illicit drugs fail to consider the long-term implications of harsh penalties for, and elaborate and punitive police operations (such as occurred throughout my Nimbin research) against, small-scale independent growers and dealers. The only way to directly engage with drug markets and all the attendant problems, is to legitimise and regulate the supply of recreational drugs. I discuss several examples of the important role of the drug culture in mitigating problems caused by illegality. One example is the influence of Nimbin's alternative community on the style of the drug market. The village drug scene more closely resembles the many north coast village craft markets, than it does Kings Cross, Cabramatta or New York's Bronx. Buyers are north coast locals, along with national and international tourists (the small village is known to cannabis users world-wide, both through media attention and word-of-mouth). Nimbin offers a 'safe' village market ambience and competitive prices to a mainly cannabis using clientele. I suggest that there are two major underlying influences on the experience of a ‘drug problem’, regardless of the drug or the place. They are: 1. Political influences — specifically the effects of government policy on black markets, law enforcement practices, and access to services and resources; 2. Cultural influences — particularly the beneficial effects of norms and functional role models for the safe use of a drug, cultural effects on the drug market, and the role/s of the drug in the day-to-day life of the culture. These influences can operate with, or despite, each other, and can create or ameliorate many ‘drug problems’. In the case of Nimbin’s alternative culture, government policy has created a number of drug problems and the counter-culture has worked to minimise them. In my research into Nimbin’s ‘drug problem’ I have clarified some issues and raised a number of others. I have examined the notion of a ‘drug problem’ from several perspectives using a range of research tools, and discussed some key influences on the problem associated with drug use. Drawing from the Nimbin research and my reading, I suggest legalising the recreational drugs to bring them under the dual controls of supply legislation and social norms. In conclusion, I suggest that we need to be very clear about what ‘drug problem’ it is that we are talking about, and indeed, whether the problem is really about drugs at all.

Comorbidity between substance use disorders and post traumatic stress disorder (PTSD) is common. Despite evidence to suggest that people with heroin dependence are at particular risk of PTSD, there is a dearth of research focussing on the interrelationship between these disorders. The present thesis aims to identify the prevalence of PTSD among people with heroin dependence, the correlates of this comorbidity, and its impact on treatment outcomes, the utilisation of treatment services, and treatment costs. Study 1 examines the epidemiology of PTSD and heroin dependence among 10,641 Australian adults who participated in the National Survey of Mental Health and Wellbeing. The prevalence of PTSD was highest among people with heroin or other opioid use disorders compared with any other drug class (33.2%). Comorbid PTSD was associated with poorer occupational functioning, and poorer physical and mental health. While general population studies provide crucial population estimates they do not allow for a detailed examination of the relationship between highly disabling but low prevalence disorders. The remaining studies were undertaken using a sample of 615 treatment seeking and non-treatment seeking dependent heroin users. Study 2 examines the prevalence and correlates of this comorbidity. PTSD was common (lifetime 41%; current 31%) and was associated with a more severe clinical profile. Studies 3 and 4 were based on follow-up data on this large cohort. Study 3 is the first study to examine the impact of PTSD on 2 year treatment outcomes for heroin dependence. Across the 2 year period, those with current PTSD at baseline performed more poorly in terms of their occupational functioning, physical and mental health. Study 4 found that this did not equate to the greater use of treatment services or an increased cost to the health care system among those with PTSD. It is concluded that PTSD and heroin dependence are highly comorbid conditions, and that this comorbidity is associated with poorer functioning and poorer treatment outcomes. Individuals entering treatment for heroin dependence should be assessed for PTSD so that they may receive appropriate treatment and referral. Further research is also needed to determine how best to treat this comorbidity.

Misguided drug policy in the United States has led to many severe social and economic problems that have burgeoned over the past century. I analyzed heroin policy specifically, investigating new treatment methods and alternative decriminalization policies that would ameliorate some of these problems.

Does Nimbin have a drug problem? This tiny village in north-eastern NSW has an international reputation for its alternative community and its street drug market. Ever since the Aquarius Festival thirty years ago Nimbin has fascinated the media, and recurrent headlines about the village's (undefined) 'drug problem' suggested my research topic. My research aim was to investigate the meaning/s of Nimbin's 'drug problem' in the context of Nimbin's 'alternative' culture. Because the topic of illicit drugs is both ethically challenging and highly sensitive, my research design was strongly participant-focused, with an emphasis on confidentiality balanced by a mixed methodology to cross-validate results. My methods included an anonymous household (door-to-door) survey based on a national household survey; an anonymous mailed-back survey of Nimbin and Lismore drug injectors; taped interviews with health and legal professionals, cannabis activists and drug dealers; semi-structured interviews with 'professional' cannabis crop growers; and participant observation over several years. I found the multi-method research design to be particularly effective for investigating illegal drug marketing and use, and the design provided me with multiple perspectives on a complex issue. Superficially, there appeared to be two drug 'problems' in Nimbin — one was the (largely cannabis) street market, and the other revolved around heroin users, and included complaints about scruffy-looking people hanging around the main street, or overdosing in the public toilet. However, my research suggested that these issues, while immediately comprehensible as 'drug problems', obscured more complex issues. For example, the village's street drug market was intertwined with the local economy and with the alternative community's values and drug use, while close to half of the drug injectors lacked secure housing (which creates problems that are not related to heroin), and all heroin users were blamed for the actions of few. Many factors influence the creation and maintenance of what we might call 'problems', and drugs are frequently blamed for broader social problems. What is Nimbin’s drug problem? The answer depends, in part, on the drug of interest, but more importantly it depends on your definition of a ‘problem’. Some useful and meaningful perspectives on this important social issue include quantified indicators such as death, injury, arrest rates, the economics of black markets, the demographics of drug use, and estimates of ‘social costs’. Qualitative perspectives include people’s opinions about drugs, media-generated moral panics, the effects of social marginalisation, and the role of drug cultures. A number of ‘drug problems’ arise as a direct result of drug illegality. They include black markets, corruption, drug-related violence, theft, stronger forms of the drug, and more dangerous using practices (with the risk drug overdoses and HIV/AIDS), as well as public nuisance issues. Government policy, judicial sentencing and public opinion are moving towards the social reintegration of illicit drug users, but this is almost invariably counter-balanced by a toughening of legal sanctions against supply of the same drug. Most discussions about illicit drugs fail to consider the long-term implications of harsh penalties for, and elaborate and punitive police operations (such as occurred throughout my Nimbin research) against, small-scale independent growers and dealers. The only way to directly engage with drug markets and all the attendant problems, is to legitimise and regulate the supply of recreational drugs. I discuss several examples of the important role of the drug culture in mitigating problems caused by illegality. One example is the influence of Nimbin's alternative community on the style of the drug market. The village drug scene more closely resembles the many north coast village craft markets, than it does Kings Cross, Cabramatta or New York's Bronx. Buyers are north coast locals, along with national and international tourists (the small village is known to cannabis users world-wide, both through media attention and word-of-mouth). Nimbin offers a 'safe' village market ambience and competitive prices to a mainly cannabis using clientele. I suggest that there are two major underlying influences on the experience of a ‘drug problem’, regardless of the drug or the place. They are: 1. Political influences — specifically the effects of government policy on black markets, law enforcement practices, and access to services and resources; 2. Cultural influences — particularly the beneficial effects of norms and functional role models for the safe use of a drug, cultural effects on the drug market, and the role/s of the drug in the day-to-day life of the culture. These influences can operate with, or despite, each other, and can create or ameliorate many ‘drug problems’. In the case of Nimbin’s alternative culture, government policy has created a number of drug problems and the counter-culture has worked to minimise them. In my research into Nimbin’s ‘drug problem’ I have clarified some issues and raised a number of others. I have examined the notion of a ‘drug problem’ from several perspectives using a range of research tools, and discussed some key influences on the problem associated with drug use. Drawing from the Nimbin research and my reading, I suggest legalising the recreational drugs to bring them under the dual controls of supply legislation and social norms. In conclusion, I suggest that we need to be very clear about what ‘drug problem’ it is that we are talking about, and indeed, whether the problem is really about drugs at all.