Heroin

Basic Data

(Description) "Heroin is an opiate drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as 'black tar heroin.'"

(Prevalence of Heroin Use) "The number and percentage of persons aged 12 or older who were current heroin users in 2011 (281,000 or 0.1 percent) were similar to those from 2006 through 2010 (239,000 or 0.1 percent in 2010; 193,000 or 0.1 percent in 2009; 213,000 or 0.1 percent in 2008; 161,000 or 0.1 percent in 2007; and 339,000 or 0.1 percent in 2006), but were higher than those in 2005 (136,000 or 0.1 percent) and 2003 (119,000 or 0.1 percent) (Figure 2.4). Additionally, the number and percentage of persons aged 12 or older who were past year heroin users in 2011 (620,000 or 0.2 percent) were similar to those in 2008 to 2010 (621,000 or 0.2 percent in 2010; 582,000 or 0.2 percent in 2009; and 455,000 or 0.2 percent in 2008) and in 2006 (560,000 or 0.2 percent), but were higher than those from 2003 through 2005 and in 2007."

(Regional Law Enforcement and Treatment Indicators of Heroin Use)
"• Heroin indicators were reported as high by most CEWG area representatives in 2010, with the exception of five area representatives—from Denver, Honolulu/Hawaii, Atlanta, South Florida/Miami-Dade and Broward Counties, and Maine—who reported relatively low indicators for their areas. Upward heroin trends were reported by area representatives for Cincinnati, San Diego, and Seattle. Decreasing indicators were reported by area representatives for San Francisco and the Baltimore/Maryland/Washington, DC, area. The remaining representatives reported stable or mixed indicators (figures 1a though 4).
"• Among all substance abuse treatment admissions, including those for whom alcohol was the primary drug in 2010, heroin ranked first in 3 of the 22 CEWG reporting areas (Baltimore City, Boston, and Detroit), second in 4 areas (Maryland, Phoenix, St. Louis, and San Diego), and third in 4 areas (Cincinnati, Los Angeles, New York City, and Seattle) (table 2).
"• In more than one-half (13) of the 23 CEWG areas, heroin items accounted for less than 10 percent of total drug items seized and identified in NFLIS forensic laboratories in 2010. Proportions were highest in Baltimore City, and lowest in Honolulu (figure 5). Heroin was not ranked first in drug items seized in any CEWG area, although it appeared in second rank in St. Louis in 2010 (table 1)."

(Global Opiate Consumption) "The world consumes some 3,700 tons of illicit opium per year (1/3 raw and 2/3 processed into heroin) and seizes 1,000 tons."

(Global Heroin Seizures, 2010) "With a slight increase of some 7 per cent, global seizures of heroin remained rather stable in 2010 (81 tons in 2010 compared with 76 tons in 2009), though different trends were observed in different illicit markets. Heroin seizures increased in the trafficking routes that stem from the opium production areas in South-East Asia and Central and South America (Colombia, Guatemala and Mexico), confirming an increase in the supply of heroin deriving from an increase in production in those areas in recent years. However, along the established trafficking routes for heroin manufactured from Afghan opium, leading to the Russian Federation and Western and Central Europe, a consistent decrease in heroin seizures was observed in 2010. This most probably reflects falling levels of opium production in Afghanistan after 2007 and the shortage of opium observed in Afghanistan in 2010."

(Heroin Seizures in the Americas, 2010) "In North America, heroin seizures in the United States rose by almost one half, from 2.4 tons in 2009 to a record level of 3.5 tons in 2010. Heroin entering the United States from countries other than from Mexico originated in South America, notably Colombia. In 2010, heroin seizures reached 1.7 tons, a record level in Colombia, more than twice the level in 2009, while in Ecuador heroin seizures increased to 853 kg in 2010, almost five times the level in 2009 (177 kg). The increase in heroin seizures was less pronounced in Mexico (from 283 kg in 2009 to 374 kg in 2010). In Canada, although there had been an increase in heroin seizures from 2008 to 2009, seizures decreased considerably, from 213 kg in 2009 to 98 kg in 2010."

(Health Risks) "Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, and liver or kidney disease. Pulmonary complications, including various types of pneumonia, may result from the poor health of the abuser as well as from heroin’s depressing effects on respiration. In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs."

(Mortality) "The majority of drug deaths in an Australian study, conducted by the National Alcohol and Drug Research Centre, involved heroin in combination with either alcohol (40 percent) or tranquilizers (30 percent)."

(Opioid Overdose Deaths) "There can be no doubt, however, that fatal opioid overdose, long a chronic health problem in the United States, is now a rapidly growing one.⁷¹ National surveillance data suggest that almost 83,000 Americans died from this form of overdose between 1999 to 2005, with over 16,000 fatalities in 2005 alone.⁷² Opioid overdose death has seen a sharp increase over the last decade, especially in the category of overdose from prescription medications.⁷³ Because of gaps in the surveillance system, the actual figure is likely to be substantially higher."

(Withdrawal Syndrome) "The withdrawal syndrome usually includes symptoms and signs of CNS hyperactivity. Onset and duration of the syndrome depend on the specific drug and its half-life. Symptoms may appear as early as 4 h after the last dose of heroin, peak within 48 to 72 h, and subside after about a week. Anxiety and a craving for the drug are followed by increased resting respiratory rate (> 16 breaths/min), usually with diaphoresis, yawning, lacrimation, rhinorrhea, mydriasis, and stomach cramps. Later, piloerection (gooseflesh), tremors, muscle twitching, tachycardia, hypertension, fever and chills, anorexia, nausea, vomiting, and diarrhea may develop. Opioid withdrawal does not cause fever, seizures, or altered mental status. Although it may be distressingly symptomatic, opioid withdrawal is not fatal.
"The withdrawal syndrome in people who were taking methadone (which has a long half-life) develops more slowly and may be less acutely severe than heroin withdrawal, although users may describe it as worse. Even after the withdrawal syndrome remits, lethargy, malaise, anxiety, and disturbed sleep may persist up to several months. Drug craving may persist for years."

(Heroin Toxicity or Overdose) "The main toxic effect is decreased respiratory rate and depth, which can progress to apnea. Other complications (eg, pulmonary edema, which usually develops within minutes to a few hours after opioid overdose) and death result primarily from hypoxia. Pupils are miotic. Delirium, hypotension, bradycardia, decreased body temperature, and urinary retention may also occur.
"Normeperidine, a metabolite of meperidine, accumulates with repeated use (including therapeutic); it stimulates the CNS and may cause seizure activity."

"A striking finding from the toxicological data was the relatively small number of subjects in whom morphine only was detected. Most died with more drugs than heroin alone 'on board', with alcohol detected in 45% of subjects and benzodiazepines in just over a quarter. Both of these drugs act as central nervous system depressants and can enhance and prolong the depressant effects of heroin."

"The disadvantage of continuing to describe heroin-related fatalities as 'overdoses' is that it attributes the cause of death solely to heroin and detracts attention from the contribution of other drugs to the cause of death. Heroin users need to be educated about the potentially dangerous practice of concurrent polydrug and heroin use."

(Adulterants) "If it is not pure drugs that kill, but impure drugs and the mixture of drugs, then the myth of the heroin overdose can be dangerous. If users had a guaranteed pure supply of heroin which they relied on, there would be little more likelihood of toxic doses than occur with narcotics administered in a hospital.
"But when people take whatever they can off the street, they have no way of knowing how the drug is adulterated. And when they decide to augment heroin's effects, possibly because they do not want to take too much heroin, they may place themselves in the greatest danger."

(Global Heroin Treatment Need and OD Deaths) "More than 60 per cent of drug treatment demand in Asia and Europe relate to opiates that are, especially heroin, the most deadly drugs. Deaths due to overdose are, in any single year, as high as 5,000-8,000 in Europe, and several times this amount in the Russian Federation alone."

(Global Opium Production) "Estimated potential opium production increased from 4,700 tons in 2010 to 7,000 tons in 2011, reaching levels comparable to the levels of previous years. In Afghanistan itself, potential opium production fell to 3,600 tons in 2010 but resurged to 5,800 tons in 2011. A considerable increase in potential opium production was also reported in South-East Asia in this period. In Myanmar, for example, potential opium production increased from 580 tons in 2010 to 610 in 2011, while in the Lao People’s Democratic Republic it increased from 18 tons in 2010 to 25 tons in 2011. A preliminary 2010 estimate for Mexico shows that, after the year-to-year increase observed since 2005, opium production decreased from 2009."

(Global Opium Cultivation) "The total area under opium poppy cultivation globally also increased from 191,000 hectares (ha) in 2010 to some 207,000 ha in 2011 (see table 10). Afghanistan remains the main country cultivating opium poppy, accounting for approximately 63 per cent of global opium poppy cultivation, while the Lao People’s Democratic Republic and Myanmar in South-East Asia account for over 20 per cent, and countries in Central America and South America (mainly Mexico and Colombia) account for almost 7 per cent. Reports of opium poppy eradication also indicate the existence of smaller areas under opium poppy cultivation in many other countries and regions, with at least 13,000 ha of opium poppy cultivation estimated outside the main countries cultivating opium poppy.
"For example, a considerable level of illicit opium poppy cultivation is estimated to occur in India, where the licit production of opium has taken place for decades. Eradication reports also suggest that illicit opium poppy cultivation is expanding in Guatemala, but there are no data available to estimate the exact size of the total area under cultivation."

Opiate Overdose Prevention and Treatment: Naloxone

"The heart of the challenge is the possibility that things could be different: overdose is a public health problem that can be solved. Unlike many of the other leading causes of death, death from opioid overdose is almost entirely preventable,²¹ and preventable at a low cost.²² Opioids kill by depressing respiration, a slow mode of death that leaves plenty of time for effective medical intervention.²³ Overdose is rapidly reversed by the administration of a safe and inexpensive drug called naloxone. Naloxone strips clean the brain’s opioid receptors and reverses the respiratory depression causing almost immediate withdrawal.²⁴ A growing number of harm reduction organizations in the United States are offering overdose prevention programs that provide injection drug users with resuscitation training and take-home doses of naloxone.²⁵"

(Feasibility) "This pilot trial is the first in North America to prospectively evaluate a program of naloxone distribution to IDUs to prevent heroin overdose death. After an 8-hour training, our study participants' knowledge of heroin overdose prevention and management increased, and they reported successful resuscitations during 20 heroin overdose events. All victims were reported to have been unresponsive, cyanotic, or not breathing, but all survived. These findings suggest that IDUs can be trained to respond to heroin overdose by using CPR and naloxone, as others have reported. Moreover, we found no evidence of increases in drug use or heroin overdose in study participants. These data corroborate the findings of several feasibility studies recommending the prescription and distribution of naloxone to drug users to prevent fatal heroin overdose."

(Benefits from Naloxone Distribution) "Naloxone distribution to heroin users would be expected to reduce mortality and be cost-effective even under markedly conservative assumptions of use, effectiveness, and cost. Although the absence of randomized trial data on naloxone distribution and reliance on epidemiologic data increase the uncertainty of results, there are few or no scenarios in which naloxone would not be expected to increase QALYs [Quality-Adjusted Life-Years] at a cost much less than the standard threshold for cost-effective health care interventions. Ecological data, in fact, suggest that naloxone distribution may have far greater benefits than those forecast in this model: Reductions in community-level overdose mortality from 37% to 90% have been seen concordant with expanded naloxone distribution in Massachusetts (7), New York City (11), Chicago (10), San Francisco (9, 67, 68), and Scotland (69). Such a result is approached in this model only by maximizing the likelihood of naloxone use or by assuming that naloxone distribution reduces the risk for any overdose. Preliminary data showing that naloxone distribution is associated with empowerment and reduced HIV risk behaviors (70, 71) suggest that future research is needed to test these hypotheses."

(Rapid Effect)"Heroin is particularly toxic because of high lipid solubility, which allows it to cross the blood–brain barrier within seconds and achieve high brain levels.¹⁰
"Naloxone is also lipid soluble and enters the brain rapidly. Reversal of respiratory depression is evident 3–4 minutes after IV and 5–6 minutes after subcutaneous administration.¹¹"

(Barriers to Naloxone Access) "A more prosaic, but no less important, legal barrier to widespread naloxone access is the Food and Drug Administration’s (FDA) classification of naloxone as a prescription drug. This means that public health and harm reduction agencies cannot distribute naloxone like condoms or sterile syringes. Instead, naloxone must be prescribed by a properly licensed health care provider after an individualized evaluation of the patient. Because health care providers have to be involved, naloxone programs must deal with concerns about liability, which among doctors can be powerful even when they are not wellfounded in fact.³¹ The prescription status raises the cost of naloxone distribution and makes it illegal to give naloxone to lay people willing to administer the drug to others suffering an overdose."

(Effectiveness) "Treatment with naloxone can reverse respiratory failure within a few minutes (Darke and Hall, 1997; Physician’s Desk Reference, 2000). Naloxone is an opiate antagonist, and is thought to displace heroin at the Mu2 receptors. Physicians and emergency personnel treat patients suspected of heroin overdose by administering an initial dose of naloxone parenterally. While 2 mg are almost always sufficient to revive a patient, additional doses can be administered if the desired improvement does not occur, and smaller doses are often used to minimize the discomfort of sudden heroin withdrawal (Physician’s Desk Reference, 2000). In adults, naloxone has a half-life of between 30 and 81 minutes (Physician’s Desk Reference, 2000). Therefore, repeated administration could be necessary to reverse the effect of particularly large or long-lasting doses of heroin. (Sporer, 1999; Physician’s Desk Reference, 2000). In practice, however, a single 2 mg does is almost always sufficient. If a patient has not taken opioids, naloxone has no pharmacological effect (Darke and Hall, 1997).
"While administration of naloxone may produce acute withdrawal symptoms in patients with heroin dependence (Physician’s Desk Reference, 2000), the drug does not have long-term or life threatening adverse effects when it is administered at therapeutic doses (Strang, et al, 1996). Naloxone has been associated with complications such as seizures and arrhythmia, (Physician’s Desk Reference, 2000) but more recent research suggests that complications are exceedingly rare, that past reports of complications may have been erroneous (Goldfrank and Hoffman, 1995), or that complications occur, if at all, in patients with pre-existing heart disease (Goldfrank and Hoffman, 1995). Naloxone is not addictive, and has no psycho-pharmacological effects."

(Cost-Effectiveness of Naloxone Distribution) "Naloxone distribution was cost-effective in our base-case and all sensitivity analyses, with incremental costs per QALY [Quality-Adjusted Life-Year] gained much less than $50 000 (Table 2 and Appendix Figure 3, available at www.annals.org; see Appendix Table 3, available at www.annals.org, for detailed results of selected analyses). Cost-effectiveness was similar at starting ages of 21, 31, and 41 years; the greater QALY gains of younger persons were roughly matched by higher costs. In scenarios where naloxone administration reduced reliance on EMS, naloxone distribution was cost-saving and dominated (that is, less costly and more effective than) the no-distribution comparison. Cost-effectiveness was somewhat sensitive to the efficacy of lay-administered naloxone and the cost of naloxone but was relatively insensitive to the breadth of naloxone distribution, rates of overdose and other drug-related death, rates of abstinence and relapse, utilities, or the absolute cost of medical services. Naloxone was no longer cost-effective if the relative increase in survival was less than 0.05%, if 1 distributed kit cost more than $4480, or if average emergency care costs (as a proxy for downstream health costs) exceeded $1.1 million. A worst-case scenario, in which the likelihood of an overdose being witnessed, the effectiveness of naloxone, and the likelihood of naloxone being used were minimized and the cost of naloxone was maximized, resulted in an incremental cost of $14,000 per QALY gained. A best-case scenario, in which naloxone distribution reduced the risk for overdose, was dominant."

(Effectiveness of Enforcement) "Similar evidence of the drug war’s failure is provided by US drug surveillance data. For example, from 1981 to 2011, the budget of the US Office of National Drug Control Policy increased by more than 600 percent (inflation-adjusted). However, despite increasing annual multibillion dollar investments in drug control, US government data suggest an approximate inflation- and purity-adjusted decrease in heroin price of 80 percent, and a greater than 900 percent increase in heroin purity between 1981 and 2002, clearly indicating that expenditures on interventions to reduce the supply of heroin into the United States were unsuccessful."

(Non-Injection Means of Ingestion a Reason for Growth in Use) "We do think that the expansion in the world supply of heroin, particularly in the 1990s, had the effect of dramatically raising the purity of heroin available on the streets, thus allowing for new means of ingestion. The advent of new forms of heroin, rather than any change in respondents’ beliefs about the dangers associated with injecting heroin, very likely contributed to the fairly sharp increase in heroin use in the 1990s. Evidence from this study, showing that a significant portion of the self-reported heroin users in recent years are using by means other than injection, lends credibility to this interpretation."

Effects

(Acute Effects) "Acute intoxication is characterized by euphoria and drowsiness. Mast cell effects (eg, flushing, itching) are common, particularly with morphine. GI [gastro-intestinal] effects include nausea, vomiting, decreased bowel sounds, and constipation."

(Chronic Effects) "Tolerance develops quickly, with escalating dose requirements. Tolerance to the various effects of opioids frequently develops unevenly. Heroin users, for example, may become relatively tolerant to the drug's euphoric and respiratory depression effects but continue to have constricted pupils and constipation.
"A minor withdrawal syndrome may occur after only several days' use. Severity of the syndrome increases with the size of the opioid dose and the duration of dependence.
"Long-term effects of the opioids themselves are minimal; even decades of methadone use appear to be well tolerated physiologically, although some long-term opioid users experience chronic constipation, excessive sweating, peripheral edema, drowsiness, and decreased libido. However, many long-term users who inject opioids have adverse effects from contaminants (eg, talc) and adulterants (eg, nonprescription stimulant drugs) and cardiac, pulmonary, and hepatic damage due to infections such as HIV infection and hepatitis B or C, which are spread by needle sharing and nonsterile injection techniques (see Drug Use and Dependence: Injection Drug Use)."

(Health Risks) "Unlike alcohol or tobacco, heroin causes no ongoing toxicity to the tissues or organs of the body. Apart from causing some constipation, it appears to have no side effects in most who take it. When administered safely, its use may be consistent with a long and productive life. The principal harm comes from the risk of overdose, problems with injecting, drug impurities and adverse legal or financial consequences."

(Price of Heroin) In 2010, a kilogram of heroin typically sold for an average wholesale price of $2,527.60 in Pakistan. The 2010 wholesale price for a kilogram of heroin in Afghanistan ranged around $2,266. In Colombia, a kilogram of heroin typically sold for $10,772.3 wholesale in 2010. In the United States in 2010, a kilogram of heroin ranged in price between $33,000-$100,000.

Laws and Policies

(Sentences) The US Code violations for heroin and possible sentences:
Violation: "1 kilogram or more of a mixture or substance containing a detectable amount of heroin"
Sentence: "not less than 10 years or more than life" ... "No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment imposed therein."
Violation: "100 grams or more of a mixture or substance containing a detectable amount of heroin"
Sentence: "not less than 5 years and not more than 40 years" ... "No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment imposed therein."

In November 1997, the National Institutes of Health (NIH) convened a Consensus Panel on Effective Medical Treatment of Heroin Addiction. The panel of national experts concluded:
"• Vigorous and effective leadership is needed within the Office of National Drug Control Policy (ONDCP) (and related Federal and State agencies) to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.
"• Society must make a commitment to offering effective treatment for opiate dependence to all who need it.
"• The panel calls attention to the need for opiate-dependent persons under legal supervision to have access to MMT [methadone maintenance treatment]. The ONDCP and the U.S. Department of Justice should implement this recommendation.
"• The panel recommends improved training of physicians and other health care professionals in diagnosis and treatment of opiate dependence. For example, we encourage the National Institute on Drug Abuse and other agencies to provide funds to improve training for diagnosis and treatment of opiate dependence in medical schools.
"• The panel recommends that unnecessary regulation of MMT and all long-acting agonist treatment programs be reduced.
"• Funding for MMT should be increased.
"• We advocate MMT as a benefit in public and private insurance programs, with parity of coverage for all medical and mental disorders.
"• We recommend targeting opiate-dependent pregnant women for MMT.
"• MMT must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.
"• Patients, underrepresented minorities, and consumers should be included in bodies charged with policy development guiding opiate dependence treatment.
"• We recommend expanding the availability of opiate agonist treatment in those States and programs where this treatment option is currently unavailable."

(Naloxone Programs) "Naloxone distribution programs in the US are ongoing in Chicago, Baltimore, San Francisco, New Mexico and New York City. Additional community-based organizations interested in minimizing the adverse consequences of drug use in several cities in the US, including Los Angeles, Providence, Pittsburgh and Boston, are in the process of planning and developing naloxone administration programs for drug users."

(Heroin Assisted Treatment vs Methadone Maintenance) "The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

(Effectiveness of Heroin-Assisted Treatment [HAT] and Overview of Research) "A few key conclusions and discussion points regarding the state and future of HAT (heroin-assisted treatment) can be offered based on the above review of completed or ongoing studies.
"First, although the basic goal of the different HAT studies is similar, each of the studies is distinct in key aspects, thus limiting direct comparisons and meta-analyses.⁴⁰ Although this might be a desirable goal for science, it should be noted that heroin addiction and its consequences occur in distinct real-life environments (including unique cultural and system factors), and interventions need to be devised, measured, and evaluated within these to have authentic relevance for policy and practice.^33,41
"Second, the discussed studies above have demonstrated in several different contexts that the implementation of HAT is feasible, effective, and safe as a therapeutic intervention.^21,24,26,30 This should not be seen as a conclusion that could be taken for granted because many observers expected disastrous consequences from the provision of medical heroin prescription.
"Third, even within the contexts of relevant methodological constraints, e.g., the Swiss study relying purely on prospective observational data, and most of the other RCTs comparing HAT outcomes against a control intervention (MMT), which participants have previously either rejected by choice or proven to be ineffective, ^32,42 the reviewed HAT studies have demonstrated rather robust and consistently positive therapeutic outcomes on the various indicators chosen for a population of high-risk heroin addicts for whom currently no effective alternative therapies are available. Clearly, this demonstrated effectiveness is at this point limited to short-term outcomes, and long-term examinations ought to follow (albeit Swiss follow-up data present initial positive evidence in this regard).⁴³ It may very well emerge that HAT's main long-term benefit does not materialize through life-long maintenance, but by stabilizing and readying many of its patients for other simpler therapeutic interventions or even abstinence.
"Fourth, also given the current expansion and diversification of alternative oral opioid maintenance therapies (e.g., buprenorphine and morphine) and considering the complex logistics (on both providers and patients_ ends), high costs, and sociopolitical controversy around (especially injection) HAT, the most sensible role of HAT is likely that of an exceptional 'last resort' option for heroin addicts who cannot be effectively attracted into or treated in other available therapeutic interventions.^44,45 Granted the above, the primary emerging challenge for science—rather than conducting new and more HAT effectiveness studies—is to provide evidence-based guidelines on how to effectively match existing heroin addict profiles and needs with existing treatment options. This challenge has recently been complicated—in at least some jurisdictions—with the increasing diversification of heroin into poly-opioid (e.g., prescription) use profiles.⁴⁶
"Finally, after extensive HAT research efforts over the past decade, the principal onus of action has shifted from the scientific to the political arena in the jurisdictions under study.^12,18 Despite the overall positive results of completed HAT trials undoubtedly justifying some role of HAT in the addiction treatment landscape, authorities in only two countries, Switzerland and the Netherlands, have decisively acted on this issue.³⁴"

(HIV and IDUs in Russia and Central Asia) "In terms of absolute numbers, the Russian Federation is particularly affected with its 1.5 million addict population. The hugely damaging threat of HIV/AIDS is directly related to heroin injection. To date, there are over a quarter of a million registered HIV cases (although the number of unregistered cases is estimated to be much higher than this) in the Russian Federation. Of these, over 80% are intravenous drug users. In the CARs, nearly 15 years of continuous heroin transit has created a local market of 282,000 heroin users, consuming approximately 11 mt of heroin annually. Local opium consumption is estimated at approximately 34 mt (although demand in Turkmenistan may be underestimated). This puts some Central Asian states on par with countries with the highest global opiate abuse prevalence."