Eric C. Schneider is a historian at the University of Pennsylvania and the author of "Smack: Heroin and the American City."
Smack, horse, dope, H, whatever it is called, heroin is king of underworld drugs. While pretenders such as cocaine and methamphetamines sometimes challenge its supremacy, heroin never fully relinquishes the crown.
No other drug (except alcohol) has as many poets and painters, musicians and models, and really, really cool adherents. If you want to flirt with the dark side and see how far into the abyss you can go without falling, heroin remains the best way to try.
That dark allure may account for the drug's longevity, but heroin use has waxed and waned over time. At the moment, it appears to be surging among young people on Long Island and, police say, in suburban areas across the Northeast.
Locally, in just the past few days, Brookhaven has hosted a public forum on the rise in heroin addiction, and the Smithtown school district said it is negotiating with police to admit drug-sniffing dogs into its high schools after hours.
How does heroin use manage to go in and out of fashion?
Some connect drug preferences to the national mood - in troubled times, the bliss of the narcotic nod makes all your troubles seem far way, whereas when times are good, stimulants, such as cocaine, make the good times last.
Others see the loss of "social learning" accounting for an increase in heroin; when there are many heroin users and consequently more addicts, young people readily see what heroin might lead to and are scared away. Over time, as a drug epidemic fades, so does fear of the drug, and a new cycle starts.
Still others argue that popular culture explains heroin's attraction: seeing Charlie Parker, Kurt Cobain and Hillel Slovak (depending on your generation) achieve celebrity despite their drug use leads the young to associate heroin and cultural prominence.
Users themselves report that a drug ripples through peer groups, which are far more important than drug educators or even older users in determining consumption patterns. Drug fads, once they start, take on lives of their own.
But while fads emerge and then run their course, heroin is different. Pockets of heroin users remain after the conclusion of an epidemic, and they form the basis for a new wave of dope fiends once heroin is rediscovered. In medical language, heroin is endemic, lurking constantly in the shadows, until conditions for a new epidemic appear.
The key word here is "pockets." Heroin users have never been distributed randomly across the population, even during those times - the 1910s, the 1940s, the 1960s, the 1990s - when heroin epidemics swelled. According to the National Institute on Drug Abuse, the national trend for heroin initiation has been broadly downward since the mid-1990s, although there was a slight uptick in 2006.
But national surveys are misleading, as the recent surge of heroin use on Long Island suggests. The surveys indicate what they have always shown, namely that only a select few experiment with heroin and fewer still become addicted. The problem is that those few cluster together.
Heroin use concentrates among specific populations and in defined locations, historically in inner-city communities. Retail markets tend to locate in poor neighborhoods because abandoned buildings and clusters of the unemployed provide cover for the drug trade.
Hard-core users tend to live near those markets, which provide a source of employment, cheap places to stay and an opportunity to hear the "news" - whose dope is good, who has been arrested and might be snitching to the police, and who might be looking to do some crime. And consumers, both experienced and novice, rely on stable market locations in order to score.
Groups of users and sellers replenish themselves through the marketplace. Novices interested in trying a drug have to acquire "drug knowledge" (the ability to negotiate the market by learning the lingo and developing the appearance of a drug user and the understanding of how much of a particular drug to use), and this happens most readily in a place that mixes novices and experienced users.
Young people in the community hosting the market find it easier to acquire drug knowledge than young people elsewhere and are also more likely to take advantage of that knowledge as either users or sellers. Markets thus perpetuate themselves over time, and once they are rooted in a community, it is difficult to get them out.
Are we at the start of a new suburban heroin epidemic? Suburbs, especially those located near cities, such as New York, that have a long history of drug importation and many drug marketplaces, began hosting secondary drug markets in the late 1960s. Entrepreneurial users, willing to brave the possibility of rip-offs and worse, began establishing regular connections to inner-city primary markets. By doubling or tripling the price for the drug, these users were able to support their own habits.
Typically heroin use spread through peer groups via the institutional settings controlled by the young: schools, local parks and teen hangouts. This dispersed marketplace, as Long Island authorities are finding, is difficult to police precisely because it is so decentralized. Should suburban markets cohere with specific areas noted as drug-coping sites, it will signify the emergence of an even more serious, and likely long-lived problem.
There are also changes that have occurred in heroin and the "gateway" into drug use that have implications for the future. Heroin now is purer, cheaper, and more readily available than in the past. According to the Suffolk County district attorney's office, a bag containing one dose sells for $5 to $7 in New York City, and $10 in Suffolk.
The increased purity (a bag purchased in a primary market might contain over 70 percent heroin), means that beginners can snort rather than inject the drug. Forty years ago a street bag might have had 90 percent adulterants and only 10 percent heroin, and while a new user might snort it, a shift to IV injection happened quickly.
Now that barrier doesn't have to be crossed, at least initially, and those with an understandable fear of HIV or hepatitis can snort the drug for months, if they are careful, until their nasal tissue turns into a bloody jelly. If they persist, a switch to injection is likely, with far more significant health problems than addiction - and addiction is more likely than in the past, given heroin's purity.
Gateway theories are controversial, with drug experts in the past arguing, for example, that marijuana was a gateway into heroin use. That has been proven to be nonsense, but one aspect lingers on. In negotiating the illegal marketplace for marijuana, one is likely to encounter offers of more serious drugs. That is, the gateway is a social, not a physiological, one.
What is insidious about the marketplace is that teenagers are being offered what they call "pharmies," namely pharmaceutical narcotics such as OxyContin and Percocet that do not seem as dangerous as heroin. In one sense, this is right. These drugs are safer, in part because no one is ever sure what heroin has been cut with, and the dose is clear, making accidental overdose deaths less likely. But these drugs are expensive and heroin costs significantly less money, making a shift likely as kids develop tolerance and start ingesting larger amounts.
What can be done to forestall the further spread of heroin among our young? Parents can start by reviewing what's in the medicine cabinet. Unused portions of prescription medications should be disposed of appropriately. Physicians might limit the amount they prescribe; having a patient request additional medication is preferable to leaving that patient with unused pills.
Under the Nixon administration about two-thirds of the drug control budget was devoted to treatment and prevention, and only a third to enforcement. Now those numbers are reversed. Is anyone prepared to argue that our policies are a success, especially given the evidence of increased purity and static cost?
Since pharmaceutical companies produce more drugs than the medical market can absorb, no one should be surprised when these drugs wind up in the illegal market. It has happened repeatedly in the past. Perhaps it's time to ask if controlling drugs also means controlling drug companies.
Finally, it is important to ask users why they take narcotics. One once explained that addiction provides life with a purpose, a reason to get up each morning, an organizing principle for one's life. Sad perhaps, but what messages are our children trying to convey to us?