The Spread of Speedballing

							A Speedball
Wake-Up Call
Dr. Russell Newcombe, Senior Researcher
        Lifeline, Manchester, England

              May 2007




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The aim of this presentation
This presentation has two objectives:

(1) To draw the attention of the drugs field to the
    neglected rise in speedballing in Britain

(2) To provide an introduction to speedballing, and
    the risks and harms involved in this injecting habit




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       What is a speedball?
Other slang names: snowballing, curry & rice,
                  brown & white, smack & crack

Broad definition: the multi-injection (in a single
              shot) of an opioid with a stimulant
Strict definition: the multi-injection (in a single
                shot) of heroin with crack/cocaine

Use of ‘speedball’ to describe this multi-injecting habit
goes back to at least the 1930s in the USA

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The 3 waves of speedballing in Britain
Period          Drugs in speedball                    Typical speedballer .
1880-1920: morphine with cocaine HCl                  Upper-class or soldier
1950-1970: heroin with cocaine HCl                    Young (esp. London)
1990-2007: heroin with cocaine FB                     Socially excluded,
                                                      young to middle-aged
Key: HCl = hydrochloride (cocaine powder, aka coke, snow)
     FB = freebase (cocaine rocks, aka crack, stone)

Other differences between speedballing ‘waves’
(1) Source: in the first two waves, the two drugs were pharmaceutical (over-the-
     counter pharmacy in first wave, and NHS prescription in second wave); while in
     the third wave, they were illicit (Asian heroin, and South American cocaine)
(2) Prevalence: numbers unknown in first wave; in 1,000s in second wave; and in
     10,000s in third wave. The vast majority were male in each phase.


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Estimated prevalence of speedballing
and other injecting habits in UK, 2007,
  based on the available evidence
Total number of IDUs                        200,000
     Speedballers                              60,000
     Heroin-only injectors                   120,000
 *   Stimulant-only injectors                  20,000

__________________________________________________________________________________
IDUs: injecting drug users  Estimate excludes steroid injectors (Newcombe 2007a)
* Amphetamines, or cocaine and/or crack



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  Direct evidence of an outbreak of
  speedballing in Britain is limited
(1) A survey of 100 clients of Lifeline Needle Exchange Scheme
    (NES) in Manchester in February 2006 found that 8 in 10 were
    speedballers – climbing from 2 in 10 in early 1990s, and rising
    notably from late 1990s (Newcombe 2007b)
(2) A Druglink survey in March 2006 found that 8 out of 20 cities/
    towns in England & Wales reported a growth in speedballing -
    from Newcastle to Bristol and Ipswich - and new research in
    London also found a rise in speedballing (Rhodes et al. 2006)
(3) At time of writing (May 2007), Turning Point published a study
    of 874 IDUs at 25 NESs in England & Wales in 2006/07. They
    found that 19% reported their main injecting habit to be
    speedballing, and 77% heroin only; with 33% reporting past-
    month speedballing (ranging from 12% to 77%).

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Indirect evidence of outbreak
  of speedballing in Britain
Though direct evidence of a rise in speedballing is limited,
since 2000 several studies/reports have provided indirect
evidence, either by reporting:
(a) increases in ‘crack injecting’; and/or
(b) increases in ‘poly-drug use’ among IDUs, notably heroin
    and crack – without mentioning the speedballing habit.

  Yet injecting of crack on its own is fairly rare: not one of the
  100 IDUs in the Lifeline NES survey in 2006 injected crack
  on its own - typically because the stimulant effects are too
  powerful without a sedative to take the ‘edge’ off

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 Recent national research which implies
but does not mention rise in speedballing
(injection of heroin and crack in same shot)
 A survey of 952 IDUs in 6 English cities in 2003/04 reported
 that most injected heroin - and that 40% injected crack, with
 rates up to 70% in Manchester & Bristol (HPA et al. 2005).
 A study of the prevalence of problem drug use in London,
 Brighton and Liverpool in 2000/2001 concluded that “though
 nearly nine in ten of the IDUs in the survey injected heroin in the
 previous year, over half had also used crack or cocaine … It is
 therefore recommended that prevalence estimation of problem
 drug use focus on injecting drug use, opiate and crack/cocaine
 use, with an assessment of the most appropriate data sources
 for each type” (Hickman et al., 2004: 29).

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  Reports on North West Drug Agency
Monitoring Systems which imply but do not
 explicitly identify a rise in speedballing
“Evidence from historical regional monitoring data … going back to
the mid-1990s … indicates a continuing upward trend in poly-drug
use (crack and heroin combined, in particular)”
    Bullock et al. (2005). Drug treatment in North West England,
    2003/04. Centre for Public Health, Liverpool JMU.
Of 35,500 PDUs on North-West Drug Treatment Monitoring System in
2005/06, 66% reported heroin use and 20% crack use. Overall, about
4 in 10 heroin-using PDUs also used crack (Khundakar et al. 2006).
Annual reports on clients of the six NESs in Manchester in 2003/04
and 2004/05 indicated that 9 in 10 injected heroin and 3 in 10 injected
crack/cocaine (National Drug Evidence Centre, 2005).


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Other major annual studies/reports which note
   that crack injecting or poly-drug use has
 increased – but do not identify speedballing

Annual reports of National Drug Treatment Monitoring System
UK Drug Situation - annual reports to EMCDDA
National Conference on Injecting Drug Use [with a few exceptions]
Shooting Up – annual reports on drug injecting of HPA
 “There is evidence of an increase in the injecting of crack-cocaine”
 Peter Borriello, Director of the HPA's Centre for Infections
 (press release on Shooting Up, 2006)



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Why has the growth of speedballing been
    ignored (or heavily neglected)?
Both routine monitoring systems for drug users (eg.
National Drug Treatment Monitoring System), and the
data-collection instruments used by drugs researchers
are designed to record information about drug use/
injecting in a singular manner – primary drug, and
secondary drugs (drug by drug) - and are thus ‘blind’ to
multi-drug use/injecting

This weakness in data collecting/reporting stems from
the inadequacy of the standard concept of poly-drug
use or poly-drug injecting for describing the different
ways in which drugs can be combined.

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   The Speedball Blind-Spot
Describing people’s drug use by simply reporting the
numbers/percentages using each ‘primary drug’ and each
‘secondary drug’ does not adequately measure or
conceptualise their actual drug-taking behaviour/habits

It is like trying to describe human eating habits to aliens
by saying our main foodstuff is bread, indicated by 80% as
their primary food; with other food use being indicated by
60% for potatoes, 50% for cheese, 45% for eggs. etc.
[invented figures!]. From this, the aliens would have no
idea that humans usually eat meals three times a day, and
that each meal contains two or more different foodstuffs

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       How does poly-drug injecting
      differ from multi-drug injecting?
Mono-drug injecting: injecting one drug only across time
Poly-drug injecting: injecting 2+ drugs across time - 3 types:
Singular drug injecting: separate injections of each drug on
different occasions (no overlap in main effects or after-effects)
Serial drug injecting: separate injections of each drug, but in
same time period (some overlap in main effects or after-effects)
Multi-drug injecting: injection of two or more drugs in the same
shot/syringe (simultaneous experience of the effects of each
drug) – notably speedballing (heroin with crack)

In short: poly-use covers all 3 ways of combining drugs, while multi-use is
one of the 3 types of poly-use (use covers injecting, or other methods of use)

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Why has speedballing become so
 popular among IDUs in Britain?
Dopamine is the neurotransmitter responsible for pleasure
  in the brain, and is released when we eat food, have sex,
  interact with others, etc.. Most depressant and stimulant
  drugs boost dopamine beyond normal levels, producing
  euphoria – esp. heroin, cocaine & methamphetamine.

In animal research, dopamine levels are boosted 70% by
    heroin, and almost 400% by cocaine - but when the two
    drugs are injected together in a single shot (as a
    speedball), dopamine levels are boosted by over 1000%
    - called a synergistic effect (more than sum of parts)

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Full effects of speedball on neurotransmitters
     in the brain, and linked mental states
The brain has over 100 neurotransmitters (chemical messengers)
in four main groups: peptides, monoamines, amino acids, and
endocannabinoids.

HEROIN mainly affects three neurotransmitters in two groups:
Peptides:   (1) mimics endorphins (analgesia & sedation)
Monoamines: (2) boosts dopamine (euphoria)
             (3) inhibits noradrenaline (reduced alertness)

CRACK/COCAINE affects three neurotransmitters in one group:
Monoamines: (1) boosts serotonin (elevated mood)
            (2) boosts dopamine (euphoria)
            (3) boosts noradrenaline (increased alertness)

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What does injecting a speedball feel like?

“ You feel the white first, sharpening your mind,
boosting your energy, along with that orgasmic surge
of pleasure – then, within half a minute, the brown kicks
in, softening the razor edges of the crack, and soothing
your overcharging brain. Your body stops aching, your
mind stops hurting, and for a few brief heavenly
minutes things are more than just shit or alright. The
two drugs go together like men and women, yin and
yang. Why is it the only thing that makes me feel good
if all it’s doing is killing me? ”
35-year old male speedballer in Manchester, 2006


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     Main reasons for speedballing
(injecting heroin and crack in same shot)
1. Maximum pleasure: the 2 drugs produce a synergistic dopamine
    surge, as well as boosting endorphins and serotonin

2. Complementary: the 2 drugs reduce each other’s negative effects

3. Convenience: one injection is easier than two

4. Marketing: drug dealers sell heroin and crack together

5. Sub-culture: New users pick up the habit off older users, and its
    an increasingly popular/prevalent habit



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  Risks & harms associated with speed-
balling compared with injecting heroin only

 More likely to be male, single, and homeless
 Greater injecting frequency, larger doses injected;
 thus more money spent, and more crime conducted
 Greater probability of public injecting, re-using own
 needles, groin injecting, and ‘digging and fishing’
 More likely to have infectious diseases (esp. HCV)
 and other health damage (abscesses, etc.)
 Greater risk of overdose (fatal and non-fatal)


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Photograph of speedball shooting gallery in NW England (Lifeline 2001)

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Doubled-up risks of speedballing
Double analgesia effect: heroin reduces pain perception in
brain, and crack acts as a local anaesthetic – leading to
greater damage at injecting site (abscesses, etc.)
Double dependence: physical addiction to heroin, and strong
mental dependence on crack – with underlying synergistic
dopamine ‘hook’. Consequently, double-withdrawals too:
heroin cold turkey combined with crack come-down
Double chance of overdosing, i.e. 2 different types:
Cocaine OD (agitation, seizure, heart attack, etc.)
Opioid OD (respiratory failure, unconsciousness, etc.)
Double exposure to adulterants & contaminants: purity
averages 40% for heroin & 60% for crack (down from 90%).
Both may contain bacteria, aflatoxins & pesticides.

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          The annual purity of crack in England & Wales - based on maximum
             and minimum quarterly purities of police seizures, 1992-2004
    100
                                                                                maximum
                                                                                minimum
     90


%    80

                                                                                                     72%
     70


     60
                                                                                                     55%

     50
          1992   1993   1994   1995   1996   1997   1998   1999   2000   2001   2002   2003   2004




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           Recommendations
Treatment:
   Treatment agencies should develop services for drug users
   with dual dependence on heroin and crack (speedballers),
   and consider such options as:
   - substitute drugs for crack – longer-acting & less harmful,
      eg. amphetamine, modafinil, methylphenidate, coca-leaf
    - smokable prescriptions - to prevent transition to injecting

Research & monitoring:
 - multi-drug use/injecting and other forms of poly-drug
   use/injecting should become core variables in drug
   treatment and needle exchange monitoring systems
 - urgent research should be conducted into the prevalence,
   causes, risks and consequences of speedballing

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