To the Editor The review by Alambyan and colleagues1 is an excellent critical summary of the literature on leukoencephalopathy due to “chasing the dragon” (ie, heroin smoking). However, the review misrepresents the urgency of the situation by getting a few issues on heroin source forms and use incorrect, especially as they pertain to the US situation. There is no doubt that the United States is experiencing the consequences of an intertwined heroin and synthetic opioid epidemic of historic proportions2; however, there is no evidence that heroin smoking is rising in the United States. Different chemical forms of heroin lead to different medical consequences.3 The predominant form of heroin in the United States is a powdered hydrochloride salt, and thus it is not easily sublimated and instead burns with heating, destroying the active properties and discouraging this use pattern. The article conflates different forms of inhalation, such as nasal insufflation, which is readily done with heroin hydrochloride powders and vapor (pulmonary) inhalation (ie, smoking), which is much more feasible with base forms of heroin. Heroin base will vaporize before burning on gentle heating. Insufflating heroin is much more common in the United States than smoking. The data cited in the review on US heroin treatment admissions are correct in stating that 21% of admissions involved (nasal) inhalation; however, a deeper look at the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration Treatment Episode Data Set reveals that only 4.8% involved smoking heroin.4 The fact that insufflation is more common east of the Mississippi River is because of differences in distribution of heroin source forms, which include Colombian-sourced powdered heroin hydrochloride salt to the east and a Mexican-sourced heroin hydrochloride salt, a solid form called “black tar,” to the west.3 Heroin smoking is more common in Europe, which has base heroin sourced from Afghanistan, and most of the article’s cited literature on leukoencephalopathy is from Europe.
Ciccarone D. Heroin Smoking Is Not Common in the United States. JAMA Neurol. 2019;76(4):508. doi:https://doi.org/10.1001/jamaneurol.2019.0183
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