Cocaine
Cocaine, both powdered and crack, was Massachusetts' chief drug threat throughout much of the 1990s, and it still predominates in the less populous regions of the state. Law enforcement authorities in counties with fewer than 500,000 people (Berkshire, Franklin, Hampshire, Hampden, Plymouth, Barnstable, Dukes, and Nantucket) identify cocaine, particularly crack cocaine, as their greatest drug threat; heroin-marijuana or marijuana-heroin are second and third, respectively. In the state's larger counties (Suffolk, Essex, Middlesex, Worcester, Norfolk, and Bristol), heroin has emerged as a threat greater than cocaine due in large part to its high purity and low price. In statewide substance abuse help-line calls in which drugs were specified, cocaine was mentioned in 17 percent of calls between May and September of 1999, compared to 23 percent for heroin.

Abuse
Over the last 4 years, cocaine has dropped to second, ranking behind heroin as the drug of choice of those entering treatment in Massachusetts. Thirty-one percent of admissions to drug treatment centers in Boston in the first three quarters of FY1999 used powdered or crack cocaine in the month prior to admission. This figure is up from 29 percent in FY1998 but is still lower than any year in the period FY1994 to FY1997, when percentages ranged from 34 percent to 40 percent. Admissions for powdered and crack cocaine in the first three quarters of FY1999 were lower only than those for heroin and other opiates (34%) and alcohol (59%); they were significantly higher than those for marijuana (14%) and all other drugs combined (9%). The percentages were lower for the remainder of Massachusetts, but the patterns were similar: 22 percent reported using powdered or crack cocaine in the month prior to admission, up from 20 percent the year before, but equal to or lower than any other year during the period FY1994 to FY1997, when figures ranged between 22 percent and 25 percent. Admissions for cocaine were lower only than those for heroin and other opiates (31%) and alcohol (57%); they were higher than those for marijuana (18%) and all other drugs combined (10%).

According to DAWN data, ED cocaine mentions viewed as a percentage of total drug mentions were higher than every other drug type every year during the 1990s. During the period 1993 to 1998, cocaine mentions were relatively stable, accounting for between 15 and 18 percent of total drug mentions annually. Also according to DAWN data, the total number of ED cocaine mentions in Boston was up 35 percent in 1998 following a 2-year decline. There were more cocaine mentions in the 1990s than mentions of all other drug types combined.

Among admissions to state-funded substance abuse treatment centers in the first three quarters of FY1999 reporting powdered or crack cocaine as their primary drug, 68 percent reported using at least one other drug in the month prior to treatment. The most common secondary drug reported was alcohol, which drug users often take to moderate the effects of crack cocaine.

According to the Massachusetts DPH, substance abuse treatment centers in Boston in the first three quarters of FY1999 provided the following data for admissions reporting powdered or crack cocaine as their primary drug:

• 60 percent were male, a percentage consistent with the previous 4 years.
• 63 percent were African American and 22 percent were Caucasian, percentages consistent with the previous 2 years.
• The percentage of admissions aged 19 to 29 dropped every year from 40 percent in FY1995 to 22 percent in the first three quarters of FY1999. Conversely, the percentage of admissions aged 30 to 49 climbed every year from 58 percent in FY1995 to 74 percent in the first three quarters of FY1999.
• 85 percent earned less than $10,000 per year, a percentage consistent with the previous 2 years, and the percentage of admissions who were homeless dropped for the second straight year from 28 percent in FY1997 to 24 percent in the first three quarters of FY1999.
• The percentage of admissions with some involvement with the criminal justice system stayed level or rose every year from 20 percent in FY1995 to 33 percent in the first three quarters of FY1999.
• The percentage of admissions reporting a mental health problem rose every year save one from 21 percent in FY1995 to a high of 28 percent in the first three quarters of FY1999.
• 76 percent of cocaine users preferred smoking as a method of administration; those preferring injection accounted for only 4 percent.

Cocaine use remains relatively rare among school age adolescents, but inadvertent exposure via marijuana joints or "blunts" laced with crack cocaine occurs. Of Massachusetts high school students assessed by the 1999 Youth Risk Behavior Surveillance survey, 9.6 percent reported ever using cocaine, ranking the drug third behind marijuana (50.2%) and inhalants (14.4%) and ahead of methamphetamine, steroids, and heroin. Even fewer students, 4.3 percent, reported using cocaine during the 30 days preceding the survey, ranking the drug second behind only marijuana (30.6%). The patterns of use were similar in Boston, but the user percentages were lower: 3.8 percent reported ever using cocaine (ranking third behind marijuana and inhalants), and 2.1 percent reported using cocaine during the 30 days preceding the survey (ranking second behind marijuana).

Heroin
Heroin has emerged as a threat equal to or greater than cocaine in Massachusetts, after posing less of a threat throughout much of the 1990s. Heroin's increasing popularity is due in large part to a significant rise in the drug's purity and drop in price. Heroin appears to be a greater problem than cocaine in high population areas; law enforcement authorities in all counties with more than 500,000 people (Suffolk, Essex, Middlesex, Worcester, Norfolk, and Bristol) identify heroin as their greatest drug threat. In statewide substance abuse help-line calls in which drugs were specified, heroin was mentioned in 23 percent of calls between May and September of 1999, cocaine in 17 percent. The heroin percentage was consistent with the previous 5-month period.

The level of heroin use in Boston and the surrounding area is particularly alarming. The medical director of methadone clinics in Lawrence and Lowell reports that the percentage of drug users seeking treatment for heroin in the Merrimack Valley, which runs north from the Lawrence and Lowell area, increased from 29 to 51 percent during the period 1993-1999. The largest increases occurred in northeastern Massachusetts, which is home to the most heroin users in the state. There are 8,000 to 10,000 heroin users in the Merrimack Valley, and 1,200 of them go to Lawrence or Lowell daily for methadone treatment. This upward trend in the Northeast has been evident for several years. In Greater Lowell, 50 percent more people sought treatment for heroin use in 1997 than in 1992. Also, the number of people seeking treatment for injection drug use climbed 45 percent in Greater Haverhill and 36 percent in Greater Lawrence over the same period.

Abuse
Heroin has overtaken cocaine as the drug of choice among users entering Massachusetts treatment centers. Primary heroin admissions account for the largest percentage by far of illicit drug admissions in Greater Boston and the state. Thirty-four percent of admissions to drug treatment centers in Boston in the first three quarters of FY1999 used heroin or other opiates in the month prior to admission, up from 32 percent in FY1998 and 28 percent in FY1997. This rise followed 2 years of stability (29% in FY1995, 28% in FY1996). Admissions for heroin or other opiates for the first three quarters of FY1999 were lower only than those for alcohol (59%); they were higher than powdered and crack cocaine admissions (31%) for the second straight year, and were significantly higher than those for marijuana (14%) and all other drugs combined (9%). The percentages and patterns for the remainder of Massachusetts were similar: 31 percent of admissions reported using heroin or other opiates in the month prior to admission, up from 29 percent in FY1998, 25 percent in FY1997 and FY1996, 23 percent in FY1995, and 21 percent in FY1994. Admissions for heroin and other opiates were lower only than those for alcohol (57%); they were higher than powdered and crack cocaine (22%) for the third straight year, and were significantly higher than marijuana (18%) and all other drugs combined (10%).

According to DAWN data, ED heroin/morphine mentions in Boston viewed as a percentage of total drug mentions were second to cocaine mentions every year during the 1990s except in 1998 when they fell to a close third behind marijuana/hashish. The percentage of heroin/morphine mentions rose in 1995, rose again in 1996, and remained stable in 1997 and 1998, a total increase of approximately 3 percent. Total ED heroin/morphine mentions were relatively constant from 1995 through the first half of 1999, as well. The patterns of heroin use in Boston appear to parallel other areas of the country. Since 1996, Boston has ranked either eighth or ninth in heroin/morphine mentions per 100,000 population among the 21 cities nationwide from which DAWN reports data.

Heroin overdoses have become a significant problem in Massachusetts. The Boston Medical Center reports that heroin-related overdoses are on the rise,14 and police data and news reports from other cities in Massachusetts indicate that overdoses have increased statewide. The city of Lynn experienced notable increases in the number of heroin overdose deaths prior to 1999. Thirty fatal and 206 nonfatal overdoses were recorded in Lynn from 1996 to late 1999, and the rate of deaths from heroin was twice the city's homicide rate in 1999. In the Merrimack Valley, the death rate from heroin has remained steady since 1992, except for a spike in 1995 when "bad" heroin was known to be circulating in the area. Law enforcement indicates that Lynn, South Boston, and Worcester are the three areas in the eastern half of Massachusetts with the greatest heroin overdose problem. In general, there are at least four explanations why heroin overdoses occur: (1) heroin is often mixed with toxic additives including scopolamine and ketamine; (2) purity is variable and unpredictable; (3) users often co-use benzodiazepines, synthetic opiates, cocaine, or alcohol; and (4) users who have recently left heroin treatment have a lower tolerance for the drug.

Among admissions to state-funded substance abuse treatment centers in the first three quarters of FY1999 reporting heroin as their primary drug, 88 percent reported using at least one other drug in the month prior to treatment. This rate of polysubstance use among primary heroin users was higher than for users of any other primary drug. The most common secondary drug reported was alcohol (32%), followed by cocaine (17%). Polydrug heroin users admitted to treatment centers in Boston in 1998 and 1999 reported using heroin with benzodiazepines (e.g., Valium, Xanax), synthetic opiates, cocaine, and alcohol.

According to the Massachusetts DPH, substance abuse treatment centers in Boston provided the following data for admissions in the first three quarters of FY1999 who reported heroin or opiates as their primary drug:

• 73 percent were male, marginally higher than any of the previous 4 years.
• 48 percent were Caucasian, 24 percent were African American, 23 percent were Hispanic, and 5 percent were other races/ethnicities, percentages consistent with the previous 3 years.
• 42 percent were aged 30 to 39, 28 percent were 19 to 29, and 24 percent were 40 to 49, percentages consistent with the previous 4 years.
• 91 percent earned less than $10,000 per year, a percentage consistent with the previous 4 years, and 28 percent were homeless, a percentage consistent with the previous 2 years.
• 21 percent had some involvement with the criminal justice system, a percentage consistent with the previous 3 years.
• 20 percent reported a mental health problem, a percentage consistent with the previous 2 years.

Heroin does not appear to be a popular drug among youths in Massachusetts. Only 3.8 percent of Massachusetts high school students assessed by the 1999 Youth Risk Behavior Surveillance survey reported ever using heroin, a lower percentage than for any other drug surveyed (marijuana, inhalants, cocaine, methamphetamine, and steroids). The patterns of use were similar in Boston, but the user percentages were markedly lower: heroin still ranked last, but only 1.4 percent reported ever using heroin. Most adolescents in focus groups reported little use or awareness of heroin compared to marijuana, diverted prescription drugs, LSD (lysergic acid diethylamide), and MDMA. However, the Bureau of Substance Abuse Services reports that statewide, the percentage of heroin users aged 18 or younger entering treatment rose from 4 percent in FY1992 to 13 percent in the first three quarters of FY1999.

Among admissions to state-funded substance abuse treatment centers in the first three quarters of FY1999 reporting heroin as their primary drug, 63 percent preferred injection, 33 percent snorting, and 4 percent other methods of administration. The cities in northeastern Massachusetts report high rates of heroin injection, too, including Boston where injection was reported as the method of administration in 73.3 percent of heroin ED mentions in 1998. Some reporting indicates that heroin injection in Massachusetts has dropped and heroin smoking and snorting has risen, including among youths; however, treatment providers point out that users commonly progress from smoking and snorting to injection because a smaller amount of injected heroin provides the same high. Most users taking advantage of needle exchange programs in Boston are traditional users who have injected heroin for many years. However, exchange programs in Cambridge and Northampton (western Massachusetts) have seen an increase in younger heroin injectors.

Injection drug use accounted for 36 percent of new AIDS (Acquired Immune Deficiency Syndrome) cases reported between May 1 and October 31, 1999, the highest proportion for any category of AIDS transmission.

Marijuana
The marijuana threat in Massachusetts is generally perceived as lower than that posed by heroin or cocaine because marijuana users do not often seek treatment for marijuana substance abuse or commit violent crimes. However, marijuana is readily available in the state, and there could be more marijuana users than all other drug users combined. Moreover, marijuana trafficking and sales have much stronger associations with violent crime than does marijuana use. Overall, the costs of marijuana abuse to the user and to society are less than that of heroin or cocaine abuse, and, therefore, most treatment providers and law enforcement authorities believe it to be a lower threat. In some rural areas of the state (e.g., Plymouth, Franklin, and Hampshire Counties), law enforcement ranks the marijuana threat second behind cocaine. Most marijuana distributed in Massachusetts is of Mexican origin, but some cannabis is cultivated in Massachusetts.

Abuse
According to DAWN data, ED marijuana/hashish mentions in Boston increased 39 percent in 1998 following a 2-year decline. Marijuana/hashish mentions were lower than cocaine and heroin/morphine mentions throughout the 1990s until 1998, when they outnumbered heroin/morphine mentions for the first time. Annual marijuana/hashish mentions viewed as a percentage of total drug mentions rose every year from 1990 to 1996, dipped slightly in 1997, then rose sharply in 1998. Every year since 1991, Boston ranked between fourth and seventh in marijuana/hashish mentions per 100,000 population among the 21 cities nationwide from which DAWN reports data, except for 1997, when it ranked eleventh.

Only 4 percent of admissions to drug treatment centers in Boston in the first three quarters of FY1999 were primary marijuana users, consistent with past years. Admissions for marijuana for the first three quarters of FY1999 were lower than those for powdered and crack cocaine (31%), heroin (34%), and alcohol (59%). However, 14 percent of admissions to drug treatment centers in Boston in the first three quarters of FY1999, and 18 percent of admissions to centers in the remainder of Massachusetts, reported using marijuana in the month prior to admission, percentages consistent with the previous year. In statewide substance abuse help-line calls in which drugs were specified, marijuana was mentioned in 5 percent of calls between May and September of 1999, level with the previous 5-month period.

According to the Massachusetts DPH, substance abuse treatment centers in Boston in the first three quarters of FY1999 provided the following data for admissions reporting marijuana as their primary drug:

• 76 percent were male, a percentage marginally lower than the previous year but the same as in FY1997.
• 42 percent were African American, a percentage marginally lower than the previous year; 28 percent were Caucasian, down for the second straight year and 9 percent lower than in FY1997; and 25 percent were Hispanic, up for the third straight year and 7 percent higher than in FY1996.
• The average age of admissions was 25. The percentage of admissions aged 19 to 29 rose for the second straight year from 43 percent in FY1997 to 47 percent in the first three quarters of FY1999. The percentage of admissions under 19 years of age dropped to 28 percent, the lowest level in 3 years, and 25 percent of admissions were aged 30 or older, a percentage consistent with the previous 2 years.
• 86 percent earned less than $10,000 per year, a percentage consistent with the previous 4 years.
• The percentage of admissions with some involvement with the criminal justice system rose for the second straight year from 47 percent in FY1997 to 62 percent in the first three quarters of FY1999.
• The percentage of admissions reporting a mental health problem dropped for the second straight year from 41 percent in FY1997 to 27 percent in the first three quarters of FY1999.

Marijuana remains very popular among youths, who perceive the drug to be less risky than cocaine, heroin, or LSD. Of Massachusetts high school students assessed by the 1999 Youth Risk Behavior Surveillance survey, 50.2 percent reported ever using marijuana, more than reported using all other surveyed drugs combined (inhalants, cocaine, methamphetamine, steroids, and heroin). A smaller percentage, 30.6, reported using marijuana during the 30 days preceding the survey, and 12.5 percent reported using the drug before they were 13 years old. The patterns of use were similar in Boston, but the user percentages were markedly lower: 38.2 percent reported ever using marijuana, 20.5 percent reported using marijuana during the 30 days preceding the survey, and 9.4 percent reported using the drug before the age of 13. One report states that marijuana use among adolescents is approaching the level of cigarette use.

The Massachusetts Cannabis Reform Coalition (MASSCAN) is trying to gather the 57,100 votes needed to put several pro-marijuana proposals before the state legislature. These proposals would (1) legalize the sale of marijuana as long as taxes are paid on the sale, (2) legalize adult possession of up to 7 cannabis plants or 16 ounces (453.4 grams) of harvested marijuana, and (3) lower the penalties for possessing a small quantity of marijuana, treating possession as a "violation" (like exceeding the speed limit while driving) rather than a "crime."

Methamphetamine
Methamphetamine is available in small quantities in Massachusetts, but the drug is not a significant threat to users or society. Some reporting occasionally suggests that methamphetamine might be growing in popularity in New England, but the region has yet to see a widespread increase in trafficking, distribution, or use. Methamphetamine production occurs in Massachusetts on only a very small scale.

Abuse
Abuse of methamphetamine is very limited in Massachusetts. Less than 1 percent of all treatment admissions in the first three quarters of FY1999 reported using amphetamines in the month before admission. Treatment providers and needle exchange program workers report that methamphetamine use is uncommon among their clients. According to DAWN data, ED methamphetamine mentions in Boston were very low in the 1990s (84 mentions from 1990 to 1998, an average of 9.3 mentions per year).

Most methamphetamine users are students and young adults, especially those who frequent rave parties or who are familiar with "crystal methamphetamine" from the U.S. West Coast. Of Massachusetts high school students assessed by the 1999 Youth Risk Behavior Surveillance survey, 8.3 percent reported ever using methamphetamine, ranking the drug fourth behind marijuana (50.2%), inhalants (14.4%), and cocaine (9.6%) and ahead of steroids and heroin. The patterns of use were similar in Boston, but the user percentages were markedly lower: 3.1 percent reported ever using methamphetamine, again ranking behind marijuana (38.2%), inhalants (7.0%), and cocaine (3.8%) and ahead of steroids and heroin. Anecdotal reporting indicates most regular methamphetamine users live in outlying and rural areas of the state and include members of biker gangs and other traditional users.

Other Dangerous Drugs
After heroin, cocaine, and marijuana, the most significant drug threats in Massachusetts are MDMA and diverted prescription drugs. Seizures of MDMA have risen sharply over the past year. Many distributors are finding that they can derive large profits with little risk by selling the drug to young users at colleges, nightclubs, and "raves," large dance parties characterized by loud music and psychedelic lighting. Most MDMA is manufactured in the Netherlands and Belgium. The "club drugs" GHB and GBL (gamma-butyrolactone) have risen in popularity among adolescents and young adults as well. Pharmaceutical stimulants and depressants are widely available, and hallucinogenic drugs and steroids are popular among certain user groups.

Abuse
MDMA is the most abused other dangerous drug (ODD) in Massachusetts. The use of MDMA has risen sharply, particularly among adolescents and young adults and in urban areas. The drug commonly is used at raves and nightclubs, and its use is believed to be increasing in other social venues as well. Ketamine is used in combination with MDMA to enhance its hallucinogenic effects. Users may take ketamine, marijuana, GHB, or heroin to moderate the very stimulating MDMA high.39 MDMA overdoses rose in 1999, and the Massachusetts Poison Control Center reported a rise in calls related to MDMA during the period October 1998 to June 1999.

Regarding the abuse of other stimulant drugs:

Less than 1 percent of all treatment admissions in the first three quarters of FY1999 reported using amphetamines in the month before admission. However, the amphetamines Adderall and Ritalin figured prominently in calls to the Massachusetts Poison Control Center during the period October 1998 to June 1999. One survey found that as many as five in 40 Massachusetts students abuse Ritalin. Its use most commonly occurs in middle- and upper-class communities.

The Massachusetts Poison Control Center reported two calls during the period October 1998 to June 1999 related to khat, a leafy plant shipped from Africa to the United States by air. The leaves and buds of the plant are chewed for their stimulant properties.
Regarding the abuse of depressants in Massachusetts:

The Massachusetts Poison Control Center reported a surge of calls related to GHB and GBL during the period October 1998 to June 1999.

Benzodiazepines are widely abused in the state. Prescription drugs including Valium (diazepam) and Klonopin (clonazepam) were mentioned in 5 percent of statewide substance abuse help-line calls in which drugs were specified between December 1998 and September 1999. Klonopin and Xanax (alprazolam) are readily available, and the use of Rohypnol (flunitrazepam) is reported in Massachusetts.

Opiates and opioids (synthetic drugs manufactured to resemble the natural opiates in action and effect) are also abused in the state. Percodan, Percocet, and Tylox (oxycodone) are widely available. Vicodin ES, Hycodan, and Tussionex (hydrocodone), Dilaudid (hydromorphone), Duragesic (fentanyl), MS Contin (morphine), Tylenol No. 4 (containing codeine), and methadone are available as well.

Barbiturates, a group of sedative/hypnotic drugs prescribed to relieve tension, are available in Massachusetts, but their use is not common. Among admissions to state-funded substance abuse treatment centers in the first three quarters of FY1999, less than 1 percent reported using barbiturates or other sedatives in the month prior to treatment.

Less than 1 percent of admissions to state-funded substance abuse treatment centers in the first three quarters of FY1999 reported using hallucinogenic drugs in the month prior to treatment. Still, hallucinogenic drugs continue to be used in certain circles. Use of LSD and psilocybin mushrooms is not uncommon among adolescents and young adults; most LSD is encountered in college areas and at rave parties. Mescaline use has been occasionally reported. DXM (dextromethorphan), the active ingredient in some cough medicines, is commonly abused by teens for its hallucinatory properties and to prolong and enhance the effects of other drugs. Ketamine often is used by Caucasian middle-class adults and by youths at clubs and rave parties. PCP (phencyclidine) abuse is not widespread in New England.

Anabolic-androgenic steroid use is insignificant in Massachusetts. Only 4.6 percent of Massachusetts high school students assessed by the 1999 Youth Risk Behavior Surveillance survey reported ever using steroids. The patterns of use were similar in Boston, but the user percentages were even lower (2.5%). Young, heterosexual, male body-builders are reported to be the chief users.

Use of inhalants by adolescents continues, probably because they are inexpensive and readily available. Of high school students assessed by the 1999 Youth Risk Behavior Surveillance survey, 7.0 percent in Boston and 14.4 percent in the remainder of Massachusetts reported ever using inhalants, more than for any other drug surveyed except marijuana. In addition, 2.0 percent in Boston and 4.1 percent in the remainder of Massachusetts reported using inhalants during the 30 days preceding the survey.