The Spread of Speedballing

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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
• 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
• increases in crack injecting and/or
• 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 Shooti
ng 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 peoples 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
its 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 others 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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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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