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Speed Ball Wake up Call

Slang names: snowballing, curry & rice, brown & white, smack & crack

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

History of Speedballing

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)

How Many People are Speedballing?

Estimated prevalence of speedballing and other injecting habits in UK, 2007, based on the available evidence

IDU Type	Number
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

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. Injecting of crack on its own is fairly rare: - typically because the stimulant effects are too powerful without a sedative to take the 'edge' off

How does Poly Drug Injecting Differ from Multi 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)

Why has Speedballing Become so Popular Amongst Injectors 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)
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:
  1. boosts dopamine (euphoria)
  2. 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)

"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

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

Risks and Harms Associated with Speedballing Compared to Using Heroin Alone

• 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)

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.

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

Dr. Russell Newcombe, Senior Researcher
Lifeline, Manchester, England, May 2007

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