Despite its strong association with spoons and syringes, there are many ways to use heroin, including snorting or smoking it. A recent report makes the claim that smoking heroin is on the rise in the United States, especially among young people, and that it can lead to irreversible brain damage.

It has to do with a way of inhaling heroin called “chasing the dragon.” That method involves using a lighter to burn off the oils on the shiny side of aluminum foil, then a dime-sized piece of heroin is placed in the “tray” and lit from the underside until it melts and runs. Using a straw or “tooter,” users “chase” and inhale the smoke. The high reportedly hits you quicker than injecting, but it is less intense and shorter-lived.

But there is no hard data to suggest that chasing the dragon is actually on the rise in the US, or causing an outbreak of neurological damage. And a lot of the hand-wringing about this report on smoking heroin flies in the face of years of harm reduction research which suggests that smoking is less risky than injecting.

The report was a review in JAMA Neurology last month titled “The Emerging Role of Inhaled Heroin in the Opioid Epidemic.” It looked at all the available literature on chasing the dragon—or CTD, as the authors refer to it—in order to build a better criteria for diagnosing mental health complications linked to heroin use.

The review suggests that CTD is associated with a type of brain damage called leukoencephalopathy, a term for a group of diseases impacting the white substance of the brain. White matter is an important part of the nervous system, and when certain toxins create holes in these regions of the brain, it can lead to loss of cognitive and motor functions—essentially, brain damage.

“People are not diagnosing it. And [doctors] are not asking the right questions to the patients,” says Ciro Ramos-Estebanez, one of the lead authors and a neuroscientist at the Neurocritical Care and Stroke Divisions at Case Western Reserve University in Cleveland, Ohio. “We’re bringing up awareness that one, smoking or inhaling [heroin] is not safe. Two, why it hits the brain in a way that other ways of abuse don’t. And three, that this could be also on the rise east of the Mississippi River and in urban areas.”

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The authors’ hypothesis for why brain damage is reportedly more common in people who chase the dragon is because certain heroin metabolites are able to cross the blood-brain barrier much easier via inhaling smoke, causing more damage than injecting or snorting do.

Still, there are a few issues with this study, and they start in the introduction. The paper doesn’t distinguish between different forms of heroin and it claims that chasing the dragon is on the rise east of the Mississippi, and that it may carry “a high fatality rate and long-term disability cost.”

However, there is no epidemiological data to support the claim that heroin smoking is on the rise, at least not in the US. The citation used for the claim that inhaling is the “most rapidly spreading [heroin] modality” was published in 2004, and uses data on Texans from the late 90s and does not distinguish between inhaling heroin (i.e. snorting) or chasing the dragon. (The paper does, however, note increases in chasing the dragon in Europe and Asia.)

The authors also cited data from the Substance Abuse and Mental Health Services Administration (SAMHSA) claiming that “in the United States, 21 percent of all heroin abuse inpatient hospital admissions among people aged 12 to 19 years in 2014 involved inhalation.” But SAMHSA broke out data on heroin smoking separately from inhalation and says smoking accounted for 4.8 percent of hospital admissions that year, while inhalation was 21.6 percent and injection was 71.7 percent (see Table 2.4b). We’ve contacted Ramos-Estebanez for additional comment and will update this story when we hear back.

From the start, the study conflates inhaling heroin with chasing the dragon, according to Dan Ciccarone, a family medicine professor at University of California, San Francisco, who has studied the medical consequences of heroin use for almost 20 years.

“They develop this tautological, confounded argument, none of which is true. It's appalling. I mean, it's a JAMA article,” Ciccarone says. “It's making a mountain out of a molehill, and it's irresponsible.”

Ciccarone has spent years on the ground, studying heroin markets and use patterns up close. He’s the principal investigator on the Heroin In Transition project, a five-year study funded by the National Institute on Drug Abuse that is examining the changing heroin supply, the effects of heroin use on people’s health, and the societal costs of using opioids.

In fact, thanks to the rise of deadly fentanyl in our drug supply, Ciccarone says he wishes inhaling heroin would become popular again, like it was in the early 2000s with the rise of Colombian product which, he's noted, “is not smokable but can be insufflated (snorted).” Fentanyl is so potent, he argues, that heroin users should try to “understand it through different bodily experience before they inject it.” It’s still possible to overdose on snorted fentanyl, but it’s less likely than via injection because there is less bioavailability, i.e. you absorb less amounts of the drug less quickly.

Let’s be clear: It does appear that heroin can cause this sort of brain damage, no matter how you take the drug. But it also seems to be extremely rare and is usually only found in long-term users. Furthermore, many other substances can cause this damage, which the JAMA study notes, including alcohol, cocaine, arsenic, paint fumes, even prescription drugs like cyclosporine, an immunosuppressant.

The researchers did a decent job of filtering out all these potential cofactors. But that left them with few actual cases of toxic leukoencephalopathy—less than 160 case reports globally since 1960. As Ramos-Estebanez mentioned, however, that could be due to poor diagnosis of this condition.

“This is a review on literature that’s pretty sparse and subject to a lot of bias in itself because the reporting is probably only going to be [that] severe cases will get published,” says Ryan Marino, an emergency medical toxicologist at the University of Pittsburgh. Marino has seen a lot of overdoses, including several leukoencephalopathy cases. He rarely encounters people who smoke heroin, he says, but that may be mostly related to the nature of his work in an ER and only seeing severe overdose cases.

Marino says that while the researchers don’t have great data to rely on, it’s still worth reviewing. “It shows there is something that needs to be looked at more and people should at least be aware of and be concerned about [leukoencephalopathy],” Marino says. “Without knowing what is really causing it or having demonstrated true causation, I think it’s hard to say this is definitely a heroin process.”

The earliest and largest report cited is a 1982 study of 47 heroin users with leukoencephalopathy in Amsterdam. Some patients were plagued with spasms and tics, others became partially paralyzed. Eleven of them died. But even the researchers couldn’t make a direct connection between this brain damage and heroin use. They ruled out some other toxic chemical mixed in heroin, such as mercury or bismuth, but concluded that they “have not yet been able to identify the causative factor.”

“[Leukoencephalopathy] is pretty bad, I won't lie about that,” Marino says. “But the people who have been diagnosed, most of the cases that are described, people actually go on to do pretty well and get back to their functional baseline, essentially. I don't know if that means that the changes in their brain are necessarily reversed, that you would see on an MRI. Certainly, some of the people who have the more severe form and have a very high death rate associated with it, but that’s still a smaller percentage of people who've been described to have toxic leukoencephalopathy.”

But Ramos-Estebanez disagrees. “They're very sick. They may not wake up, they may stay in coma or die. So you don't go back to being 100 percent,” he says. “If young people—and these are the people that I see with these problems—are smoking it, then that's a big loss and a big cost to society. Because the moment you have this problem and you come to the neurocritical care unit, then your professional life is over. You’re not gonna come back, you’re not gonna be able to have a job again, you're gonna be a huge burden to society.”

Still, brain damage from heroin is a pretty rare phenomenon. Syringe exchange clinics in the United Kingdom, Germany, and the Netherlands have been encouraging heroin users to chase the dragon rather than inject for decades. Smoking heroin not only limits vein injury and the risk of blood-borne diseases like HIV, it’s also considered harder to overdose on. One harm reduction site even sells specialty aluminum foil. If leukoencephalopathy was that big of a risk from smoking, Ciccarone insists we would likely see outbreaks in Europe, where chasing the dragon has been popular for years.

Marino agrees. “That would kind of argue against heroin [alone] being the cause,” he says. “Maybe there is something else going on.”

Not only did the authors of this paper lump together smoking and snorting, they also don’t distinguish between the different types of heroin. Not all dope is created equal, and different regions get different quality; some are smokeable, some are not. In Europe and Asia—places where it does seem like there’s an increase in chasing the dragon—most of the heroin comes in base form, which means it burns at a lower temperature and doesn’t dissolve very well in water.

“The US doesn't get base heroin—all of our heroin is a hydrochloride salt,” Ciccarone says. “Hydrochloride salts burn really badly, which is why nobody does [chasing the dragon]. You're getting five percent of your heroin instead of, if you inject it, the bioavailability approaches 100 percent.”

That doesn’t mean chasing the dragon never happens in the US, only that it’s uncommon. For this story, I spoke to nine people who said they’ve smoked heroin, past or present. Most were in Arizona, where salt-form black tar heroin is pretty much all you can get, according to multiple people I’ve spoken to and years of street experience from living in the Grand Canyon State. Black tar, which is sticky and usually dark, melts easily on a tray of aluminum foil—but it tastes terrible, it “burns the crap out of your nose,” Ciccarone says, and the leftover acid from the process can be really irritating. It also doesn’t get you as high as injecting.

That’s likely why most smokers I spoke with eventually moved to injection use. One woman told me that once she started shooting up, she stopped smoking altogether, fearful of “wasting” anything. “In my opinion, [injection] is much better than smoking,” she says. One man said he found it more “financially sustainable” to smoke when he was broke, as the heroin would last longer. (None of them had ever heard of anyone overdosing from smoking alone, but that doesn’t mean it’s impossible.)

One person switched from opioid pills due to scarcity and high cost and was later “shown how to run lines on a foil,” as he puts it. He later told his dealer it wasn’t helping and he came over with a syringe. “And from that point on, it had to be the needle,” he tells me. “Once you start the needle, you watch these people smoke it and you are in complete disgust because it’s just wasting such large, unholy amounts of black.” He said that, in his experience, it's very difficult to overdose while smoking. "Damn near impossible, even with benzos in your system.”

It’s long been rumored that it’s the aluminum foil, not the heroin, that causes brain damage via smoking the dragon, but the JAMA study notes this is unlikely, in line with other research about foil toxicity. Interestingly, a few folks I spoke to have started to smoke heroin using dab rigs—glass, bong-like water pipes typically used for smoking marijuana concentrates such as wax or shatter. Some people are also using glass straws, instead of plastic, so they can rinse them out and smoke the residue.

On the East Coast, smoking heroin is practically nonexistent, according to several sources I spoke with. It’s mostly inexperienced users who smoke, Ciccarone says. “And then they've learned quickly that it didn't work very well.”

One Arizonan who used to live in Maryland several years ago says he and his friends were “cool with” smoking pills (which is sometimes called “chasing the bean”), but afraid to smoke heroin because of brain-damage rumors they’d heard about in New York.

Tino Fuentes, a veteran harm-reduction advocate who does regular outreach in New York City, says he never encounters people who chase the dragon and he’s been looking for some time. "I've asked and suggested, but no luck. No one wants to smoke. I don't blame them,” Fuentes says.

Ciccarone also spent considerable time across the country trying to find people who chase the dragon and found very few. In a paper released earlier this year in the Harm Reduction Journal, he and his colleagues spent a year documenting different ways people test their heroin. Because so much heroin today is adulterated with potent synthetic opioids like fentanyl, some users are developing techniques to sample their heroin with less risk of overdose by snorting, shooting, or smoking a minuscule dose. But smoking was very uncommon. “In a couple hundred folks that I've interviewed over the last two years, I haven't talked to anyone who was a dedicated or even a part-time smoker,” Ciccarone says.

Of course, none of this is to say that using heroin in any form is “safe.” It’s obviously highly addictive and can cause fatal overdoses, no matter how it’s ingested. But as Ciccarone puts it, “Harm reduction doesn't say that drugs don't cause harm—it says that we understand that drugs cause harm and we look for the most harmful modes of using drugs to try to ameliorate those.”

But Ramos-Estebanez is in the camp that people “should not inhale, period,” he tells me. He suggests rehab or methadone. That argument doesn’t always work for someone addicted to opioids who may not have access to treatment. That’s why one of the core principles of harm reduction is to meet people where they are.

So why respond to a study like this at all? One could argue that it’s just one review with a few things wrong. Why not just ignore it?

However, JAMA is a publication with a high impact factor, meaning what it publishes gets taken pretty seriously. This study was covered in Gizmodo and Newsweek, with alarming headlines warning of “irreversible” brain damage. Popular blogs Boing Boing and IFLScience also picked it up, as well as Medpage Today and Medscape. When ideas like this enter the mainstream without nuance, it can impact harm reduction efforts. It can make people less likely to recommend or seek out safer options—and by all accounts, snorting or smoking heroin is safer than injecting, even if it’s not safe in and of itself.

Of course, that depends on what form the heroin comes in, but if we want fewer HIV and hepatitis C infections or fewer overdoses, we should recommend other consumption methods when possible. Rumors like Narcan parties or overdosing on fentanyl by touching it have real-world impacts on the way we respond to public health crises like addiction.

“The problem we have in the current epidemic is fear,” Ciccarone says. “Fear does not give us our best responses. We waste a lot of money when we have fear and we start labeling drug users as 'addicts' and we start labeling them as expensive for the system. I say courage, I say wisdom, I say go slowly on exaggerating your points because otherwise, people are going to run away. And we’re gonna go back to the bad old days of HIV where a heavy dose of stigma caused more to die.”

“I'm not saying we shouldn't study this rare disease—heroin has a number of minor complications that all should be well understood,” Ciccarone goes on. “But exactly what's going on here, whether it's a stimulation or destruction of an astrocyte or some kind of toxic white blood cell that's destroying neurons, it's still under debate.”

Ultimately, one goal of this JAMA paper is to create an international registry where researchers can submit case studies under this proposed diagnostic criteria. Such a database would help us better understand how prevalent and serious these heroin-linked brain damage cases really are, as well as proposing treatment.

And that is really what we need—more information, more research, before we start labeling certain behaviors as an epidemic, and potentially steering people away from less harmful drug use.