Cheese: An old drug in a new wrapper

Background: An unexpected outbreak of " cheese" heroin, which contained diphenhydramine and usually acetaminophen, began in Dallas around 2004. Onset occurred among youths living in neighborhoods populated by first-generation Hispanic immigrants. Little was known about the problem or the social strengths and deficits of these youth, who were primarily inhalers (" snorters" ) but at risk of transitioning to injection. Methods: Multiple data sources were used, including surveys, data from emergency departments, law enforcement, treatment programs, and coroner, and interviews with users and key informants. Results: Among heroin users under age 20, overdose deaths peaked in 2006, the school survey responses to using " cheese" heroin peaked in 2007, and treatment admissions peaked in 2008. Hispanic youth entering treatment were less likely to be injectors and report fewer problems than their Anglo counterparts and they were more likely to live with their families and to be supported by them. Sixty percent of the Hispanic youth had been in treatment previously and only 53% completed treatment. Cocaine and/or benzodiazepines were involved in 32% of the adolescent heroin deaths. Conclusions: The timely use of multiple data sources enabled this outbreak to be quickly identified and monitored, and the Cheese Heroin Task Force used the collected data to help respond to the problem, although retention in treatment and readmissions remained problematic. Cultural problems including immigration status, language, and misunderstandings about the nature of treatment were barriers to successful treatment outcomes. Completion of treatment as an inhaler is critical to reducing the likelihood of transitioning to injection.