"Cheese" is a heroin-based

recreational drug Recreational drug use indicates the use of one or more psychoactive drugs to induce an altered state of consciousness either for pleasure or for some other casual purpose or pastime by modifying the perceptions and emotions of the user. When a ...

that came to the attention of the media inside and outside the United States after a string of deaths among

adolescents Adolescence () is a transitional stage of physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated with the ...

Dallas Dallas () is the List of municipalities in Texas, third largest city in Texas and the largest city in the Dallas–Fort Worth metroplex, the List of metropolitan statistical areas, fourth-largest metropolitan area in the United States at 7.5 ...

, between 2005 and 2007. As of 2012 the drug use is now among older people who were teenagers around the period the drug was first discovered. Cheese is a combination of drugs, made by combining heroin with crushed tablets of certain

over-the-counter Over-the-counter (OTC) drugs are medicines sold directly to a consumer without a requirement for a prescription from a healthcare professional, as opposed to prescription drugs, which may be supplied only to consumers possessing a valid prescr ...

cold Cold is the presence of low temperature, especially in the atmosphere. In common usage, cold is often a subjective perception. A lower bound to temperature is absolute zero, defined as 0.00K on the Kelvin scale, an absolute thermodynamic ...

medication, such as

Tylenol PM Tylenol may refer to: * Paracetamol (acetaminophen), a medication used to treat pain and fever * Tylenol (brand) Tylenol () is a brand of medication, advertised for reducing pain, reducing fever, and relieving the symptoms of allergies, cold ...

. Such cold medications contain

acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferio ...

(paracetamol), the

active ingredient An active ingredient is any ingredient that provides biologically active or other direct effect in the diagnosis, cure, mitigation, treatment, or prevention of disease or to affect the structure or any function of the body of humans or animals. The ...

Tylenol Tylenol may refer to: * Paracetamol (acetaminophen), a medication used to treat pain and fever * Tylenol (brand) Tylenol () is a brand of medication, advertised for reducing pain, reducing fever, and relieving the symptoms of allergies, cold ...

, and the

antihistamine Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provide ...

diphenhydramine Diphenhydramine (DPH) is an antihistamine and sedative mainly used to treat allergies, insomnia, and symptoms of the common cold. It is also less commonly used for tremor in parkinsonism, and nausea. It is taken by mouth, injected into a v ...

, the active ingredient in

Benadryl Benadryl is a brand of various antihistamine medications used to stop allergies, whose content varies in different countries, but which includes some combination of diphenhydramine, acrivastine, and/or cetirizine. It is sold by Johnson & Joh ...

. Cheese samples obtained in

north North is one of the four compass points or cardinal directions. It is the opposite of south and is perpendicular to east and west. ''North'' is a noun, adjective, or adverb indicating direction or geography. Etymology The word ''no ...

contained between 2% and 8% heroin, in contrast to the 30% commonly found in

black tar heroin Black tar heroin is a form of heroin that is sticky like tar or hard like coal. Its dark color is the result of crude processing methods that leave behind impurities. Despite its name, black tar heroin can also be dark orange or dark brown in a ...

. Users commonly take the powder by

insufflation In religious and magical practice, insufflation and exsufflation are ritual acts of blowing, breathing, hissing, or puffing that signify variously expulsion or renunciation of evil or of the devil (the Evil One), or infilling or blessing with go ...

("snorting") rather than by

intravenous injection Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...

. This mixture is also known as "Tylenol With Smack", by analogy to the Tylenol With Codeine series. Due to the high concentrations of non-opiate substances relative to the

diamorphine Heroin, also known as diacetylmorphine and diamorphine among other names, is a potent opioid mainly used as a recreational drug for its euphoric effects. Medical grade diamorphine is used as a pure hydrochloride salt. Various white and brow ...

content of the drug, abuse and overdose of cheese are more dangerous than pure-form opiate overdoses. Emergency personnel must address the overdose effects of each component of the drug, since the contents and concentrations of each component vary widely among batches they must wait for either the completion of the toxicology report to begin treatment or wait for the effects of each drugs overdose to manifest. The acetaminophen content of the drug induces severe, irreversible damage to the liver when taken in high doses for long periods of time. Very high doses of acetaminophen are capable of producing acute liver failure and death within hours, and patients who survive this acute phase of the toxicity generally require dialysis and eventually a liver transplant. Due to the many methods of preparation a user can not know how much acetaminophen is in any given batch and therefore can not reliably determine a safe dose. A dose of the last batch which produced no toxic effects may produce lethal effects in the next batch.

Emergence

The drug made many news headlines when it appeared in several public middle and high schools in

Texas Texas (, ; Spanish language, Spanish: ''Texas'', ''Tejas'') is a state in the South Central United States, South Central region of the United States. At 268,596 square miles (695,662 km2), and with more than 29.1 million residents in 2 ...

. The

United States Drug Enforcement Administration The Drug Enforcement Administration (DEA; ) is a United States federal law enforcement agency under the U.S. Department of Justice tasked with combating drug trafficking and distribution within the U.S. It is the lead agency for domestic en ...

,Donna Leinwand
Texas schools battle 'starter heroin'
''USA Today'', April 26, 2006 some police agencies and the

Dallas Independent School District The Dallas Independent School District (Dallas ISD or DISD) is a school district based in Dallas, Texas ( USA). It operates schools in much of Dallas County and is the second-largest school district in Texas and the seventeenth-largest in the ...

(DISD) dubbed the mixture "starter heroin." The district handled fifty-four property cases and found twenty-four felony offenses involving "cheese" between August 15, 2005 and March 1, 2006, at eleven schools."Cheese" May 2006
(), WhiteHouseDrugPolicy.gov On February 24, 2007,

United Press International United Press International (UPI) is an American international news agency whose newswires, photo, news film, and audio services provided news material to thousands of newspapers, magazines, radio and television stations for most of the ...

reported that DISD would increase

drug-sniffing dog A detection dog or sniffer dog is a dog that is trained to use its senses to detect substances such as explosives, illegal drugs, wildlife scat, currency, blood, and contraband electronics such as illicit mobile phones. The sense most used ...

patrols in order to eliminate Cheese from its schools. As of mid-2007, police records for the northwest quadrant of Dallas showed almost daily arrests for and confiscations of the drug.Sergio Chapa
"Stores stop selling medicines that contain 'cheese' ingredient,"
''Al Día'', July 17, 2007. According to Dallas school district authorities,

Hispanic The term ''Hispanic'' ( es, hispano) refers to people, cultures, or countries related to Spain, the Spanish language, or Hispanidad. The term commonly applies to countries with a cultural and historical link to Spain and to viceroyalties for ...

teenagers are the demographic group most frequently charged with possession of the drug;Dallas Morning News , News for Dallas, Texas , Latest News
/ref> Hispanics also constitute a majority (60 percent) of all DISD students.Kent Fischer

''The Dallas Morning News'', July 16, 2007. By February 1, 2007, usage of Cheese was reported in the fourth-grade level at several elementary schools; By February 2007, Monty Moncibais, a detective of the Dallas Police Narcotics Division, noted 71 cheese-related arrests in children aged 10 through 16.Anna Schecter

''The Blotter'', ABC News, Feb. 1, 2007 Dallas-area treatment centers have noted that the drug's growing use has led to a lowering in the age of teens admitted to their programs. From a typical clientele of 15- to 17-year-olds admitted under court order, one Dallas-area center noted it had begun to admit 11, 12, and 13-year-olds voluntarily or at a parent's request. Kim Horner

''The Dallas Morning News'', November 18, 2006 ''

Newsweek ''Newsweek'' is an American weekly online news magazine co-owned 50 percent each by Dev Pragad, its president and CEO, and Johnathan Davis, who has no operational role at ''Newsweek''. Founded as a weekly print magazine in 1933, it was widely ...

'' posted an article about Cheese, titled "Stopping a Kid Killer," in 2007. Jack Schafer, a columnist for ''

Slate Slate is a fine-grained, foliated, homogeneous metamorphic rock derived from an original shale-type sedimentary rock composed of clay or volcanic ash through low-grade regional metamorphism. It is the finest grained foliated metamorphic ro ...

'', criticized the ''Newsweek'' article; Schafer believes that the Newsweek article does not adequately explain the process of creating Cheese and did not use scientists as sources. Jane C. Maxwell, a senior research scientist of the Gulf Coast Addiction Technology Transfer Center at

The University of Texas at Austin The University of Texas at Austin (UT Austin, UT, or Texas) is a public research university in Austin, Texas Austin is the capital city of the U.S. state of Texas, as well as the county seat, seat and largest city of Travis County, Te ...

, stated in "“Cheese” Heroin: Status as of May 2, 2007" that she believes that the effect of Cheese could increase due to media reporting aspects such as "unsubstantiated numbers" and "sensationalistic emphasis" regarding "new highs" and "schoolboy drugs," leading to

copycat Copycat refers to a person who copies some aspect of some thing or somebody else. Copycat may also refer to: Intellectual property rights * Copyright infringement, use of another’s ideas or words without permission * Patent infringement, a ...

outbreaks.Maxwell, Jane C
"'Cheese' Heroin: Status as of May 2007,"
Gulf Coast Addiction Technology Transfer Center,

University of Texas at Austin The University of Texas at Austin (UT Austin, UT, or Texas) is a public research university in Austin, Texas. It was founded in 1883 and is the oldest institution in the University of Texas System. With 40,916 undergraduate students, 11,075 ...

, May 2, 2007. Retrieved August 26, 2007. In mid-2007, a number of area stores opted either to remove Tylenol PM and similar products from their shelves or to move them to shelves within a pharmacist's view or control. The manager of a

Fiesta Mart Fiesta Mart, L.L.C., formerly Fiesta Mart Inc., is a Latino-American supermarket chain based in Houston, Texas that was established in 1972. Fiesta Mart stores are located in Texas. The chain uses a cartoon parrot as a mascot. As of 2004 it ope ...

supermarket A supermarket is a self-service shop offering a wide variety of food, beverages and household products, organized into sections. This kind of store is larger and has a wider selection than earlier grocery stores, but is smaller and more lim ...

in northwest Dallas explained his store's policy shift regarding various diphenhydramine-containing products by saying local youths were stealing these items, adding, "We didn't want to be part of the problem or anybody dying," implying that the store also pulled the products to curb abuse."Dallas Stores Pull Medicine Containing 'Cheese' Ingredient,"
ABC News, July 18, 2007. The manager stated that theft decreased after removing the products, and various local

Carnival Carnival is a Catholic Christian festive season that occurs before the liturgical season of Lent. The main events typically occur during February or early March, during the period historically known as Shrovetide (or Pre-Lent). Carnival ...

supermarkets and

Walgreens Walgreen Company, d/b/a Walgreens, is an American company that operates the second-largest pharmacy store chain in the United States behind CVS Health. It specializes in filling prescriptions, health and wellness products, health information, a ...

pharmacies also voluntarily shifted the products to pharmacist-controlled or -monitored shelves. ''

The Dallas Morning News ''The Dallas Morning News'' is a daily newspaper serving the Dallas–Fort Worth area of Texas, with an average print circulation of 65,369. It was founded on October 1, 1885 by Alfred Horatio Belo as a satellite publication of the ''The Galves ...

'' unofficially reported that arrests for Cheese in DISD decreased. The district performed 71 arrests for Cheese in the 2006-2007 school year. During the 2007-2008 school year from August to December the district performed 17 arrests. The number of children seeking treatment for use of Cheese remained steady. The paper reported that usage of Cheese spread from the northwest Dallas area and into areas outside of Dallas County. Deputy Chief Julian Bernal, the commander of the narcotics division of the

Dallas Police The Dallas Police Department, established in 1881, is the principal law enforcement agency serving the city of Dallas, Texas. Organization The department is headed by a chief of police who is appointed by the city manager who, in turn, is hir ...

, said that he encountered more

White White is the lightness, lightest color and is achromatic (having no hue). It is the color of objects such as snow, chalk, and milk, and is the opposite of black. White objects fully diffuse reflection, reflect and scattering, scatter all the ...

and

Black Black is a color which results from the absence or complete absorption of visible light. It is an achromatic color, without hue, like white and grey. It is often used symbolically or figuratively to represent darkness. Black and white ha ...

teenagers using the drug. Michelle Hemm, the director of the Phoenix Academy of Dallas, believes that Cheese arrests decreased because users took more care to conceal the drugs or did not bring the drugs to schools for fear of detection.

Production methods

According to a 14-year-old girl being treated at the Phoenix Academy, water is added to the heroin. The watered-down heroin, often called "monkey juice," is mixed with

tablets. The makers of Cheese heat the mixture to remove excess water, resulting in the final product. A more refined method for creating Cheese heroin is done by taking #4 powder heroin and crushed diphenhydramine tablets, and adding them to water such that the active ingredients dissolve into the solution. The solution is then filtered via a micron filter to remove all the cuts and binders/fillers, leaving the user with a solution of high purity diamorphine HCl and diphenhydramine hcl. The water is then evaporated off, yielding a clumpy powder containing a highly purified mixture of heroin and DPH. It can also be further purified by titrating the solution with a weak to intermediate base such as sodium carbonate or sodium hydroxide to freebase the diamorphine and DPH. This releases the bound hydrochloride salts on both the diamorphine and DPH, such that the HCl ions dissolve into the water while the heroin and diphenhydramine are freebased; this allows the molecules to precipitate out as the solution is titrated. The precipitates (heroin and DPH) are then collected, leaving behind all of the process waste. Lastly (and optionally) the super high purity (90%-99%) heroin-DPH mixture is added to a water solution and hydrochloric, acetic, or citric acid is carefully titrated to yield up to 99.9% pure "cheese" heroin in the salt form, which is again run through a micron filter and extracted to a powder via evaporation (water-soluble, and as such is the type used for injection and insufflation ROA's) otherwise this step is excluded and the Cheese is in a super pure base form (which can be efficiently smoked).

Deaths

Deaths directly attributable to this form of heroin are difficult to confirm because coroner's offices frequently do not have a method to track cause of death to one specific form of a drug. Centralized reporting of cheese heroin deaths does not exist in Texas since each county has its own official to sign death certificates.

2006: The first deaths are reported

Several of the deaths are notable due either to the publicity that followed or unusual circumstances of the case. One of the earliest published instances of a death attributed to cheese heroin was that of Karen Becerra, an 18-year-old high school senior found dead by her father in their West Dallas home on April 24, 2006. Police attributed her death to snorting cheese and drinking alcohol. On November 1, 2006, 17-year-old Keith Witherspoon died in nearby

Mesquite Mesquite is a common name for several plants in the genus '' Prosopis'', which contains over 40 species of small leguminous trees. They are native to dry areas in the Americas. They have extremely long roots to seek water from very far under g ...

; a story the following month in ''

'' profiled Witherspoon as "the first Dallas-area youth publicly known to have died of a heroin overdose since the 'cheese' concerns were raised."Kim Horner
"Mesquite family unable to save teen from drugs: Seeking help, family found only dead ends"
''The Dallas Morning News'', December 31, 2006 The death was also notable because Mesquite is located northeast of Dallas, indicating the problem had moved beyond its origins in the northwest quadrant of the city.

Early 2007: Deaths in younger populations

The first middle-school "cheese" death in published accounts was that of Oscar Gutierrez, a 15-year-old eighth grader in northwest Dallas, who died February 18, 2007;Rebecca Lopez

WFAA-TV (Dallas, Texas), Feb. 21, 2007 his brother stated that the boy had previously survived an overdose of the same drug. Community rallies followed Gutierrez' death as parents and others urged the police and school district to become more active in fighting what was viewed as a growing problem. The death of Logan Michael Howatt., a high school student, on March 31, 2017, led to further community activism. Initially this death was linked to cheese heroin based on the father's comments in press reports; the father said his son was at a Corvallis party when he was offered "cheese" and that the boy had not tried drugs before that he was aware of.
KXAS-TV, April 4, 2007."Muere otro estudiante por drogas: Estudiaba en la escuela Molina de Dallas,"
Another student dies from drugs: He studied at Dallas' Molina school" Univision KUVN-TV, April 4, 2007 (in Spanish) Martín Martínez
"Padre de joven víctima aconseja a familias vigilar a menores,"
Father of young victim advises families to keep watch over minors"''Diario La Estrella'', April 4, 2007 (in Spanish)Sergio Chap
"Family believes teen's death may be tied to 'cheese' heroin,"
'The Dallas Morning News'', April 4, 2007 Cortez's father went on to become a speaker at community meetings within the school system, urging that parents keep closer watch over their children.Sergio Chap

A lesson filled with pain" ''Al Día'', May 1, 2007 (in Spanish) On April 24, the same day toxicology results were announced confirming the link to cheese, police announced a family friend would be charged with murder for having mixed the drugs for Cortez.Jason Trahan
"'Cheese' heroin claims 18th school-age victim,"
''The Dallas Morning News'', April 24, 2007.

Spring/summer 2007: Old deaths examined, new deaths occur

Between the time of Cortez Jr.'s death and the announcement of his toxicology tests in late April, ''The Dallas Morning News'' published the results of a lengthy analysis of autopsy results between 2005 and 2007, conducted in concert with the Dallas County medical examiner's office, which suggested that as many as 17 deaths among adolescents during that period were attributable to cheese heroin, not including the Cortez death. The conclusion was based in part on the presence of both heroin and diphenhydramine in the blood of the deceased; additionally, the families of 11 victims confirmed the deceased had used cheese heroin. Some

toxicologists Toxicology is a scientific discipline, overlapping with biology, chemistry, pharmacology, and medicine, that involves the study of the adverse effects of chemical substances on living organisms and the practice of diagnosing and treating expo ...

questioned the results due to the absence of acetaminophen. Other experts argued that acetaminophen has a shorter

half-life Half-life (symbol ) is the time required for a quantity (of substance) to reduce to half of its initial value. The term is commonly used in nuclear physics to describe how quickly unstable atoms undergo radioactive decay or how long stable at ...

and might have been

metabolized Metabolism (, from el, μεταβολή ''metabolē'', "change") is the set of life-sustaining chemical reactions in organisms. The three main functions of metabolism are: the conversion of the energy in food to energy available to run cell ...

by the body prior to death. Susan Dalterio, a

University of Texas at San Antonio The University of Texas at San Antonio (UTSA) is a public research university in San Antonio, Texas. With over 34,000 students across its four campuses spanning 758 acres, UTSA is the largest university in San Antonio and the eighth-largest by ...

pharmacology expert, insisted that the combination was unlikely to be a coincidence, as a person sleepy from diphenhydramine would be unlikely to be abusing heroin at the same time.Jason Trahan
"'Cheese' crisis runs deep,"
''The Dallas Morning News'', April 15, 2007 It is common for users of heroin and other

opioid Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioi ...

drugs to take diphenhydramine-containing medications as an attempt to alleviate side effects resulting from histamine release induced by opioid administration, such as

pruritus Itch (also known as pruritus) is a sensation that causes the desire or reflex to scratch. Itch has resisted many attempts to be classified as any one type of sensory experience. Itch has many similarities to pain, and while both are unpleasant ...

, as well as potentiate the sedative effects of the drug. On April 18, days after findings from the medical examiner's review were published, two more deaths occurred, though once again their connection to cheese heroin took weeks to be confirmed. The body of 18-year-old Keridma Godina was found on a porch in

Balch Springs Balch Springs ( , ) is a city in Dallas County, Texas, United States. It is an inner-ring suburb of Dallas and part of the Dallas–Fort Worth metroplex. The population was 23,728 at the 2010 census, and 25,007 at 2019's census estimates. Histor ...

the day after her death;Jason Trahan
"Woman, 18, confirmed as 'cheese' victim,"
''The Dallas Morning News'', May 3, 2007 police charged two men immediately with abandoning the body, but were unable to make any drug-related charge when confirmation of the link to cheese came three weeks later. The death of 17-year-old Lauren Paulson of The Colony, was reported that same week, but was not linked to cheese heroin until late summer.Jason Trahan
"Girl, 17, apparently dies of overdose,"
''The Dallas Morning News'', April 21, 2007. Retrieved August 4, 2007. In mid-May, the Dallas County medical examiner's office confirmed that two earlier teen deaths — one in January and another in April — were confirmed by toxicology tests as linked to cheese heroin; these additions brought the known toll at that time to 21 deaths among those 18 and under, not including the Paulson case.Jason Trahan

''The Dallas Morning News'', May 9, 2007 Over the summer vacation months of 2007, the push against cheese heroin continued. Parents and police organized a June 30 March, Sen. John Cornyn visited the area as part of an anti-cheese campaign in early July, the director of the White House Office of National Drug Control Policy gave a press conference from Dallas ISD headquarters in August praising the district's efforts, and local stores pulled Tylenol PM and similar drugs from the shelves to make them less accessible.Sam Hodges
"Parents, police march to promote awareness of 'cheese,'"
''The Dallas Morning News'', June 30, 2007.Frank Trejo

''The Dallas Morning News'', July 7, 2007. Retrieved August 4, 2007.Tawnell D. Hobbs

''The Dallas Morning News'', August 2, 2007.Gary Reaves

WFAA-TV, July 18, 2007. July also saw the addition of two more names to the list of deaths, as Paulson's death became the 22nd linked to the drug, and a 17-year-old member of a high school

drill team A drill team can be one of four different entities: # A military drill team is a marching unit that performs routines based on military foot or exhibition drills. Military drill teams perform either armed or unarmed. # A dance drill team cre ...

died at

Parkland Memorial Hospital Parkland Memorial Hospital is a public hospital in Dallas, Texas, United States. It is the main hospital of the Parkland Health & Hospital System and serves as Dallas County's public hospital. It is located within the Southwestern Medical Di ...

eleven days after being found unconscious on the morning her group was to take its yearbook photo.Sergio Chapa
"Dallas County's 23rd 'cheese' victim buried: Dallas: Drill team member, good student is 23rd to die in county,"
''Al Día'', July 12, 2007.

Autumn 2007: Deaths across north Texas

The spread of the drug to the outlying suburbs of Dallas was confirmed in September by the return of toxicology reports from the July 13 death of an 18-year-old student from

McKinney McKinney is a city in and the county seat of Collin County, Texas. It is Collin County's third-largest city, after Plano and Frisco. A suburb of the Dallas–Fort Worth metroplex, McKinney is about north of Dallas. The U.S. Census Bureau lis ...

, located northeast of Dallas in

Collin County Collin County is located in the U.S. state of Texas. It is part of the Dallas- Fort Worth- Arlington metropolitan statistical area, and a small portion of the city of Dallas is in the county. At the 2020 United States census, the county's popula ...

,Marissa Alani
"'Cheese' confirmed as cause of McKinney student's death,"
''The Dallas Morning News'', September 2, 2007. and from two July deaths in nearby Tarrant County, one involving a 17-year-old male and the other, a 26-year-old male.Debra Dennis
"Two confirmed as 'cheese' victims,"
''The Dallas Morning News'', September 21, 2007. Additional suburban deaths in September — in

Irving Irving may refer to: People *Irving (name), including a list of people with the name Fictional characters * Irving, the main character's love interest in Cathy (comic strip) * Lloyd Irving, the main protagonist in the ''Tales of Symphonia'' vide ...

to the west and Rockwall to the east — were believed to be linked to cheese heroin, though police cautioned toxicology reports would not likely be complete until November. The Tarrant County medical examiner's office announced on September 24 that a review of deaths in Tarrant County (west) and

Denton County Denton County is located in the U.S. state of Texas. As of the 2020 census, its population was 906,422, making it the 7th-most populous county in Texas. The county seat is Denton. The county, which was named for John B. Denton, was establish ...

(north) showed an additional 15 deaths between 2004 and 2007 that appeared to be linked to "cheese," and Collin and Rockwall counties had reported one death each.Associated Press
"Tarrant officials confirm 2 'cheese' heroin deaths,"
''The Dallas Morning News'', September 24, 2007. These new figures brought the total number of deaths associated with cheese heroin in northern Texas to 40, a figure that included many older adults along with those age 18 and under.