Heroin is an illegal, highly addictive drug. It
is both the most abused and the most rapidly acting of the opiates. Heroin is processed
from morphine, a naturally occurring substance extracted from the seed pod of certain
varieties of poppy plants. It is typically sold as a white or brownish powder or as the
black sticky substance known on the streets as "black tar heroin." Although
purer heroin is becoming more common, most street heroin is "cut" with other
drugs or with substances such as sugar, starch, powdered milk, or quinine. Street heroin
can also be cut with strychnine or other poisons. Because heroin abusers do not know the
actual strength of the drug or its true contents, they are at risk of overdose or death.
Heroin also poses special problems because of the transmission of HIV and other diseases
that can occur from sharing needles or other injection equipment.
Heroin is usually injected, sniffed/snorted, or
smoked. Typically, a heroin abuser may inject up to four times a day. Intravenous
injection provides the greatest intensity and most rapid onset of euphoria (7 to 8
seconds), while intramuscular injection produces a relatively slow onset of euphoria (5 to
8 minutes). When heroin is sniffed or smoked, peak effects are usually felt within 10 to
15 minutes. Although smoking and sniffing heroin do not produce a "rush" as
quickly or as intensely as intravenous injection, NIDA researchers have confirmed that all
three forms of heroin administration are addictive.
Injection continues to be the predominant method of heroin use among addicted users
seeking treatment; however, researchers have observed a shift in heroin use patterns, from
injection to sniffing and smoking. In fact, sniffing/snorting heroin is now a widely
reported means of taking heroin among users admitted for drug treatment in Newark,
Chicago, New York, and Detroit.
With the shift in heroin abuse patterns comes an even more diverse group of users.
Older users (over 30) continue to be one of the largest user groups in most national data.
However, several sources indicate an increase in new, young users across the country who
are being lured by inexpensive, high-purity heroin that can be sniffed or smoked instead
of injected. Heroin has also been appearing in more affluent communities.
|Depressed respiration |
|Clouded mental functioning |
|Nausea and vomiting |
|Suppression of pain |
|Spontaneous abortion |
Soon after injection (or inhalation), heroin
crosses the blood-brain barrier. In the brain, heroin is converted to morphine and binds
rapidly to opioid receptors. Abusers typically report feeling a surge of pleasurable
sensation, a "rush." The intensity of the rush is a function of how much drug is
taken and how rapidly the drug enters the brain and binds to the natural opioid receptors.
Heroin is particularly addictive because it enters the brain so rapidly. With heroin, the
rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling
in the extremities, which may be accompanied by nausea, vomiting, and severe itching.
After the initial effects, abusers usually will be drowsy for several hours.
Mental function is clouded by heroin's effect on the central nervous system. Cardiac
functions slow. Breathing is also severely slowed, sometimes to the point of death. Heroin
overdose is a particular risk on the street, where the amount and purity of the drug
cannot be accurately known.
|Infectious diseases, for example, HIV/AIDS and hepatitis B and C
|Collapsed veins |
|Bacterial infections |
|Infection of heart lining and valves |
|Arthritis and other rheumatologic problems |
One of the most detrimental long-term effects of
heroin is addiction itself. Addiction is a chronic, relapsing disease, characterized by
compulsive drug seeking and use, and by neurochemical and molecular changes in the brain.
Heroin also produces profound degrees of tolerance and physical dependence, which are also
powerful motivating factors for compulsive use and abuse. As with abusers of any addictive
drug, heroin abusers gradually spend more and more time and energy obtaining and using the
drug. Once they are addicted, the heroin abusers' primary purpose in life becomes seeking
and using drugs. The drugs literally change their brains.
Physical dependence develops with higher doses of the drug. With physical dependence,
the body adapts to the presence of the drug and withdrawal symptoms occur if use is
reduced abruptly. Withdrawal may occur within a few hours after the last time the drug is
taken. Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia,
diarrhea, vomiting, cold flashes with goose bumps ("cold turkey"), and leg
movements. Major withdrawal symptoms peak between 24 and 48 hours after the last dose of
heroin and subside after about a week. However, some people have shown persistent
withdrawal signs for many months. Heroin withdrawal is never fatal to otherwise healthy
adults, but it can cause death to the fetus of a pregnant addict.
At some point during continuous heroin use, a person can become addicted to the drug.
Sometimes addicted individuals will endure many of the withdrawal symptoms to reduce their
tolerance for the drug so that they can again experience the rush.
Physical dependence and the emergence of withdrawal symptoms were once believed to be
the key features of heroin addiction. We now know this may not be the case entirely, since
craving and relapse can occur weeks and months after withdrawal symptoms are long gone. We
also know that patients with chronic pain who need opiates to function (sometimes over
extended periods) have few if any problems leaving opiates after their pain is resolved by
other means. This may be because the patient in pain is simply seeking relief of pain and
not the rush sought by the addict.
Medical consequences of chronic heroin abuse
include scarred and/or collapsed veins, bacterial infections of the blood vessels and
heart valves, abscesses (boils) and other soft-tissue infections, and liver or kidney
disease. Lung complications (including various types of pneumonia and tuberculosis) may
result from the poor health condition of the abuser as well as from heroin's depressing
effects on respiration. Many of the additives in street heroin may include substances that
do not readily dissolve and result in clogging the blood vessels that lead to the lungs,
liver, kidneys, or brain. This can cause infection or even death of small patches of cells
in vital organs. Immune reactions to these or other contaminants can cause arthritis or
other rheumatologic problems.
Of course, sharing of injection equipment or fluids can lead to some of the most severe
consequences of heroin abuse - infections with hepatitis B and C, HIV, and a host of other
blood-borne viruses, which drug abusers can then pass on to their sexual partners and
A variety of effective treatments are available
for heroin addiction. Treatment tends to be more effective when heroin abuse is identified
early. The treatments that follow vary depending on the individual, but methadone, a
synthetic opiate that blocks the effects of heroin and eliminates withdrawal symptoms, has
a proven record of success for people addicted to heroin. Other pharmaceutical approaches,
like LAAM (levo-alpha-acetyl-methadol), and many behavioral therapies also are used for
treating heroin addiction.
The primary objective of detoxification is to relieve withdrawal symptoms while
patients adjust to a drug-free state. Not in itself a treatment for addiction,
detoxification is a useful step only when it leads into long-term treatment that is either
drug-free (residential or outpatient) or uses medications as part of the treatment. The
best documented drug-free treatments are the therapeutic community residential programs
lasting at least 3 to 6 months.
Methadone treatment has been used effectively and safely to treat opioid addiction for
more than 30 years. Properly prescribed methadone is not intoxicating or sedating, and its
effects do not interfere with ordinary activities such as driving a car. The medication is
taken orally and it suppresses narcotic withdrawal for 24 to 36 hours. Patients are able
to perceive pain and have emotional reactions. Most important, methadone relieves the
craving associated with heroin addiction; craving is a major reason for relapse. Among
methadone patients, it has been found that normal street doses of heroin are ineffective
at producing euphoria, thus making the use of heroin more easily extinguishable.
Methadone's effects last for about 24 hours - four to six times as long as those of
heroin - so people in treatment need to take it only once a day. Also, methadone is
medically safe even when used continuously for 10 years or more. Combined with behavioral
therapies or counseling and other supportive services, methadone enables patients to stop
using heroin (and other opiates) and return to more stable and productive lives.
LAAM and other medications
LAAM, like methadone, is a synthetic opiate that can be used to treat heroin addiction.
LAAM can block the effects of heroin for up to 72 hours with minimal side effects when
taken orally. In 1993 the Food and Drug Administration approved the use of LAAM for
treating patients addicted to heroin. Its long duration of action permits dosing just
three times per week, thereby eliminating the need for daily dosing and take-home doses
for weekends. LAAM will be increasingly available in clinics that already dispense
Naloxone and naltrexone are medications that also block the effects of morphine,
heroin, and other opiates. As antagonists, they are especially useful as antidotes.
Naltrexone has long-lasting effects, ranging from 1 to 3 days, depending on the dose.
Naltrexone blocks the pleasurable effects of heroin and is useful in treating some highly
motivated individuals. Naltrexone has also been found to be successful in preventing
relapse by former opiate addicts released from prison on probation.
Although not yet approved for the treatment of opioid addiction, buprenorphine is
another medication being studied by NIDA as a treatment for heroin addiction.
Buprenorphine is a particularly attractive treatment because it does not produce the same
level of physical dependence as other opiate medications, such as methadone. Discontinuing
buprenorphine is easier than stopping methadone treatment because there are fewer
withdrawal symptoms. Several other medications with potential for treating heroin overdose
or addiction are currently under investigation by NIDA.
Although behavioral and pharmacologic treatments can be extremely useful when employed
alone, science has taught us that integrating both types of treatments will ultimately be
the most effective approach. There are many effective behavioral treatments available for
heroin addiction. These can include residential and outpatient approaches. An important
task is to match the best treatment approach to meet the particular needs of the patient.
Moreover, several new behavioral therapies, such as contingency management therapy and
cognitive-behavioral interventions, show particular promise as treatments for heroin
addiction. Contingency management therapy uses a voucher-based system, where patients earn
"points" based on negative drug tests, which they can exchange for items that
encourage healthy living. Cognitive-behavioral interventions are designed to help modify
the patient's thinking, expectancies, and behaviors and to increase skills in coping with
various life stressors. Both behavioral and pharmacological treatments help to restore a
degree of normalcy to brain function and behavior.
What are the opioid analogs and their dangers?
Drug analogs are chemical compounds that are
similar to other drugs in their effects but differ slightly in their chemical structure.
Some analogs are produced by pharmaceutical companies for legitimate medical reasons.
Other analogs, sometimes referred to as "designer" drugs, can be produced in
illegal laboratories and are often more dangerous and potent than the original drug. Two
of the most commonly known opioid analogs are fentanyl and meperidine (marketed under the
brand name Demerol, for example).
Fentanyl was introduced in 1968 by a Belgian pharmaceutical company as a synthetic
narcotic to be used as an analgesic in surgical procedures because of its minimal effects
on the heart. Fentanyl is particularly dangerous because it is 50 times more potent than
heroin and can rapidly stop respiration. This is not a problem during surgical procedures
because machines are used to help patients breathe. On the street, however, users have
been found dead with the needle used to inject the drug still in their arms.
Heroin abuse can cause serious
complications during pregnancy, including miscarriage and premature delivery. Children
born to addicted mothers are at greater risk of SIDS (sudden infant death syndrome), as
well. Pregnant women should not be detoxified from opiates because of the increased risk
of spontaneous abortion or premature delivery; rather, treatment with methadone is
strongly advised. Although infants born to mothers taking prescribed methadone may show
signs of physical dependence, they can be treated easily and safely in the nursery.
Research has demonstrated also that the effects of in utero exposure to methadone are
Because many heroin addicts often share needles
and other injection equipment, they are at special risk of contracting HIV and other
infectious diseases. Infection of injection drug users with HIV is spread primarily
through reuse of contaminated syringes and needles or other paraphernalia by more than one
person, as well as through unprotected sexual intercourse with HIV-infected individuals.
For nearly one-third of Americans infected with HIV, injection drug use is a risk factor.
In fact, drug abuse is the fastest growing vector for the spread of HIV in the Nation.
NIDA-funded research has found that drug abusers can change the behaviors that put them
at risk for contracting HIV, through drug abuse treatment, prevention, and community-based
outreach programs. They can eliminate drug use, drug-related risk behaviors such as needle
sharing, unsafe sexual practices, and, in turn, the risk of exposure to HIV/AIDS and other
infectious diseases. Drug abuse prevention and treatment are highly effective in
preventing the spread of HIV.
According to the 1996 National Household Survey
on Drug Abuse, which may actually underestimate illicit opiate (heroin) use, an estimated
2.4 million people use heroin at some time in their lives, and nearly 216,000 of them
reported using it within the month preceding the survey. The survey report estimates that
there were 141,000 new heroin users in 1995, and that there has been an increasing trend
in new heroin use since 1992. A large proportion of these recent new users were smoking,
snorting, or sniffing heroin, and most were under age 26. Estimates of use for other age
groups also increased, particularly among youths age 12 to 17: the incidence of first-time
heroin use among this age group increased fourfold from the 1980s to 1995.
The 1996 Drug Abuse Warning Network (DAWN), which collects data on drug- related
hospital emergency department (ED) episodes from 21 metropolitan areas, estimates that 14
percent of all drug-related ED episodes involved heroin. Even more alarming is the fact
that between 1988 and 1994, heroin-related ED episodes increased by 64 percent (from
39,063 to 64,013).
NIDA's Community Epidemiology Work Group (CEWG), which provides information about the
nature and patterns of drug use in 20 cities, reported in its December 1996 publication
that heroin was the primary drug of abuse related to drug abuse treatment admissions in
Newark, San Francisco, Los Angeles, and Boston, and it ranked a close second to cocaine in
New York and Seattle.
|source: NIDA Research Report - Heroin Abuse and Addiction: NIH
Publication No. 97-4165