Heroin abuse refers to the recreational use of and dependency on heroin, an opiate derived from morphine that is illegal to manufacture, possess, or use in the United States. The preferred international generic name for heroin is diamorphine; other chemical names include diacetylmorphine, acetylated morphine, and morphine diacetate. Interestingly, the common street name “heroin” began as a brand name. Between 1898 and 1910, the A.G. Bayer Company in Elberfeld, Germany, marketed diamorphine as an over-the-counter cough suppressant and pain reliever that was erroneously thought to be less addictive than morphine. Bayer named its product Heroin on the grounds that it was “heroically strong” in relieving troublesome coughs.
Between 1914 and 1924, the United States permitted the sale of diamorphine for medical purposes but strictly regulated and taxed it, but in 1924, Congress banned the manufacture, sale, or importation of heroin in the United States. As of 2017, heroin is classified as a Schedule I drug in the United States, which means that it has a high potential for abuse; has no currently accepted medical use in treatment in the United States; and lacks accepted safety standards for its use under medical supervision.
Heroin is one of the most frequently abused drugs in the United States; researchers estimate that about 1% of Americans have tried heroin at least once. The country accounts for about 5% of the world's population but consumes 80% of the world's opioid supply. Since the late 1990s, the number of deaths from opioid overdose (including prescription opioids as well as heroin) quadrupled in the United States. According to the Centers for Disease Control and Prevention (CDC), as of 2017, 91 Americans die each day from opioid overdoses.
Much of the rise in heroin abuse since the early 2000s has been attributed to increasingly aggressive prescribing of opioid pain relievers, particularly OxyContin, a form of oxycodone introduced by Purdue Pharma in 1996. Many people who were prescribed the drug for chronic pain became addicted to oxycodone and turned to heroin as a less expensive alternative to the prescription drug. The CDC notes that the greatest increases in heroin abuse in recent years have occurred in groups that historically had low rates of heroin use: women; people with private health insurance; and people with higher incomes.
Heroin was first made by a British chemist, C.R.A Wright, in 1874; he used morphine, a natural product of the opium poppy, Papaver somniferum, and combined it with various acids until he produced what is now known as diamorphine. Wright did little with his discovery, however, and heroin was resynthesized by a German chemist named Felix Hoffman in 1897. Although Hoffman hoped that heroin would be less addictive than the morphine from which it was derived, the new drug turned out to be twice as potent as morphine itself and even more addictive.
Heroin has anxiolytic (anxiety-relieving) properties as well as analgesic (pain-relieving) qualities. A central nervous system depressant, heroin is dangerous to combine with alcohol or benzodiazepine tranquilizers because these drugs in combination can lead to cessation of breathing and death from lack of oxygen. Pure heroin is a pure white powder with a bitter taste; the heroin sold on the street, however, is often off-white or brownish in color because it has been cut with sugar, starch, powdered milk, quinine, or even other drugs.
The purity of street heroin varies from 11% to 72% depending on the area where it is purchased. The recent trend in the United States and Canada to mix street heroin with fentanyl, a much more potent synthetic opioid, has led to an increase in the number of overdose deaths. Street names for heroin include horse, H, skag, dope, junk, smack, and brown sugar. One form of street heroin known as black tar is made without the additional steps of purification needed after the acetylation of morphine. Black tar heroin may look like a dark-colored goo or a brown powder if it has been refined and cut with lactose. Black tar heroin is most common in Latin America and the western United States.
Heroin can be taken into the body through a number of different routes:
- Intravenous injection. Known as mainlining, shooting up, or banging, this route offers the most rapid and Page 1722 | Top of Articleintense response to the drug but is the most dangerous if the drug or the needle is contaminated.
- Subcutaneous injection. Known by the slang term skin popping, subcutaneous injection of heroin is preferred by some users if their veins have become too scarred or fragile to use for intravenous injections.
- Vaporization. Heroin can be smoked when the user heats it in a glass tube or on a small piece of aluminum foil over a flame and inhales the drug's vapors, either directly or through the tube. Smoking heroin is known as chasing the dragon.
- Insufflation. Powdered heroin can be inhaled through a small tube into the nasal passages, where it is absorbed through the mucous membranes that line the nasal passages. Snorting is the slang term for this method of heroin use.
- Oral ingestion. This is one of the slowest methods of taking heroin, requiring at least half an hour before the user feels any effects. Heroin is converted into morphine in the stomach; the bioavailability of morphine from an oral dose of heroin is about twice that of orally ingested morphine.
- Suppository. Although using heroin in suppository form is relatively uncommon, some users employ an oral syringe containing heroin dissolved in water. The syringe is lubricated and inserted into the rectum or vagina before the plunger is pushed. The heroin is absorbed through the membranes lining the vaginal or rectal walls.Although not all routes of heroin administration lead to the euphoric “rush” that most users seek, heroin users can become addicted to the drug by any route.
Body packing or body pushing is a specific form of heroin abuse that involves transporting the drug in small packets either attached to the body under clothing or swallowed for later retrieval from the feces. Heroin may be sealed inside condoms, the fingers of rubber gloves, or balloons in order to make small packets that can be swallowed by the smuggler. There is a considerable risk of one or more of the packets rupturing inside the digestive tract and causing either intestinal obstruction or an overdose of heroin.
Once heroin reaches the brain through the bloodstream, it is converted back to morphine and binds to opioid receptors located in the areas of the brain that govern sensations of pain or pleasure. Heroin also binds to opioid receptors in the brainstem, the portion of the brain continuous with the spinal cord that governs such processes as breathing and blood pressure. The peak effects of heroin are generally reached within 10 minutes with intravenous injection; within 30 minutes with intramuscular injection or insufflation, and within 90 minutes when injected subcutaneously. The pain-relieving effects of heroin generally last for 3 to 5 hours.
According to the CDC, the following groups of people are at increased risk of heroin abuse:
- Those addicted to oxycodone or other opioid pain relievers; most people who abuse heroin abuse at least one other drug.
- Those addicted to cocaine.
- Those addicted to marijuana and alcohol.
- Males in any age group.
- People between the ages of 18 and 25.
- Non-Hispanic Caucasians.
- People who are uninsured or enrolled in Medicaid.
- People living in large metropolitan areas.
Causes and symptomsCauses
As of 2017, the cause of heroin abuse is considered to be about 50% genetic, with the remainder due to a combination of environmental factors. A person's beliefs and attitudes, along with exposure to a peer group that encourages drug use, play an important role in the initial decision to use heroin. After the person starts to use heroin, progression to dependence and addiction is thought to be influenced by genetic traits that may either delay or accelerate the development of addiction. An additional causal factor is the changes in the brain that result from taking heroin over a period of time. These changes include alterations in the brain's perception of pleasure; impairment of judgment and self-control; and an intense craving for the drug. The area of the brain that is most heavily affected by heroin and other opioids is the nucleus accumbens, a region in the forebrain near the hypothalamus. The nucleus accumbens plays an important role in motivation, pleasure, reward, and positive reinforcement, and thus is heavily involved in the process of drug dependence and addiction.
The symptoms of heroin abuse include those associated with intoxication, withdrawal, and overdose.
INTOXICATION. Heroin abuse produces both shortterm and long-term symptoms of intoxication. Short-term symptoms of heroin use include:
- The initial “rush” or “high”: A feeling of euphoria that may develop within 2–3 minutes of an intra venous injection of heroin.Page 1723 | Top of Article
- Warm flushing sensation in the skin.
- Dry mouth.
- A sense of heaviness or weakness in the arms and legs.
- Slowing-down of mental processes.
- Alternating wakefulness and drowsiness; the drowsiness is sometimes called “going on the nod.”
- Respiratory depression (slow and shallow breathing).
- Miosis: constricted (pinpoint) pupils.
- Nausea and vomiting.
The long-term effects of heroin abuse result not only from dependence on the drug but also from combining heroin with such other CNS depressants as alcohol and benzodiazepines, or taking it in combination with cocaine, a practice known as speedballing. Intravenous injection of heroin is particularly dangerous because of the risks of using impure heroin or contaminated needles. Some common long-term effects of heroin abuse include:
- Skin abscesses; these often result from subcutaneous injection or skin popping.
- Collapsed veins.
- Endocarditis (inflammation of the valves and lining of the heart).
- Viral infections, including HIV and hepatitis C.
- Viral or bacterial pneumonia.
- Decreased liver function.
- Miscarriage of a pregnancy.
- Permanent damage to the lungs, kidneys, liver, or other organs from heavy metals and other toxic impurities contained in street heroin.
WITHDRAWAL. People who use heroin almost always become dependent on the drug, as repeated exposure to the drug results in an increase (upregulation) of opioid receptors in the brain, spinal cord, and digestive tract. The user requires larger and larger doses of heroin to obtain the same pleasurable effect, and will experience withdrawal symptoms if she or he discontinues use of the drug. Withdrawal symptoms begin between 6 and 24 hours after the last dose of heroin, and typically include:
- A general feeling of discomfort and uneasiness (malaise), anxiety, and depression.
- Cold sweating, shivering, piloerection (“goose bumps”).
- Yawning, sneezing, rhinorrhea (runny nose), teary or watery eyes.
- Nausea, vomiting, diarrhea, abdominal cramping.
- Insomnia and akathisia (restlessness, pacing, inability to keep still).
- Severe muscle aches and pains, involuntary cramping sensations in the legs.
- Priapism (long-lasting erection) in men, unusual sensitivity of the genitals in women.
- Intense craving for the drug.
OVERDOSE. The median lethal dose of heroin is estimated to be between 75 mg and 375 mg for a person weighing 165 pounds who is opioid-naive (unused to opioids). People who abuse heroin often start out with low doses, between 5 and 20 mg per dose, but quickly escalate; a Swiss study reported that when heroin users with a high tolerance for the drug were offered unlimited quantities of heroin, they generally used between 300 mg and 500 mg per day. Other sources state that the average heroin abuser uses between 150 mg and 250 mg per day.
Because there is a small margin between the dose that people who abuse heroin require after they have developed tolerance to the drug and a lethal dose, heroin abusers can easily overdose on the drug in one of several ways: 1) they have obtained a sample of heroin that is purer than what they normally use and are thus ingesting a larger than normal quantity of the drug; 2) they are taking heroin together with another CNS depressant like alcohol, another opioid, or a benzodiazepine; 3) their heroin has been cut with fentanyl or another strong opioid; 4) they have developed a decreased tolerance for heroin as a result of a period of abstinence. The symptoms of heroin overdose are as follows:
- Respiratory: slow, shallow breathing or no breathing at all.
- Cardiovascular: low blood pressure, weak pulse.
- Oral cavity: discolored tongue, dry mouth.
- Eyes: miosis (pinpoint pupils).
- Skin: cyanotic (bluish) lips and nails.
- Digestive system: constipation, abdominal cramps.
- Nervous system: disorientation, delirium, uncontrolled movements, extreme drowsiness, coma.
Many first responders as well as emergency medical personnel are trained to recognize the symptoms of a heroin overdose, particularly coma, respiratory depression (shallow breathing), and miosis. Although there are other drugs that can cause similar symptoms, this triad is about 76% specific for heroin.
The symptom profile may be different when the overdose results from the rupture of drug-filled packets in a body pusher. The initial symptoms may be intestinal blockage or bowel rupture, although the person may also have the symptoms of a severe heroin overdose and fail to respond to a standard dose of naloxone. Body packing Page 1724 | Top of Articleshould be suspected in persons who are found unconscious at airports or on international flights.
People suspected of a heroin overdose may have telltale needle puncture marks on the arms as well as the other symptoms of an overdose. In addition, the patient's airway is checked at once to make sure that it is clear; many overdose victims die from choking on their own vomit rather than from respiratory depression.
The patient is given intravenous fluids and his or her vital signs are monitored until the healthcare provider is certain that heroin and all other opioids have been cleared from the system.
Blood and urine tests can be used to monitor heroin abusers; to confirm the diagnosis of heroin overdose or intoxication; to test for the presence of other drugs that may have been combined with heroin; or as part of a medicolegal investigation of a death. The major metabolites of heroin—6-monoacetylmorphine (6-MAM), morphine, morphine-3glucuronide, and morphine-6-glucuronide, can all be detected in blood and urine.
X-rays or other imaging tests may be ordered if the doctor suspects the patient's lungs are full of fluid or otherwise damaged, or if the patient has the symptoms of a rupture related to body packing.
Emergency treatment of a heroin overdose involves administration of naloxone (Narcan), a drug that reverses the effects of heroin or other opioids and brings about an immediate return to consciousness. It can be given intravenously, intramuscularly, or intranasally, and is now included in emergency response kits given to firefighters, police officers, and other rescue personnel. The emergency medical technician or other healthcare provider may need to give repeated doses of naloxone until the full dose of heroin has been metabolized by the body. Naloxone often produces withdrawal symptoms, however, and the patient should be supervised by a healthcare provider. In 2014, the FDA approved a Page 1725 | Top of Articlehandheld naloxone autoinjector (Evzio) for use in the home by family members of an at-risk heroin abuser. As of 2017, 35 of the 50 states permit people to purchase naloxone over the counter from a registered pharmacist without a prescription.
Long-term treatment for heroin abuse usually combines medication-assisted treatments (MATs) with psychosocial therapies. The most effective treatment is highly individualized. Patients may be treated in a variety of different settings, ranging from methadone clinics and therapists’ offices to outpatient support groups and shortor long-term rehabilitation programs.
The drugs most often used in treating heroin abuse are methadone; buprenorphine; or buprenorphine combined with naloxone. The American Psychiatric Association (APA) recommends the following treatment strategies:
- Using methadone (Dolophine) or buprenorphine (Subutex, Cizdol) as a substitute for the heroin, followed by gradually tapering the dose of the substitute. Methadone and buprenorphine work by binding to the same opioid receptors in the brain as heroin but binding more weakly, reducing the patient's cravings and withdrawal symptoms.
- Discontinuing heroin abruptly while using clonidine (Catapres, Nexiclon) to treat withdrawal symptoms.
- Detoxifying the patient with a combination of clonidine and naltrexone (Revia, Vivitrol). Naltrexone blocks the opioid receptors and prevents heroin or other opioids from having an effect on the patient's system.
According to the APA, the psychosocial interventions most often used to treat heroin abusers are as follows:
- Cognitive behavioral therapy, which typically includes social skills training and relapse prevention.
- Psychodynamic therapy and interpersonal therapy.
- Group therapy.
- Family therapy.
- Contingency management, which is the use of stimulus control and positive reinforcement—typically vouchers or small amounts of cash—to change the patient's behavior.
The prognosis of heroin abusers varies with age group. In general, people who begin using heroin as teenagers are at greatest risk of an eventual fatal overdose, with the highest rate of death from heroin overdose occurring in young adults between the ages of 25 and 34. Other factors that indicate a worse prognosis are the use of alcohol and other drugs in combination with heroin; the presence of toxic substances (including heavy metals) or bacterial contaminants in the heroin; and the presence of traumatic injuries, disorders of the central nervous system, or other chronic health problems in the patient.
The prognosis for sustained recovery from heroin abuse is poor as of 2017. Relapse rates are high, even months or years after the user has stopped ingesting heroin and the withdrawal symptoms have long since disappeared. As of 2017, research indicates that there are four major factors that contribute to relapse:
- New stressors in the patient's life.
- Exposure to cues related to past drug use.
- Treatment with a drug with properties similar to those of heroin.
- Permanent changes in some of the brain's neurons brought about by long-term heroin use.
Healthcare team roles
People who abuse heroin require care from a wide variety of healthcare professionals. They may be treated by first responders at the scene of an overdose or by physicians and nurses in the emergency department of a hospital. After being treated with naloxone, between 3% and 7% of these patients must remain in the hospital for treatment of such complications as pneumonia, infections, and pulmonary edema (fluid accumulation in the lungs).
Patients receiving medication-assisted therapy are monitored by physicians and increasingly by advanced practice nurses. Those who are receiving cognitive behavioral therapy or other forms of psychotherapy are seen by psychiatrists and clinical psychologists.
Advanced practice nurses are playing an increasingly important role, alongside primary care physicians and public health specialists, in educating adolescents and the general public about the dangers of heroin use.
Prevention of heroin abuse is a complex task because of the many factors that have contributed to the present epidemic and because of heroin users' susceptibility to relapse. Current strategies include:
- Education of teenagers and young adults about the dangers of heroin, through school programs; government websites; government-sponsored documentaries at the state as well as federal level; and primary care doctors.
- Research into the genetic, pharmacological, social, and psychological factors that increase susceptibility to heroin abuse.
- Increased state monitoring of prescriptions for opioid medications.
- Revised models of treatment for chronic pain. Such professional organizations as the American Society of Interventional Pain Physicians are reviewing their standards for the use of opioids in treating chronic non-cancer pain in order to reduce the likelihood of prescription opioid abuse.
- Rulings on the part of the FDA in 2014 to limit the use of extended release and long-acting (ER/LA) opioids to patients requiring 24/7 pain management; and to reformulate opioid medications to make them difficult to crush, dissolve, or otherwise prepare for intravenous injection. The FDA has also added new boxed warnings and other changes to the precautions, drug interactions, and patient counseling information sections of the required labels for oxycodone, fentanyl, and other prescription opioids.
- Recommendations made by the CDC in 2016 intended to prevent overprescribing of opioid drugs. The primary recommendation states that opioids should not be firstline treatment for chronic pain; healthcare providers should prescribe non-opioid analgesics instead. Other CDC recommendations include prescribing immediaterelease as opposed to longer-acting opioids, and limiting treatment for acute pain to usually no more than 7 days.
Allen, John. The Dangers of Heroin. San diego, CA: ReferencePoint Press, 2017.
Horning, Nicole. Heroin: Killer Drug Epidemic. New York: Lucent Press, 2017.
Perritano, John. Opioids: Heroin, Oxycontin, and Painkillers. Broomall, PA: Mason Crest, 2017.
Quinones, Sam. Dreamland: The True Tale of America's Opiate Epidemic. New York: Bloomsbury Press, 2015.
Ali, M.M., et al. “Prescription Drug Monitoring Programs, Nonmedical Use of Prescription Drugs, and Heroin Use: Evidence from the National Survey of Drug Use and Health.” Addictive Behaviors 69 (June 2017): 65–77.
Kerensky, T., and A.Y. Walley. “Opioid Overdose Prevention and Naloxone Rescue Kits: What We Know and What We Don't Know.” Addiction Science and Clinical Practice 12 (January 7, 2017): 4.
Leahy, L.G. “The Opioid Epidemic: What Does It Mean for Nurses?” Journal of Psychosocial Nursing and Mental Health Services 55 (January 1, 2017): 18–23.
Manchikanti, L., et al. “Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines.” Pain Physician 20 (February 2017): S3–S92.
Morizio, K.M., et al. “Characterization and Management of Patients with Heroin versus Nonheroin Opioid Overdoses: Experience at an Academic Medical Center.” Pharmacotherapy, January 18, 2017 [E-publication ahead of print].
Pisano, V.D., et al. “The Association of Psychedelic Use and Opioid Use Disorders among Illicit Users in the United States.” Journal of Psychopharmacology, February 1, 2017 [E-publication ahead of print].
Rudd, R.A., et al. “Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014.” Morbidity and Mortality Weekly Report 64 (January 1, 2016): 1378–1382.
Tomassoni, A.J., et al. “Multiple Fentanyl Overdoses—New Haven, Connecticut, June 23, 2016.” Morbidity and Mortality Weekly Report 66 (February 3, 2017): 107–111.
Wickramatilake, S., et al. “How States Are Tackling the Opioid Crisis.” Public Health Reports, January 1, 2017 [E-publication ahead of print].
Wollman, S.C., et al. “Gray Matter Abnormalities in Opioiddependent Patients: A Neuroimaging Meta-analysis.” American Journal of Drug and Alcohol Abuse, November 3, 2016 [E-publication ahead of print].
Woody, G.E. “Advances in the Treatment of Opioid Use Disorders.” F1000Research 6 (January 27, 2017): 87.
Centers for Disease Control and Prevention (CDC). “Heroin.” https://www.cdc.gov/drugoverdose/opioids/heroin.html (accessed February 27, 2017).
Dixon, David W. “Opioid Abuse.” Medscape Reference. http://emedicine.medscape.com/article/287790-overview (accessed February 27, 2017).
Federal Bureau of Investigation (FBI) News. “Raising Awareness of Opioid Addiction.” This web page includes information about and links to a 45-minute documentary (titledChasing the Dragon) about opioid addiction among young people; it includes the perspectives of prosecutors and law enforcement about the problem of heroin abuse. https://www.fbi.gov/news/stories/raising-awareness-of-opioid-addiction (accessed February 27, 2017).
Habal, Rania. “Heroin Toxicity.” Medscape Reference. http://emedicine.medscape.com/article/166464-overview (accessed February 27, 2017).
National Institute on Drug Abuse (NIDA). “Heroin.” https://www.drugabuse.gov/publications/drugfacts/heroin (accessed February 27, 2017).
American Psychiatric Association (APA), 1000 Wilson Boulevard, Suite 1825, Arlington, VA, United States 22209-3901, (703) 907-7300, firstname.lastname@example.org, https://psychiatry.org/ .
Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, United States 30329, (800) CDC-INFO, CDC-INFO, http://www.cdc.gov/ .
Federal Bureau of Investigation (FBI) Headquarters, 935 Pennsylvania Avenue, NW, Washington, DC, United States 20535-0001, (202) 324-3000, https://www.fbi.gov/ .
National Institute on Drug Abuse (NIDA), 6001 Executive Boulevard, Room 5213, MSC 9561, Bethesda, MD, United States 20892-9561, (301) 443-1124, https://www.drug abuse.gov/about-nida/contact-nida, https://www.drugabuse.gov .
U.S. Food and Drug Administration (FDA), 10903 New Hampshire Avenue, Silver Spring, MD, United States 20993, (888) 463-6332, email@example.com, http://www.fda.gov/ .
Rebecca J. Frey, PhD