What is Heroin?

Heroin is an illegal, highly addictive drug. It is both the most abused and the most rapidly acting of the opiates. 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 processed from morphine, a naturally occurring substance extracted from the seed pod of the Asian poppy plant. Heroin usually appears as a white or brown powder. Street names associated with heroin include "smack," "H," "skag," and "junk." Other names may refer to types of heroin produced in a specific geographical area, such as "Mexican black tar."

What is the scope of heroin use in the United States?

According to the 2003 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 121,000 to 164,000 new heroin users in 2002, 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 18 or older (on the average 75 percent) and most were male (on average 63 percent).

During the 1990s, a number of national surveys showed that younger and wider segments of the population were abusing heroin. New drug trafficking patterns, increased purity, and decreased price may all have contributed to the increasing use of heroin.

Heroin was the leading illicit drug among treatment admissions in 2000, reported by 15 percent of the 1.6 million substance abuse treatment admissions in the Treatment Episode Data Set (TEDS). Between 1992 and 2000, heroin admissions to substance abuse treatment facilities increased by 44 percent, from 168,000 to 243,000. During this time, the number of admissions for new heroin users (those admitted to treatment within 3 years of first using heroin) increased by 52 percent, from 24,000 to 36,000, peaking at 44,000 in 1998. This report uses data from TEDS to examine new heroin users from 1992 to 2000.

Primary Substance of Abuse

In 2002, heroin was reported as the primary substance of abuse for 15% of the 1.9 million admissions in SAMHSA's Treatment Episode Data Set (TEDS).

Figure 1. All Heroin Admissions and New Heroin Admissions: 1992-2000

Community Epidemiology Work Group (CEWG)

CEWG reported that the availability of low-priced, high-quality heroin continues to increase, especially in the East and some areas of the Midwest. This increase has also been reported in some cities that previously had escaped the influx of high-quality heroin.

Quantitative indicators and field reports continue to suggest an increasing incidence of new users (snorters) in the younger age groups, often among women. One concern is that young heroin snorters may shift to needle injecting, because of increased tolerance, nasal soreness, or declining or unreliable purity. Injection use would place them at increased risk of contracting HIV/AIDS.

In some areas, such as Boston and San Francisco, the recent initiates increasingly include members of the middle class. In Newark, heroin users are usually found in suburban populations.

How is Heroin used?

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.

Route of Administration Among Heroin Treatment Admissions in Selected Areas

Source: Community Epidemiology Work Group, NIDA, June 1996

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.

What are the immediate (short-term) effects of heroin use?

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.

Short-term effects of heroin

• "Rush"
• Depressed respiration
• Clouded mental functioning
• Nausea and vomiting
• Suppression of pain
• Spontaneous abortion

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.

What are the long-term effects of heroin use?

One of the most detrimental long-term effects of heroin is addiction itself. Addiction is a chronic, relapsing condition, 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.

Long-term effects of heroin

• Addiction
• Infections diseases, i.e., HIV/AIDS - hepatitis B & C
• Collapsed veins
• Bacterial infections
• Abscesses
• Infection of heart lining and valves
• Arthritis and other rheumatic problems

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.

What are the medical complications of chronic heroin use?

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 rheumatic 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 children.

How does heroin abuse affect pregnant women?

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 relatively benign.

Why are heroin users at special risk for contracting HIV/AIDS and hepatitis B and C?

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.