Heroin

DEFINITION: Heroin is a highly addictive opioid drug derived from the poppy plant. As an opiate, it functions as a central nervous system depressant similar to morphine, opium, methadone, and hydromorphone (Dilaudid).

CATEGORY: Substances

ALSO KNOWN AS: Big H; black; black tar heroin; boy; brown sugar; diacetylmorphine; diamorphine; dope; dragon; horse; junk; mud; skag; smack; snow; snowball; tar; white

STATUS: Illegal in the United States and worldwide

CLASSIFICATION: Schedule I controlled substance

SOURCE: A synthetic derivative of morphine, the most potent constituent of the opium poppy; formed by adding two acetyl groups to the morphine molecule; most of the illicit supply is smuggled into the United States from opium refinement sources in Southeast Asia, Afghanistan, and Mexico or is produced in illegal laboratories. Often cut with other substances, including synthetic opioids such as fentanyl.

TRANSMISSION ROUTE: Primarily exists in three forms: as a pure white bitter-tasting powder, an impure brown powder, and a black sticky substance called black tar heroin. Most street heroin is mixed or cut with other drugs, additives, and impurities, causing variations in color and potency. Heroin may be smoked, snorted, sniffed, or injected intravenously.

History of Use

Diacetylmorphine, later named heroin, was originally synthesized in 1874 in London by the English chemist C. R. Alder Wright. However, it was not until 1898 that Bayer Pharmaceutical Company of Germany commercially introduced heroin as a new pain remedy and nonaddictive substitute for morphine. During the next several decades, heroin was sold legally worldwide and aggressively marketed as a cough medicine and as a safer, more potent form of morphine.

By the early twentieth century, heroin's intense euphoric effects were fully recognized, leading to widespread misuse. Numerous restrictions on the production, use, sale, and distribution of heroin were established to help prevent further abuse. These restrictions included the Harrison Narcotics Act of 1914, the Dangerous Drug Act of 1920, and the Heroin Act of 1924. As a result, heroin consumption briefly declined, but illicit production and trafficking grew.

Over time heroin became one of the most sought after drugs in the world and, by 1970, the US Drug Enforcement Administration (DEA) classified it as a schedule I controlled narcotic. Class I drugs are those with a high abuse potential and no legitimate medical use. Heroin is considered one of the most dangerous and psychologically and physically addictive drugs available. It remains a serious health issue throughout the world.

Various methods have been used to gain heroin highs over the years, depending on user preference and drug purity. The most common and economical method of heroin use is injection, or "shooting up." Popular forms of shooting up include "mainlining" (injecting directly into a vein) and "skin-popping" (injecting directly into a muscle or under the skin).

Snorting and smoking heroin became popular as a result of the availability of higher quality heroin; the fear of contracting blood-borne illnesses, such HIV/AIDS and Hepatitis C, through needle sharing; and the erroneous belief that inhaling heroin would not lead to addiction. The best-known method of smoking heroin is nicknamed "chasing the dragon." Originating in the 1950s in Hong Kong, this method involves heating and liquefying the drug on tin foil and inhaling the vapors. Heroin is such a potent and addicting drug, however, that most users soon are forced to begin using the drug intravenously as their tolerance increases and greater amounts are needed to achieve a high and forestall the horrendous physical symptoms of withdrawal.

Some users crave an even greater high and engage in "speedballing" or "crisscrossing," which involves simultaneously injecting or snorting alternate lines of heroin and cocaine, respectively. Heroin users may also move on to even more powerful opioids, such as fentanyl, or consume such drugs unknowingly through illicit mixtures, increasing the risk of overdose.

Effects and Potential Risks

Heroin is a fast-acting opiate; it is three times more potent than morphine. It acts by depressing the central nervous system through an endorphin-like mechanism. Heroin rapidly crosses the blood-brain barrier because of its high lipid solubility. It is quickly metabolized into morphine and binds to the opioid receptors responsible not only for suppressing pain sensation and relieving anxiety but also for critical life processes.

The short-term effects of heroin are attributed to its properties as an opiate. These effects have made heroin one of the most desirable drugs in the world. Heroin produces a warm surge of pleasure and euphoria referred to as a rush. This rush is followed by feelings of peacefulness, well-being, contentment, and physical relaxation. Users alternate between wakeful and drowsy states, a condition commonly referred to as "nodding" since the user will be awake one moment then will fall asleep the next. At this point the user's neck relaxes and the chin drops down toward the chest, which in turn wakes the user enough to lift the head back up. This action of nodding the head up and down continues, with the user seemingly unaware it is occurring.

While high on heroin, the user will also experience little sensitivity to pain. Minor, negative, short-term effects of heroin use include nausea, vomiting, constipation, severe itching, dry mouth, difficulty urinating, heavy extremities, impaired mental functioning, and constricted, pin-point pupils. Nonpleasurable sensations, such as severe irritability, irrational anger, and depression, can occur as the high dissipates.

The most serious and most common side effect of heroin use is overdose, which is a result of respiratory depression and is fatal unless an opioid antagonist such as Narcan (naloxone) is administered. Narcan, which is dispensed nasally as a spray or injected intramuscularly, reverses the overdose by removing the opioids from the opiate receptors in the brain. This will then send the user into immediate withdrawal, which is painful but not life-threatening. Because the half-life of Narcan is much shorter than that of heroin, it is critical that the revived, overdosing user be medically monitored after administering Narcan since the potential for a recurrence of respiratory depression is possible.

The most immediate and intense heroin rush is achieved by intravenous injection. However, this transmission route also has the most dangerous potential side-effects. The risk of contracting infectious diseases such as human immunodeficiency virus (HIV) and hepatitis viruses is substantial. Furthermore, illegal street heroin is contaminated with unknown additives and impurities such as sugar, starch, and poisons, which can cause blood vessel inflammation, blockage, and permanent damage. In the 2010s, the United States saw a rise in heroin laced (or "cut") with the synthetic opioid fentanyl. Fentanyl, which was first developed in the 1960s and used as an effective palliative care medication for cancer treatment, is eighty to one hundred times more potent than morphine. Once mixed with heroin, it is often fatal since the user is sent into immediate respiratory distress, and unless Narcan is administered within minutes, irreversible brain damage and/or death occurs. By the 2020s fentanyl had become the leading cause of overdose deaths in the US; 75 percent of overdose deaths in 2021 involved opioids other than heroin, primarily fentanyl.

Long-term heroin use can lead to adverse physical effects, including collapsed veins, heart and skin infections, liver and kidney disease, and pulmonary complications. Continuous heroin use may affect brain functioning as a result of repeated respiratory suppression and lack of oxygen. However, the most detrimental long-term effect of heroin use is physical and psychological dependence and addiction, which can occur as quickly as after using heroin for the first time; users soon crave larger and larger doses of the drug to achieve the original high and to keep from experiencing the painful physical effects of withdrawal.

Heroin abuse is a problem that affects people across the world at every socioeconomic and education level. Afghanistan is the world leading producer of the opium poppies used to make heroin. Opiate use is prevalent in much of the Middle East as a result, but is also a significant problem in Western nations including the United States. In 2016 the National Survey on Drug Use and Health (NSDUH) found that an estimated 948,000 people in the United States had used heroin in the past year, with about 170,000 of those being new users. These figures represented sharp increases over a decade, although use among adolescents decreased during that period. The 2021 NSDUH found that roughly 1.1 million people, or .4 percent of the US population, had used heroin in the last year, with 1 million of these users reporting having a heroin use disorder that year.

Heroin and the Opioid Epidemic

The increase in heroin use in the United States in the 2010s was tied to a general rise in substance abuse and corresponding overdose deaths that became widely known as the opioid crisis. The trend was recognized as an epidemic by the administration of President Barack Obama and many local agencies and officials. In 2017 the US Department of Health and Human Services (HHS) declared the crisis a public health emergency. This declaration remained active in subsequent years and was renewed in 2022.

The opioid crisis was linked to an increase in the use of prescription painkillers beginning in the late twentieth century. The US Food and Drug Administration (FDA) approved the opioid pain medication Oxycontin in December 1995. Its manufacturer, Connecticut-based Purdue Pharma, which was owned by the Sackler family, characterized the drug as "abuse resistant" and marketed it heavily to physicians nationwide. From 1999 to 2010, the sale of prescription painkillers quadrupled in the United States. Many patients, as well as those using prescription drugs recreationally, ended up developing dependencies on the medications, which are chemically similar to heroin. People with addictions to opioid painkillers who are unable to refill prescriptions often turn to illicit sources to fulfill cravings. Because heroin is a fraction of the cost of illegal pain medication, individuals who first become addicted to prescribed opiate medication will often turn to heroin. According to the American Society of Addiction Medicine, four in five heroin users were first addicted to prescribed painkillers. Purdue Pharma plead guilty to criminal charges in 2007 and 2020 related to their activities; the company, along with the Sackler family, also faced lawsuits seeking billions of dollars in settlements from dozens of US states attorneys general. While Purdue Pharma eventually reached an $8 billion settlement which would allow the Sackler family to avoid further liability and allow various plaintiffs, including individuals as well as governments, to collect damages, in June 2024 the US Supreme Court rejected this settlement.

The rate of deaths from heroin overdose quadrupled in the United States from 2000 to 2013, with a 67 percent increase in heroin-related overdoses during the 2010–13 time period. The Substance Abuse and Mental Health Services Administration (SAMHSA) noted a 51 percent increase in the number of heroin users in the Untied States between 2013 and 2014 alone, despite double the seizure amounts of heroin by law enforcement between 2010 and 2014. In 2018 a HHS report on the opioid epidemic estimated there were 886,000 heroin users in the United States, with 15,482 deaths attributed to heroin overdose. In 2021 the US experienced 16,706 opioid overdose deaths, a slight increase over 2020 and a significant increase over 2019. Thousands of these deaths were attributed to fentanyl and other synthetic opioids.

In 2023 the US experienced over 81,000 opioid-related deaths, which represented a slight decrease over the previous year and the first time since 2018 that annual opioid deaths in the US decreased instead of increased.

The broad scope of the opioid epidemic shifted the demographics of US heroin users. While the drug was traditionally associated with urban environments and lower-income people, public health experts noted that these stereotypes did not hold up in the 2010s and 2020s. While large cities continued to see drug use, suburban and rural areas also saw considerable increases in heroin overdoses and deaths. Addiction counselors and advocacy organizations emphasized the fact that people with heroin use disorder came from all walks of life.

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