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Heroin

The Bottom Line

Heroin, an addictive, illegal drug, can cause fatal overdoses. It is an opioid, a class of drugs that includes morphine, codeine, oxycodone, and hydrocodone, among others. Heroin use is increasing due to tighter controls on prescription opioids. Naloxone is the antidote for an acute overdose. Withdrawal should be medically supervised.

The Full Story

Since ancient times, opium was the world's leading pain reliever. It is prepared from the opium poppy, Papaver somniferum. Heroin is a drug developed in the 19th century to mimic the pain-relieving effects of opium and morphine, which was derived from opium.

Opium, morphine, and related drugs are highly addictive and can cause euphoria, or a "high". Heroin was promoted as a medicine that was preferred to opium and morphine because it was:

  • more pure than opium, which is plant based;
  • more precisely dosed than opium;
  • faster-acting and less addictive than morphine;
  • more potent than codeine, which also is derived from opium.

Heroin rapidly became the drug of choice to treat common and painful respiratory conditions. Pneumonia and tuberculosis could not be cured. Heroin was often prescribed to relieve cough and pain and for sedation, even as its addictive properties became well-known.

Heroin also was included in non-prescription (patent) medicines for a range of real or imagined ailments. (The same was true of opium and cocaine.) The first federal regulation of heroin in the U.S. occurred in 1914 when President Wilson signed the Harrison Narcotic Act. (Note that, while heroin use is illegal in the U.S., it is legal for medical uses in some other countries.)

Abuse of heroin continued, though now it was illegal. And, abuse of heroin has continued since then.

Opioids: Heroin belongs to the class of drugs called "opioids". Some terminology can help.

  • Opium is produced from plant material which is physically scraped from the pods of the poppy plants.
  • Products that are based on the crude opium plant but have been chemically altered are often called opiates. Morphine and codeine are opiates.
  • Pain medications that are manufactured in a lab to simulate opiates are opioids. There are many, including oxycodone and hydrocodone.

In practice, the entire class of pain medications is simply referred to as opioids.  Heroin is considered to be an opioid, even though it is no longer used for medicinal purposes in the U.S.

Different opioids have their own specific effects, but there are general positive and negative effects associated with the class as a whole.

  • The positive effects of opioids are decreased pain perception, a sense of euphoria, and cough suppression.
  • The negative effects include significant addiction potential, depressed breathing, sedation, low heart rate, low blood pressure, and constipation.

Heroin in the community: Heroin makes its way into the United States primarily from China, India, Afghanistan and Mexico. It enters and is transported via mail services, boats, trucks, and buses. There is simply not enough manpower to catch all of the product coming in and being distributed. It is estimated that for every 1 package seized, about 10 more make it through.

In order to drive up profit margins, the pure heroin is diluted, or "cut", many times through the distribution chain. The product begins as 100% heroin, but what is sold on the street contains a varying but small percentage of heroin. Sometimes the added ingredients make the end product weaker, e.g. quinine, mannitol, acetaminophen, sugar or caffeine (to name a few). Other contaminants make the end product stronger, for example fentanyl.

Most often, heroin is abused by injection because that yields the fastest effects. Sometimes, heroin is "snorted", or inhaled into the nose, to get a fairly rapid high without having to inject the drug. Heroin is sometimes smoked, as well.

Some people believe that heroin is just as safe as other opioids, because it is metabolized to morphine, but that is not true. Illicit drugs are not regulated. Heroin production is not overseen by the FDA. Overdoses can occur in people who have been using heroin for a long time.

In the past few years, heroin tainted with fentanyl has been implicated in deaths. Fentanyl is a chemically-derived opioid that is used for treating severe pain in patients who are tolerant to other opioids, such as cancer patients. It is much stronger than heroin, and does not come in an injectable form. The fentanyl found in tainted heroin was determined to have been produced in illicit labs.

Over time, heroin users have suffered countless toxic effects from contaminants and countless infectious diseases from unsanitary injections, ranging from skin infections to hepatitis to HIV/AIDS.

Rise in heroin use: After a period of declining heroin use, there has been a significant rise in heroin overdoses for the past six to eight years. The death rate from heroin overdoses doubled from 2010 to 2012. Men between the ages of 25 to 34 were at the highest risk for fatal heroin overdoses.

This rise in heroin use might be correlated with a recent slight decline in prescription opioid abuse. The Centers for Disease Control (CDC) interviewed a group of people who began abusing heroin after 2000. They reported that "heroin is more readily accessible, less expensive, and offers a more potent high than prescription opioids".

A number of reasons have been proposed for the [so-far slight] decline in prescription opioid abuse, and thus the increase in heroin abuse and deaths.

  • New drug monitoring programs have been successful in tracking opioid use in patients, so that it is harder to "shop" for doctors who will write a new prescription for opioids.
  • Many emergency rooms have developed policies prohibiting physicians from prescribing long-acting opioids. Prescriptions for opioids will provide for only a few days of use.
  • In October 2014, hydrocodone, an opioid combined with acetaminophen in the drug Vicodin®, became a Schedule II drug, instead of a Schedule III.  Like Percocet®, Vicodin® and generic equivalents now can be prescribed in limited quantities only. People who are addicted to opioids are pressed to find other sources and they may turn to heroin as a replacement opioid.
  • The price of prescription opioids is relatively high compared to heroin. Prices vary greatly depending on the region but here is one example.
    • In Washington, DC, one gram (one thousand milligrams) of multi-dose heroin reportedly costs $80-$120 (or 8 to 12 cents per milligram) for higher quality products, though versions with more impurities, such as black tar heroin, cost less.
    • In contrast, oxycodone, the opioid found in Percocet® and the long-acting opioid OxyContin®, sells for about $1 per milligram of drug. People addicted to prescription opioids may require several 80 mg pills per day.

Heroin overdose: An overdose of heroin and other opioids can be life-threatening or fatal. Breathing is suppressed to the point that oxygen does not reach the brain, lungs, and other body organs. Coma and death may follow. Other signs of a heroin overdose include tiny (pinpoint) pupils and frothy secretions from the mouth.

Treatment of heroin overdose: Naloxone is the antidote for overdoses of heroin and other opioids; Narcan® is a brand name. For decades, naloxone has been used safely by emergency physicians and emergency medical personnel. It quickly reverses the dangerously slow breathing that leads to death after opioid overdoses. Naloxone is given by injection or by spraying it into the patient's nose.

Because naloxone is so safe and so easy to give, some states allow non-medical people to give naloxone to others after an opioid overdose. After receiving training, people who live with or spend time with opioid users are allowed to keep naloxone on hand, ready to administer quickly if needed.

If someone collapses, is having trouble breathing, or is having seizures, always call 911 right away. That is true for a heroin overdose or any other medical condition. Turn the person onto the left side; that way, if the person vomits, it is less likely that material will be inhaled down into the lungs. If naloxone is available, give it right away.

Treatment of opioid addiction: Someone addicted to heroin or other opioids will have withdrawal symptoms if they stop using drugs. Many or most will require medical assistance to withdraw safely. Effects of withdrawing from opioids may range from skin sensations and stomach disturbances to seizures, thus the need for medical supervision.

Withdrawal from opioids may require the use of other drugs, even other narcotic drugs such as methadone or buprenorphine. Continued abstinence may require maintenance therapy on these drugs, professional therapy, and family and peer support.

Sources of assistance vary by community and by state.

For questions about medicines or a possible overdose: Poison Control can answer questions about medicines and their effects. Use the webPOISONCONTROL® online tool for guidance or call Poison Control at 1-800-222-1222 in case of possible poisoning. Both are available 24 hours a day.

Pela Soto, PharmD, BSHS, BS
Certified Specialist in Poison Information

Rose Ann Gould Soloway, RN, BSN, MSEd, DABAT emerita
Clinical Toxicologist


For More Information

National Institute of Drug Abuse; National Institutes of Health. Heroin [Internet]. Bethesda (MD). 2014 February [accessed 2014 Sept 26]

Substance Abuse and Mental Health Services Administration


References

Department of Justice. Justice News; Attorney General Holder, Calling Rise in Heroin Overdoses ‘Urgent Public Health Crisis, ‘ Vows Mix of Enforcement, Treatment [Internet]. 2014 March 10. [accessed 2014 Sep 26]

Scott I.  Heroin: A Hundred-Year Habit. History Today [Internet]. 1988 June [cited 2014 Sept 26]; Volume 48 Issue 6.  

Nelson LS, Olsen O. Opioids. In Nelson LS, Lewin NA, Howland M, Hoffman R, Goldfrank L, Flomenbaum N. Goldfrank’s Toxicologic Emergencies. 9th ed. Philadelphia: The McGraw-Hill Companies, 2006. pp.559-85.

Frieden, Thomas. Keynote Symposium: The Prescription Opioid Abuse Epidemic.  Presented at: North American Congress of Clinical Toxicology 2013 Conference.  2013 Sept 27-Oct 2. Atlanta, GA. Accessed via Prolibraries.com [accessed 2014 Sept 26].

Bi-Monthly Heroin Working Group, FBI Washington Field Office and Washington Regional Threat Analysis Center. 2014 Aug 14. Washington, DC.

Rudd R, Paulozzi L, Bauer M et al. Increases in Heroin Overdose Deaths - 28 States, 2010-2011. MMWR. 2014;63(39):849-854.

Poisoned?

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Prevention Tips

  • Abusing opioids can be life-threatening, whether they are legal or illegal.
  • If someone overdoses on heroin, call 911 immediately and place the person on the left side.
  • If people you know abuse heroin, find out if naloxone is available to non-medical people in your community.

This Really Happened

An emergency physician called Poison Control to discuss a heroin overdose. A 42-year-old woman with a history of heroin addiction had been "shooting up". She became unresponsive, with shallow breathing. A friend called 911.

The ambulance arrived on the scene and the paramedics administered naloxone, a specific antidote that can quickly reverse the effects of opioids. The patient woke up, her breathing improved, and she was transported to the hospital.

At the hospital, the patient was awake and alert. Her urine drug screen tested positive for benzodiazepines and opiates.

Poison Control recommended the patient be watched for 4 hours from the time that the antidote was given. Depending on which opioid was used, the antidote can sometimes wear off before the opioid does, although that's not likely with heroin.

Several hours later, the patient was sent home.