Heroin is one of many synthetic opiates derived from morphine, which was the first synthetic opioid from the opium poppy. Like other related illicit substances, it acts rapidly on the brain, creating a sense of sedation that has been very addictive for millions of people.
The Drug Enforcement Administration (DEA) has put heroin on the Schedule I list under the Controlled Substances Act (CSA), meaning that heroin has no legitimate medical use and is completely unsafe because it is so potent and addictive. Other opioid drugs, including morphine, oxycodone, fentanyl, and hydrocodone, are Schedule II because they may still be used as tightly controlled prescription drugs in some instances.
Although the drug is illegal in the U.S. now, it was originally developed as a prescription painkiller, intended to have greater effectiveness and less addictive potential than morphine.
A Problematic History
Heroin is processed from morphine, the original synthetic opiate. It is primarily a white powder mainly imported from South America, or a brownish or black powder, which is mainly imported from Central America and known as “black tar heroin.”
In many places, white powder heroin is becoming more common. The purity is higher as different places illicitly import the drug into the U.S., and drug dealers mix other substances into heroin or sell them in its place. Fentanyl is the current synthetic opioid most often sold instead of it or mixed with it.
Since this substance is about 80 times more potent than heroin alone, accidental fentanyl overdose has been the leading cause of opioid overdose deaths in the past several years.
Heroin has been a very addictive and widely abused substance almost since its beginning. Widespread overprescribing of morphine and opium powders in the mid and late 19th centuries led to a similar epidemic of opioid addictions and overdoses, with a reported 1 in 200 Americans abusing opiates. Like the modern opioid abuse epidemic, the main demographic struggling with addiction was upper-class and middle-class white American adults.
By the end of the 19th century, however, doctors began turning away from narcotic prescriptions, and both states and the federal government created laws regulating drugs, especially opium-based substances. As laws were passed criminalizing opium abuse, including heroin abuse, at the beginning of the 20th century, fewer older, affluent white adults in the U.S. abused the drug, but more young men — primarily Caucasian, Chinese, and immigrant youth — were found to abuse the cheaper illicit drug in opium dens.
Finally, the Harrison Narcotic Act was passed in 1914, making heroin illegal in the U.S. for the first time. The act tightened regulations of opioid drugs so much that many other drugs like morphine were effectively banned, although they could still be prescribed.
The second wave of heroin and opioid addiction and abuse came about during the Vietnam War when traumatized soldiers returned from some of the toughest, most violent battles in American history with co-occurring heroin addiction. While these soldiers returned home in the late 1960s and early 1970s, their addiction to opioids began with prescription drugs and turned into heroin abuse.
The National Institute on Drug Abuse (NIDA) states that about 80 percent of people suffering from heroin addiction in the 1960s began with prescription narcotics. This led to the drug being placed in Schedule I when the CSA was passed. The increase in veterans with mental health disorders and addiction led to the proliferation of methadone clinics as an approach to stabilizing people struggling with heroin addiction and to the Nixon-era War on Drugs.
The current epidemic of heroin abuse has, like the other two waves of addiction, stemmed from overprescribing of opioid painkillers. Between 75 and 80 percent of people between 2008 and 2009 reported that they developed an addiction to a prescription painkiller they were given, which then turned to heroin abuse when they could no longer acquire prescription narcotics.
Purdue Pharmaceuticals faces lawsuits from six states in the U.S. because of their role in developing OxyContin, one of the most addictive and widely abused prescription painkillers that were overprescribed after its approval in 1996.
The U.S.Centers for Disease Control and Prevention (CDC) reports a steep rise in opioid-related overdose deaths since 1999, with 350,000 people dying between then and 2016 due to an overdose of opioids. These overdoses have increasingly involved heroin since 2010.
The CDC reported that 15,469 people died from a heroin overdose in 2016 alone. The organization also reported that most people who abuse it abuse at least one other drug. As of 2018, there are an estimated 175 people in the U.S. who die every day due to an overdose.
Heroin is one of the riskiest opioid narcotic drugs. Not only does it lead to a fast and intense high but the body also quickly develops a dependence on the substance and a tolerance to it. Compulsive behaviors associated with addiction start soon after the first dose of heroin is consumed.
Signs of Heroin Addiction
While more people are snorting the powdered forms of heroin, the drug is still most commonly mixed with water or alcohol and injected intravenously. Some people also mix heroin with tobacco or marijuana. Some just roll it up in rolling paper or put it in a pipe to smoke. Much more rarely, it can be eaten.
Injecting the drug leads to the fastest high, which lasts less than 30 minutes. Smoking and snorting also cause fast highs that last for less than an hour, while eating it may lead to the drug’s effects lasting over an hour.
Because heroin binds to opioid receptors in the brain quickly, it is metabolized quickly out of the body. As a result, people who abuse it are at risk of bingeing this drug. Although the euphoric, relaxing high from abusing this narcotic does not last for very long, other effects like respiratory depression, sleepiness, and changes to heart rate and blood pressure can last for several hours. Overlapping doses of heroin to stay high on the drug is very dangerous and can lead to an overdose.
Sometimes, people who abuse heroin will try to quit on their own via a cold-turkey detox process. They may be unable to do so because the withdrawal symptoms are uncomfortable. This may also lead to an overdose when the individual relapses back into substance abuse and takes too much of it.
There are several potential warning signs to identify if a loved one may suffer from an addiction to heroin.
- Drug paraphernalia like a pipe, hypodermic needles, etc
- Changes in sleep patterns, behaviors, personal appearance/hygiene
- Suffering from financial difficulties
- Track marks on the arms or near other veins, coughing fits, consistent fatigue
- Stealing money or drugs, or lying about taking drugs
- Becoming more reclusive
- Failing to meet personal obligations
- Appearing intoxicated a lot of the time
Health Problems From Heroin Abuse
There are several side effects associated with heroin abuse. Short-term, the drug can lead to various problems:
- Dry mouth
- Warm, flushed skin
- Arms and legs feeling heavy
- Stomach upset, nausea, and vomiting
- Trouble thinking clearly and remembering things
- Stumbling when walking
- Going “on the nod,” or “nodding,” which is falling unconscious then waking up rapidly several times
There are many long-term negative side effects as well:
- Insomnia or sleep disorders
- Chronic constipation
- Trouble breathing
- Low blood pressure
- Changes to heart rate, especially slower heart rate
- Kidney damage from oxygen deprivation
- Muscle weakness
- Liver damage
- Infections, including heart or lung infections
- Viral infections like HIV or hepatitis B or C due to needle sharing
Tolerance, dependence, and addiction are also long-term effects associated with most drug abuse, especially the abuse of heroin. One of the signs of addiction, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is attempting to stop abusing the drug (often without social support or medical oversight) and failing, leading to relapse back into substance abuse. This is usually because withdrawal symptoms are uncomfortable, especially emotionally and psychologically. Without help, most people relapse to stop feeling discomfort, mood swings, and cravings.
Withdrawal from heroin is not life-threatening, but symptoms occur in two basic stages, so it may feel like the symptoms continue for a long time. Heroin withdrawal, without tapering or medication-assisted treatment (MAT), usually lasts 10 days or less.
Early withdrawal symptoms include:
- Muscle aches
- Runny nose
- Watery eyes
- Excessive sweating
- Trouble sleeping
- Yawning a lot
Essentially, the first several days of withdrawal will feel like having the flu. This will be paired with cravings for heroin. Later withdrawal symptoms include:
- Abdominal cramping
- Nausea and vomiting
- Dilated pupils and blurry vision
- Rapid heart and breathing rate
- Higher blood pressure
These symptoms will go away within three days after they start. The psychological and emotional effects of cravings, anxiety, depression, and worry may be disturbing. These effects are the reason, more than the physical symptoms, that medical supervision and social support are needed during the detox process and why therapy through rehabilitation is needed.
Symptoms of Heroin Overdose
If you try to stop abusing heroin without help from addiction specialists, you are at risk of relapsing back into drug abuse. Your body may have lost some of its tolerance to the drug, which means you are at a greater risk of overdosing on heroin. Opioid overdoses are very dangerous because the primary effect of an opioid drug, aside from lowering pain, is to suppress breathing. If someone abuses a large enough dose, they will stop breathing and die.
Even if someone survives an opioid overdose, oxygen deprivation can damage their brain and body. All body systems are affected by a lack of oxygen. The breakdown of muscles can damage the kidneys, heart tissue can die, and blood can clot, among several other problems.
- Slow, irregular, shallow, or difficult breathing
- Cold, clammy, or blue-tinted skin
- Extreme confusion
- Stumbling as if intoxicated
- Low blood pressure and weak pulse
- Passing out
- Extremely small pupils
If someone is overdosing on heroin or another opioid, call 911 immediately so they can get emergency medical help.
Evidence-Based Approaches to Overcoming Abuse
If you struggle with heroin abuse, you must get help to safely detox from this drug as the first step in the recovery process. A physician at a detox program will assess you upon intake, and this assessment will include questions about how long you have struggled with abuse, how much you took regularly, if you abuse other drugs that may require detox assistance, and if you have any co-occurring physical or mental health conditions. Once the physician understands your baseline health, they can determine if you need MAT and how long your taper with these drugs should last.
There are two main drugs used in MAT.
This long-acting opioid agonist lasts for one to two days and binds to the opioid receptors in the brain, greatly reducing cravings and withdrawal symptoms in people who have abused heroin for a long time. Although methadone has been a popular treatment since the 1970s, it is only dispensed through specific clinics, so it is not convenient for many people who have struggled with opioid addiction for less time or who have fewer withdrawal symptoms. Methadone clinics were among the first approaches to treating opioid addiction in the U.S., and many provide counseling and other services.
Approved in 2002 by the Food and Drug Administration (FDA), buprenorphine is a partial opioid agonist that has been used in Europe as MAT for a few decades. In the U.S., buprenorphine is prescribed through a physician who has some additional training, but it is much more accessible than methadone. Treatment can be more flexible for those who want to end their heroin addiction.
While both of these medications are applied differently and involve different tapering schedules, the intention is that both will be tapered slowly until the person no longer needs any opioids in the body to feel normal and functional. Buprenorphine will likely involve a faster taper, but both drugs will have individual tapering schedules based on what your physician determines is appropriate for your detox process.
The benefit of MAT is that counseling can begin once you have been medically stabilized with a prescription drug. As you taper, you can learn to manage compulsive behaviors and stress differently. Some rehabilitation programs require you to be completely detoxed before you enter while others allow MAT during treatment. Regardless, the combination of detox and rehabilitation has been the most successful approach to help people overcome heroin addiction and other forms of opioid abuse