12 Things to Know About the Key Driver of the Ongoing Opioid Crisis
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More than 60,000 people in the U.S. use heroin every day or almost every day. Some researchers claim that the number of daily users could be as high as 1,000,000.1 The number of first-time users almost doubled from 90,000 in 2006 to 170,000 in 2016.2
The 2015 National Survey on Drug Use and Health suggests 807,000 people aged 18 or older reported using the drug.3
What Caused the Increase?
Many factors have fueled the rising incidence of abuse, addiction, and overdose. These include higher rates of opioid prescriptions, lower costs, and easy availability. Of these, the increasing number of opioid prescriptions is a major concern. This is because prescription opioid addiction causes a fortyfold increase in the risk of heroin addiction.4
In a 2014 survey, investigators asked 3000 heroin users “why they preferred heroin to other opioid drugs.” The answers revealed that:5
- Over 98% of participants preferred “heroin high” to highs form other opioid drugs 98% 98%
- 31.7% said injecting or inhaling heroin was easier than using other opioid drugs 31.7% 31.7%
- 94% preferred heroin due to its lower costs and easy availibility 94% 94%
What is Heroin?
Heroin (diacetylmorphine) is an opioid drug. Opioids are strong substances that act on the pain receptors of the brain. It is highly addictive and can cause fatal effects. Unlike prescription opioids such as hydrocodone (Vicodin) or oxycodone (OxyContin), heroin is illegal in most parts of the world.
Heroin does not occur naturally. It is prepared by refining the juice of opium poppy, which mainly contains morphine. The refining process converts morphine into the drug.
The pure drug is a white bitter-tasting powder. However, street heroin can greatly vary in color and consistency. Likewise, the color and consistency may vary depending on the source and the city of purchase. For example, in Philadelphia, heroin is usually white or light brown while the one you get in San Francisco appears like black tar. Mexican-sourced heroin can be either white/brown powder or sticky tar-like substance. The Colombian-sourced drug is usually white.6
Illicit drug traders often mix (cut) pure heroin with other substances. For example, sugar, starch, quinine, or even poisons like strychnine. The substances used to “cut” can affect color, smell, and consistency.
Types of Heroin
Types of Heroin based on the source are:
MEX/T – Mexican tar
MEX/BP (Mexican brown powder)
MEX-SA (Mexican white powder)
SA (Colombian white powder)
SWA (Southwest Asia)
SEA (Southeast Asia)
Inconclusive South American (INC-SA)
In 2016, MEX-SA and MEX/T were the most commonly found types in the US.
What Other Names Does It Go By?
The street names for heroin include:
Cheese (a mixture of heroin and OTC cold medications or allergy drugs)
Dead on arrival
How Does Heroin Work?
Heroin works in a way similar to other opioids such as morphine, hydrocodone (Vicodin), and oxycodone (OxyContin). However, scientists do not know why it is more addictive and dangerous than these drugs.
When you inject, snort, smoke, or plug heroin, the drug first reaches the bloodstream. Then, it crosses the brain’s protective barrier and enters the brain. Once inside the brain, it acts on specific sites that regulate sensations of pain, hormone production, and well-being. The sites are known as opioid receptors.
Activation of opioid receptors produces euphoria or rush. If the drug is injected into a vein effects can occur within less than a minute. The “rush” is followed by periods of wakefulness and drowsiness. It’s common to call it “a nod”. The nod can last up to five hours. This is the reason why some people use the drug every five to six hours to avoid withdrawal symptoms.
Heroin causes an increase in the release of a brain chemical – dopamine. Increased dopamine levels can trigger drug craving and compulsive use.
What are the Health Side Effects?
Death from heroin abuse typically occurs due to stopped breathing. Breathing problems may occur in the first use itself.
Within 2 to 3 days after stopping use, tolerance begins to go down. This means the dose that previously caused a “high” can now produce fatal symptoms. People who have a prior exposure (but have not used it for some time) may die either from stopped breathing or airway blockage due to vomit.
Short-Term Side Effects of Heroin Use
A surge of euphoric feelings or a rush is the first effect of short-term use. People who use heroin report one or more of the following effects following a surge.
Skin flushing or blushing
Nausea and vomiting
Alternating states of wakefulness and drowsiness that can last for several hours
Feelings of heaviness in the hands or feet
Long-Term Side Effects of Heroin Use
Continuous use changes both the structure and function of the brain. This can lead to imbalances in the levels of hormones and brain chemicals.
Imaging studies show that people who use heroin for longer than two years have reduced brain volume. As a result, they can develop problems with decision-making, memory, and stress management.
Heroin is notorious for producing rapid tolerance and dependence. Tolerance develops when the body needs a higher amount of a drug to experience the previous effects. Dependence occurs when you cannot function normally without using a drug. Dependence can be physical or psychological. Stopping use can cause many undesirable effects. These are known as withdrawal symptoms.
Both tolerance and dependence can lead to addiction.
How is it Used and Abused?
Snorting or Sniffing Powder or Solution
Some people consider snorting a safer alternative to smoking or injecting. Snorting does not require any specific tools. Some people may also snort (toot) a small amount before injecting. Effects typically begin five minutes after snorting.
Smoking heroin is rare in the US. The risk of contracting an infection or overdosing is almost zero with chasing. However, chasing carries a significant risk of lung and heart damage.
Most importantly, some chasers may develop a rare condition called leukoencephalopathy. Leukoencephalopathy causes damage to the brain and spinal cord. The symptoms can include vision problems, seizures, impaired memory, coma, or even death.
Inserting into the Rectum (Plugging)
Some people call this method of use booty pumping. They insert a heroin solution into their rectum using a needless syringe.
The drug may be injected into a vein, muscle, or tissues beneath the skin. Injecting a drug significantly increases the risk of overdose and infections (such as HIV/AIDS). Nonetheless, people with heroin use disorder report a more intense high with injection compared to other methods. This method of use is also known to be cheaper.
To avoid overdose, some people inject only a small amount before deciding to inject the entire dose. This is known as a “tester shot” or “test shot”. Many people who use heroin intravenously have marks on the skin known as track marks, though there is a common attempt to hide these by injecting the drug in hidden areas of the body.
Signs of Heroin Use and Abuse
Initially, it may be hard to notice if someone you love is using heroin. However, over time, users develop various signs and symptoms, which can include:
Speech problems, such as mumbling or changes in tone and vocal quality
Shrinking of pupils
Difficulty remembering things
Wearing unseasonable clothing (long sleeves or pants in the summer to hide track marks)
Excess nasal drainage
Decreased pain sensitivity
Personality or behavior changes
Poor performance at school or work
How Long Does Heroin Stay in Your System?
It’s common to test positive for a urine heroin screening 2 to 6 hours after the last dose. Notably, many continue to test positive for 1-3 days.7
Blood tests may show positive results 12 hours after the last dose. Likewise, hair samples may contain the drug for up to 3 months.
How Testing Works
How long a drug stays in the body depends on several factors, including dose, half-life, individual metabolism, and frequency of intake. The body breakdowns the drug into substances known as metabolites.
The half-life of a drug is the time it takes for half of a drug in the bloodstream to clear from the system. Simply put, the longer the half-life, the longer a drug is likely to stay in your system. Typically, a drug is no longer detectable in the blood sample after five half-lives.
Testing Shows Metabolites
A drug test determines the presence of metabolites in urine, blood, and hair samples.
The presence of metabolites in a sample is a good indicator of drug use. There are two major metabolites of heroin. They are 6 Mono acetyl morphine (6-MAM) and morphine. The half-life of heroin following injection into a vein is about three minutes.8
6-MAM has a half-life of approximately thirty minutes. Thus, tests typically detect metabolites rather than the drug itself.
Street versions of the drug contain impurities such as acetylcodeine and 6-acetyl morphine. The presence of both the impurities in urine can trigger a drug test.
How to Tell if Fentanyl is in Heroin
The 2016 DEA Heroin Domestic Monitor Program (HDMP) reports that 11% of heroin sold in US cities are contaminated with illicit fentanyl or other related substances.9 Fentanyl is 100 times more powerful than morphine and 50 times more powerful than heroin.
Too much fentanyl is enough to kill a person. When combined with other opioids, the risk of overdose death increases significantly.
Fentanyl Test Strips
Fentanyl test strips can be an effective tool for reducing the risk of a fentanyl overdose. The strips can detect small amounts of fentanyl in the drug solution or urine sample. Many people report that the strips are useful and easy to use.
Positive results from fentanyl testing can help people change their drug use behavior and reduce the risk of death. This can include:
- Throwing away the drug
- Using the drug only in the presence of another person
- Carrying naloxone (Narcan). Naloxone is a rapidly acting antidote for opioid toxicity.
- Using a smaller amount of drug
Even in cases of negative test results, it’s still vitally important to exercise precautions. This is critical because the test is not always accurate. One can overdose even with a negative result.10
What are the Withdrawal Symptoms?
Usually, heroin withdrawal does not cause life-threatening effects, though they are typically severe. Withdrawal symptoms can be severe enough to cause a relapse. More severe symptoms may occur when use suddenly stops. Symptoms can develop within a few hours after the last dose. These can include:
Pain in the muscle and bone
Difficulty falling or staying asleep
Abnormal leg movements
Seeing or hearing things that are not there
Elevated blood pressure
The symptoms peak between 1 to 2 days after the last dose. They typically last for seven days. Nonetheless, some people may experience symptoms for several months.
Treatment of Withdrawal
Withdrawal management (WM) mainly focuses on stabilizing the body and relieving withdrawal symptoms. People who have been on methadone maintenance do not require WM.
WM requires 24-hour monitoring in the presence of a doctor and nurses, typically in a quiet place. For mild symptoms, taking fluids to maintain electrolyte balance, along with vitamins and pain medications are sufficient.
If the symptoms are severe, medications may be prescribed to lower blood pressure. Other medications like codeine, methadone, or buprenorphine may be recommended as well.
In the meantime, the following activities have been shown to help the body heal from substance abuse:
- Drinking 2-3 liters of water each day
- Taking vitamin B and C supplements
- Meditation or other relaxation techniques
- Eating nutrient-dense meals at regular intervals
What is Detox from Heroin Like?
Detox or detoxification is the gradual removal of a drug from the system. Detox is essential in cases of physical dependence. It is the first stage of addiction treatment. The second and third stages are rehabilitation and aftercare, respectively, which help to address the causes of addiction and work to prevent relapse.
Ending opioid use can cause severe withdrawal symptoms. Thus, working with a medical professional is always recommended. A person may need to take medications such as methadone, buprenorphine, or clonidine during the detox process. These prescriptions make withdrawal symptoms more manageable and reduce the risk of complications. This is known as medication-assisted detox.
For heroin, detox should be done at a rehab facility. This is critical, as detoxing at home may cause serious complications like seizures. Both inpatient and outpatient detox programs are available. Medication-assisted detox can last from 5 to 7 days in an inpatient setting.
An overdose occurs when a large amount of the drug is consumed within a short period. Heroin is one of the leading causes of overdose deaths in the US. The death rates have soared in at least 14 states. Washington D.C., West Virginia and Ohio have higher death rates than any other states.
From 2010 through 2016, more than 60,000 people died due to the overdose.13 Even worse, during the first half of 2018, heroin was involved in 5231 deaths.14 This accounted for nearly 40% of 13,415 opioid overdose deaths in the same period.
Deaths due to overdose increased 28 %, from 8260 in 2013 to 10,574 in 2014. Likewise, the number of overdose deaths increased by 21%, from 12,989 in 2015 to 15,469 in 2016.15
Symptoms of an Overdose
Slow or stopped breathing
The excessive shrinking of pupils
Changes in the color of the tongue
Severe hypotension (low blood pressure)
Bluish discoloration of nails and lips
A faint pulse
Pain in the stomach and intestines
- 21% Increase in Overdose Deaths from 2015 to 2016 21% 21%
Complications of Overdose
Lung inflammation caused by inhaling the vomit
Fluid accumulation in the lungs
Severe muscle damage that may lead to kidney damage
If you think an overdose has occurred, seek emergency medical care. You can also call the national toll-free Poison Help hotline (1-800-222-1222). An FDA-approved antidote for opioid overdose is available. The antidote – Naloxone (Narcan) – is an injection to be given under the skin or into a muscle.
Understanding the History of Heroin: A Timeline
When heroin first became available for medical use, it was considered a wonder drug. This was because of its high potency as a substitute for another powerful drug morphine. However, over time, the face of the so-called wonder drug gradually changed to what it is now.
Below is a timeline of its discovery and major changes in use and legal status.16
1874: English researcher Charles Romley Alder Wright at St. Mary’s Hospital in London synthesized heroin. He was looking for a nonaddictive substitute for morphine. His method of preparation involved boiling morphine with acetic anhydride for several hours. However, the discovery did not receive much attention at the time.
1890: German scientist W. Dankwortt synthesized heroin using a different method. His method is considered a major milestone in the synthesis of the drug.
1897: German chemist Felix Hoffman synthesized heroin. At that time, he was working for the German pharma giant Bayer Pharmaceutical Company. He could not patent it because Wright had already discovered it in 1874.
1898: Bayer Company began commercial production. They named the compound “Heroin.” Researchers believe the word originates from “heroisch.” Heroisch is a German medical term. It refers to something so powerful that small amounts produce strong effects.
1898: Strube, a researcher at the Medical University Clinic of Berlin, reported observing no side effects associated with the use of the drug. However, he called for more studies to confirm his findings.
1898 to 1910: Bayer sold it as a remedy for dry cough and morphine dependence. The company also exported the drug (as a cough remedy) to 23 countries.
1899: American physician Horatio C Wood noted that patients taking the drug developed tolerance.
1901 onwards: Its popularity as a wonder drug began to decline.
1903: Dr. George E Pettey, in an article entitled “The Heroin Habit Another Curse,” reported that the drug could be as addictive as other opioids.17
1913: Bayer recalled cough remedies containing the opioid from the market after several physicians reported addiction problems in their patients.18
1916: The Public Health Service Hospitals in the United States stopped dispensing it at its relief stations.
1920: The House of Delegates of the American Medical Association called for a ban on the use of heroin-containing preparations.
1924: Anti-Heroin Act banned the importation and possession of opium for heroin synthesis.
Is Heroin Legal?
Some countries, such as Canada and the UK, have recently approved the use of pharmaceutical-grade heroin. Nonetheless, it is an illegal drug in the US.19 In 1924, the US Congress banned the import of opium.20 Currently, its possession, manufacture, sale, or distribution is a felony.
According to the Drug Enforcement Administration (DEA), it is a Schedule I controlled substance. Substances in the Schedule I category have no approved medical uses. Schedule I controlled substances also have high abuse potential. Other examples of Schedule I controlled substances include LSD and Ecstasy.
Safe Injection Programs Cause a Divide
Recently, there have been some attempts at establishing legal injection sites in the US. Safe-injection sites allow people to inject a certain amount of their drug of choice under medical supervision. This reduces the risk of overdose as well as the spread of HIV/AIDS.
While proponents consider this approach an indispensable part of harm reduction, the Justice Department has vowed to prohibit opening such sites.
Top 3 Misconceptions about Heroin
Myth: Sniffing or Smoking Will Not Cause Addiction
This is one of the most prevalent misconceptions among people who use heroin. While it is true that sniffing or smoking does not deliver as much drug as injecting does, this does not mean it is addictive only when injected. Given heroins high addiction potential, addiction is possible regardless of the method of use.
Sniffing or smoking the drug can also cause overdose and many health problems. These include an increased risk of respiratory infections, breathing difficulties, nasal congestion, and fatal asthma attacks. Notably, there have been reports of death from sniffing or smoking.21
Myth: Using The “Pure” Drug Will Not Kill You
Many people believe that death can occur only if you use the adulterated drug. However, science does not support the purity myth. The truth is death can occur because of pure heroin, impurities, or both.
Impurities such as fentanyl account for a significant number of deaths. Nonetheless, pure heroin can kill if taken in large doses. High death rates associated with prescription opioids clearly show that purity has little to do with overdose deaths.
Myth: Heroin Addiction Will Not Go Away Even with Treatment
This myth likely stems from the fact that heroin is more dangerous than prescription opioids. Sadly, the prevailing myth may prevent people from seeking professional help.
One should keep in mind that many types of treatments are available, including drug therapy and behavioral therapy. Timely treatment not only reduces the risk of long-term complications but also increases the chances of full recovery.
Talking to a doctor can help you find treatments that suit unique individual needs.
- https://www.dea.gov/sites/default/files/2018-10/Heroin Domestic Monitor Report DEA-GOV FINAL.pdf
- Synthetic Opioid Involvement in Overdose Death Involving Illicit and Psychotherapeutic Drugs in the United States, 2010-2016
- https://www.dea.gov/sites/default/files/2018-11/DIR-032-18 2018 NDTA %5Bfinal%5D low resolution11-20.pdf