Common or street names: smack, H, skag, junk, brown sugar, horse, and black tar

Heroin (diacetylmorphine) is derived from themorphine alkaloid found in opium and is roughly 2-3 times more potent. A highly addictive drug, heroin exhibits euphoric (“rush”), anxiolytic and analgesic central nervous system properties. Heroin is classified as a Schedule I drug under the Controlled Substances Act of 1970 and as such has no acceptable medical use in the United States. Pure heroin is a white powder with a bitter taste. Most illicit heroin is sold as a white or brownish powder and is usually “cut” with other drugs or with substances such as sugar, starch, powdered milk, or quinine. It 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. Another form of heroin known as “black tar” may be sticky, like roofing tar, or hard, like coal. Its color may vary from dark brown to black.

Methods of Heroin Use

Heroin is most often injected, however, it may also be vaporized (“smoked”), sniffed (“snorted”), used as a suppository, or orally ingested. Smoking and sniffing heroin do not produce a “rush” as quickly or as intensely as intravenous injection. Oral ingestion does not usually lead to a “rush”, but use of heroin in suppository form may have intense euphoric effects. Heroin can be addictive by any given route.

Side Effects of Heroin Use

Heroin is metabolized to morphine and other metabolites which bind to opioid receptors in the brain. The short-term effects of heroin abuse appear soon after a single dose and disappear in a few hours. After an injection of heroin, the user reports feeling a surge of euphoria (the “rush”) accompanied by a warm flushing of the skin, a dry mouth, and heavy extremities. Following this initial euphoria, the user experiences an alternately wakeful and drowsy state. Mental functioning becomes clouded due to the depression of the central nervous system. Other effects that heroin may have on users include respiratory depression, constricted (“pinpoint”) pupils and nausea. Effects of heroin overdose may also include slow and shallow breathing, hypotension, muscle spasms, convulsions, coma, and possible death.

Intravenous heroin use is complicated by other issues such as the sharing of contaminated needles, the spread of HIV/AIDS, hepatitis, and toxic reactions to heroin impurities. Other medical complications that may arise due to heroin use include collapsed veins, abscesses, spontaneous abortion, and endocarditis (inflammation of the heart lining and valves). Pneumonia may result from the poor health condition of the abuser, as well as from heroin’s depressing effects on respiration. Heroin addiction can remove an otherwise healthy and contributing member from society, and may lead to severe disability and eventually death.

Other Health Hazards of Heroin

With regular heroin use, tolerance develops where the abuser must use more heroin to achieve the same intensity or effect. As higher doses are used over time, physical dependence and addiction develop. With physical dependence, the body has adapted to the presence of the drug and withdrawal symptoms may occur if use is reduced or stopped. Withdrawal, which in regular abusers may occur as early as a few hours after the last administration, produces drug craving, restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps (“cold turkey”), kicking movements and other symptoms. Major withdrawal symptoms peak between 48 and 72 hours after the last dose and subside after about a week. Sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal, although heroin withdrawal is considered much less dangerous than alcohol or barbiturate withdrawal.

Treatment Options for Heroin Addiction or Overdose

Several medical treatment options exist for heroin addiction. These treatments can be effective when combined with a medication compliance program and behavioral therapy. Methadone(Dolophine, Methadose), buprenorphine (Subutex, brand discontinued in U.S), buprenorphine combined with naloxone (Suboxone) and naltrexone (Depade, ReVia) are approved in the US to treat opioid dependence. These treatments work by binding fully or partially to opiate receptors in the brain and work as agonists, antagonists or a combination of the two. Agonists mimic the action of the opiate, and antagonists block and reverse the action of the opiate. Oral administration of these drugs may allow for a more gradual withdrawal from opiates. A long-acting intramuscular depot formulation of naltrexone (Vivitrol) is also available for use following opiate detoxification.

Methadone has been used for over a quarter century to treat heroin addiction. The use of methadone in opiate dependency is highly regulated in the US, and may differ between states. Oral methadone is approved for opiate detoxification and maintenance only in approved and certified treatment programs, although certain emergency or inpatient care exceptions exist. Patients usually need to visit a center daily for treatment and follow-up; however, special exceptions may be granted for Sunday, State and Federal holidays, and other times as determined by the Treatment Center Medical Director.

Buprenorphine/naloxone, like methadone, has been shown in clinical trials to be effective in treating heroin dependence, and may have a lower risk for withdrawal effects upon discontinuation. Naloxone (a pure opiate antagonist at receptor sites) is present to help prevent the intravenous abuse of the buprenorphine component. Buprenorphine/naloxone treatment takes place in an authorized physicians’ office, and this may be more acceptable to patients. Buprenorphine is also available as a single agent and is used primarily for induction at treatment onset. Patients are usually switched to the combined buprenorphine/naloxone agent for outpatient maintenance therapy. A 2013 report by the Drug Abuse Warning Network (DAWN) highlights the fact that buprenorphine has become a popular drug of abuse itself. Emergency department visits involving buprenorphine increased substantially from 3,161 in 2005 to 30,135 in 2010.

Naltrexone, available orally and as an intramuscular depot injection is another treatment option, but patients must be opioid-free for at least 7 to 10 days prior to treatment. Naltrexone is a pure opioid antagonist and may result in withdrawal symptoms if the patient is not opioid-free.

Heroin overdose is a medical emergency that requires treatment with naloxone. Intravenous naloxone will result in reversal of the opioid-induced respiratory depression within 2 minutes. Retreatment with naloxone may be required as the duration of action of naloxone (30 to 120 minutes) may be shorter than the action of the opioid. Respiratory support, intravenous fluids, and other adjunctive medications may be required.

Extent of Heroin Use

Heroin addiction is a treatable condition, but its use is increasing in recent years. According to the 2011 Survey on Drug Use and Health by the US Substance Abuse and Mental Health Administration, it is estimated that 607,000 persons per year used heroin in the years 2009-2011, compared to 374,000 during 2002-2005. Similarly, the estimated number of new heroin users increased from 109,000 per year during 2002-2005 to 169,000 per year during 2009-2011.

The increase in initiation is evident among young adults aged 18 to 25 and adults aged 26 and older. There were 28,000 youth initiates per year in 2002-2005 and 27,000 in 2009-2011. Young adult initiates increased from 53,000 per year to 89,000 per year, and older adult initiates increased from 28,000 to 54,000 for these combined time periods. Past year use estimates for 2002-2005 and 2009-2011 showed the same pattern: for youths, estimates were 43,000 and 39,000; for young adults, the estimates were 124,000 and 208,000; and for older adults, the estimates were 207,000 and 361,000. Monitoring the Future (MTF) data indicates an increase for young adults aged 19 to 28 and a decrease for 10th graders in rates of past year heroin use between 2002 and 2011. MTF data did not indicate any changes among 8th and 12th graders between these 2 years.

Patients with heroin addiction should seek advice from health care providers who can guide them with the most appropriate and safe treatment. Combined behavioral and medical therapies may allow the patient to integrate back into mainstream society and lead a positive and productive life.