An Overview

Heroin is an illegal opioid drug abused for its intense euphoric effects. While it can be smoked or snorted, most users choose to inject heroin intravenously. Following injection, users immediately experience an intense, pleasurable “rush” followed by hours of a relaxed, trance-like state known as a “nod.”

Heroin is often seen as a white or brown powder; its color and consistency may vary depending on impurities added to it. “Black tar heroin” is a sticky, gummy form of heroin resembling roofing tar that is commonly seen in areas of the United States west of the Mississippi River.

Unlike a prescription opioid such as hydrocodone or oxycodone, which is legal to possess with a prescription, all forms of heroin are illegal.

Opium – The Source of Heroin

Heroin is derived from morphine, a natural alkaloid of the opium poppy plant. Most illicit opium originates in Afghanistan, where it is grown as a cash crop and exported to Europe and the United States. The opium is refined into morphine, then converted into heroin through chemical processes.

The conversion of morphine to heroin makes it stronger and facilitates more rapid movement across the blood-brain-barrier, allowing the effects to hit faster.

Dirty and Dangerous

Heroin may be “cut”, or diluted, with dangerous impurities to bulk up its weight. Not only is this dangerous because the user can never be sure how much heroin they are taking, but the impurities themselves can be dangerous. Some impurities that are commonly added to heroin include:

• Talc powder
• Baking soda
• Caffeine
• Flour
• Fentanyl

Of all the impurities, fentanyl is perhaps the most dangerous. Fentanyl, like heroin, is an opioid, except significantly stronger. Only small amounts of fentanyl are required to cause an overdose, making heroin diluted fentanyl particularly deadly.

Heroin and the Opioid Epidemic

The United States is currently experiencing an “opioid epidemic.” Over the past 20 years, opioids have contributed to an increasing number of deaths countrywide.  The Centers for Disease Control (CDC) estimates that between 1999 and 2017, opioids have been responsible for more than 700,000 deaths.3

The number of overdose deaths due to heroin has risen dramatically from 1,960 in 1999 to 15,482 in 2017, nearly an eight-fold increase.

How Heroin Works in the Brain

Heroin is a potent opioid agonist that binds to opioid receptors in the central nervous system. After injection, heroin enters the brain and latches on to opioid receptors, causing an intense, pleasurable feeling known as the “rush.”

When heroin is used repeatedly, opioid receptors become less sensitive to its effects. This results in tolerance, where a higher dose of the drug is required to feel the same effect.

Effects of Heroin

In addition to the feeling of euphoria, heroin is also associated with a significant amount of side effects, which include:

• Flushing of the skin
• Nausea and vomiting
• Severe itching
• Constipation
• Respiratory depression

Respiratory depression is characterized by slow, ineffective breathing that can be fatal if not treated quickly.

Heroin Overdose – Recognize and Act

Someone who has overdosed on heroin is potentially at risk of death due to respiratory depression. It is important to be able to identify the signs and symptoms of heroin overdose.

• Pinpoint pupils
• Unresponsive at attempts to wake them up
• Very slow, labored breathing
• Bluish, cold and clammy skin
• Bluish or purple fingernails
• Slow or irregular heartbeat

If someone is suspected to have overdosed on heroin, emergency services should be called. The drug Narcan is used to reverse heroin overdose. Narcan is an opioid antagonist available as a nasal spray, working within minutes to reverse respiratory depression. It is available without a prescription in most states, including California.

Heroin Abuse and Addiction

Because heroin is illegal, any use is considered abuse as there is no medically accepted reason why someone should be taking it. People who use heroin repeatedly can quickly spiral down the path of addiction, where their life revolves around obtaining and taking the drug.

The following signs may signal addiction to heroin:

• Trace marks – Users who inject heroin will often have bloodied or bruised arms due to repeated injections.
• Drug seeking behavior – Many users will lie and steal from a friend or family member to support their substance abuse habit.
• Chronic tiredness – When a user is “nodding off” after the initial rush, they may appear tired, “zoned out”, or have difficulty carrying on a conversation.
• Pinpoint pupils – Heroin constricts the pupils, making them significantly smaller than normal. Constant pinpoint pupils may signal repeated use of heroin or another opioid.

Tolerance and Dependence

Over time, tolerance will develop to heroin, where the user takes more to achieve the same effect. Long term use will make the user dependent, meaning they require it to feel normal. Once dependent, a user will suffer painful withdrawal symptoms soon after the effects wear off.

Withdrawal from Heroin

Heroin withdrawal is an incredibly painful experience; so painful in fact that most users will continue taking heroin not only to experience the high, but also in fear of withdrawal. This is what makes heroin so difficult to quit, not only are the effects addicting, but stopping is painful.

Symptoms of heroin withdrawal are listed below:

• Muscle aches/pains
• Night sweats, feeling “hot and cold”
• Diarrhea
• Dilated pupils
• Insomnia
• Vomiting

Addiction Treatment

Treatment of heroin addiction marks the first step towards the restoration of a user’s physical and mental health. The end goal of addiction treatment is complete discontinuation of heroin use and prevention of use in the future.

While some may attempt to quit “cold turkey” by suddenly and completely stopping heroin, this is associated with extreme withdrawal symptoms; most people are unable to cope with the severity of withdrawal and continue using it to alleviate withdrawal. It is recommended that heroin users admit themselves to a treatment center for drug detox where they can receive the help they need.

There are several options for the treatment of heroin addiction. Among the most common is opioid replacement therapy (ORT) with methadone or Suboxone.

• Methadone – One option is replacing heroin with methadone. Methadone is an opioid, however it stays in the body significantly longer than heroin, allowing long-lasting control of withdrawal symptoms. One major drawback of methadone is that it must be administered in a registered methadone clinic, which can be inconvenient and impractical for some.
• Suboxone – Another option involves the use of Suboxone, a drug containing a combination of the opioid buprenorphine and the opioid antagonist naloxone. With a valid prescription, Suboxone can be bought at most retail pharmacies.

Seeking Help

Drug addiction is a difficult challenge to overcome, with heroin ranked as one the most difficult drugs to quit. Drug addiction specialists are available to keep users safe and mitigate the painful symptoms of withdrawal along the process of recovery.