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He roin is an illegal, highly addictive drug. It is both the most abused and
the most rapidly acting of the opiates. Heroin is processed fro m morphine,
a naturally occurring substance extracted from the seed pod of certain varieties
of poppy plants. It is typically sold as a white or brownish powder or as the
black sticky substance known on the streets as “black tar heroin.” Although
purer heroin is becoming more common, most street heroin is “cut” with other
drugs or with substances such as sugar, starch, powdere d milk, or quinine.
Street hero i n can also be cut with strychnine or other poisons. Because hero
i n abusers do not know the actual s t rength of the drug or its true contents,
they are at risk of overdose or death. Heroin also poses special problems because
of the transmission of HIV and other diseases that can occur from sharing needles
or other injection equipment.
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According to the 1998 National Household Survey on Drug Abuse, which may actually
underestimate illicit opiate (heroin) use, an estimated2.4 million people had
used h e roin at some time in their lives, and nearly 130,000 of them reported
using it within the month p receding the survey. The survey report estimates
that there w e re 81,000 new hero in users in 1997. A large pro p o r t i o
n of these recent new users were smoking, snorting, or sniff i n g h e roin,
and most (87 perc e n t ) w e re under age 26. In 1992, only 61 percent were
younger than 26.
The 1998 Drug Abuse Wa rning Network (DAWN), which collects data on drugrelated
hospital emerg e n c y department (ED) episodes fro m 21 metropolitan areas,
estimates that 14 percent of all drug-re l a t e ED episodes involved hero i
n . Even more alarming is the fact that between 1991 and 1996, h e ro i n -
related ED episodes more than doubled (from 35,898 to 73,846). Among youths
aged 12 to 17, hero i n - related episodes nearly quadrupled.
NIDA’s Community Epidemiology Work Gro u p (CEWG), which provides information
about the nature and p a t t e rns of drug use in 21 cities, reported in its
December 1999 publication that heroin was mentioned most often as the primary
drug of abuse in drug abuse treatment admissions in B a l t i m o re, Boston,
Los Angeles, Newark, New York, and San Francisco.
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He roin is usually injected, s n i ffed/snorted, or smoked. Typically, a heroin
abuser may inject up to four times a day. Intravenous injection provides the
g reatest intensity and most rapid onset of euphoria (7 to 8 seconds), while
intramuscular injection produces a relatively slow onset of euphoria (5 to 8
minutes). When heroin is sniffed or smoked, peak effects are usually felt within
10 to 15 minutes. Although smoking and sniffing heroin do not produce a “rush”
as quickly or as intensely as intravenous injection, NIDA researchers have confirmed
that all three forms of heroin administration are addictive.
Injection continues to be the p redominant method of hero i n use among addicted
users seeking treatment; however, researchers have observed a shift in heroin
use patterns, from injection to sniffing and smoking. In fact, sniff i n g /
s n o r t i n g h e roin is now the most widely reported means of taking hero
i n among users admitted for drug t reatment in Newark, Chicago, and New York.
With the shift in heroin abuse patterns comes an even more diverse group of
users. Older users (over 30) continue to be one of the largest user groups in
most national data. However, the i n c rease continues in new, young users across
the country who are being lured by inexpensive, highpurity heroin that can be
sniffed or smoked instead of injected. Heroin has also been appearing in more
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Soon after injection (or inhalation), heroin crosses the blood-brain barrier.
In the brain, heroin is converted to morphine and binds rapidly to opioid receptors.
Abusers typically re p o r t feeling a surge of pleasurable sensation, a “rush.”
The intensity of the rush is a function of how much drug is taken and how rapidly
the drug enters the brain and binds to the natural opioid receptors. Heroin
is particularly addictive because it enters the brain so rapidly. With heroin,
the rush is usually accompanied by a warm flushing of the skin, dry mouth, and
a heavy feeling in the extremities, which may be accompanied by nausea, vomiting,
and severe itching.
After the initial effects, abusers usually will be dro w s y for several
hours. Mental function is clouded by heroin’s effect on the central nervous
system. Cardiac function slows. Breathing is also severely slowed, sometimes
to the point of death. H e roin overdose is a particular risk on the street,
where the amount and purity of the drug cannot be accurately known.
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One of the most detrimental l o n g - t e rm effects of hero i n is addiction
itself. Addiction is a chronic, re l a p s i n g disease, characterized by compulsive
drug seeking and use, and by n e u rochemical and molecular changes in the brain.
Heroin also p roduces profound degrees of tolerance and physical dependence,
which are also powerful motivating factors for compulsive use and abuse. As
with abusers of any addictive drug, heroin abusers gradually spend more and
more time and energy obtaining and using the drug. Once they are addicted, the
heroin abusers’ primary purpose in life becomes seeking and using drugs. The
drugs literally change their brains.
Physical dependence develops with higher doses of the drug. With physical dependence,
the body adapts to the presence of the drug and withdrawal symptoms occur if
use is reduced abruptly. Withdrawal may occur within a few hours after the last
time the drug is taken. Symptoms of withdrawal include restles sness, muscle
and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold
turkey”), and leg movements. Major withdrawal symptoms peak between 24 and 48
hours after the last dose of heroin and subside after about a week. However,
some people have shown persistent withdrawal signs for many months. Heroin withdrawal
is never fatal to otherwise healthy adults, but it can cause death to the fetus
of a pregnant addict.
At some point during continuous heroin use, a person can become addicted to
the drug. Sometimes addicted individuals will endure many of the withdrawal
symptoms to reduce their tolerance for the drug so that they can again experience
the r u s h .
Physical dependence and the e m e rgence of withdrawal symptoms were once believed
to be the key features of heroin addiction. We now know this may not be the
case entirely, since craving and relapse can occur weeks and months after withdrawal
symptoms are long gone. We also know that patients with chro n i c pain who
need opiates to function (sometimes over extended periods) have few if any pro
blems leaving opiates after their pain is resolved by other means. This may
be because the patient in pain is simply seeking relief of pain and not the
rush sought by the addict.
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Medical consequences of c h ronic heroin abuse include scarred and/or collapsed
veins, bacterial infections of the blood vessels and heart valves, abscesses
(boils) and other soft-tissue infections, and liver or kidney disease. Lung
complications (including various types of pneumonia and tuberculosis) may result
from the poor health condition of the abuser as well as from heroin’s depressing
effects on respiration. Many of the additives in street heroin may include substances
that do not readily dissolve and result in clogging the blood vessels that lead
to the lungs, liver, kidneys, or brain. This can cause infection or even death
of small patches of cells in vital organs. Immune reactions to these or other
contaminants can cause arthritis or other rheumatologic problems.
Of course, sharing of injection equipment or fluids can lead to some of the
most severe consequences of heroin abuse— infections with hepatitis B and C,
HIV, and a host of other blood - borne viruses, which drug abusers can then
pass on to their sexual partners and children.
|Short- and Long-Term Effects of Heroin Abuse
Short - Term Effects:
- Depressed respiration
- Clouded mental functioning
- Nausea and vomiting
- Suppression of pain
- Spontaneous abortion
| Long - Term Effects:
- Infectious diseases, for example, HIV/AIDS and hepatitis B and
- Collapsed veins
- Bacterial infections
- Infection of heart lining and valves
- Arthritis and other rheumatologic problems
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Heroin abuse can cause serious complications during p regnancy, including miscarriage
and pre m a t u re delivery. C h i l d ren born to addicted mothers are at greater
risk of SIDS (sudden infant death syndro m e ) , as well. Pre g n a n t women
should not be d e t o x i f i e d f rom opiates because of the incre a s e d
risk of spontaneous abortion or pre m a t u re delivery; rather, tre a tment
with methadone is strongly advised. Although infants born to mothers taking
p re s c r i b e d methadone may show signs of physical dependence, they can
be treated easily and safely in the nursery. R e s e a rch has demonstrated
also that the effects of in utero exposure to methadone are relativelybenign
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Heroin addicts are at risk for contracting HIV, hepatitis C, and other infectious
diseases. Drug abusers may become infected with HIV, hepatitis C, and other
bloodb o rne pathogens through sharing and reuse of syringes and injection paraphern
a l i a that have been used by infected individuals. They may also become infected
with HIV and, although less often, to hepatitis C thro u g h u n p rotected
sexual contact with an infected person. Injection drug use has been a factor
in an estimated one-third of all HIV and more than half of all hepatitis C cases
in the N a t i o n . N I D A - f u n d e d re s e a rch has found that drug
abusers can change the behaviors that put them at risk for contracting HIV,
t h rough drug abuse tre a tment, prevention, and community-based outreach programs.
They can eliminate drug use, drugrelated risk behaviors such as needle sharing,
unsafe sexual practices, and, in turn, the risk of e x p o s u re to HIV/AIDS
and other infectious diseases. Drug abuse p revention and treatment are highly
effective in preventing the s p read of HIV.
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A variety of effective tre a tments are available for h e roin addiction. Tre
a t m e n t tends to be more effective when h e roin abuse is identified early.
The treatments that follow vary depending on the individual, but methadone,
a synthetic opiate that blocks the effects of hero i n and eliminates withdrawal
symptoms, has a proven record of success for people addicted to h e roin. Other
pharm a c e u t i c a l a p p roaches, like LAAM (levoalpha- acetyl-methadol)
and b u p renorphine, and many behavioral therapies also are used for treating
The primary objective of detoxification is to relieve withdrawal symptoms
while patients adjust to a drug-free state. Not in itself a t reatment for addiction,
detoxification is a useful step only when it leads into long-term tre a t m
e n t that is either drug-free (re s i d e n t i a l or outpatient) or uses
medications as part of the treatment. The best documented drug-free tre a tments
are the therapeutic community residential pro g r a m s lasting at least 3 to
Methadone treatment has been used effectively and safely to t reat opioid addiction
for more than 30 years. Properly prescribed methadone is not intoxicating or
sedating, and its eff e c t s do not interf e re with ordinary activities such
as driving a car. The medication is taken orally and it suppresses narcotic
withdrawal for 24 to 36 hours. Patients are able to perceive pain and have emotional
re a c t i o n s . Most important, methadone relieves the craving associated
with heroin addiction; craving is a major reason for relapse . Among methadone
patients, it has been found that normal stre e t doses of heroin are ineffective
at producing euphoria, thus making the use of heroin more easily extinguishable
Methadone’s effects last for about 24 hours—four to six times as long as those
of hero i n — s o people in treatment need to take it only once a day. Also,
methadone is medically safe even when used continuously for 10 years or m o
re. Combined with behavioral therapies or counseling and other supportive services,
methadone enables patients to stop using h e roin (and other opiates) and re
t u rn to more stable and productive lives.
Methadone dosages must be carefully monitored in patients who are receiving
antiviral therapy for HIV infection, to avoid potential medication interactions.
LAAM and other medications
LAAM, like methadone, is a synthetic opiate that can be used to treat heroin
addiction. LAAM can block the e ffects of heroin for up to 72 hours with minimal
side e ffects when taken orally. In 1993 the Food and Drug A d m i n i s t r
a t i o n a p p roved the use of LAAM for t reating patients addicted to hero
i n . Its long duration of action permits dosing just thre e times per week,
t h e reby eliminating the need for daily dosing and take-home doses for weekends.
LAAM will be i n c reasingly available in clinics that a l ready dispense methadone.
Naloxone and naltrexone are medications that also block the e ffects of morphine,
hero i n , and other opiates. As antagonists, they are especially useful as
antidotes. Naltre x o n e has long-lasting effects, ranging f rom 1 to 3 days,
depending on the dose. Naltrexone blocks the pleasurable effects of heroin and
is useful in treating some highly motivated individuals. Naltre x o n e has
also been found to be successful in preventing relapse by former opiate addicts
released f rom prison on probation .
Another medication to treat heroin addiction, buprenorphine , may already be
available by the time this Research Report appears. Buprenorphine is a particularly
attractive treatment because, compared to other medications, such as methadone,
it causes weaker opiate effects and is less likely to cause overdose problems
. Buprenorphine also produces a lower level of physical dependence, so patients
who discontinue the medication generally have fewer withdrawal symptoms than
do those who stop taking methadone. Because of these advantages, buprenorphine
may be appropriate for use in a wider variety of treatment settings than the
currently available medications. Several other medications with potential for
treating hero i n overdose or addiction are c u r rently under investigation
Although behavioral and pharmacologic treatments can be extremely useful when
employed alone, science has taught us that integrating both types of treatments
will ultimately be the most effective appro a c h . T h e re are many effective
behavioral treatments available for h e roin addiction. These can include residential
and outpatient a p p roaches. An important task is to match the best tre a t
m e n t a p p roach to meet the particular needs of the patient. More o v e
r, several new behavioral therapies, such as contingency management therapy
and cognitive-behavioral interventions, show particular p romise as treatments
for hero i n addiction. Contingency management therapy uses a voucherbased system,
where patients e a rn “points” based on negative drug tests, which they can
exchange for items that encourage healthy living. Cognitivebehavioral interventions
are designed to help modify the patient’s thinking, expectancies, and behaviors
and to incre a s e skills in coping with various life s t ressors. Both behavioral
and p h a rmacological treatments help to restore a degree of normalcy to brain function and behavior,
with increased employment rates
and lower risk of HIV and other
diseases and criminal behavior.
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Drug analogs are chemical compounds that are similar to other drugs in their
e ffects but differ slightly in their chemical structure. Some analogs a re
produced by pharm a c e u t i c a l companies for legitimate medical reasons.
Other analogs, sometimes re f e r red to as “designer” drugs, can be produced
in illegal laboratories and are often more d a n g e rous and potent than the
original drug. Two of the most commonly known opioid analogs a re fentanyl and
meperidine (marketed under the brand name Demerol, for example).
Fentanyl was introduced in 1968 by a Belgian pharmaceutical company as a synthetic
narcotic to be used as an analgesic in s u rgical procedures because of its
minimal effects on the heart. Fentanyl is particularly dangero u s because it
is 50 times more potent than heroin and can rapidly stop respiration. This is
not a problem during surgical procedures because machines a re used to help
patients breathe . On the street, however, users have been found dead with the
needle used to inject the drug still in their arms.
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