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Heroin Addiction and Abuse

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What Is Heroin?

Heroin is an illegal, highly addictive drug. It is both the most abused and the most rapidly acting of the non-prescription opiates. Heroin is processed from 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, powdered milk, or quinine. Street heroin also can 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. Heroin also poses special problems because of the transmission of HIV and other diseases that can occur from sharing needles or other injection equipment.

How is heroin used?

Heroin can be injected, snorted/sniffed, or smoked—routes of administration that rapidly deliver

the drug to the brain. Typically, a heroin abuser may inject up to four times a day. Intravenous

injection provides the greatest 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, where it is absorbed into the bloodstream through the nasal tissues,

peak effects are usually felt within 10 to 15 minutes. All forms of heroin administration are

addictive.

Route of Administration Among Heroin Treatment Admissions in Selected Areas

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Source: Community Epidemiology Work Group, NIDA, December 2003, Vol. II.

*Includes first half 2003 data from treatment facilities.

Injection continues to be the predominant method of heroin use among addicted users seeking

treatment; in many CEWG areas, heroin injection is reportedly on the rise, while heroin

inhalation is declining. However, certain groups, such as White suburbanites in the Denver area,

report smoking or inhaling heroin because they believe that these routes of administration are

less likely to lead to addiction.

With the shift in heroin abuse patterns comes an even more diverse group of users. In recent

years, the availability of higher purity heroin (which is more suitable for inhalation) and the

decreases in prices reported in many areas have increased the appeal of heroin for new users who

are reluctant to inject. Heroin has also been appearing in more affluent communities.

What are the immediate (short-term) effects of heroin use?

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 report 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.

Opiates Act on Many Places in the Brain and Nervous System

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After the initial effects, abusers usually will be drowsy 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. Heroin overdose is a particular risk on the

street, where the amount and purity of the drug cannot be accurately known.

What are the long-term effects of heroin use?

One of the most detrimental long-term effects of heroin use is addiction itself.

Addiction is a chronic, relapsing disease, characterized by compulsive drug seeking and use, and

by neurochemical and molecular changes in the brain. Heroin also produces 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

and their behavior.

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 restlessness, 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 rush.

Physical dependence and the emergence 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 chronic pain who need opiates to function (sometimes over extended

periods) have few if any problems 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.

An additional concern is that Persons addicted to alcohol or drugs are at 5-10 times higher risk for suicide compared to the general population (Voss, Kaufman, O’Conner, Comtios, Conner, Ries, 2013).

Heroin Addiction and Abuse - CEU-Hours.com - p 5

Short- and Long-Term Effects of Heroin Use

Short-Term Effects "Rush"

Depressed respiration

Clouded mental functioning

Nausea and vomiting

Suppression of pain

Spontaneous abortion

Long-Term Effects Addiction

Infectious diseases, for example, HIV/AIDS and hepatitis B and C

Collapsed veins

Bacterial infections

Abscesses

Infection of heart lining and valves

Arthritis and other rheumatologic

What Other Adverse Effects Does Heroin Have on Health?

Heroin abuse is associated with serious health conditions, including fatal overdose, spontaneous

abortion, and—particularly in users who inject the drug—infectious diseases, including

HIV/AIDS and hepatitis. Chronic users may develop collapsed veins, infection of the heart lining

and valves, abscesses, and liver or kidney disease. Pulmonary complications, including various

types of pneumonia, may result from the poor health of the abuser as well as from heroin’s

depressing effects on respiration. In addition to the effects of the drug itself, street heroin often

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contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver,

kidneys, or brain, causing permanent damage to vital organs.

Chronic use of heroin leads to physical dependence, a state in which the body has adapted to the

presence of the drug. If a dependent user reduces or stops use of the drug abruptly, he or she may

experience severe symptoms of withdrawal. These symptoms—which can begin as early as a few

hours after the last drug administration—can include restlessness, muscle and bone pain,

insomnia, diarrhea and vomiting, cold flashes with goose bumps (“cold turkey”), and kicking

movements (“kicking the habit”). Users also experience severe craving for the drug during

withdrawal, which can precipitate continued abuse and/or relapse. Major withdrawal symptoms

peak between 48 and 72 hours after the last dose of the drug and typically subside after about 1

week. Some individuals, however, may show persistent withdrawal symptoms for months.

Although heroin withdrawal is considered less dangerous than alcohol or barbiturate withdrawal,

sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal. In

addition, heroin craving can persist years after drug cessation, particularly upon exposure to

triggers such as stress or people, places, and things associated with drug use.

How does heroin abuse affect pregnant women?

Heroin abuse during pregnancy and its many associated environmental factors (e.g., lack of

prenatal care) have been associated with adverse consequences including low birth weight, an

important risk factor for later developmental delay. Methadone maintenance combined with

prenatal care and a comprehensive drug treatment program can improve many of the detrimental

maternal and neonatal outcomes associated with untreated heroin abuse, although infants

exposed to methadone during pregnancy typically require treatment for withdrawal symptoms. In

the United States, several studies have found buprenorphine to be equally effective and as safe as

methadone in the adult outpatient treatment of opioid dependence. Given this efficacy among

adults, current studies are attempting to establish the safety and effectiveness of buprenorphine in

opioid-dependent pregnant women. For women who do not want or are not able to receive

pharmacotherapy for their heroin addiction, detoxification from opiates during pregnancy can be

accomplished with relative safety, although the likelihood of relapse to heroin use should be

considered.

Why are heroin users at special risk for contracting

HIV/AIDS and hepatitis B and C?

Heroin users are at risk for contracting HIV, hepatitis C (HCV), and other infectious diseases,

through sharing and reuse of syringes and injection paraphernalia that have been used by infected

individuals, or through unprotected sexual contact with an infected person. Injection drug users

(IDUs) represent the highest risk group for acquiring HCV infection; an estimated 70 to 80

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percent of the 35,000 new HCV infections occurring in the United States each year are among

IDUs.

NIDA-funded research has found that drug abusers can change the behaviors that put them at

risk for contracting HIV through drug abuse treatment, prevention, and community-based

outreach programs. They can eliminate drug use, drug-related risk behaviors such as needle

sharing, unsafe sexual practices, and, in turn, the risk of exposure to HIV/AIDS and other

infectious diseases. Drug abuse prevention and treatment are highly effective in preventing the

spread of HIV.

What Treatment Options Exist?

A range of treatments exist for heroin addiction, including medications and behavioral therapies.

Science has taught us that when medication treatment is combined with other supportive

services, patients are often able to stop using heroin (or other opiates) and return to stable and

productive lives.

Treatment usually begins with medically assisted detoxification to help patients withdraw from

the drug safely. Medications such as clonidine and buprenorphine can be used to help minimize

symptoms of withdrawal. However, detoxification alone is not treatment and has not been shown

to be effective in preventing relapse—it is merely the first step.

Medications to help prevent relapse include the following:

Methadone has been used for more than 30 years to treat heroin addiction. It is a

synthetic opiate medication that binds to the same receptors as heroin; but when taken

orally, it has a gradual onset of action and sustained effects, reducing the desire for other

opioid drugs while preventing withdrawal symptoms. Properly administered, methadone

is not intoxicating or sedating, and its effects do not interfere with ordinary daily

activities. Methadone maintenance treatment is usually conducted in specialized opiate

treatment programs. The most effective methadone maintenance programs include

individual and/or group counseling, as well as provision of or referral to other needed

medical, psychological, and social services.

Buprenorphine is a more recently approved treatment for heroin addiction (and other

opiates). Compared with methadone, buprenorphine produces less risk for overdose and

withdrawal effects and produces a lower level of physical dependence, so patients who

discontinue the medication generally have fewer withdrawal symptoms than those who

stop taking methadone. The development of buprenorphine and its authorized use in

physicians’ offices give opiate-addicted patients more medical options and extend the

reach of addiction medication. Its accessibility may even prompt attempts to obtain

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treatment earlier. However, not all patients respond to buprenorphine—some continue to

require treatment with methadone.

Naltrexone is approved for treating heroin addiction but has not been widely utilized due

to poor patient compliance. This medication blocks opioids from binding to their

receptors and thus prevents an addicted individual from feeling the effects of the drug.

Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical

settings, although initiation of the treatment often begins after medical detoxification in a

residential setting. To prevent withdrawal symptoms, individuals must be medically

detoxified and opioid-free for several days before taking naltrexone.

Naloxone is a shorter-acting opioid receptor blocker, used to treat cases of overdose.

For pregnant heroin abusers, methadone maintenance combined with prenatal care and a

comprehensive drug treatment program can improve many of the detrimental maternal and

neonatal outcomes associated with untreated heroin abuse. Preliminary evidence suggests that

buprenorphine may also be a safe and effective treatment during pregnancy, although infants

exposed to either methadone or buprenorphine prenatally may still require treatment for

withdrawal symptoms. For women who do not want or are not able to receive pharmacotherapy

for their heroin addiction, detoxification from opiates during pregnancy can be accomplished

with medical supervision, although potential risks to the fetus and the likelihood of relapse to

heroin use should be considered.

Behavioral therapies

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 approach. There are many effective behavioral treatments available for heroin

addiction. These can include residential and outpatient approaches. An important task is to match

the best treatment approach to meet the particular needs of the patient. Moreover, several new

behavioral therapies, such as contingency management therapy and cognitive-behavioral

interventions, show particular promise as treatments for heroin addiction, especially when

applied in concert with pharmacotherapies. Contingency management therapy uses a voucher-

based system, where patients earn "points" based on negative drug tests, which they can

exchange for items that encourage healthy living. Cognitive-behavioral interventions are

designed to help modify the patient's expectations and behaviors related to drug use, and to

increase skills in coping with various life stressors. Both behavioral and pharmacological

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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How Widespread Is Heroin Abuse?

Monitoring the Future Survey*

According to the Monitoring the Future survey, there was little change between 2008 and 2009

in the proportion of 8th- and 12th-grade students reporting lifetime,†† past-year, and past-month

use of heroin. There was, however a drop in both Lifetime and Past year use at all levels between

2009 and 2012. Past month figures were no longer available for heroin use in this population for

2012. These figures indicate a reduction in reported use among this population over the 3 year

span.

Heroin Use by Students, 2009: Monitoring the Future Survey

8th Grade 10th Grade 12th Grade

Lifetime 1.3% 1.5% 1.2%

Past Year 0.7 0.9 0.7

Past Month 0.4 0.4 0.4

Heroin Use by Students, 2012: Monitoring the Future Survey

8th Grade 10th Grade 12th Grade

Lifetime 0.8% 1.1% 1.1%

Past Year 0.5 0.6 0.6

Past Month - - -

According to the 2003 National Survey on Drug Use and Health, which may actually

underestimate illicit opiate (heroin) use, an estimated 3.7 million people had used heroin at some

time in their lives, and over 119,000 of them reported using it within the month preceding the

survey. An estimated 314,000 Americans used heroin in the past year, and the group that

represented the highest number of those users were 26 or older. The survey reported that, from

1995 through 2002, the annual number of new heroin users ranged from 121,000 to 164,000.

During this period, most new users were age 18 or older (on average, 75 percent) and most were

male. In 2003, 57.4 percent of past year heroin users were classified with dependence on or

abuse of heroin, and an estimated 281,000 persons received treatment for heroin abuse.

In the 2012 National Survey on Drug Use and Health, the rate of use of heroin within the

preceding 1 year was 0.9% among those with any mental illness, compared with 0.1% among

those with no mental illness.

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Other Information Sources

For additional information on heroin, please refer to the following sources on NIDA’s Web site:

Research Report Series - Heroin Abuse and Addiction

NIDA Notes - Heroin

NIDA Notes - Opioids

Other Data Sources

* These data are from the 2009 Monitoring the Future survey, funded by the National Institute on

Drug Abuse, National Institutes of Health, Department of Health and Human Services, and

conducted annually by the University of Michigan’s Institute for Social Research. The survey

has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-

graders were added to the study. For the latest data visit: High School and Youth Trends.

** “Lifetime” refers to use at least once during a respondent’s lifetime. “Past year” refers to use

at least once during the year preceding an individual’s response to the survey. “Past month”

refers to use at least once during the 30 days preceding an individual’s response to the survey.

What are the opioid analogs and their dangers?

Drug analogs are chemical compounds that are similar to other drugs in their effects but differ

slightly in their chemical structure. Some analogs are produced by pharmaceutical companies for

legitimate medical reasons. Other analogs, sometimes referred to as "designer" drugs, can be

produced in illegal laboratories and are often more dangerous and potent than the original drug.

Two of the most commonly known opioid analogs are 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 surgical procedures because of its minimal effects on the heart.

Fentanyl is particularly dangerous because it is 50 times more potent than heroin and can rapidly

stop respiration. This is not a problem during surgical procedures because machines are used to

help patients breathe. On the street, however, users have been found dead with the needle used to

inject the drug still in his or her arm.

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A major source of information on substance use, abuse, and dependence among Americans aged

12 and older is the annual National Survey on Drug Use and Health (NSDUH) conducted by the

Substance Abuse and Mental Health Services Administration. Following are facts and statistics

on substance use in America from 2011, the most recent year for which NSDUH survey data

have been analyzed.

Illicit Drug Use

Illicit drug use in America has been increasing. In 2011, an estimated 22.5 million Americans

aged 12 or older—or 8.7 percent of the population—had used an illicit drug or abused a

psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past

month. This is up from 8.3 percent in 2002. The increase mostly reflects a recent rise in the use

of marijuana, the most commonly used illicit drug.

A study conducted by Noruma, Hurd and Pilowsky (2012) examined overall risk, age of

initiation, and functional impairments in adults with substance use problems (N = 1748) by child

abuse status. They found that a history of child abuse was associated with earlier onset of

marijuana, cocaine, and heroin use, and had there were increased risks of use for all drugs

studied. Furthermore, child abuse was associated with increased medical and functional

impairments, including ER visits, health problems, drug dealing, drug dependence, and drug

cravings.

Marijuana use has increased since 2007. In 2011, there were 18.1 million current (past-month)

users—about 7.0 percent of people aged 12 or older—up from 14.4 million (5.8 percent) in 2007.

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Use of most drugs other than marijuana has not changed appreciably over the past decade

or has declined. In 2011, 6.1 million Americans aged 12 or older (or 2.4 percent) had used

psycho-therapeutic prescription drugs nonmedically (without a prescription or in a manner or for

a purpose not prescribed) in the past month—a decrease from 2010. And 972,000 Americans

(0.4 percent) had used hallucinogens (a category that includes Ecstasy and LSD) in the past

month—a decline from 2010.

Cocaine use has gone down in the last few years; from 2006 to 2011, the number of current users

aged 12 or older dropped from 2.4 million to 1.4 million. Methamphetamine use has also

dropped, from 731,000 current users in 2006 to 439,000 in 2011.

Most people use drugs for the first time when they are teenagers. There were just over 3.0

million new users (initiates) of illicit drugs in 2011, or about 8,400 new users per day. Half (51

percent) were under 18.

More than half of new illicit drug users begin with marijuana. Next most common are

prescription pain relievers, followed by inhalants (which is most common among younger teens).

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Drug use is highest among people in their late teens and twenties. In 2011, 23.8 percent of

18- to 20-year-olds reported using an illicit drug in the past month.

For more information on drug use among adolescents, see Drug Facts: High School and Youth

Trends.

Drug use is increasing among people in their fifties. This is, at least in part, due to the aging of

the baby boomers, whose rates of illicit drug use have historically been higher than those of

previous cohorts.

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Substance Dependence/Abuse and Treatment

Rates of alcohol dependence/abuse declined from 2002 to 2011In 2011, 16.7 million

Americans (6.5 percent of the population) were dependent on alcohol or had problems related to

their use of alcohol (abuse). This is a decline from 18.1 million (or 7.7 percent) in 2002

After alcohol, marijuana has the highest rate of dependence or abuse among all drugs. In

2011, 4.2 million Americans met clinical criteria for dependence or abuse of marijuana in the

past year—more than twice the number for dependence/abuse of prescription pain relievers (1.8

million) and four times the number for dependence/abuse of cocaine (821,000).

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There continues to be a large “treatment gap” in this country. In 2011, an estimated 21.6

million Americans (8.4 percent) needed treatment for a problem related to drugs or alcohol, but

only about 2.3 million people (less than 1 percent) received treatment at a specialty facility.

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Glossary

Addiction: A chronic, relapsing disease, characterized by compulsive drug seeking and use and

by neurochemical and molecular changes in the brain.

Agonist: A chemical compound that mimics the action of a natural neurotransmitter to produce a

biological response.

Analog: A chemical compound that is similar to another drug in its effects but differs slightly in

its chemical structure.

Antagonist: A drug that counteracts or blocks the effects of another drug.

Buprenorphine: A mixed opiate agonist/antagonist medication for the treatment of heroin

addiction.

Craving: A powerful, often uncontrollable desire for drugs.

Detoxification: A process of allowing the body to rid itself of a drug while managing the

symptoms of withdrawal; often the first step in a drug treatment program.

Fentanyl: A medically useful opioid analog that is 50 times more potent than heroin.

Meperidine: A medically approved opioid available under various brand names (e.g., Demerol).

Methadone: A long-acting synthetic medication shown to be effective in treating heroin

addiction.

Physical dependence: An adaptive physiological state that occurs with regular drug use and

results in a withdrawal syndrome when drug use is stopped; usually occurs with tolerance.

Rush: A surge of euphoric pleasure that rapidly follows administration of a drug.

Tolerance: A condition in which higher doses of a drug are required to produce the same effect

as during initial use; often leads to physical dependence.

Withdrawal: A variety of symptoms that occur after use of an addictive drug is reduced or

stopped.

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References:

Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (December 19, 2012). "The rise in

teen marijuana use stalls, synthetic marijuana use levels, and use of 'bath salts' is very low." University of

Michigan News Service: Ann Arbor, MI. Retrieved 03/10/2013 from

http://www.monitoringthefuture.org.

National Institute on Drug Abuse, NIH Publication Number 05–4165. Heroin Abuse and Addiction.

Printed October 1997; Reprinted September 2000, Revised May 2005.

National Institute on Drug Abuse. Drug Facts: Heroin. Retrieved 03/10/2013 from

http://www.drugabuse.gov/publications/drugfacts/heroin

Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on

Drug Use and Health: Mental Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) 12-

4725. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Voss WD, Kaufman E, O'Connor SS, Comtois KA, Conner KR, Ries RK. Preventing addiction related

suicide: A pilot study. Journal of Substance Abuse Treatment. January, 2013 [In print at time of

publication].

Yoko Nomura, Yasmin L. Hurd and Daniel J. Pilowsky. Life-Time Risk for Substance Use Among

Offspring of Abusive Family Environment From the Community. Substance Use and Misuse, October

2012, Vol. 47, No. 12 , Pages 1281-1292.

Heroin Addiction and Abuse - CEU-Hours.com - p 18

Heroin Addiction and Abuse Post Test This course may be completed online at www.CEU-Hours.com 1) Street heroin is commonly cut with which of the following substances? o Sugar o Powdered Milk o Starch o All of the above 2) The effects of IV injected heroin is usually onset in about how long? o 1 second o 7-8 seconds o 1 minute o 3-5 minutes 3) According to the text, addicted individuals are about ____ more likely to commit suicide than non-addicted individuals. o 2-3 times o 3-5 times o 5-10 times o 20 times 4) Not listed as a common medical complication of heroin use. o Infection of the hear lining o Abscesses o Lung Complications o Tachycardia (Increased heart rate) 5) One advantage of Burenorphine over Methadone is: o Blood levels remain lower throughout treatment o It's completely safe in all populations o It develops lower levels of physical dependence o None of the above 6) Reported use of heroin in 8th, 10th and 12th graders ________ in the period between 2009 and 2012. o Increased o Decreased o Remained Steady o Inverted 7) Pregnant women should never be detoxed from heroin. o True o False