What is heroin?

Heroin is extremely addictive and its use is a severe problem. It is both the most abused and the most rapidly acting of the opiates. It is normally sold as a brownish powder. Heroin addiction is often a stage in a young adult's life, rather than the final chapter. In many places the addiction is more to the lifestyle of the needle and to whatever can be injected through it, including a wide range of opiates - part of the same family of drugs as heroin. Pure heroin addiction is very unusual, as pure heroin is not readily available.

Heroin used to be an end-stage drug; the one someone used after all the others. This is no longer true. With the huge fall in the street price of heroin, heroin is becoming an experimental drug for large numbers of young people, who may not be injecting it. Deaths can be accidental from overdosing, or from multiple medical problems caused by injecting infected material over a long time, but heroin can wipe out a large section of an entire community. Once addiction is established, heroin kills around 1.5% of heroin users a year, but that's without the impact of AIDS. Lots of current studies suggest a shift from injecting heroin to snorting or smoking because of increased purity and the delusion that these forms of use will not lead to addiction.

All street heroin is "cut" with other drugs or with substances such as sugar, starch, powdered milk, or quinine. Street heroin 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. Heroin also poses special problems because of the spread of HIV and other diseases that can occur from sharing needles or other injection equipment. Heroin is off-white brown powder made from extracts of poppies, papaverum somniferum. The raw opium is collected from the dried milky sap of the opium poppy, which forms a gum containing codeine, morphine and alkaloids. Heroin is made from the morphine and is estimated to be 50% more powerful than morphine.

These poppies are now grown in many countries including Burma, Afghanistan and more recently in the former republics of the Soviet Union as well as Columbia. Many synthetic opiates are also finding their way onto the street from pharmaceutical companies. These include pethidine, buprenorphine (Temgesic), dipipanone (Diconal) and methadone (Physeptone). Other milder opiate preparations are also abused including dihydrocodeine (DF118) and codeine. Heroin usually appears as a off-white brown powder. Street names for heroin include "smack," "H," "skag," “brown” “horse” and "junk." Other names may refer to types of heroin produced in a specific geographical area, such as "Mexican black tar."

Heroin addiction makes headlines and raises the blood pressure of politicians yet nothing is what it seems.

How is heroin used?

Heroin can be smoked, swallowed, sniffed or injected. Fumes from heated heroin on tin foil can be inhaled ("chasing the dragon"). It makes the user feel tranquil and content, preoccupied and drowsy in larger doses. It slows reactions and damages concentration. Blood levels halve in three hours so the effect rarely lasts more than four or five hours. It causes nausea and vomiting, especially with first-time use. On-sterile injections cause abscesses, damaged veins and septicaemia, hepatitis and AIDS. Heroin, like all other opiates, also causes severe constipation. Sniffing heroin damages the nose. Heroin depresses the nervous system including coughing, breathing and heart rate, dilating blood vessels so the person feels a warm glow and dilating the pupils of the eyes. Overdoses can also occur when a user who has been supplied in the past with very impure heroin suddenly shoots up with very pure stock. The same can happen if a user has been off opiates for a while, and then uses the old dose.

The 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. 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 functions slow. 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 precisely known.

The long-term effects of heroin use?

In a word “ADDICTION”.

One of the most detrimental long-term effects of heroin is addiction itself. Addiction is a chronic, relapsing disease, characterized by compulsive drug seeking and use, and by petrochemical 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.

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 sweats 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.

Does heroin abuse affect pregnant women?

Heroin abuse can cause serious complications during pregnancy, including miscarriage and premature delivery. Children born to addicted mothers are at greater risk of SIDS (sudden infant death syndrome), as well. Pregnant women should not be detoxified from opiates because of the increased risk of spontaneous abortion or premature delivery; rather, treatment with methadone is strongly advised. Although infants born to mothers taking prescribed methadone may show signs of physical dependence, they can be treated easily and safely in the nursery. Research has demonstrated also that the effects of exposure to methadone are relatively benign.

Heroin addiction and withdrawal

With regular heroin use, tolerance develops. This means 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.

Much has been written about "cold turkey" and the huge trauma of getting a heroin addict off the drug. Withdrawal can certainly be very difficult "clucking" or "cold turkey" is characterised by unpleasant symptoms such as cold sweats, nausea, confusion and intense craving. None of these symptoms are physically dangerous. Withdrawal effects start around eight to twenty four hours after the last dose, with symptoms similar to flu - aches, chills, and sweating, sneezing, yawning and muscular spasms. These effects take a week or two to subside but feeling of weakness and loss of well being can last months. Psychological dependence can be even harder to overcome than physical dependence. Despite all this, some people have successfully come off high doses of heroin without medication or massive withdrawal symptoms (particularly common in some rehab units run as Christian foundations outside Europe). Many factors are involved, not least of all mental state. For example, a heroin user who injects regularly may experience a "hit" even if he or she is injecting medical saline (salty water) so long as the person believes it to be heroin. This so-called placebo effect can be very powerful.

Convulsions, Increased heart rate, abnormal heartbeat, Heart attack, sudden sharp blood pressure increase, Stroke, Extreme depression, Suicidal behavior.

As withdrawal progresses, elevations in blood pressure, pulse, respiratory rate and temperature occur. Symptoms of overdose -- which may result in death -- include shallow breathing, clammy skin, convulsions and coma.

Other problems that can occur from heroin addiction?

How does heroin work in the brain? So how is it that such a dangerous and addictive drug can be so safely used in medicine? To answer this question we first need to understand how the body feels pain and how the brain adjusts to it.

Heroin mimics naturally occurring opiate-like substances in the brain called endorphins. These have been extensively studied and are well understood. Endorphins are released by a whole range of normal activities including exercise and sex as well as body massage and acupuncture. They affect our perception of pain and our sense of well being.

When the same drug is given to someone who is not in pain, the brain decides that the level of opiates is too high and shuts down endorphin production, trying to bring levels back to normal. Then when the drug level falls, the person becomes endorphin deficient, and experiences withdrawal. These changes do not occur with the first dose, but accumulate over time. Recovery from physical addiction to heroin is therefore linked directly to the time it takes for the brain to get going again with its own endorphin production.

We see the contrast in medicine when someone who has been in severe pain and on high doses of opiates is suddenly relieved of pain. I remember looking after a man with advanced lung cancer who had pain in his ribs for which he was given morphine. An anaesthetist came to the ward and gave him an injection to destroy some of the pain-carrying nerves. Because these nerve blocks are often only partly successful I left the morphine dose unchanged overnight to review in the morning.

Heroin can cause feelings of depression, which may last for weeks. Attempts to stop using heroin can fail simply because the withdrawal can be overwhelming, causing the addict to use more heroin in an attempt to overcome these symptoms. This overpowering addiction can cause the addict to do anything to get heroin.