Heroin is an illicit drug that is highly addictive in nature. Processed with morphine, which is derived from poppy plants, it is usually found in powder form, but there are various ways heroin is made, affecting its purity. Pure heroin looks like a white powder and may be smoked or snorted. Darker, more impure heroin is diluted or dissolved, and then injected into one’s skin, muscles, or veins.
The nature of the drug’s effects brings an increased risk of overdose. Exacerbating the problem further are variations in purity. The Centers for Disease Control reported over 10,500 heroin overdose deaths in 2014, which is more than quadruple the number in 2002, in part because of unknown purity and the presence of cutting agents and filler.
What Is Heroin?
Heroin is a powder derived from opium poppies. It may come from South America, Mexico, or Southeast and Southwest Asia. Most heroin in the United States comes from South America, but “black tar” varieties from Mexico are more common in the western US. It has the appearance of coal or roofing tar, with a dark brown to black color.
The drug is extremely addictive. It works by binding to mu-opioid receptors in the brain. According to the National Institute on Drug Abuse (NIDA), these receptors are turned on as a result, stimulating the release of dopamine and inducing a feeling of pleasure. Normally, the body’s natural neurotransmitters bind to these same receptors to release dopamine. The process regulates pain and hormone release. It also helps a person naturally feel a sense of wellbeing.
By activating opioid receptors artificially, one can essentially rewire the reward system. A repeated cycle of craving and euphoria leads people down the path to addiction. Soon, they become chemically dependent on the drug and, without it, experience the severe symptoms of withdrawal. The body also develops a natural resistance to the substance, so people require higher doses over time to compensate for the lack of pleasure and/or increased withdrawal symptoms.
Street heroin is almost never pure. It may be a white powder or dark brown. The consistency can vary widely as there may be many impurities depending on the manufacturing process. Sugars, starches, powdered milk, and even other types of drugs may be added as filler. The unpredictable strength of the drug further complicates matters on top of the person’s addiction to it.Many heroin overdoses are accidental. Some people switch from a prescription opioid-based medication to the drug, for various reasons. The problem is these medications are supplied in known dosages and compositions, and heroin isn’t. Even if heroin may be easier to obtain, the purity can vary regardless of the source. There’s little or no regulation of dosage, so people often don’t know how much drug they are taking.
Impurities may be introduced to increase potency or cut production costs. In 2009, the United Nations Office on Drugs and Crime reported Afghanistan had identified several chemicals used for cutting heroin. Substances included caffeine and other compounds, such as phenolphthalein, chloroquine, and paracetamol. Caffeine makes heroin vaporize when exposed to lower temperatures, while chloroquine, a drug used to fight malaria, is widely available and low in price, but does not change the properties or use of the drug. Some believe the additive may be sold as fake heroin in Southwest Asia.
Cutting agents used include:
- Phenolphthalein: This substance has been used as a laxative, acid, or base indicator, and is a known carcinogenic, but its reasons for cutting heroin are not fully known.
- Paracetamol: An over-the-counter painkiller, it has a bitter taste and a mild analgesic effect. It might be used to disguise poor-quality heroin and is commonly used in many countries.
- Fentanyl: This narcotic pain medication is used as a cutting agent or sold as heroin. It is as much as 100 times more potent than morphine, which is why the House of Representatives Judiciary Committee approved bill H.R. 3713 in 2016 to increase the penalty of trafficking heroin cut with this drug by up to five years. This drug has been the reason for many drug-related deaths in the US.
- Tylenol PM: Cutting black tar heroin with these tablets is more practical because of the cooking process used for creating what’s known as cheese heroin. Other medications with diphenhydramine and acetaminophen may be used as well.
Flour, chalk, talcum powder, starch, and more dangerous agents, such as cocaine, methamphetamine, alprazolam, ecstasy, and crack cocaine, may also be used. The purity of street heroin, therefore, can vary greatly, anywhere from 3-99 percent, based on statistics from Johns Hopkins University. One can easily see why the risk of overdose is so high.
Effects on the Body
In the brain, heroin is converted to morphine. It binds to opioid receptors very quickly, and the resulting rush sensation is what users seek. How intense this feeling is depends on how much the person takes and how quickly the drug gets into the brain. According to the NHTSA’s Drugs and Human Performance Fact Sheets, effects start within 15-60 minutes and last up to 6 hours; the initial rush might last from less than a minute up to a couple hours. An intravenous dose can take as little as 7 seconds to produce a reaction.
When effects hit, skin may feel warm and flushed. Side effects often include dry mouth and heaviness in the arms and legs. Some effects can also include nausea, vomiting, and itching and, after initially experiencing the rush, a person usually feels tired for the next several hours. Slow mental, heart, and lung function results as well. If breathing slows down too much, it can be life-threatening.
On a long-term basis, heroin use changes the brain physically and chemically. It can deteriorate the white matter in the brain to some extent, which can affect a person’s behavior, stress response, and ability to make decisions. A person also builds tolerance over time, so more and more heroin is required to get the same rush.
Withdrawal may be felt just a few hours after taking a dose, so physical dependence becomes quite strong. Users may need as many as four doses per day totally anywhere from 300-500 milligrams and in severe addictions up to 1,500 milligrams. NHTSA lists similar numbers for heroin and morphine.
When in withdrawal, a user will experience muscle/bone pain, restlessness, insomnia, vomiting, diarrhea, cold flashes, involuntary leg movements, and goosebumps. The symptoms peak within a couple of days but can last a week or even months. Variations in purity once again present a problem, because one cannot know for sure how much drug is being ingested. Combined with other drugs or chemicals that might be mixed in, this can severely complicate the presentation and outcome of a heroin overdose.
Long-term health effects of abusing heroin include:
- Contraction of diseases such as HIV and/or hepatitis B and C
- Bacterial infections
- Collapsed veins
- Heart and heart valve infections
- Liver and kidney disease
- Weight loss
- Reduced or ceased endorphin production
- Decreased pain tolerance
- Difficulty concentrating
- Learning difficulties
- Inability to think clearly
- Irresponsible and self-destructive behavior
MedlinePlus, the U.S. National Library of Medicine, says heroin and opiate users are up to 20 times more likely to die than the average person. Antidotes can be given in a hospital and a person can recover in a day or two, unless additional substances, or adulterants, are mixed in. Polydrug use increases the risks of an overdose as well. The signs of an acute overdose include:
- Dry mouth
- Low blood pressure
- Weak pulse
- Slow, difficult, shallow, or lack of breathing
- Constipation and gastric spasms
How to Treat Heroin Overdose and Addiction
A heroin overdose affects heart rate and breathing such that medical intervention is needed in order to survive. The presence of other drugs, chemicals, and substances in an impure mixture can affect survival rates and outcomes. Physical and psychological effects from these may alter the required course of treatment. Examples include fentanyl, a strong narcotic that can have biological impacts of its own.
Overdoses may be treated with naloxone. An opioid receptor antagonist, this medication binds to the receptors and blocks heroin from binding to and activating them. The medication can reverse an overdose. In 2014, the FDA approved a handheld injector to reverse opioid overdose; a single dose under the skin or into muscle is enough to suppress the drug’s effects until the person can receive medical assistance.
Medical detox is a common procedure for people with heroin addiction. Some of the medication administered may include:
- Methadone: An opioid agonist with a slow-acting formulation, methadone is taken orally. It reaches the brain and activates the receptors slowly so the person gets a dampened high. Withdrawal symptoms can be prevented by administering the medication daily and reducing or maintaining the dose over time.
- Buprenorphine: It does not produce any high or side effects, but buprenorphine takes away drug cravings and has naloxone in it. A person will therefore not get a rush by injecting the medication. The FDA approved its use in 2002.
- Naltrexone: This nonaddictive opioid antagonist blocks heroin without risk of physical dependence. It is also available in an injectable form needed only once a month.
There’s no safe way to take heroin. Whether people smoke, inhale, or inject the drug, they can never be sure of its purity and how high a dose they are getting. People develop a tolerance over time and require more heroin to experience its effects and avoid withdrawal. There’s also the issue of additional cutting agents that may be other drugs, chemicals, or toxic and hazardous compounds. A heroin overdose therefore comes with much uncertainty, so it’s best to get a friend or loved one on the path to sobriety as soon as possible.