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Heroin is a highly addictive drug, and its abuse has repercussions
that extend far beyond the individual user. The medical
and social consequences of drug abuse - HIV/AIDS, tuberculosis,
fetal effects, crime, violence, and disruptions in family,
workplace, and educational environments - have a devastating impact
on society and cost billions of dollars each year.
Although heroin abuse has trended downward during the past several
years, its prevalence is still higher than in the early
1990s. These relatively high rates of abuse, especially among
school-age youth, and the glamorization of heroin in music and
films make it imperative that the public has the latest scientific
information on this topic. Heroin also is increasing in
purity and decreasing in price, which makes it an attractive option
for young people.
Like many other chronic diseases, addiction can be treated.
Fortunately, the availability of treatments to manage opiate
addiction and the promise from research of new and effective
behavioral and pharmacological therapies provides hope for
individuals who suffer from addiction and for those around them. For
example, buprenorphine, approved by the Food and Drug
Administration (FDA) in 2002, provides a less addictive alternative
to methadone maintenance, reduces cravings with only mild
withdrawal symptoms, and can be prescribed in the privacy of a
doctor's office.
The National Institute on Drug Abuse (NIDA) has developed this
publication to provide an overview of the state of heroin
abuse and addiction. We hope this compilation of scientific
information on heroin will help to inform readers about the
harmful effects of heroin abuse and addiction as well as assist in
prevention and treatment efforts.
Nora D.Volkow, M.D.
Director
National Institute on Drug Abuse
Heroin is an illegal, highly addictive drug. It is both the most
abused and the most rapidly acting of the 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.
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.
According to the Monitoring the Future survey, NIDA's nationwide
annual survey of drug use among the Nation's 8th-, 10th-,
and 12th-graders, heroin use remained stable from 2003 to 2004.
Lifetime heroin use measured 1.6 percent among 8th-graders
and 1.5 percent among 10th- and 12th-graders.
The 2002 Drug Abuse Warning Network (DAWN), which collects data on
drug-related hospital emergency department (ED) episodes
from 21 metropolitan areas, reported that in 2002, heroin-related ED
episodes numbered 93,519.
NIDA's Community Epidemiology Work Group (CEWG), which provides
information about the nature and patterns of drug use in 21
areas, reported in its December 2003 publication that heroin was
mentioned as the primary drug of abuse for large portions of
drug abuse treatment admissions in Baltimore, Boston, Detroit, Los
Angeles, Newark, New York, and San Francisco.
Heroin is usually injected, sniffed/snorted, or smoked. 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, peak effects are
usually felt within 10 to 15 minutes. NIDA researchers have
confirmed that all forms of heroin administration are addictive.
Route of Administration Among
Heroin Treatment Admissions in Selected Areas
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.
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
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. eroin overdose is a particular risk on the street, where the amount
and purity of the drug cannot be accurately known.
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.
Short- and Long-Term Effects of Heroin Use
Short-Term Effects
Long-Term Effects
"Rush"
Depressed respiration
Clouded mental functioning
Nausea and vomiting
Suppression of pain
Spontaneous abortion
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 problems
Medical consequences of chronic heroin injection use 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
bloodborne viruses, which drug abusers can then pass on to their
sexual partners and children.
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.
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 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.
A variety of effective treatments are available for heroin
addiction. Treatment tends to be more effective when heroin abuse
is identified early. The treatments that follow vary depending on
the individual, but methadone, a synthetic opiate that
blocks the effects of heroin and eliminates withdrawal symptoms, has
a proven record of success for people addicted to
heroin. Other pharmaceutical approaches, such as buprenorphine, and
many behavioral therapies also are used for treating
heroin addiction. Buprenorphine is a recent addition to the array of
medications now available for treating addiction to
heroin and other opiates. This medication is different from
methadone in that it offers less risk of addiction and can be
prescribed in the privacy of a doctor's office. Buprenorphine/naloxone
(Suboxone) is a combination drug product formulated to
minimize abuse.
NIDA National Drug Abuse Treatment Clinical Trials Network
States highlighted currently have CTN Nodes in place.
Detoxification
Detoxification programs aim to achieve safe and humane withdrawal
from opiates by minimizing the severity of withdrawal
symptoms and other medical complications. The primary objective of
detoxification is to relieve withdrawal symptoms while
patients adjust to a drug-free state. Not in itself a treatment for
addiction, detoxification is a useful step only when it
leads into long-term treatment that is either drug-free (residential
or outpatient) or uses medications as part of the
treatment. The best documented drug-free treatments are the
therapeutic community residential programs lasting 3 to 6 months.
Opiate withdrawal is rarely fatal. It is characterized by acute
withdrawal symptoms which peak 48 to 72 hours after the last
opiate dose and disappear within 7 to 10 days, to be followed by a
longer term abstinence syndrome of general malaise and
opioid craving.
Buprenorphine
A New Medication for Treating Opiate Addiction
First medication developed to treat opiate addiction in the privacy
of a physician's office.
Binds to same receptors as morphine, but does not produce the same
effects.
Offers a valuable tool for physicians in treating the nearly 900,000
chronic heroin users in the U.S.
As of March 2004, 3,951 U.S. physicians were eligible to prescribe
buprenorphine to patients.
The Story of Discovery
First synthesized as an analgesic in England, 1969.
Recognized as a potential addiction treatment by NIDA researchers in
the 1970s.
NIDA created Medications Development Division to focus on developing
drug treatments for addiction, 1990.
NIDA formed an agreement with the original developer to bring
buprenorphine to market in the U.S., 1994.
Buprenorphine tablets approved by the FDA, 2002.
Methadone programs
Methadone treatment has been used for more than 30 years to
effectively and safely treat opioid addiction. Properly
prescribed methadone is not intoxicating or sedating, and its
effects do not interfere 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 reactions. 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 street doses of heroin are
ineffective at producing euphoria, thus making the use of heroin
more easily extinguishable.
Methadone's effects last four to six times as long as those of
heroin, so people in treatment need to take it only once a
day. Also, methadone is medically safe even when used continuously
for 10 years or more. Combined with behavioral therapies
or counseling and other supportive services, methadone enables
patients to stop using heroin (and other opiates) and return
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.
Buprenorphine and other medications
Buprenorphine is a particularly attractive treatment for heroin
addiction because, compared with 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 heroin
overdose or addiction are currently under investigation by NIDA.
In addition to methadone and buprenorphine, other drugs aimed at
reducing the severity of the withdrawal symptoms can be
prescribed. Clonidine is of some benefit but its use is limited due
to side effects of sedation and hypotension. Lofexidine,
a centrally acting alpha-2 adrenergic agonist, was launched in 1992
specifically for symptomatic relief in patients
undergoing opiate withdrawal. Naloxone and naltrexone are
medications that also block the effects of morphine, heroin, and
other opiates. As antagonists, they are especially useful as
antidotes. Naltrexone has long-lasting effects, ranging from 1
to 3 days, depending on the dose. Naltrexone blocks the pleasurable
effects of heroin and is useful in treating some highly
motivated individuals. Naltrexone has also been found to be
successful in preventing relapse by former opiate addicts
released from prison on probation.
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.
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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