Heroin is an illegal, highly addictive drug processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. It is typically sold as white or brownish powder that is “cut” with sugars, starch, powdered milk, or quinine. Pure heroin is a white powder is white powder with a bitter taste that predominantly originates in South America and, to a lesser extent, from Southeast Asia, and dominates U.S markets east of the Mississippi River. Highly pure heroin can be snorted or smoked and may be more appealing to new users because it eliminates the stigma associated with injection drug use. “Black tar” heroin is sticky like roofing tar or hard like coal and is predominantly produced in Mexico and sold in U.S. areas west of the Mississippi River. The dark color associated with black tar heroin results from crude processing methods that leave behind impurities. Impure heroin is usually from crude processing methods that leave behind impurities. Impure heroin is usually dissolved, diluted, and injected into veins, muscles, or under the skin.
According to the National Survey on Drugs Use and Health (NSDUH), in 2012 about 669,000 Americans reported using heroin in the past year, a number that has been on the rise since 2007. This trend appears to be driven largely by young adults aged 18- 25 among whom there have been the greatest increases. The number of people using heroin for the first time is unacceptably high, with 156,000 people starting heroin use in 2012, nearly double the number of people in 2006 (90,000). In contrast, heroin use has been declining among teens aged 12- 17. Past- year heroin use among the Nation’s 8th, 10th, and 12th- graders is at its lowest levels in the history of the Monitoring the Future survey, at less than 1 percent of those surveyed in all 3 grades from 2005 to 2013.
It is no surprise that with heroin use on the rise, more people are experiencing negative health effects that occurs from repeated use. The number of people meeting Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for dependence or abuse of heroin doubled from 214,000 in 2002 to 467,000 in 2012. The recently released DSM-V no longer separates substance abuse from dependence, but instead provides criteria for opioid use disorders that range from mild to severe, depending on the number of symptoms a person has. Data on the scope and severity of opioid use disorders in the United States are not yet available for these new criteria.
The impact of heroin use us felt all across the United States, with heroin being identified as the most or one of the most important drug abuse issues affecting several local regions from coast to coast. The rising harm associated with heroin use at the community level was presented in a report produced by NIDA Community Epidemiology Work Group (CEWG). The CEWG is comprised of researchers from major metropolitan areas in the United States and selected foreign countries and provides community- level surveillance of drug abuse and its consequences to identify emerging trends.
Heroin use no longer predominates solely in urban areas. Several suburban and rural communities near Chicago and St. Louis report increasing amounts of heroin seized by officials as well as increasing numbers of overdose deaths due to heroin use. Heroin use is also on the rise in many urban areas among young adults aged 18-25. Individuals in this age group seeking treatment for heroin abuse increased from 11 percent of total admissions in 2008 to 26 percent in the first half of 2012.
Heroin binds to and activates specific receptors in the brain called mu-opioid receptors (MORs). Our bodies contain naturally occurring chemicals called neurotransmitters that bind to these receptors throughout the brain and body to regulate pain, hormone release, and feelings of well- being. When MORs are activated in the reward center of the brain, they stimulate the release of the neurotransmitter dopamine, causing a sensation of pleasure. The consequences of activating opioid receptors with externally administered opioids such as heroin (versus naturally occurring chemicals within our bodies) depend on a variety of factors: how much is used, when in the brain or body it binds, how strongly it binds and for how long, how quickly it gets there, and what happens afterward.
Once heroin enters the brain, it 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 opioid receptors. 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, users usually will be drowsy for several hours; mental function is clouded; heart function slows; and breathing is also severely slowed, sometimes enough to be life- threatening. Slowed breathing can also lead to coma and permanent brain damage.
Repeated heroin use changes the physical structure13 and physiology of the brain, creating long-term imbalances in neuronal and hormonal systems that are not easily reversed. Studies have shown some deterioration of the brain’s white matter due to heroin use, which may affect decision-making abilities, the ability to regulate behavior, and responses to stressful situations. Heroin also produces profound
degrees of tolerance and physical dependence. Tolerance occurs when more and more of the drug is required to achieve the same effects. 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 24–48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Finally, repeated heroin use often results in addiction—a chronic relapsing disease that goes beyond physical dependence and is characterized by uncontrollable drug-seeking no matter the consequences. Heroin is extremely addictive no matter how it is administered, although routes of administration that allow it to reach the brain the fastest (i.e., injection and smoking) increase the risk of addiction. Once a person becomes addicted to heroin, seeking and using the drug becomes their primary purpose in life.
No matter how they ingest the drug, chronic heroin users experience a variety of medical complications including insomnia and constipation. Lung complications (including various types of pneumonia and tuberculosis) may result from the poor health of the user as well as from heroin’s effect of depressing respiration. Many experience mental disorders such as depression and antisocial personality disorder. Men often experience sexual dysfunction and women’s menstrual cycles often become irregular. There are also specific consequences associated with different routes of administration. For example, people who repeatedly snort heroin can damage the mucosal tissues in their noses as well as perforate the nasal septum (the tissue that separates the nasal passages). Medical consequences of chronic injection use include scarred and/or collapsed veins, bacterial infections of the blood vessels and heart valves, abscesses (boils), and other soft-tissue infections. 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. 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.
Heroin use increases the risk of being exposed to HIV, viral hepatitis, and other infectious agents through contact with infected blood or body fluids (e.g., semen, saliva) that results from the sharing of syringes and injection paraphernalia that have been used by infected individuals or through unprotected sexual contact with an infected person. Snorting or smoking does not eliminate the risk of infectious disease like hepatitis and HIV/AIDS because people under the influence of drugs still engage in risky sexual and other behaviors that can expose them to these diseases.
Injection drug users (IDUs) are the highest-risk group for acquiring hepatitis C (HCV) infection and continue to drive the escalating HCV epidemic: Each IDU infected with HCV is likely to infect 20 other people.21 Of the 17,000 new HCV infections occurring in the United States in 2010, over half (53 percent) were among IDUs.22 Hepatitis B (HBV) infection in IDUs was reported to be as high as 20 percent in the United States in 2010,23 which is particularly disheartening since an effective vaccine that protects against
HBV infection is available. There is currently no vaccine available to protect against HCV infection.
Drug use, viral hepatitis and other infectious diseases, mental illnesses, social dysfunctions, and stigma are often co-occurring conditions that affect one another, creating more complex health challenges that require comprehensive treatment plans tailored to meet all of a patient’s needs. For example, NIDA funded research has found that drug abuse treatment along with HIV prevention and community-based outreach programs can help people who use drugs change the behaviors that put them at risk for contracting HIV and other infectious diseases. They can reduce drug use and drug-related risk behaviors such as needle sharing and unsafe sexual practices and, in turn, reduce the risk of exposure to HIV/AIDS and other infectious diseases. Only through coordinated utilization of effective antiviral therapies coupled with treatment for drug abuse and mental illness can the health of those suffering from these conditions be restored.
A variety of effective treatments are available for heroin addiction, including both behavioral and pharmacological (medications). Both approaches help to restore a degree of normalcy to brain function and behavior, resulting in increased employment rates and lower risk of HIV and other diseases and criminal behavior. Although behavioral and pharmacologic treatments can be extremely useful when utilized alone, research shows that for some people, integrating both types of treatments is the most effective approach.
Scientific research has established that pharmacological treatment of opioid addiction increases retention in treatment programs and decreases drug use, infectious disease transmission, and criminal activity.
When people addicted to opioids first quit, they undergo withdrawal symptoms (pain, diarrhea, nausea, and vomiting), which may be severe. Medications can be helpful in this detoxification stage to ease craving and other physical symptoms, which often prompt a person to relapse. While not a treatment for addiction itself, detoxification is a useful first step when it is followed by some form of evidence-based treatment.
Medications developed to treat opioid addiction work through the same opioid receptors as the addictive drug, but are safer and less likely to produce the harmful behaviors that characterize addiction. Three types of medications include: (1) agonists, which activate opioid receptors; (2) partial agonists which also activate opioid receptors but produce a smaller response; and (3) antagonists, which block the receptor and interfere with the rewarding effects of opioids. A particular medication is used based on a patient’s specific medical needs and other factors. Effective medications include:
• Methadone (Dolophine® or Methadose®) is a slow-acting opioid agonist. Methadone is taken orally so that it reaches the brain slowly, dampening the “high” that occurs with other routes of administration while preventing withdrawal symptoms. Methadone has been used since the 1960s to treat heroin addiction and is still an excellent treatment option, particularly for patients who do not respond well to other medications. Methadone is only available through approved outpatient treatment programs, where it is dispensed to patients on a daily basis.
• Buprenorphine (Subutex®) is a partial opioid agonist. Buprenorphine relieves drug cravings without producing the “high” or dangerous side effects of other opioids. Suboxone® is a novel formulation of buprenorphine that is taken orally or sublingually and contains naloxone (an opioid antagonist) to prevent attempts to get high by injecting the medication. If an addicted patient were to inject Suboxone, the naloxone would induce withdrawal symptoms, which are averted when taken orally as prescribed. FDA approved buprenorphine in 2002, making it the first medication eligible to be prescribed by certified physicians through the Drug Addiction Treatment Act. This approval eliminates the need to visit specialized treatment clinics, thereby expanding access to treatment for many who need it. In February 2013, FDA approved two generic forms of Suboxone, making this treatment option more affordable.
• Naltrexone (Depade® or Revia®) is an opioid antagonist. Naltrexone blocks the action of opioids, is not addictive or sedating, and does not result in physical dependence; however, patients often have trouble complying with the treatment, and this has limited its effectiveness. An injectable long-acting formulation of naltrexone (Vivitrol®) recently received FDA approval for treating opioid addiction. Administered once a month, Vivitrol® may improve compliance by eliminating the need for daily dosing.
The many effective behavioral treatments available for heroin addiction can be delivered in outpatient and residential settings. Approaches such as contingency management and cognitive-behavioral therapy have been shown to effectively treat heroin addiction, especially when applied in concert with medications. Contingency management uses a voucher-based system in which patients earn “points” based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitive-behavioral therapy is designed to help modify the patient’s expectations and behaviors related to drug use and to increase skills in coping with various life stressors. An important task is to match the best treatment approach to meet the particular needs of the patient.