Heroin

"Heroin is a synthetic opiate drug that is highly addictive. It is made from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as 'black tar heroin.'"

"Heroin (diamorphine) was the trade name of a drug launched by Bayer in 1898,¹ although it is now better known as an illicit drug responsible for infectious disease spread, fatal overdoses, and criminal activity.^2,3"

Heroin - Effects

"Acute intoxication is characterized by euphoria and drowsiness. Mast cell effects (eg, flushing, itching) are common, particularly with morphine. GI [gastro-intestinal] effects include nausea, vomiting, decreased bowel sounds, and constipation."

"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, they may experience severe symptoms of withdrawal. These symptoms, which can begin as early as a few hours after the last drug administration, include restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps ('cold turkey'), kicking movements ('kicking the habit'), and other symptoms. Users also experience severe craving for the drug during withdrawal, precipitating continued abuse and/or relapse. Major withdrawal symptoms peak between 48 and 72 hours after the last dose and typically subside after about a week; however, some individuals 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."

"The withdrawal syndrome usually includes symptoms and signs of CNS [Central Nervous System] hyperactivity. Onset and duration of the syndrome depends on the specific drug and its half-life. Symptoms may appear as early as 4 h after the last dose of heroin, peak within 48 to 72 h, and subside after about a week. Anxiety and a craving for the drug are followed by increased resting respiratory rate (> 16 breaths/min), usually with diaphoresis, yawning, lacrimation, rhinorrhea, mydriasis, and stomach cramps. Later, piloerection (gooseflesh), tremors, muscle twitching, tachycardia, hypertension, fever and chills, anorexia, nausea, vomiting, and diarrhea may develop. Opioid withdrawal does not cause fever, seizures, or altered mental status. Although it may be distressingly symptomatic, opioid withdrawal is not fatal."

"The withdrawal syndrome is self-limited and, although severely uncomfortable, is not life threatening. Minor metabolic and physical withdrawal effects may persist up to 6 mo. Withdrawal is typically managed in outpatient settings, unless patients require hospitalization for concurrent medical or mental health problems.

"Options for management of withdrawal include: Allowing the process to run its course ('cold turkey') after the patient's last opioid dose and administering another opioid (substitution) that can be tapered on a controlled schedule. Clonidine can provide some symptom relief during withdrawal."

"The shift toward less restrictive access to care is predicated not only on the aforementioned treatment gap but also on strong scientific evidence supporting the efficacy of opioid replacement therapy. There appears to be a specific neurologic basis for the compulsive use of heroin. Chronic heroin abusers end up with an endogenous opioid deficiency because of down-regulation of opioid production. This creates an overwhelming craving, which necessitates effective treatments that shift the addicted patient’s interests from obsessive preoccupation with the timing and dose of an illicit substance to more ordinary topics and less dangerous behaviors.³⁸"

"Long-term effects of the opioids themselves are minimal; even decades of methadone use appear to be well tolerated physiologically, although some long-term opioid users experience chronic constipation, excessive sweating, peripheral edema, drowsiness, and decreased libido. However, many long-term users who inject opioids have adverse effects from contaminants (eg, talc) and adulterants (eg, nonprescription stimulant drugs); cardiac, pulmonary, and hepatic damage from infections such as HIV infection and hepatitis B or C, which are spread by needle sharing and nonsterile injection techniques."

"In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog the blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs."

"Medications to help prevent [opiate] relapse include:

"Methadone, which 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, as dispensed, it has a gradual onset of action and sustained effects, reducing the desire for other opioid drugs while preventing withdrawal symptoms. Properly prescribed methadone is not intoxicating or sedating, and its effects do not interfere with ordinary daily activities. At the present time, methadone is only available through specialized opiate treatment programs."

"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."

"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."

"Unlike alcohol or tobacco, heroin causes no ongoing toxicity to the tissues or organs of the body. Apart from causing some constipation, it appears to have no side effects in most who take it. When administered safely, its use may be consistent with a long and productive life. The principal harm comes from the risk of overdose, problems with injecting, drug impurities and adverse legal or financial consequences."

"People rarely die from heroin overdoses - meaning pure concentrations of the drug which simply overwhelm the body's responses."

"But when people take whatever they can off the street, they have no way of knowing how the drug is adulterated. And when they decide to augment heroin's effects, possibly because they do not want to take too much heroin, they may place themselves in the greatest danger."

"A range of treatments exist for heroin addiction, including medications and behavioral therapies. Science has taught us that when medication treatment is integrated with other supportive services, patients are often able to stop using heroin (or other opiates) and return to stable and productive lives."

"Treatment providers anecdotally report that some prescription opioid abusers are switching to heroin as they build tolerance to prescription opioids and seek a more euphoric high. Further anecdotal reporting by treatment providers indicates that some prescription opioid abusers are switching to heroin in a few areas where heroin is less costly or more available than prescription opioids."

Heroin - Data

(2009)
"• The global area under opium poppy cultivation declined to 181,400 hectares (ha) in 2009 (15%) or by 23% since 2007.

"• In line with declines in the area under cultivation, global opium production fell from 8,890 metric tons (mt) in 2007 to 7,754 mt in 2009 (-13%), and potential heroin production declined from 757 mt in 2007 to 657 mt in 2009."

(2008) "According to the 2008 National Survey on Drug Use and Health, the number of current (past-month) heroin users aged 12 or older in the United States increased from 153,000 in 2007 to 213,000 in 2008. There were 114,000 first-time users of heroin aged 12 or older in 2008."

(2008) "In terms of absolute numbers, the Russian Federation is particularly affected with its 1.5 million addict population. The hugely damaging threat of HIV/AIDS is directly related to heroin injection. To date, there are over a quarter of a million registered HIV cases (although the number of unregistered cases is estimated to be much higher than this) in the Russian Federation. Of these, over 80% are intravenous drug users. In the CARs, nearly 15 years of continuous heroin transit has created a local market of 282,000 heroin users, consuming approximately 11 mt of heroin annually. Local opium consumption is estimated at approximately 34 mt (although demand in Turkmenistan may be underestimated). This puts some Central Asian states on par with countries with the highest global opiate abuse prevalence."

(2006) "In 2006, heroin abuse indicators decreased in 7 CEWG areas, were stable in 14, and mixed in 1 (Texas). Injection continued to be the preferred route of heroin administration among primary heroin admissions in most CEWG areas, particularly areas west of the Mississippi River where black tar heroin is the most available form of the drug. Heroin primary treatment admissions, as a percentage of total admissions (excluding primary alcohol admissions), were particularly high in Boston (approximately 76 percent), Baltimore (54 percent), Chicago (47 percent), Detroit and New York City (each 38 percent). As shown in the Cocaine/Crack section (pages 11-20), high percentages of all primary heroin treatment admissions in 10 CEWG areas reported using cocaine as a secondary or tertiary drug, with the proportions ranging from 19 percent in Los Angeles to 43 percent in New York City. Deaths involving heroin or heroin/morphine continued to be high in the Albuquerque, Detroit, Philadelphia, and New York City areas. Purity of white powder heroin, the most likely form to be inhaled or snorted, increased in 2005 in eight CEWG areas after substantial declines in most of these areas from 1999, including a decline in 2004. The purity of Mexican black tar heroin varied across 10 CEWG areas but increased in 4 from 2002 to 2005. CEWG representatives cited changes in the patterns of heroin use, based on a number of factors, including purity levels, the way heroin was used, and the number and types of substances
used with heroin."

(2005) "The proportion of heroin and opium seizures has increased every year since 1999 and seizures of these two drugs increased from 38 percent in 2005 to 67 percent in 2006. At the same time, the number of significant heroin and opium seizures (according to UNODC classification) has also increased."

(2002) "The incidence of regular heroin use in the canton of Zurich started with about 80 new users in 1975, increased to 850 in 1990, and declined to 150 in 2002, and was thus reduced by 82%. Incidence peaked in 1990 at a similar high level to that ever reported in New South Wales, Australia, or in Italy. But only in Zurich has a decline by a factor of four in the number of new users of heroin been observed within a decade. This decline in incidence probably pertains to the whole of Switzerland because the number of patients in substitution treatment is stable, the age of the substituted population is rising, the mortality caused by drugs is declining, and confiscation of heroin is falling. Furthermore, incidence trends did not differ between urban and rural regions of Zurich. This finding is suggestive of a more similar spatial dynamic of heroin use for Switzerland than for other countries."

(2007 - price of heroin) In 2007, a kilogram of heroin no. 3 typically sold for an average wholesale price of $2,520 in Pakistan; the average 2005 per-kilogram wholesale price of heroin no. 4 in that country equaled approximately $4,159. The 2007 wholesale price for a kilogram of heroin in Afghanistan ranged around $2,405. In Colombia, a kilogram of heroin no. 4 typically sold for $9,992 wholesale in 2006. In the United States in 2007, a kilogram of heroin no. 4 cost an average of $71,200 wholesale.

Heroin - Law and Policy

The U.S. Penal Code violations for heroin and possible sentences:

Violation: "1 kilogram or more of a mixture or substance containing a detectable amount of heroin"
Sentence: "not less than 10 years or more than life" ... "No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment imposed therein."

Violation: "100 grams or more of a mixture or substance containing a detectable amount of heroin"
Sentence: "not less than 5 years and not more than 40 years" ... "No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment imposed therein."

(law) "Many countries believe (erroneously) that the international drug conventions prohibit the use of heroin in medical treatment. Furthermore, the International Narcotics Control Board (INCB) has exerted great pressure on countries to cease prescribing heroin for any medical purpose. Nevertheless, a few countries, including the UK, Belgium, the Netherlands, Iceland, Malta, Canada and Switzerland, continue to use heroin (diamorphine) for general medical purposes, mostly in hospital settings (usually for severe pain relief). Until recently, however, Britain was the only country that allowed doctors to prescribe heroin for the treatment of drug dependence."

(policy)In November 1997, the National Institutes of Health (NIH) convened a Consensus Panel on Effective Medical Treatment of Heroin Addiction. The panel of national experts concluded:

"• Vigorous and effective leadership is needed within the Office of National Drug Control Policy (ONDCP) (and related Federal and State agencies) to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.

"• Society must make a commitment to offering effective treatment for opiate dependence to all who need it.

"• The panel calls attention to the need for opiate-dependent persons under legal supervision to have access to MMT. The ONDCP and the U.S. Department of Justice should implement this recommendation.

"• The panel recommends improved training of physicians and other health care professionals in diagnosis and treatment of opiate dependence. For example, we encourage the National Institute on Drug Abuse and other agencies to provide funds to improve training for diagnosis and treatment of opiate dependence in medical schools.

"• The panel recommends that unnecessary regulation of MMT and all long-acting agonist treatment programs be reduced.

"• Funding for MMT should be increased.

"• We advocate MMT as a benefit in public and private insurance programs, with parity of coverage for all medical and mental disorders.

"• We recommend targeting opiate-dependent pregnant women for MMT.

"• MMT must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.

"• Patients, underrepresented minorities, and consumers should be included in bodies charged with policy development guiding opiate dependence treatment.

"• We recommend expanding the availability of opiate agonist treatment in those States and programs where this treatment option is currently unavailable."

Heroin - Research

"The majority of drug deaths in an Australian study, conducted by the National Alcohol and Drug Research Centre, involved heroin in combination with either alcohol (40 percent) or tranquilizers (30 percent).

(heroin - naloxone) "Naloxone distribution programs in the US are ongoing in Chicago, Baltimore, San Francisco, New Mexico and New York City. Additional community-based organizations interested in minimizing the adverse consequences of drug use in several cities in the US, including Los Angeles, Providence, Pittsburgh and Boston, are in the process of planning and developing naloxone administration programs for drug users. The recommendations presented [in this study] are designed to assist other SEPs [Syringe Exchange Programs] and health promotion centers in their planning, implementation and evaluation of similar programs for opiate users ....

"First, take-home naloxone distribution programs for opiate users are feasible and both programmatic experience and data suggests that drug users can be trained to respond to heroin overdose by giving naloxone ....

"Second, flexibility is essential in the development, implementation and evaluation of naloxone administration programs. This flexibility means adapting overdose prevention training curriculum to be delivered quickly and effectively in numerous settings ....

"Third, evaluation components should be designed for feasibility and simplicity ....

"Fourth, the program is entirely dependent on opiate user participation–responding to and incorporating feedback from participants (i.e. multiple outreach strategies, flexible hours for naloxone prescription by the medical physician, an abbreviated training curriculum) is integral for program success.

(heroin maintenance vs. methadone) "The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs.

"The NAOMI study will enrol 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal sites are expected to begin recruitment this spring. "Each site will enroll about 157 participants. About half of these volunteers will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic. Those in the heroin group will be treated for 12 months then transitioned, over three months, into either methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that the total time to complete the study will be 21 to 24 months."

(heroin maintenance) "The central result of the German model project shows a significant superiority of heroin over methadone treatment for both primary outcome measures. Heroin treatment has significantly higher response rates both in the field of health and the reduction of illicit drug use. According to the study protocol, evidence of the greater efficacy of heroin treatment compared to methadone maintenance treatment has thus been produced. Heroin treatment is also clearly superior to methadone treatment when focusing on patients, who fulfill the two primary outcome measures."

(heroin maintenance) "To conclude, it must be stated that heroin treatment involves a somewhat higher safety risk than methadone treatment. This is mainly due to the intravenous form of application. The rather frequently occurring respiratory depressions and cerebral convulsions are not unexpected and can easily be clinically controlled. Overall, the mortality rate was low during the first study phase, and no death occurred with a causal relationship with the study medication. Compared to much higher health risks related to the i.v. application of street heroin, the safety risk of medically controlled heroin prescription has to be considered as low."

(heroin maintenance) "The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

(heroin maintenance) "The UK is exceptional internationally because heroin is included in the range of legally sanctioned treatments for opiate dependence. In practice, this treatment option is rarely utilised: only about 448 heroin users receive heroin on prescription."`

(heroin - overdose) "A striking finding from the toxicological data was the relatively small number of subjects in whom morphine only was detected. Most died with more drugs than heroin alone 'on board', with alcohol detected in 45% of subjects and benzodiazepines in just over a quarter. Both of these drugs act as central nervous system depressants and can enhance and prolong the depressant effects of heroin."

(heroin - overdose)" If it is not pure drugs that kill, but impure drugs and the mixture of drugs, then the myth of the heroin overdose can be dangerous. If users had a guaranteed pure supply of heroin which they relied on, there would be little more likelihood of toxic doses than occur with narcotics administered in a hospital."

(heroin - overdose)"Our findings that an ambulance was called while the subject was still alive in only 10% of cases, and that a substantial minority of heroin users died alone, strongly suggest that education campaigns should also emphasise that it is safer to inject heroin in the company of others, and important to call for an ambulance early in the event of an overdose. Consideration should also be given to trialling the distribution of the opioid antagonist naloxone to users to reduce mortality from heroin use."

(heroin - overdose)" The disadvantage of continuing to describe heroin-related fatalities as 'overdoses' is that it attributes the cause of death solely to heroin and detracts attention from the contribution of other drugs to the cause of death. Heroin users need to be educated about the potentially dangerous practice of concurrent polydrug and heroin use."

(heroin - naloxone & overdose) "This pilot trial is the first in North America to prospectively evaluate a program of naloxone distribution to IDUs to prevent heroin overdose death. After an 8-hour training, our study participants' knowledge of heroin overdose prevention and management increased, and they reported successful resuscitations during 20 heroin overdose events. All victims were reported to have been unresponsive, cyanotic, or not breathing, but all survived. These findings suggest that IDUs can be trained to respond to heroin overdose by using CPR and naloxone, as others have reported. Moreover, we found no evidence of increases in drug use or heroin overdose in study participants. These data corroborate the findings of several feasibility studies recommending the prescription and distribution of naloxone to drug users to prevent fatal heroin overdose."

(heroin maintenance) "These pilot study findings showed that opiate-dependent injecting drug users with long injecting careers (most started between 1970 and 1982) and for whom opiate treatment had failed multiple times previously were attracted into and retained by therapy with injectable opiates."