16. Heroin Toxicity or Overdose

"The main toxic effect is decreased respiratory rate and depth, which can progress to apnea. Other complications (eg, pulmonary edema, which usually develops within minutes to a few hours after opioid overdose) and death result primarily from hypoxia. Pupils are miotic. Delirium, hypotension, bradycardia, decreased body temperature, and urinary retention may also occur.
"Normeperidine, a metabolite of meperidine, accumulates with repeated use (including therapeutic); it stimulates the CNS and may cause seizure activity."

"Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Feb. 16, 2013.

17. Heroin Toxicity, Adulterants, and Overdose Potential

"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.
"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."

Peele, Stanton, MD, (1998), "The persistent, dangerous myth of heroin overdose." Last accessed Nov. 7, 2017.

18. Opioid Withdrawal Syndrome

"The withdrawal syndrome usually includes symptoms and signs of CNS hyperactivity. Onset and duration of the syndrome depend 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 in people who were taking methadone (which has a long half-life) develops more slowly and may be less acutely severe than heroin withdrawal, although users may describe it as worse. Even after the withdrawal syndrome remits, lethargy, malaise, anxiety, and disturbed sleep may persist up to several months. Drug craving may persist for years."

"Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Jan. 12, 2013.

19. Community Epidemiology Working Group Indicators of Heroin Use in the US, 2013

"Sixteen of 19 CEWG area representatives reported stable or increasing heroin indicators for the 2013 reporting period, compared with 2012. Indicators, including mainly mortality, primary treatment admissions, and some law enforcement indicators, were observed as increasing in Atlanta, Baltimore City and Maryland, Boston, Cincinnati, Denver/Colorado, Maine, Minneapolis/St. Paul, New York City, San Francisco, Seattle, South Florida/Miami-Dade and Broward Counties, and Texas. Heroin levels were described as high relative to other drugs and indicators as relatively stable by area representatives from Chicago, Detroit, St. Louis, and San Diego. Heroin indicators were reported by area representatives as mixed (with some indicators decreasing, some stable, and some increasing) in two CEWG areas — Los Angeles and Phoenix. Trends for heroin were unclear in Philadelphia in this reporting period, according to the area representative. None of the 19 CEWG area representatives reported declining indicators for heroin for 2013."

"Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group, Highlights and Executive Summary, June 2014" (Bethesda, MD: National Institute on Drug Abuse, September 2014), p. 20.

20. Data Limitations Make Estimating Demographics of Heroin Users in the US Difficult

"The prevalence of heroin use is extremely difficult to estimate despite the fact that harm to society associated with heroin marketing and use is substantial. A disproportionate number of heroin users are part of the nonsampled populations in general prevalence surveys (persons with no fixed address, prison inmates, etc.) Also, heroin users are believed to represent less than one half of one percent of our total population, making heroin usage a relatively rare event. Sample surveys are not sensitive enough to measure rare events reliable. Data from the National Household Survey on Drug Abuse (which is considered to produce conservative estimates), indicated that 1.9 percent of blacks, 1.6 percent of Hispanics, and 1.4 percent of whites had ever tried heroin. As will be noted later in this report, the data available from hospital emergency rooms and from drug abuse treatment programs indicated that heroin use is a more serious problem among blacks than whites and Hispanics."

Andrea N. Kopstein and Patrice T. Roth, "Drug Abuse Among Racial/Ethnic Groups" (Rockville, MD: National Institute on Drug Abuse, 1993), p. 13.