heroin: abuse and addiction (research reports)

8/2/2019 Heroin: Abuse and Addiction (Research Reports)

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What is heroin?

Heroin is an illegal, highly addictive drug. It is both

the most abused and themost rapidly acting of the opi-ates. Heroin is processed frommorphine, a naturally occurringsubstance extracted from theseed pod of certain varieties of poppy plants. It is typically soldas a white or brownish powderor as the black sticky substanceknown on the streets as “blacktar heroin.” Although purer her-

oin is becoming more common,most street heroin is “cut” withother drugs or with substancessuch as sugar, starch, powderedmilk, or quinine. Street heroincan also be cut with strychnine

Heroin is a highly addictive drug,and its abuse has repercussions that extend far beyond the individual user. The medical and social conse-quences of drug abuse—HIV/AIDS,tuberculosis, fetal effects, crime,violence, and disruptions in family,workplace, and educational environ-ments—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 rela-tively high rates of abuse, especially among school-age youth, and the

glamorization of heroin in musicand films make it imperative that the public has the latest scientificinformation on this topic. Heroinalso 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 man-age 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 withonly 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 compilationof scientific information on heroinwill 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

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HEROIN

U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s

•N a t i o n a l I n s t i t u t e s o f H e a l t h

ResearchReportN A T I O N A L I N S T I T U T E O N D R U G A B U S E

S E R I E S

Abuse and Addiction

or other poisons. Because heroinabusers do not know the actualstrength of the drug or its true

contents, they are at risk of overdose or death. Heroin alsoposes special problems becauseof the transmission of HIV andother diseases that can occurfrom sharing needles or otherinjection equipment.

What is the scopeof heroin use inthe United States?

According to the 2003National Survey on DrugUse and Health, which

may actually underestimate illicitopiate (heroin)use, an estimated3.7 millionpeople had usedheroin at sometime in theirlives, and over119,000 of themreported using it

within the monthpreceding thesurvey. An esti-mated 314,000

Americans used



2 NIDA RESEARCH REPORT SERIES

heroin in the past year, and thegroup that represented the high-est number of those users were26 or older. The survey reported

that, from 1995 through 2002, theannual number of new heroinusers ranged from 121,000 to164,000. During this period, mostnew users were age 18 or older(on average, 75 percent) andmost were male. In 2003, 57.4percent of past year heroin users

were classified with dependenceon or abuse of heroin, and anestimated 281,000 personsreceived treatment for heroinabuse.

According to the Monitoringthe Future survey, NIDA’snationwide annual survey of drug use among the Nation’s8th-, 10th-, and 12th-graders,heroin use remained stable from2003 to 2004. Lifetime heroinuse measured 1.6 percent among

8th-graders and 1.5 percentamong 10th- and 12th-graders.The 2002 Drug Abuse Warning

Network (DAWN), which collectsdata on drug-related hospitalemergency department (ED)episodes from 21 metropolitanareas, reported that in 2002,heroin-related ED episodesnumbered 93,519.

NIDA’s Community Epidemio-logy Work Group (CEWG), whichprovides information about thenature and patterns of druguse in 21 areas, reported in itsDecember 2003 publication thatheroin was mentioned as theprimary drug of abuse for largeportions of drug abuse treatmentadmissions in Baltimore, Boston,

Detroit, Los Angeles, Newark,New York, and San Francisco.

How is heroin used?

Heroin is usually injected,sniffed/snorted, or smoked.Typically, a heroin abuser

may inject up to four times aday. Intravenous injection pro-

vides the greatest intensity andmost rapid onset of euphoria(7 to 8 seconds), while intra-muscular injection produces arelatively slow onset of euphoria(5 to 8 minutes). When heroinis sniffed or smoked, peakeffects are usually felt within 10to 15 minutes. NIDA researchershave confirmed that all formsof heroin administration areaddictive.

Injection continues to bethe predominant method of

heroin use among addictedusers seeking treatment; in many CEWG areas, heroin injection isreportedly on the rise, whileheroin inhalation is declining.However, certain groups, suchas White suburbanites in theDenver area, report smoking orinhaling heroin because they believe that these routes of administration are less likely tolead to addiction.

With the shift in heroin abusepatterns comes an even morediverse group of users. In recent

years, the availability of higherpurity heroin (which is moresuitable for inhalation) and thedecreases in prices reported inmany areas have increased theappeal of heroin for new users

who are reluctant to inject.Heroin has also been appearingin more affluent communities.

100

90

80

70

60

5040

30

20

10

0Atlanta

P e r c e n

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*

L.A. Miami/ South Florida

Minneapolis/ St. Paul

New YorkCity

SanFrancisco

Source: Community Epidemiology Work Group, NIDA, December 2003, Vol. II.*Includes first half 2003 data from treatment facilities.

Inhaled Inject

Route of Administration Among HeroinTreatment Admissions in Selected Areas



NIDA RESEARCH REPORT SERIES 3

What are theimmediate (short-term) effects ofheroin use?

Soon after injection (orinhalation), heroin crossesthe blood–brain barrier. In

the brain, heroin is converted tomorphine and binds rapidly toopioid receptors. Abusers typically report feeling a surge of pleasur-able sensation—a “rush.” Theintensity of the rush is a functionof how much drug is taken andhow rapidly the drug enters thebrain and binds to the naturalopioid receptors. Heroin isparticularly addictive because

it enters the brain so rapidly. With heroin, the rush is usually accompanied by a warm flushingof the skin, dry mouth, and aheavy feeling in the extremities,

which may be accompanied by nausea, vomiting, and severeitching.

After the initial effects, abusers

usually will be drowsy for severalhours. Mental function is cloudedby heroin’s effect on the centralnervous system. Cardiac functionslows. Breathing is also severely slowed, sometimes to the pointof death. Heroin overdose is aparticular risk on the street,

where the amount and purity of the drug cannot be accurately known.

What are thelong-term effectsof heroin use?

One of the most detrimentallong-term effects of heroinuse is addiction itself.

Addiction is a chronic, relapsingdisease, characterized by com-pulsive drug seeking and use,and by neurochemical andmolecular changes in the brain.Heroin also produces profounddegrees of tolerance and physicaldependence, which are alsopowerful motivating factors forcompulsive use and abuse. As

with abusers of any addictivedrug, heroin abusers gradually spend more and more time andenergy obtaining and using thedrug. Once they are addicted,the heroin abusers’ primary purpose in life becomes seeking

and using drugs. The drugsliterally change their brains andtheir behavior.

Physical dependence develops with higher doses of the drug. With physical dependence, thebody adapts to the presenceof the drug and withdrawalsymptoms occur if use isreduced abruptly. Withdrawalmay occur within a few hours

after the last time the drug istaken. Symptoms of withdrawalinclude restlessness, muscle andbone pain, insomnia, diarrhea,

vomiting, cold flashes with goosebumps (“cold turkey”), and legmovements. Major withdrawalsymptoms peak between 24 and48 hours after the last dose of heroin and subside after about a

week. However, some people

■ Opiates can depress breathing by changing neurochemical activity in the brain stem,where automatic body functions are controlled.

■ Opiates can change the limbic system,which controls emotions, to increase feelings of pleasure.

■ Opiates can block pain messages transmitted through the spinal cord from the body.

Opiates Act on Many Places in theBrain and Nervous System




have shown persistent withdrawalsigns for many months. Heroin

withdrawal is never fatal tootherwise healthy adults, but it

can cause death to the fetus of a pregnant addict.

At some point during contin-uous heroin use, a person canbecome addicted to the drug.Sometimes addicted individuals

will endure many of the with-drawal symptoms to reduce theirtolerance for the drug so that they can again experience the rush.

Physical dependence andthe emergence of withdrawalsymptoms were once believedto be the key features of heroinaddiction. We now know thismay not be the case entirely,since craving and relapse canoccur weeks and months after

withdrawal symptoms are longgone. We also know that patients

with chronic pain who need

opiates to function (sometimesover extended periods) have fewif any problems leaving opiatesafter their pain is resolved by

other means. This may be becausethe patient in pain is simply seeking relief of pain and notthe rush sought by the addict.

What arethe medicalcomplications ofchronic heroin use?

Medical consequences of chronic heroin injectionuse include scarred

and/or collapsed veins, bacterialinfections of the blood vesselsand heart valves, abscesses(boils) and other soft-tissueinfections, and liver or kidney disease. Lung complications(including various types of pneumonia and tuberculosis)may result from the poor healthcondition of the abuser as wellas from heroin’s depressing

effects on respiration. Many of the additives in street heroin may include substances that do notreadily dissolve and result in

clogging the blood vessels thatlead to the lungs, liver, kidneys,or brain. This can cause infectionor even death of small patches

of cells in vital organs. Immunereactions to these or other conta-minants can cause arthritis orother rheumatologic problems.

Of course, sharing of injectionequipment or fluids can leadto some of the most severeconsequences of heroin abuse— infections with hepatitis B and C,HIV, and a host of other blood-borne viruses, which drugabusers can then pass on to theirsexual partners and children.

How does heroinabuse affectpregnant women?

Heroin abuse during preg-nancy and its many associ-ated environmental factors

(e.g., lack of prenatal care) havebeen associated with adverseconsequences including lowbirth weight, an important riskfactor for later developmentaldelay. Methadone maintenancecombined with prenatal care anda comprehensive drug treatmentprogram can improve many of the detrimental maternal andneonatal outcomes associated

with untreated heroin abuse,although infants exposed tomethadone during pregnancy typically require treatment for

withdrawal symptoms. In theUnited States, several studieshave found buprenorphine tobe equally effective and as safeas methadone in the adult out-patient treatment of opioiddependence. Given this efficacy

Short- and Long-Term Effects of Heroin Abuse

Short-Term Effects:■ “Rush”■ Depressed respiration■ Clouded mental functioning■ Nausea and vomiting■ Suppression of pain■ Spontaneous abortion

Long-Term Effects:■ Addiction■ Infectious diseases, forexample, HIV/AIDS and

hepatitis B and C■ Collapsed veins■ Bacterial infections■ Abscesses■ Infection of heart lining

and valves■ Arthritis and other

rheumatologic problems



NIDA RESEARCH REPORT SERIES 5

among adults, current studies areattempting to establish the safety and effectiveness of buprenor-phine in opioid-dependentpregnant women. For womenwho do not want or are not ableto receive pharmacotherapy fortheir heroin addiction, detoxi-fication from opiates duringpregnancy can be accomplishedwith relative safety, although thelikelihood of relapse to heroinuse should be considered.

Why are heroinusers at specialrisk for contractingHIV/AIDS andhepatitis B and C?

Heroin users are at risk forcontracting HIV, hepatitis C(HCV), and other infectious

diseases, through sharing andreuse of syringes and injectionparaphernalia that have beenused by infected individuals,or through unprotected sexualcontact with an infected person.

Injection drug users (IDUs)represent the highest risk groupfor acquiring HCV infection;an estimated 70 to 80 percent of the 35,000 new HCV infectionsoccurring in the United Stateseach year are among IDUs.

NIDA-funded research hasfound that drug abusers canchange the behaviors that putthem 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 asneedle sharing, unsafe sexualpractices, and, in turn, the riskof exposure to HIV/AIDS andother infectious diseases. Drugabuse prevention and treatmentare highly effective in preventingthe spread of HIV.

What are thetreatments forheroin addiction?

A variety of effective treat-ments are available forheroin addiction. Treatment

tends to be more effective whenheroin abuse is identified early.The treatments that follow vary depending on the individual, but

methadone, a synthetic opiatethat blocks the effects of heroinand eliminates withdrawalsymptoms, has a proven recordof success for people addictedto heroin. Other pharmaceuticalapproaches, such as buprenor-phine, and many behavioraltherapies also are used for treatingheroin addiction. Buprenorphineis a recent addition to the array of medications now available fortreating addiction to heroin andother opiates. This medicationis different from methadonein that it offers less risk of addiction and can be prescribedin the privacy of a doctor’soffice. Buprenorphine/naloxone(Suboxone) is a combinationdrug product formulated tominimize abuse.

DetoxificationDetoxification programs aimto achieve safe and humane

withdrawal from opiates by mini-mizing the severity of withdrawalsymptoms and other medicalcomplications. The primary objective of detoxification is torelieve withdrawal symptoms

while patients adjust to a drug-free state. Not in itself a treatment

for addiction, detoxification is auseful step only when it leadsinto long-term treatment that iseither drug-free (residential oroutpatient) or uses medicationsas part of the treatment. The bestdocumented drug-free treatmentsare the therapeutic community residential programs lasting 3 to6 months.

Opiate withdrawal is rarely fatal. It is characterized by acute

States highlighted currently have

CTN Nodes in place.

NIDA National Drug Abuse TreatmentClinical Trials Network

drugabuse.gov/CTN




withdrawal symptoms whichpeak 48 to 72 hours after the lastopiate dose and disappear within7 to 10 days, to be followed by alonger term abstinence syndromeof general malaise and opioidcraving.

Methadone programsMethadone treatment has been

used for more than 30 years toeffectively and safely treat opioidaddiction. Properly prescribedmethadone is not intoxicating orsedating, and its effects do notinterfere with ordinary activitiessuch as driving a car. The med-ication is taken orally and itsuppresses narcotic withdrawalfor 24 to 36 hours. Patientsare able to perceive pain and

have emotional reactions. Mostimportant, methadone relievesthe craving associated with heroinaddiction; craving is a majorreason for relapse. Amongmethadone patients, it has beenfound that normal street dosesof heroin are ineffective at pro-ducing euphoria, thus makingthe use of heroin more easily extinguishable.

Methadone’s effects last fourto six times as long as those of heroin, so people in treatmentneed to take it only once a day.

Also, methadone is medically safeeven when used continuously for 10 years or more. Combined

with behavioral therapies orcounseling and other supportiveservices, methadone enables

patients to stop using heroin(and other opiates) and return tomore stable and productive lives.Methadone dosages must be

carefully monitored in patients who are receiving antiviral therapyfor HIV infection, to avoidpotential medication interactions.

Buprenorphine and othermedications

Buprenorphine is a particularlyattractive treatment for heroinaddiction because, compared

with other medications, such as

methadone, it causes weakeropiate effects and is less likely to cause overdose problems.Buprenorphine also producesa lower level of physical depen-dence, so patients who discon-tinue the medication generally have fewer withdrawal symptomsthan do those who stop takingmethadone. Because of theseadvantages, buprenorphinemay be appropriate for use ina wider variety of treatment set-tings than the currently availablemedications. Several other med-ications with potential for treatingheroin overdose or addictionare currently under investigationby NIDA.

In addition to methadoneand buprenorphine, other drugsaimed at reducing the severity of the withdrawal symptoms can beprescribed. Clonidine is of somebenefit but its use is limited dueto side effects of sedation andhypotension. Lofexidine, a cen-trally acting alpha-2 adrenergicagonist, was launched in 1992specifically for symptomaticrelief in patients undergoingopiate withdrawal. Naloxoneand naltrexone are medicationsthat also block the effects of

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 asmorphine, 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 tabletsapproved by the FDA, 2002.



NIDA RESEARCH REPORT SERIES 7morphine, heroin, and otheropiates. As antagonists, they areespecially useful as antidotes.Naltrexone has long-lasting

effects, ranging from 1 to 3 days,depending on the dose.Naltrexone blocks the pleasurableeffects of heroin and is useful intreating some highly motivatedindividuals. Naltrexone has alsobeen found to be successful inpreventing relapse by formeropiate addicts released fromprison on probation.

Behavioral therapies Although behavioral and

pharmacologic treatments can beextremely useful when employedalone, science has taught us thatintegrating both types of treat-ments will ultimately be themost effective approach. Thereare many effective behavioraltreatments available for heroinaddiction. These can includeresidential and outpatientapproaches. An important taskis to match the best treatmentapproach to meet the particularneeds of the patient. Moreover,several new behavioral therapies,such as contingency managementtherapy and cognitive-behavioralinterventions, show particularpromise as treatments for heroinaddiction, especially whenapplied in concert with phar-macotherapies. Contingency manage ment therapy uses avoucher-based system, wherepatients earn “points” basedon negative drug tests, whichthey can exchange for itemsthat encourage healthy living.Cognitive-behavioral interven-tions are designed to helpmodify the patient’s expectationsand behaviors related to drug

use, and to increase skills incoping with various life stressors.Both behavioral and pharmaco-logical treatments help to restore

a degree of normalcy to brainfunction and behavior, withincreased employment ratesand lower risk of HIV and otherdiseases and criminal behavior.

What are theopioid analogsand their dangers?

Drug analogs are chemicalcompounds that are similarto other drugs in their

effects but differ slightly in theirchemical structure. Some analogsare produced by pharmaceuticalcompanies for legitimate medicalreasons. Other analogs, some-times referred to as “designer”drugs, can be produced in illegallaboratories and are often moredangerous and potent than theoriginal drug. Two of the mostcommonly known opioidanalogs are fentanyl and meperi-dine (marketed under the brandname Demerol, for example).

Fentanyl was introduced in1968 by a Belgian pharmaceuticalcompany as a synthetic narcoticto be used as an analgesic insurgical procedures because of its minimal effects on the heart.Fentanyl is particularly dangerousbecause it is 50 times morepotent than heroin and canrapidly stop respiration. This isnot a problem during surgicalprocedures because machinesare used to help patients breathe.On the street, however, usershave been found dead with theneedle used to inject the drugstill in his or her arm.

Where can I getfurther scientificinformation aboutheroin abuse andaddiction?

To learn more about heroinand other drugs of abuse,contact the National Clearing-

house for Alcohol and DrugInformation (NCADI) at1–800–729–6686. Informationspecialists are available to help

you locate information andresources.

Fact sheets, including InfoFacts, on the health effectsof heroin, other drugs of abuse,and other drug abuse topics areavailable on the NIDA Web site(www.drugabuse.gov), andcan be ordered free of chargein English and Spanish fromNCADI at www.health.org.

Access informationon the Internet• What’s new on the NIDA Web site• Information on drugs of abuse• Publications and communications

(includingNIDA NOTES )• Information on clinical trials throug• Calendar of events• Links to NIDA organizational units• Funding information (including pro

announcements and deadlines)• International activities• Links to related Web sites (access to

Web sites of many other organizatioin the field)

NCADIWeb Site: www.health.org

Phone No.: 1–800–729–668

NIDA Web Siteswww.drugabuse.gov

www.drugabuse.gov/CTN




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GlossaryAddiction:A chronic, relapsing disease,characterized by compulsive drug seeking and

use and by neurochemical and molecular changesin the brain.Agonist:A chemical compound that mimics theaction of a natural neurotransmitter to produce abiological response.Analog:A chemical compound that is similar toanother drug in its effects but differs slightly in itschemical structure.Antagonist:A drug that counteracts or blocksthe effects of another drug.Buprenorphine:A mixed opiate agonist/ antagonist medication for the treatment of heroinaddiction.Craving:A powerful, often uncontrollable desirefor drugs.Detoxification:A process of allowing thebody to rid itself of a drug while managing thesymptoms of withdrawal; often the first step in adrug treatment program.Fentanyl:A medically useful opioid analog thatis 50 times more potent than heroin.Meperidine:A medically approved opioid avail-able under various brand names (e.g., Demerol).Methadone:A long-acting synthetic medicationshown to be effective in treating heroin addiction.Physical dependence:An adaptive physiologicalstate that occurs with regular drug use and resultsin a withdrawal syndrome when drug use isstopped; usually occurs with tolerance.Rush:A surge of euphoric pleasure that rapidlyfollows administration of a drug.Tolerance:A condition in which higher doses ofa drug are required to produce the same effectas during initial use; often leads to physicaldependence.Withdrawal:A variety of symptoms that occurafter use of an addictive drug is reduced or stopped.

NIH Publication Number 05–4165.Printed October 1997; Reprinted September 2000,

Revised May 2005.Feel free to reprint this publication.

heroin: abuse and addiction (research reports)

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