Here, a guide for helping patients understand heroin, its history, and how it impacts our communities. This information is from the National Institute of Drug Abuse (NIDA),1 unless otherwise cited.
1. What is the history of opioid medications and abuse?
• Opiates were first prescribed for insomnia, pain, and gastrointestinal issues in England in the 17th century. They were considered a universal cure-all in the beginning of the 19th century, with the 1803 discovery of the active ingredient morphine.2
• Opiate dependency is the oldest, most persistent and widespread drug problem, with the exception of Alcohol.2
2. What is heroin and was it ever legal?
• Heroin is an opioid drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant.
• Bayer marketed liquid heroin as “the best cure for your child’s bronchitis,” as late as 1912.3
• Heroin was restricted to prescription-only use in the US in 1914 and eventually banned by the FDA altogether in 1924, except under very strict medical conditions.3
4. How is heroin used today and is it common?
• Today, illicit heroin usually appears as a white or brown powder or as a black sticky substance, known as “black tar heroin.”
• Heroin can be injected, inhaled by snorting or sniffing, or smoked.
• In 2012, about 669,000 Americans reported using heroin in the past year, with use rising each year since 2007; 4.2 million Americans aged 12 years or older (or 1.6%) had used heroin at least once in their lives.4 (Figure 1)
5. How does heroin affect the brain and cause death?
• When it enters the brain, heroin is converted back into morphine, which activates mu-opioid receptors (MORs). MORs activation in the reward center of the brain leads to dopamine release which causes a sensation of pleasure, a “rush,” that is experienced by users.
• MORs are also located in the brain stem, which controls automatic processes critical for life, including regulation of blood pressure, arousal, and respiration.
• Heroin overdoses deregulate MORs in the brain stem, often causing suppression of breathing, which can be fatal.
6. How does addiction to heroin occur?
• Regular heroin use changes the functioning of the brain1 which causes:
Occurs as more of the drug is needed to achieve the same intensity of effect that was previously experienced.
Heroin addiction presents as the continued need to use the drug to avoid withdrawal symptoms. If a dependent user reduces or stops use of the drug abruptly, they may experience severe symptoms of withdrawal. These symptoms can begin as early as a few hours after the last drug administration and include restlessness, muscle and bone pain, insomnia, diarrhea, and vomiting, cold flashes with goose bumps (“cold turkey”), and kicking movements (“kicking the habit”). Major withdrawal symptoms peak around 24 to 48 hours after last use and typically last around 1 week. However, many ex-users report withdrawal symptoms lasting for months.
You can have dependence and tolerance without being addicted to a medication or substance. Addiction is marked by a pattern of chronic relapsing that goes beyond physical dependence and uncontrollable drug-seeking behaviors, despite negative consequences. Once addicted, the individual’s drug-seeking and using become their primary purpose in life.4
7. Does everyone who tries heroin get addicted?
• It is estimated that about 23% of individuals who use heroin become dependent on it.
8. What is the official medical term for heroin addiction?
• DSM-5 no longer differentiates between opiate dependence and abuse. Instead, “opiate use disorder” is all-encompassing and provides criteria based on symptomatology. Diagnostic categories range from mild to severe.5
Dr Goldenberg is a psychiatry resident at Banner Good Samaritan in Phoenix, Arizona. His blog, www.docgoldenberg.com, is dedicated to mental health and addiction topics.
1. National Institute on Drug Abuse: DrugFacts: Heroin. Revised April 2013.
2. Jenkins PN. Heroin Addiction's Fraught History. The Atlantic. February 24 2014. http://www.theatlantic.com/health/archive/2014/02/heroin-addictions-fraught-history/284001. Accessed June 23, 2014.
3. Edwards J. Yes, Bayer Promoted Heroin for Children—Here Are The Ads That Prove It. Business Insider. November 17, 2011. http://www.businessinsider.com/yes-bayer-promoted-heroin-for-children-here-are-the-ads-that-prove-it-2011-11. Accessed June 23, 2014.
4. National Institute on Drug Abuse. Research Report Series: Heroin. http://www.drugabuse.gov/sites/default/files/rrheroin_4_14.pdf. Revised April 2014. Accessed June 23, 2014.
5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013.
6. Office of National Drug Control Policy. 5 things to know about opioid overdoses. February 11, 2014. http://www.whitehouse.gov/blog/2014/02/11/5-things-know-about-opioid-overdoses. Accessed June 23, 2014.
7. Gray E. Chicago Blames Big Pharma for Epidemic Addictions to Painkillers. Time. June 4, 2014. http://time.com/2822381/chicago-blaims-big-pharma-for-epidemic-addictions-to-painkillers. Acessed June 23, 2014.
8. Publicker M. Jeremiad: heroin deaths go unnoticed. ASAM Magazine. January 29, 2014. http://www.asam.org/magazine/read/article/2014/01/29/jeremiad-heroin-deaths-go-unnoticed. Accessed June 23, 2014.
9. Office of National Drug Control Policy. Announcement to Medical Community. February 19th, 2014. http://pcssmat.org/wp-site/wp-content/uploads/2014/02/White-House-Article-100-people-die.pdf. Accessed June 23, 2014.