Heroin, also known as diamorphine among other names, is an opioid most commonly used as a recreational drug for its euphoric effects. Medically it is used in several countries to relieve pain or in opioid replacement therapy. Heroin is typically injected, usually into a vein; however, it can also be smoked, snorted or inhaled. Onset of effects is usually rapid and lasts for a few hours.
Common side effects include respiratory depression (decreased breathing), dry mouth, euphoria, and addiction.Other side effects can include abscesses, infected heart valves, blood borne infections, constipation, and pneumonia. After a history of long-term use, withdrawal symptoms can begin within hours of last use. When given by injection into a vein, heroin has two to three times the effect as a similar dose of morphine. It typically comes as a white or brown powder.
Treatment of heroin addiction often includes behavioral therapy and medications. Medications can include buprenorphine, methadone, or naltrexone. A heroin overdose may be treated with naloxone. An estimated 17 million people as of 2015 use opiates such as heroin, which together with opioids resulted in 122,000 deaths. The total number of opiate users has increased from 1998 to 2007 after which it has remained more or less stable. In the United States about 1.6 percent of people have used heroin at some point in time. When people die from overdosing on a drug, the drug is usually an opioid.
Heroin was first made by C. R. Alder Wright in 1874 from morphine, a natural product of the opium poppy.Internationally, heroin is controlled under Schedules I and IV of the Single Convention on Narcotic Drugs. It is generally illegal to make, possess, or sell heroin without a license. In 2015 Afghanistan produced about 66% of the world’s opium. Often heroin, which is illegally sold, is mixed with other substances such as sugar or strychnine.
The original trade name of heroin is typically used in non-medical settings. It is used as a recreational drug for the euphoria it induces. Anthropologist Michael Agar once described heroin as “the perfect whatever drug.” Tolerance develops quickly, and increased doses are needed in order to achieve the same effects. Its popularity with recreational drug users, compared to morphine, reportedly stems from its perceived different effects. In particular, users report an intense rush, an acute transcendent state of euphoria, which occurs while diamorphine is being metabolized into 6-monoacetylmorphine (6-MAM) and morphine in the brain. Some believe that heroin produces more euphoria than other opioids; one possible explanation is the presence of 6-monoacetylmorphine, a metabolite unique to heroin – although a more likely explanation is the rapidity of onset. While other opioids of recreational use produce only morphine, heroin also leaves 6-MAM, also a psycho-active metabolite. However, this perception is not supported by the results of clinical studies comparing the physiological and subjective effects of injected heroin and morphine in individuals formerly addicted to opioids; these subjects showed no preference for one drug over the other. Equipotent injected doses had comparable action courses, with no difference in subjects’ self-rated feelings of euphoria, ambition, nervousness, relaxation, drowsiness, or sleepiness.
Short-term addiction studies by the same researchers demonstrated that tolerance developed at a similar rate to both heroin and morphine. When compared to the opioids hydromorphone, fentanyl, oxycodone, and pethidine (meperidine), former addicts showed a strong preference for heroin and morphine, suggesting that heroin and morphine are particularly susceptible to abuse and addiction. Morphine and heroin were also much more likely to produce euphoria and other positive subjective effects when compared to these other opioids.
Some researchers have attempted to explain heroin use and the culture that surrounds it through the use of sociological theories. In Righteous Dopefiend, Philippe Bourgois and Jeff Schonberg use anomie theory to explain why people begin using heroin. By analyzing a community in San Francisco, they demonstrated that heroin use was caused in part by internal and external factors such as violent homes and parental neglect. This lack of emotional, social, and financial support causes strain and influences individuals to engage in deviant acts, including heroin usage. They further found that heroin users practiced “retreatism”, a behavior first described by Howard Abadinsky, in which those suffering from such strain reject society’s goals and institutionalized means of achieving them.
Two types of heroin
Like most opioids, unadulterated heroin does not cause many long-term complications other than dependence and constipation. The purity of street heroin varies greatly. This variation has led to individuals inadvertently experiencing overdoses when the purity of the drug was higher than they expected. Intravenous use of heroin (and any other substance) with needles and syringes or other related equipment may lead to:
Contracting blood-borne pathogens such as HIV and hepatitis via the sharing of needles
Contracting bacterial or fungal endocarditis and possibly venous sclerosis
Poisoning from contaminants added to “cut” or dilute heroin
Decreased kidney function (nephropathy), although it is not currently known if this is because of adulterants or infectious diseases
Many countries and local governments have begun funding programs that supply sterile needles to people who inject illegal drugs in an attempt to reduce these contingent risks, and especially the spread of blood-borne diseases. The Drug Policy Alliance reports that up to 75% of new AIDS cases among women and children are directly or indirectly a consequence of drug use by injection. The United States federal government does not operate needle exchanges, although some state and local governments do support such programs.
Anthropologists Philippe Bourgois and Jeff Schonberg performed a decade of fieldwork among homeless heroin and cocaine addicts in San Francisco, published in 2009. They reported that the African-American addicts they observed were more inclined to “direct deposit” heroin into a vein, while “skin-popping” was a far more widespread practice: “By the midpoint of our fieldwork, most of the whites had given up searching for operable veins and skin-popped. They sank their needles perfunctorily, often through their clothing, into their fatty tissue.” Bourgois and Schonberg describes how the cultural difference between the African-Americans and the whites leads to this contrasting behavior, and also points out that the two different ways to inject heroin comes with different health risks. Skin-popping more often results in abscesses, and direct injection more often leads to fatal overdose and also to hepatitis C and HIV infection.
A small percentage of heroin smokers, and occasionally IV users, may develop symptoms of toxic leukoencephalopathy. The cause has yet to be identified, but one speculation is that the disorder is caused by an uncommon adulterant that is only active when heated. Symptoms include slurred speech and difficulty walking.
Cocaine is sometimes used in combination with heroin, and is referred to as a speedball when injected or moonrocks when smoked together. Cocaine acts as a stimulant, whereas heroin acts as a depressant. Coadministration provides an intense rush of euphoria with a high that combines both effects of the drugs, while excluding the negative effects, such as anxiety and sedation. The effects of cocaine wear off far more quickly than heroin, so if an overdose of heroin was used to compensate for cocaine, the end result is fatal respiratory depression.
Main article: Opioid withdrawal
The withdrawal syndrome from heroin (the so-called “cold turkey”) may begin within 6–24 hours of discontinuation of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose. Symptoms may include: sweating, malaise, anxiety, depression, akathisia, priapism, extra sensitivity of the genitals in females, general feeling of heaviness, excessive yawning or sneezing, tears, rhinorrhea, sleep difficulties (insomnia), cold sweats, chills, severe muscle and bone aches, nausea, vomiting, diarrhea, cramps, watery eyes, fever and cramp-like pains and involuntary spasms in the limbs (thought to be an origin of the term “kicking the habit”).
Heroin overdose is usually treated with an opioid antagonist, such as naloxone (Narcan). This reverses the effects of heroin and other opioids and causes an immediate return of consciousness but may result in withdrawal symptoms. The half-life of naloxone is shorter than most opioids, so that it has to be administered multiple times until the opioid has been metabolized by the body.
Depending on drug interactions and numerous other factors, death from overdose can take anywhere from several minutes to several hours. Death usually occurs due to lack of oxygen resulting from the lack of breathing caused by the opioid. Heroin overdoses can occur because of an unexpected increase in the dose or purity or because of diminished opioid tolerance. However, many fatalities reported as overdoses are probably caused by interactions with other depressant drugs such as alcohol or benzodiazepines. It should also be noted that since heroin can cause nausea and vomiting, a significant number of deaths attributed to heroin overdose are caused by aspiration of vomit by an unconscious person. Some sources quote the median lethal dose (for an average 75 kg opiate-naive individual) as being between 75 and 600 mg. Illicit heroin is of widely varying and unpredictable purity. This means that the user may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, tolerance typically decreases after a period of abstinence. If this occurs and the user takes a dose comparable to their previous use, the user may experience drug effects that are much greater than expected, potentially resulting in an overdose. It has been speculated that an unknown portion of heroin-related deaths are the result of an overdose or allergic reaction to quinine, which may sometimes be used as a cutting agent.
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See also: History of opium in China
The opium poppy was cultivated in lower Mesopotamia as long ago as 3400 BCE. The chemical analysis of opium in the 19th century revealed that most of its activity could be ascribed to two alkaloids, codeine and morphine.
Diamorphine was first synthesized in 1874 by C. R. Alder Wright, an English chemist working at St. Mary’s Hospital Medical School in London. He had been experimenting with combining morphine with various acids. He boiled anhydrous morphine alkaloid with acetic anhydride for several hours and produced a more potent, acetylated form of morphine, now called diacetylmorphine or morphine diacetate. The compound was sent to F. M. Pierce of Owens College in Manchester for analysis. Pierce told Wright:
Doses … were subcutaneously injected into young dogs and rabbits … with the following general results … great prostration, fear, and sleepiness speedily following the administration, the eyes being sensitive, and pupils constrict, considerable salivation being produced in dogs, and slight tendency to vomiting in some cases, but no actual emesis. Respiration was at first quickened, but subsequently reduced, and the heart’s action was diminished, and rendered irregular. Marked want of coordinating power over the muscular movements, and loss of power in the pelvis and hind limbs, together with a diminution of temperature in the rectum of about 4°.
Bayer Heroin bottle
Wright’s invention did not lead to any further developments, and diamorphine became popular only after it was independently re-synthesized 23 years later by another chemist, Felix Hoffmann. Hoffmann, working at Bayer pharmaceutical company in Elberfeld, Germany, was instructed by his supervisor Heinrich Dreser to acetylate morphine with the objective of producing codeine, a constituent of the opium poppy, pharmacologically similar to morphine but less potent and less addictive. Instead, the experiment produced an acetylated form of morphine one and a half to two times more potent than morphine itself. The head of Bayer’s research department reputedly coined the drug’s new name, “heroin,” based on the German heroisch, which means “heroic, strong” (from the ancient Greek word “heros, ????”). Bayer scientists were not the first to make heroin, but their scientists discovered ways to make it, and Bayer led commercialization of heroin.
In 1895, the German drug company Bayer marketed diacetylmorphine as an over-the-counter drug under the trademark name Heroin. It was developed chiefly as a morphine substitute for cough suppressants that did not have morphine’s addictive side-effects. Morphine at the time was a popular recreational drug, and Bayer wished to find a similar but non-addictive substitute to market. However, contrary to Bayer’s advertising as a “non-addictive morphine substitute,” heroin would soon have one of the highest rates of addiction among its users.
From 1898 through to 1910, diamorphine was marketed under the trademark name Heroin as a non-addictive morphine substitute and cough suppressant. In the 11th edition of Encyclopædia Britannica (1910), the article on morphine states: “In the cough of phthisis minute doses [of morphine] are of service, but in this particular disease morphine is frequently better replaced by codeine or by heroin, which checks irritable coughs without the narcotism following upon the administration of morphine.”
In the U.S., the Harrison Narcotics Tax Act was passed in 1914 to control the sale and distribution of diacetylmorphine and other opioids, which allowed the drug to be prescribed and sold for medical purposes. In 1924, the United States Congress banned its sale, importation, or manufacture. It is now a Schedule I substance, which makes it illegal for non-medical use in signatory nations of the Single Convention on Narcotic Drugs treaty, including the United States.
The Health Committee of the League of Nations banned diacetylmorphine in 1925, although it took more than three years for this to be implemented. In the meantime, the first designer drugs, viz. 3,6 diesters and 6 monoesters of morphine and acetylated analogues of closely related drugs like hydromorphone and dihydromorphine, were produced in massive quantities to fill the worldwide demand for diacetylmorphine—this continued until 1930 when the Committee banned diacetylmorphine analogues with no therapeutic advantage over drugs already in use, the first major legislation of this type.
Bayer lost some of its trademark rights to heroin under the 1919 Treaty of Versailles following the German defeat in World War I.
Use of heroin by jazz musicians in particular was prevalent in the mid-twentieth century, including Billie Holiday, sax legends Charlie Parker and Art Pepper, guitarist Joe Pass and piano player/singer Ray Charles; a “staggering number of jazz musicians were addicts”. It was also a problem with many rock musicians, particularly from the late 1960s through the 1990s. Pete Doherty is also a self-confessed user of heroin. Nirvana lead singer Kurt Cobain’s heroin addiction was well documented. Pantera frontman, Phil Anselmo, turned to heroin while touring during the 1990s to cope with his back pain. Many musicians have made songs referencing their heroin usage