Also known as

Smack, skag, horse, H, gear, brown, diamorphine, shit, dope, junk, mud, brown sugar, big h, charley, china white, boy, harry, Mr. Brownstone, Dr. Feelgood


Depressant, analgesic


Heroin is a drug made from morphine, which is extracted from the opium poppy. Opium has been around for many hundreds of years and was originally used to treat pain, sleeplessness and diarrhoea. When morphine is made into heroin to be used as a medicine, it's called diamorphine, and is stronger than morphine or opium. Like many drugs made from opium (called opiates), heroin is a very strong painkiller. 'Street' heroin sold as 'brown' is sometimes now used by clubbers as a chill out drug after a big night out.

It is still just the same street heroin but some people mistakenly think it's not as addictive [1].

Here are some of the main effects and risks of heroin -

  • A small dose of heroin gives the user a feeling of warmth and well-being, bigger doses can make you sleepy and very relaxed.
  • The first dose of heroin can bring about dizziness and vomiting.
  • Heroin is highly addictive and people can quickly get hooked.
  • Injecting heroin and sharing injecting equipment can be very risky, as it runs the risk of the injector catching or spreading a virus, such as HIV or hepatitis C. There is also the risk that veins may be damaged and that an abscess or blood clot may develop [1].

What does it look like?

While pharmaceutical heroin is white, most of the heroin available in the UK is a brownish powder [2]. Another form of heroin known as 'black tar' may be sticky, like roofing tar, or hard, like coal. Its colour may vary from dark brown to black [3]. Pure heroin is a white powder, but owing to the range of substances it's cut with, street heroin can be anything from brownish white to brown [1]. 'Black tar' heroin is predominantly produced in Mexico and sold in U.S. areas west of the Mississippi River. The dark colour associated with black tar heroin results from crude processing methods that leave behind impurities [4].

Heroin is usually sold as a powder; colour ranges from white, off-white, yellowish, to reddish brown, the most prevalent type now on the market. A few years ago, there was a wider availability of brands such as china white, but Afghan-sourced brown heroin is the mainstay of the UK market. Crude opiate extracts such as Black Tar Heroin don't occur in the UK [5].


Heroin is derived from the Opium poppy, which grows in many parts of the world (including Britain). The main centres of illicit production include the border regions of Iran, Afghanistan and Pakistan (known as the Golden Crescent), and around the borders of Thailand, Burma and Laos (known as the Golden Triangle) [6].

Heroin is manufactured from the sap of the Opium Poppy, Papaver Somniferum. Raw opium is extracted from the poppies. This contains a mixture of opiate alkaloids, including morphine, thebaine, codeine, noscapine and papaverine [5].


Estimates for 2014 prevalence of heroin use among young adults (15- to 34-year-olds) in the general population range between 0.0% and 0.7%. However, due to the very low figures reported and the hidden nature of heroin use, general population surveys are not considered robust means for monitoring use of this substance. Therefore, indirect statistical extrapolations, based on patterns of contact with data sources, where part of this population is observed, are used to understand the prevalence of this phenomenon.

The average prevalence of problem/high-risk opioid use among adults (15 - 64) is estimated at 0.41%, the equivalent of 1.4 million problem opioid users in Europe in 2011. In Europe, prevalence estimates of problem opioid use vary between less than one and more than seven cases per 1 000 population aged 15 - 64. 'Opioids' here include mainly heroin, however, there are countries, where significant numbers of users of other opioids exist, for example Finland (buprenorphine) or Estonia (Fentanyl) [7].

Street price

Prices can vary from region to region, but it has an average price of £10 a bag. Feeding a heroin habit can cost up to £100 a day [1].

Heroin is usually sold in small quantities, typically £10 bags. By weight, Heroin costs between £40 and £60 a gramme [5].

Why take it?

Sought after effects

  • powerful euphoriant,
  • relaxing effects,
  • feelings of wellbeing and freedom from worry [2],
  • intense rush,
  • exhilaration,
  • decreased anxiety [6].

Undesired effects

  • nausea,
  • loss of balance,
  • overdose can be fatal [2],
  • vomiting,
  • drowsiness,
  • decreased heart-rate,
  • shallow breathing,
  • coma [6].


It's likely a combination of many factors working together that cause the development of an addiction disorder, such as heroin addiction [8]. These factors may include -

  • genetic - drug abuse is known to run in families; when an individual has family members with substance abuse problems they have a greater chance of developing an addiction themselves.
  • brain chemistry - addiction to heroin causes changes in brain structures and alters brain chemicals which cause cravings for the drug. When an individual takes a drug like heroin they experience feelings of overall wellbeing which the individual desires to feel again. An addict will keep using to maintain these pleasurable feelings.
  • environmental - those who abuse heroin have often been exposed to substance abuse at an early age, making drug use seem like acceptable behavior. Additionally, those who are addicted to heroin may have learned that drug use is a way to cope with negative emotions and stressors of daily life.
  • psychological - many people who struggle with heroin addiction have undiagnosed or untreated mental illnesses. Heroin may be an attempt to suppress symptoms of these other mental illnesses [8].
  • physical factors - people who use heroin often begin by first being legally prescribed opiates for post-surgical pain or other legitimate purposes. They may first have developed addictions to this opiate and as tolerance built and the need surpassed the amount the physician was willing to prescribe they may have gone to multiple doctors. However, as pharmacists' databases are linked, when they attempted to fill multiple prescriptions at different pharmacists, they were caught and refused prescriptions. This can leave an addicted individual suddenly cut off from their drug of choice. Fearing withdrawal, they may look for the quickest way to replace this drug. Heroin is readily available, cheap and produces a more potent high than the legal opiates. Although perhaps the person intended to use heroin just to fill the gaps between when they can get other opiate prescriptions, the increased potency causes them to fully substitute heroin for other opiates [9].

What are the different forms of heroin?

The different types of heroin come from varying regions and have drastically different appearances and purities [10].

White heroin

White heroin most commonly comes from southeast Asia and is white in appearance, as the name suggests. This relatively pure heroin is found in powder form, which is easily dissolved in water. White heroin has many adverse effects that are shared with brown powder heroin, including [11] -

  • drowsiness,
  • coma,
  • slurred speech,
  • attention and memory problems,
  • increased risk of suicide,
  • collapsed veins,
  • peripheral oedema,
  • increased risk of contraction of tuberculosis, HIV, and hepatitis,
  • depression,
  • sexual dysfunction [10].

Black tar heroin

Black tar heroin, which is primarily made in Mexico, is named for its physical appearance. As opposed to its white powder counterpart, it has a dark colour and is sticky or hard [11]. It's less pure than white heroin because of how it's processed and is typically cheaper than other forms of heroin. Given its low purity, it's little surprise that the majority of black tar heroin contains toxic additives. Additives have been known to clog blood vessels in users and damage the liver, kidneys, brain, and lungs. Other side-effects of black tar heroin include -

  • wound botulism - caused by the presence of bacteria in injection sites, can cause paralysis and death [12],
  • abscesses - complications associated with untreated abscesses include infection of the heart lining, bone, or blood [13],
  • tetanus - difficulty swallowing, stiffness of back and neck, muscle spasms, excessive sweating, and difficulty breathing [14],
  • necrotizing fasciitis - caused by bacteria and characterized by a rapidly propagating, widespread death of tissues [15],
  • gas gangrene - bacterial infection can be life-threatening and also causes tissue death [16], [10].

Common in the USA, black tar heroin is rarely found in Europe. It is made using a cruder technique, which results in it consisting mainly of drugs that are part-way between heroin and morphine (3-MAM and 6- MAM). It resembles tar - being black or very dark brown, ranging from gooey to crumbly. It can be smoked and injected, though it is considered particularly damaging to inject [17].

Brown heroin

Brown heroin typically is made in southwest Asia and appears as a brown powder. Compared with the white variety, this form of heroin is less easily dissolved in water unless an acid is added to it [18]. Despite the differences in appearance, the health consequences associated with brown heroin are similar to those of white heroin.

Heroin causes severe respiratory depression in individuals, which can lead to coma and death. Due to the inconsistencies of purity associated with different forms of heroin, it can be difficult to gauge their relative potencies, which increases the risk of overdose from one use to the next [10].

Brown powder heroin is the main type of heroin found in Europe. It is an off-white to brown powder or powdery clumps that consists of heroin 'base', plus various other potentially harmful substances and adulterants [17].

Cheese heroin

A relatively new form of heroin, known as 'cheese' heroin, has claimed many young lives when teenagers use the cheap drug which is laced with acetaminophen and diphenhydramine hydrochloride [19]. This lethal combination dramatically depresses heart rate and breathing until the user dies, often rather quickly [10].

Heroin hydrochloride

Unusual in Europe, this is the hydrochloride salt form. It dissolves in water and therefore easily prepares for injection. It can also be snorted, but is less suitable for smoking as it does not vapourise easily. Pharmaceutical heroin, diamorphine hydrochloride, is a white odourless powder [17].

How long do its effects last?

Onset of effects

  • nasal - 10 - 15 seconds [20], 10 - 15 minutes [21].
  • smoked - 5 - 10 seconds [20], 5 - 10 minutes [21], 5 - 15 seconds [22].
  • intravenous - 0 - 5 minutes [21], 3 - 5 seconds [22].


  • smoked - 5 - 10 minutes [22].

Duration of effects


  • nasal - 1 - 24 hours [21].
  • smoked - 1 - 24 hours [21].
  • intravenous - 1 - 24 hours [21].


Pharmaceutical grade heroin is called diacetylmorphine or diamorphine. 'Heroin' refers to the illicit type, originating from the Golden Triangle (Thailand, Laos and Myanmar) and is usually (off) white. Most of the heroin available in the UK comes from The Golden Crescent (Afghanistan, Iran and Pakistan), and is a base form of the drug (an intermediary stage in the production process to the salt form). This makes it suitable for smoking, and much illicit heroin is smoked on tin-foil ('chasing the dragon' or 'booting').

The salt form of diamorphine/heroin is very soluble, and the base, (usually a brown powder) can also be injected, but requires an acidifier and heat to make it dissolve (citric acid or vitamin C typically). For more advice, including harm reduction, see our safer injecting section here.

The drug acts on a series of receptors in the brain, gut and spinal column, inducing feelings of well-being and calm.

Heroin crosses the blood-brain barrier extremely effectively. Once in the brain, it is broken down and to morphine, which bind to receptors, resulting in the drug's euphoric, anxiolytic (reducing anxiety) and pain killing effects [2].

Diamorphine, like morphine and many other opioids, produces analgesia. It behaves as an agonist at a complex group of receptors (the μ, κ and δ subtypes) that are normally acted upon by endogenous peptides known as endorphins. Apart from analgesia, diamorphine produces drowsiness, euphoria and a sense of detachment. Negative effects include respiratory depression, nausea and vomiting, decreased motility in the gastrointestinal tract, suppression of the cough reflex and hypothermia. Tolerance and physical dependence occur on repeated use. Cessation of use in tolerant subjects leads to characteristic withdrawal symptoms. Subjective effects following injection are known as 'the rush' and are associated with feelings of warmth and pleasure, followed by a longer period of sedation. Diamorphine is 2 - 3 times more potent than morphine. The estimated minimum lethal dose is 200 mg, but addicts may be able to tolerate ten times as much. Following injection, diamorphine crosses the blood-brain barrier within 20 seconds, with almost 70% of the dose reaching the brain. It is difficult to detect in blood because of rapid hydrolysis to 6-monoacetylmorphine and slower conversion to morphine, the main active metabolite. The plasma half-life of diamorphine is about three minutes. Morphine is excreted in the urine largely as the glucuronide conjugate. Diamorphine is associated with far more accidental overdoses and fatal poisonings than any other scheduled substance. Much morbidity is caused by infectious agents transmitted by unhygienic injection [7].

Heroin is used recreationally because it produces intense feelings of euphoria and relaxation. Dependent individuals use it to 'feel normal' and avoid withdrawal symptoms. It works by affecting brain receptors involved in reward, pleasure and the perception of pain. The chemical modification of the morphine molecule to produce diamorphine has produced a drug that crosses the blood-brain barrier more quickly than morphine - this produces a rapid rise in brain levels of the drug and what users term a 'rush' [17].

Heroin itself is an inactive drug, but it converts into morphine when inserted into the body [23]. When taken orally, heroin undergoes extensive first-pass metabolism via deacetylation, making it a prodrug for the systemic delivery of morphine [23]. When the drug is injected, however, it avoids this first-pass effect, very rapidly crossing the blood-brain barrier because of the presence of the acetyl groups which render it much more fat soluble than morphine itself [24].

Once in the brain, it is deacetylated variously into the inactive 3-monoacetylmorphine and the active 6-monoacetylmorphine (6-MAM). It is then deacetylated into morphine, which binds to μ-opioid receptors. Heroin itself exhibits relatively low affinity for the μ receptor [25].

The recreational effects of this compound occur because opioids structurally mimic endogenous endorphins which are naturally found within the body and also work upon the μ-opioid receptor set. The way in which opioids structurally mimic these natural endorphins results in their euphoria, pain relief and anxiolytic effects. This is because endorphins are responsible for reducing pain, causing sleepiness, and feelings of pleasure. They can be released in response to pain, strenuous exercise, orgasm, or general excitement [20].


Oral 35%, intramuscular 85% [21].


2 - 3 minutes [21].


Heroin is eliminated from the body via the kidneys in urine, but it can also be excreted via sweat, tears, saliva, and faeces [26].

Mode of use

Heroin can either be smoked or dissolved in water and injected - and if it's pure, it can also be snorted.

Injecting heroin - and sharing the equipment used for injecting, including needles or syringes - can be very risky, because it runs the risk of the person injecting catching or spreading a virus, such as HIV or hepatitis C.

There is also the risk that veins may be damaged and that an abscess or blood clot may develop [1].

  • Smoked - brown heroin is most suitable for smoking. Much illicit heroin is smoked on tin-foil ('chasing the dragon' or 'booting') [2]. 'Smoking' (the drug is actually vaporised rather than burned to produce smoke). Compared to injecting, there is very much lower risk of overdose when smoking heroin - users have better control over their intake and can feel the effects of the drug very rapidly, regulating or stopping intake as necessary [17].
  • Injected - brown heroin can also be injected, but needs to be acidic to make it dissolve (vitamin C is often used) [2]. Usually injected into a vein, sometimes under the skin or into muscle). As with the injection of any illicit drugs, injecting heroin poses the greatest risks. These include bacterial, fungal and viral infections, including abscesses at the site of injection, the collapse of veins, and infection with hepatitis HIV and other pathogens. Injecting, particularly intravenously, results in a strong and addictive rush of euphoria. If someone has regularly injected heroin into their veins, it tends to be very difficult to go back to using one of the less intense methods. Injecting heroin under the skin (subcutaneously) or into muscle (intramuscularly) is possible but gives a less of a 'rush'. Subcutaneous and intramuscular injections pose a higher risk of bacterial infection at the site of infection [17].
  • Snorted - bigger lumps are crushed up and powder is divided into lines and snorted (insufflated) via rolled up paper or 'bumped'/'keyed' i.e. small amount sniffed [2]. Snorting avoids injecting harms, but most European heroin is not ideal for snorting [17].
  • Rectally - 'plugging' it (squirting it up the rectum with a syringe). Rectal use avoids injecting harms but has in common with injecting the fact that there is not much you can do if you use too much, which may be a seemingly small amount [17].

Signs of usage

  • lack of interest in usual activities
  • dissasociation
  • problems with friends and family
  • difficulties at work, school and home
  • lack of concern for their hygiene and appearance
  • depression
  • anxiety
  • lying
  • loss of motivation
  • legal troubles [27].


Heroin gives users a feeling of warmth and well-being, bigger doses can make people sleepy and very relaxed.

It also slows down the way the body works and is a very strong pain-killer. The first dose of heroin can bring about dizziness and vomiting.

The effects of heroin can last for a number of hours so it is important to be careful using any other drugs or alcohol in that time [1].

Short-term effects

  • one-to-two minute 'rush',
  • warm flushing of the skin,
  • dry mouth,
  • heavy feeling in arms and legs,
  • nausea,
  • vomiting,
  • severe itching,
  • drowsiness and confusion for up to six hours,
  • slowed heart rate,
  • slowed breathing rate [28].
  • skin, heart and lung infections,
  • increases the risk of blood-borne diseases like hepatitis B, hepatitis C and HIV when sharing needles [29].

Long-term effects

Heroin's many physical dangers include -

  • constipation,
  • irregular periods and infertility in women,
  • loss of sex drive in men,
  • mood swings,
  • depression,
  • memory impairment [29].

Painful withdrawal that maintains addiction

  • restlessness,
  • muscle and bone pain,
  • muscle spasms,
  • insomnia,
  • diarrhoea and vomiting,
  • chills and goose bumps,
  • intense anxiety [28].

Cardiovascular damage

  • endocarditis - heart infection,
  • scarred and/or collapsed veins,
  • blood vessels clogged by foreign particles, causing cell death [28].

Infections and viruses

  • boils and abscesses,
  • soft-tissue infections,
  • Hepatitis B and C,
  • systemic infections (bacteremia or sepsis) [28].

Other organ damage and disease

  • liver disease,
  • kidney disease,
  • arthritis [28].

Danger during pregnancy

  • miscarriage, premature delivery, or stillbirth of pregnancies,
  • addicted newborns,
  • greater risk of Sudden Infant Death Syndrome ('cot death') [28].

Physical effects

  • physical euphoria,
  • pupil constriction,
  • appetite suppression,
  • cough suppression,
  • orgasm suppression,
  • pain relief,
  • respiratory depression,
  • sedation,
  • constipation,
  • decreased heart rate,
  • difficulty urinating,
  • increased perspiration,
  • itchiness,
  • nausea [20].

Cognitive effects

  • cognitive euphoria,
  • compulsive redosing,
  • dream potentiation,
  • anxiety suppression,
  • decreased libido [20].

Visual effects

  • internal hallucinations [20].


Overdosing is a very real danger for heroin users. It is far more common than one might expect; a 2001 study in Australia concluded that 54% of regular injecting drug users reported experiencing at least one non-fatal overdose in their lifetime [30]. Signs of an overdose can include one or more of the following -

  • extremely slow shallow breathing,
  • convulsions,
  • pinpoint pupils,
  • confusion, and possibly
  • coma,
  • death [31]

Someone who is overdosing should be taken to the hospital immediately.

There is clear evidence that death from heroin-related overdose is rarely instantaneous and therefore an overdose is not automatically fatal. Precautions can lessen the chances of a fatal overdose, and there are steps that can be taken to help someone who's overdosing [31].

  • never use heroin when you're alone, particularly behind a locked door,
  • never mix heroin with any other drugs [31].

A person who is overdosing on heroin displays abnormal mental status, dramatically slowed breathing, and tightly constricted ('pinpoint') pupils. Most overdoses occur at home in the company of others. Overdoses are more common when alcohol and other drugs are also present.

In the hospital, overdose patients need 'airway management', which means they need a breathing tube to keep their airway open, and they need intravenous medication to reverse the heroin's effects. Patients can suffer pulmonary oedema (lung swelling,) pneumonia, and other complications.

Overdoses are frighteningly common. A 1998 study in Australia revealed these statistics -

  • 48% of regular heroin users had experienced at least one non-fatal overdose their life-time (median: two overdoses),
  • 11% of regular heroin users had overdosed in the previous 6 months,
  • 70% had been present at someone else's overdose at some time (median: three overdoses),
  • At the time of their own most recent overdose, 52% had been using central nervous system depressants in addition to heroin (benzodiazepines - 33% and/or alcohol - 22%),
  • 81% of overdoses occurred in a private home,
  • 88% of overdoses in the presence of other people,
  • Despite 50% of heroin abusers understanding that half of regular heroin users would overdose during their lifetime, 73% of those surveyed said they 'rarely' or 'never' worried about possibly overdosing [28].

People taking heroin for the first time can die from sheer overdose or from allergic reaction to heroin or the additives in it. However, each year about 1% of all experienced heroin addicts in the United States die from an overdose of heroin despite their enormously increased tolerance to the effects of the drug. In a person who does not normally use heroin, the estimated deadly dose of heroin may range from 200 to 500 mg, but addicts have tolerated doses as high as 1800 mg without even being sick.

There are various explanations for the fact that it is relatively common for experienced addicts to have "overdoses" in spite of their huge tolerances -

  1. Some addicts simply push their tolerance too far and take a truly massive amount at once. However, this is rare among experienced users,
  2. An addict may unknowingly purchase heroin that is much more pure than what he is used to and take his normal dose anyway,
  3. The additives in the heroin may produce unforeseen toxic effects,
  4. The addict may take heroin together with alcohol, sedatives, or other drugs. Or,
  5. The person may suffer a sudden loss of tolerance [28].

'Sudden loss of tolerance' was the subject of one recent study. The rats in the study were given daily intravenous injections for 30 days, either of a placebo or of heroin. The injections were given in either the animal colony or a different room where there was a constant white noise. The drug and the placebo were given on alternate days. A control group of rats received only the placebo. For any one heroin-receiving rat, the heroin was always given in the same setting, either the colony or the white noise room. For other rats the heroin was always given in the colony and the placebo was always given in the white noise room.

At the end of the 30 day introduction period, all of the rats were given a large dose of heroin. The rats in one group were given the heroin in the same room where they had previously been given heroin. (This was labeled the ST group.) The other rats, the DT group, were given the heroin in the room where they had previously been given the placebo. 96% of the control group (who had never received heroin before) died, showing the lethal effect of the heroin in nontolerant animals. Rats in the DT group who received heroin were partially tolerant, and only 64% died. Only 32% of ST rats died, showing that the tolerance was even greater when the overdose test was done in the same environment where the drug previously had been administered.

The study suggests that one reason addicts suddenly lose their tolerance could be because they take the drug in a different or unusual environment like the rats in the DT group. Surveys of heroin addicts admitted to hospitals suffering from heroin overdose tend to support this conclusion [28].

Heroin overdose is a medical emergency that requires treatment with naloxone. Intravenous naloxone will result in reversal of the opioid-induced respiratory depression within 2 minutes. Retreatment with naloxone may be required as the duration of action of naloxone (30 to 120 minutes) may be shorter than the action of the opioid. Respiratory support, intravenous fluids, and other adjunctive medications may be required [32].

  • shallow, slow or difficult breathing,
  • dry mouth,
  • extremely small pupils (pinpoint pupils),
  • discoloured tongue,
  • low blood pressure,
  • weak pulse,
  • bluish-coloured nails and lips,
  • constipation,
  • spasms of the stomach and intestines,
  • coma,
  • delirium,
  • disorientation,
  • drowsiness,
  • uncontrolled muscle movements [26].


Taking heroin involves a number of risks [1]. Here's what it could do to you -

  • Overdoses can lead to coma and even death - as it can cause respiratory failure (this is what it's called when your breathing stops).
  • If you have been taking heroin regularly you may have built some tolerance, but if you then stop heroin for just for a few days, your tolerance will rapidly drop - and you risk an overdose if you simply take the high dose you previously took.
  • If heroin is taken with other drugs, including alcohol, an overdose is more likely. Other downers (such as benzodiazepine tranquillisers or methadone), are also linked with deaths from heroin overdose.
  • There's also a risk of death due to inhaling vomit - because heroin both sedates you and stops you coughing properly - and the vomit remains in the airways so you can't breathe.
  • Injecting heroin can do nasty damage to your veins and arteries, and has been known to lead to gangrene and to infections.
  • The risks of sharing needles, syringes and other equipment involved in injecting are well-known - it puts you, and others, in danger of serious infections like hepatitis B, hepatitis C and HIV/AIDS [1].


  • tolerance,
  • overdose,
  • injection problems may also arise from impurities -
    • dizziness,
    • headache,
    • loss of coordination,
    • nausea,
  • as well as risks from injecting like -
    • abscess,
    • collapsed veins [6].


  • dependence [6].

Injection of impure heroin can damage circulatory system, leading to -

  • abscesses,
  • ulcers,
  • thrombosis [6].


It's common for heroin to be mixed with a variety of substances, such as sugar, starch, powdered milk, quinine or paracetamol - this increases its weight and the drug dealer's profits.

Other substances are also sometimes added to heroin, including sedatives such as benzodiazepines and barbiturates.

Substances like nutmeg, brick dust, and even ground-up gravel have also been reported on occasions [1].

Typical UK purity rates range from 10% to 40% [6].

Apart from diamorphine, heroin contains variable amounts of other opium alkaloids and acetylated alkaloids (e.g. noscapine, papaverine and acetylcodeine) as well as adulterants such as caffeine and paracetamol. It is believed that the latter are added to heroin either at the time of manufacture or during transit. Other less common psychoactive adulterants include phenobarbitone, methaqualone and diazepam. The hydrolysis product (6-monoacetylmorphine) may also be present and arises when heroin is stored in damp conditions or in non-acidified aqueous solutions. The free base constitutes 87.2% of the hydrate hydrochloride salt.

In 2011, the mean purity of brown heroin at street level in Europe varied considerably (between 5.8% (Austria) and 43.6% (Turkey)). The mean purity of white heroin was generally higher (14% in Austria and 43% in Norway) in the five European countries reporting data [7].

Street heroin is usually 'cut' or mixed with other powders to bulk it out and increase profits. Purity normally ranges from 30% to 40%. Some of the percentage shortfall may be naturally occurring compounds of the poppy or by-products of the production process, as oppossed to cutting agents. Adulterants may be harmful, but most evidence suggests this is not typical or deliberate supplier policy. It is bad commerce to poison your customers. Periodically, very pure heroin may be sold on the street, potentially causing overdoses due to the heroin being more potent than expected [2].

Making and selling illegal drugs is not a precise science. Often drugs from the same dealer and batch have varying strengths. The active ingredient need not necessarily be evenly mixed in. If it's a powder, chop it through. If it's in a bottle, shake it thoroughly.

Even experienced users can be caught out by a different level of purity in a sample and accidentally overdose [31].

Street heroin is invariably heavily adulterated, but the extent of this varies wildly from area to area and dealer to dealer. Cutting of heroin ranges from 40% to 70%, though far lower (and higher) purities are reported.

Common adulterants include caffeine, lactose, and benzodiazepines. Reports in the media of other, dangerous adulterants are widespread and but rarely substantiated. However, compounds including builders plaster, brick dust, talc. In 1993, Paracetamol was the most widely-reported adulterant according to research by the University of Greenwich.

Periodically, very pure heroin is sold on the street, potentially causing fatalities as people overdose on exceptionally strong gear [5].

Heroin cuts

On the street, heroin goes by a variety of names, including 'junk', 'skag', 'smack', and 'H'. Regardless of the name used, anytime you purchase heroin there's *no way of knowing what's actually in it*, short of doing a chemical analysis.

A pure, uncut batch consists of pure white powder that carries a bitter taste, though it's highly unlikely that a street dealer will sell pure heroin [10].

What makes heroin additives so dangerous?

Heroin's negative effects may be particularly volatile due to the unpredictability of composition. This illicitly manufactured opioid is subject to no quality assurance or other regulations, meaning that it is often cut with any number of toxic additives and other potentially dangerous substances in order to increase profits for dealers.

These additives are often unknown and can vary from batch to batch, depending on where it is obtained. There's no way of knowing what you're putting in your body and many of the chemicals that heroin is cut with are not safe for human consumption. Additionally, the number of adulterants in heroin can result in available batches having vastly differing potencies. This results in an almost impossible-to-guess strength of the drug about to be used, and can increase the risk of overdose.

The materials used to cut heroin - which can range from toxic additives such as quinine to particulate fillers such as talcum powder - can also have harmful effects on the body, especially if it is to be used intravenously [10]. Quinine is a medication used to treat malaria and can produce life-threatening adverse effects, such as -

  • kidney damage,
  • arrhythmias,
  • severe allergic reactions,
  • serious bleeding problems [10].

Using heroin that is cut with quinine can significantly increase the risk of experiencing dangerous side-effects.

Because heroin is cut with a variety of additive agents, the colour of the final product can be anything from white to brown [10]. Some of the materials used to cut a heroin batch include -

  • caffeine,
  • flour,
  • chalk,
  • talcum powder,
  • sucrose,
  • starch,
  • powdered milk [10].

Once cut, the amount of actual heroin contained in a batch can range anywhere from 3% to 99%, according to Johns Hopkins University [33].

Chemically speaking, heroin is derived from morphine, a highly addictive opiate and pain-killing drug. Street-bought heroin arrives on the illicit market from a number of manufacturing sources, rendering the final product highly variable in appearance and form. Depending on how a person intends to use the drug, heroin comes in powder, pill, and solution form [34].

Whether in powder or solution form, heroin's attraction lies in its ability to reach the brain quickly and produce euphoric effects. Every time heroin is used, overdose is a risk. Once addiction takes hold, and as long as compulsive use persists, the looming risk of overdose remains [10].

Heroin impurities

Before heroin gets into a dealer's hands, the drug must be synthesised from its botanical source - the opium poppy. Depending on how thorough the manufacturing process is, the final product may contain as many as 40 different impurities [10]. Some of the chemical impurities found in pre-processed heroin are themselves other opiate alkaloids, and include [35] -

  • morphine,
  • codeine,
  • noscapine,
  • papaverine,
  • thebaine [10].

Some of these materials, such as papaverine and thebaine, are used as active ingredients or precursor ingredients to develop medications for managing conditions such as erectile dysfunction, gastrointestinal spasms, and pain symptoms [10].


Can you get addicted?

Heroin is highly addictive and people can quickly become very dependent on it. Over time, the effects of heroin on the brain cause cravings and a strong drive to keep on using. As heroin is used on a regular basis, the body builds up a tolerance, so that users have to start taking more and more. Initially this increase in dose is needed just to get the same high, but then it is needed to feel 'normal', and in time, it is required to avoid very unpleasant withdrawal symptoms.

Doctors have developed a number of effective ways to treat addiction to street heroin. These include initially using certain safer drugs to replace the street heroin, known as opiate substitutes. The most common opiate substitutes are methadone and buprenorphine.

Other drugs are available once you have become drug-free, that block the effects of heroin - so you can't get a high. All these drug treatments are intended to supplement the counselling and social support that normally is needed to help in becoming drug-free and to recover from addiction [1].

The signs of heroin addiction are not always recognisable at first glance. Often family members write off the strange behaviors of their loved ones as a result of stress, fatigue or perhaps a couple of drinks rather than a possible addiction to heroin.

In some cases - even when confronted - your loved one may simply not want to admit there may be a substance abuse problem.

Heroin addiction is among the most common and dangerous adult addictions in the United States. In 2013, there were 8,257 heroin overdose deaths in the U.S. [36]. Being able to spot a heroin dependency in your loved one may be the very thing that saves his or her life [37].


Perhaps you have noticed rapid mood changes in your loved one. Perhaps you have noticed your loved one becoming very secretive, and then getting angry or agitated when questioned.

You may have noticed that he or she has been socialising with a new crowd or group of friends, or has perhaps begun to isolate from everyone around them.

Personal and legal troubles may be becoming more frequent, as the pull of heroin addiction also drives people to say and do things they might not otherwise.

If your loved one struggles with addiction to heroin, you may notice some of the following signs and symptoms [33] -

  • fatigue,
  • mumbled speech,
  • itchy skin; scratching,
  • worsened memory or attention,
  • sexual dysfunctions,
  • mood swings - from joy and elation to apathy to depression,
  • constricted pupils,
  • negligence of responsibilities at school, work or home,
  • accidents or injuries from heroin-associated violence,
  • decreased participation in once-enjoyed recreational or social activities [37].

The more of these signs you notice, the more it may be possible that your loved one is struggling with an addiction to heroin. Some of the physical signs that may suggest problematic heroin use include -

  • injection marks from shooting heroin,
  • an increase in nosebleeds from snorting heroin,
  • frequent respiratory problems from smoking heroin [37].

Dangerous interactions

  • Depressants (1,4-Butanediol, 2m2b, alcohol, barbiturates, benzodiazepines, GHB/GBL, methaqualone) - This combination can result in dangerous or even fatal levels of respiratory depression. These substances potentiate the muscle relaxation, sedation and amnesia caused by one another and can lead to unexpected loss of consciousness at high doses. There is also an increased risk of vomiting during unconsciousness and death from the resulting suffocation. If this occurs, users should attempt to fall asleep in the recovery position or have a friend move them into it.
  • Dissociatives - This combination can result in an increased risk of vomiting during unconsciousness and death from the resulting suffocation. If this occurs, users should attempt to fall asleep in the recovery position or have a friend move them into it.
  • Stimulants - It is dangerous to combine heroin, a depressant, with stimulants due to the risk of excessive intoxication. Stimulants decrease the sedative effect of heroin, which is the main factor most people consider when determining their level of intoxication. Once the stimulant wears off, the effects of heroin will be significantly increased, leading to intensified disinhibition as well as other effects. If combined, one should strictly limit themselves to only taking a certain amount of heroin [20].


  • Ketamine - both substances bring a risk of vomiting and unconsciousness. If the user falls unconscious while under the influence there is a severe risk of vomit aspiration if they are not placed in the recovery position.
  • MXE - this combination can potentiate the effects of the opioid
  • DXM - CNS depression, difficult breathing, heart issues, hepatoxic, just very unsafe combination all around. Additionally if one takes dxm, their tolerance of opiates goes down slightly, thus causing additional synergistic effects.
  • Cocaine - stimulants increase respiration rate allowing a higher dose of opiates. If the stimulant wears off first then the opiate may overcome the patient and cause respiratory arrest.
  • Alcohol - both substances potentiate the ataxia and sedation caused by the other and can lead to unexpected loss of consciousness at high doses. Place affected patients in the recovery position to prevent vomit aspiration from excess. Memory blackouts are likely
  • GHB/GBL - the two substances potentiate each other strongly and unpredictably, very rapidly leading to unconsciousness. While unconscious, vomit aspiration is a risk if not placed in the recovery position
  • Tramadol - concomitant use of tramadol increases the seizure risk in patients taking other opioids. These agents are often individually epileptogenic and may have additive effects on seizure threshold during coadministration. Central nervous system- and/or respiratory-depressant effects may be additively or synergistically present
  • Benzodiazepines - central nervous system and/or respiratory-depressant effects may be additively or synergistically present. The two substances potentiate each other strongly and unpredictably, very rapidly leading to unconsciousness. While unconscious, vomit aspiration is a risk if not placed in the recovery position Blackouts/memory loss likely [21].


  • PCP - PCP can reduce opioid tolerance, increasing the risk of overdose
  • N2O - both substances potentiate the ataxia and sedation caused by the other and can lead to unexpected loss of consciousness at high doses. While unconscious, vomit aspiration is a risk if not placed in the recovery position. Memory blackouts are likely.
  • Amphetamines - stimulants increase respiration rate allowing a higher dose of opiates. If the stimulant wears off first then the opiate may overcome the patient and cause respiratory arrest.
  • MAOIs - Coadministration of monoamine oxidase inhibitors (MAOIs) with certain opioids has been associated with rare reports of severe and fatal adverse reactions. There appear to be two types of interaction, an excitatory and a depressive one. Symptoms of the excitatory reaction may include agitation, headache, diaphoresis, hyperpyrexia, flushing, shivering, myoclonus, rigidity, tremor, diarrhea, hypertension, tachycardia, seizures, and coma. Death has occurred in some cases [21].


One of the best indicators of a heroin addiction are the telltale symptoms of acute heroin withdrawal. When individuals experience withdrawal, it means they've used heroin enough times for their body to develop a physical opioid dependence.

Suddenly, when they no longer have access to the drug, they may grow anxious and even sick - at which point there will be relatively few options, short of using more heroin, for you to help alleviate their symptoms.

Withdrawal can be experienced within hours or sometimes days of being without heroin. Withdrawal symptoms can be uncomfortable, painful and sometimes even dangerous [37].

Typically heroin withdrawal symptoms will begin 6 to 12 hours after the last dose, peaking within 1 to 3 days, and gradually subsiding over 5 to 7 days [27].

  • diarrhoea,
  • stomach cramps,
  • sweating,
  • itching,
  • insomnia,
  • vomiting,
  • nausea [38],
  • chills,
  • runny nose,
  • goosebumps,
  • tears,
  • aches and pains in the muscles and joints,
  • extreme restlessness,
  • yawning,
  • dilated pupils,
  • anxiety,
  • depression,
  • severe drug cravings,
  • muscle spasms [27].

Mental signs

Mental withdrawal symptoms may not always be considered when commenting on heroin addiction, but they can be just as difficult to overcome as physical issues.

Emotional withdrawal is typically considered to include cravings you'll feel for the drug [37]. But it can also manifest itself as -

  • anxiety,
  • depression,
  • restlessness,
  • paranoia,
  • anger [37].

When you experience depression or anxiety brought on by withdrawal, it can be difficult to avoid the desire to take heroin just to have those feelings go away. When this happens, you put yourself at a high risk for overdose - just as you do when you try to avoid physical withdrawal symptoms [37].

Physical symptoms

When you withdraw from heroin, it doesn't just take a mental toll on you - it also takes a physical toll as well. Physical withdrawal is perhaps what people think of most often when the idea of withdrawal is considered. Physical withdrawal symptoms include [34] -

  • muscle spasms and joint pain,
  • nausea and vomiting,
  • fever,
  • diarrhoea,
  • insomnia,
  • sweating, runny nose,
  • stomach cramps,
  • elevated heart rate and blood pressure [37].

If you've ever attempted to detox from heroin, you've undoubtedly experienced some degree of these physical withdrawal symptoms. Many self-detox attempts fail the first time, as some individuals are unable to overcome the discomfort and pain - and instead turn back to heroin. If you're determined to quit, and are ready for detox, consider doing so in a supervised programme [37].

Safer withdrawal at detox programmes

There are a number of addiction treatment options that can help you detox in a safe, regulated way. Detox and rehab programmes can also make the withdrawal process much more comfortable than if you were to attempt it by yourself.

Medication is often used in order to help those struggling with heroin addiction ease off of consuming large amounts of heroin. These medications - including buprenorphine and methadone - are opioid receptor agonists, with similar effects to those of heroin and other opioids. These medications are able to mitigate the onset of many of the unpleasant withdrawal symptoms - but without the pronounced addictive potential and overdose dangers of heroin.

Additionally, if you're admitted to a drug treatment programme, you'll be allowed to detox from heroin under the watchful eyes of medical staff members. They're there to help you through the harshest withdrawal symptoms by providing medication as well as moral support and addiction counselling.

For individuals whose heroin dependency is very advanced, this option is one of the safest. Through supervised detox, you can safely navigate the withdrawal period - gaining a head start towards successful addiction recovery [37].

Drug testing


Heroin and other opiates such as morphine and opium are detectable by standard drug tests on urine between 24 and 48 hours after use. A urine test is the most commonly-used method, since it is both relative inexpensive and easy to administer.

A drug urine test is made up of two components. The first stage is to have the individual provide a urine sample under tightly controlled conditions.

The subject will likely be asked to go to a testing facility where he or she will need to remove street clothing and put on a hospital gown. This step virtually ensures that a clean sample from someone else is not smuggled in to the testing center and substituted fort the subject's urine.

Once the subject has changed into the gown, he or she is escorted to the testing area. This is likely a washroom where the water in the toilet tank has been dyed so that an attempt to water down the sample by adding toilet water will be quite obvious. The taps at the sink won't be any help to a person intending to use that source of liquid to alter the sample, since the water supply to them will have been shut off. A staff member will be waiting nearby to take the sample once it has been provided, and standard protocol is to test it to confirm that the temperature is consistent with normal body temperature.

A negative reading on a drug test doesn't mean that there is no heroin in the subject's system. It simply means that the sample taken didn't record a level higher than the threshold published by the Mandatory Guidelines for Federal Workplace Drug Testing Programs. For opioids like heroin, the cutoff is 2000 nanograms per milliliter.

If the initial urine test is positive for drugs, including heroin, it is repeated. A second result of 2000 ng/ml means the positive test stands and the subject will be facing consequences, and none of them will be good [31].

Heroin is detectable in a urine test for 2 - 4 days [26].

How long does heroin stay in the blood?

A blood test will detect heroin for up to 6 hours [26].

How long will heroin show up in a saliva test?

A saliva test will detect heroin from 1 - 4 days [26].

How long does heroin remain in hair?

Heroin, like many other drugs, can be detected with a hair follicle drug test for up to 90 days [26].

Other tests

Urine tests are not the only testing method used to detect the presence of opioids. A blood test will reveal the presence of heroin or other drugs in this class in a person's system. This testing method is more expensive than the urine test, and requires trained medical personnel to collect a sample. It is the most expensive test to administer, but it is also the most accurate way to determine if someone has been using heroin and other drugs.

A hair test will also provide accurate results when used to check for heroin use. It is less invasive than taking a blood sample and this method is also less expensive. When a hair test is chosen, the results will point to past use, as opposed to what the subject did during the last week or so. It involves taking a small sample of hair for analysis. Opiates don't travel down the hair shaft, so this method can be used to determine the timeline for heroin use, if any.

Saliva tests are becoming more popular over time for detecting illicit drug use. The procedure is not overly invasive, since it involves taking a swab from inside the subject's mouth. The issue with this method is that there is no national cutoff standard for determining a positive result, and the results obtained may vary depending on the brand used for testing purposes [31].

False positives on drug tests for heroin

Some over the counter pain medicines which contain codeine may give false positives, since codeine has a chemical structure that is similar to heroin. Other opioids, whether prescribed or not, will also trigger a positive result.

A person who is taking this type of medication under prescription for pain relief should mention that fact to the testing facility before providing a sample. Bringing the prescription bottle and/or providing a note from the doctor who prescribed the medication is a good idea [31].


  • Heroin is a class A drug, so it's illegal to have for yourself, give away or sell.
  • Possession is illegal and can get you up to seven years in jail and/or an unlimited fine.
  • Supplying someone else, even your friends, can get you up to life imprisonment and/or an unlimited fine [1].

What if you're caught?

If the Police catch you with heroin, they'll always take some action. This could include a formal caution, arrest and prosecution [1].

- A conviction for a drug-related offence could have a serious impact. It can stop you visiting certain countries - for example the United States - and limit the types of jobs you can apply for [1].

Did you know?

  • Like drinking and driving, driving when high is illegal - and you can still be unfit to drive the day after using heroin. You can get a heavy fine, be disqualified from driving or even go to prison.
  • Allowing other people to supply drugs in your house or any other premises is illegal. If the police catch people supplying illegal drugs in a club they can potentially prosecute the landlord, club owner or any person concerned in the management of the premises [1].

Mixing with other drugs

Heroin is a bad mixer and will only make the chances of unconsciousness, vomiting and choking greater. Only 21% of fatal overdoses in a recent Australian survey came about through using heroin by its lonesome.

Please note - there have been very few scientific studies into the effects of combining psychoactive drugs. The information presented here is anecdotal. It is based on the subjective reports of experienced users. Different people will respond differently to different drugs and drug combinations. Know your body.

  • alcohol - alcohol and heroin both depress the central nervous system. The combination has proven fatal,
  • amphetamines - mixing uppers and downers is not good; speed's stimulant effects may mask the opiate effects of heroin and make overdoses more likely,
  • cocaine - mixing the two (known as a 'speedball') is especially dangerous; the two drugs potentiate each other, increasingly their effectiveness twofold. Cocaine acts as a powerful stimulant and raises the heart rate, but its effects wear off quicker than heroin, which in turn slows the heart. As a result, the heart can lose rhythm entirely. John Belushi and River Phoenix both died after taking speedballs,
  • ecstasy - MDMA's effects may mask opiate effects of heroin and make overdose easier,
  • GHB - GHB is a liquid sedative anesthetic; mixing it with heroin could fatally depress the central nervous system,
  • ketamine doesn't work,
  • LSD - psychedelic drugs mess with the effects of opiates, making them unpredictable and usually unpleasant,
  • magic mushrooms - the same with that of LSD,
  • tobacco - no effect [31].

Harm reduction

Most heroin fatalities are the result of injecting (or less commonly, snorting), the point being that a potentially lethal dose is ingested in one dose. Smoking on foil, where small doses are inhaled consecutively is far safer.

Injecting also carries a far higher risk of contracting a blood borne virus like HIV or hepatitis C and infection through botulism or anthrax, both of which have appeared in heroin in the UK in recent years. Don't share any injecting equipment; this includes water, spoons and cottons as well as needles and syringes. It has been established that even sharing a rolled up note to snort can permit the transmission of viruses. The transition to injecting is often caused by initiation/imitation around peer behaviour - do not allow yourself to be pressured. While heroin is frequently cited as the most dangerous drug to use, this is, in fact, related to the practice of injecting, the seductive nature of the effects of the drug on people with poor coping mechanisms (many people find the drug's effects deeply unpleasant), the historic public perception of the drug; that heroin users are weak and without scruples, and its legal status.

Heroin can cause the user to be less vigilant about other high risk behaviour such as unprotected sex and a partial loss of consciousness, 'nodding out' or 'gouching' and motor/muscle control can leave the user vulnerable.

A combination of CNS depressants, such as alcohol, benzodiazepines or sleeping tablets and heroin (or other opiate/opioids) is very risky. If you imagine giving each drug type a number that indicates how potent each substance is, for example; heroin 3, Valium/Temazepam 2 and a double short of spirits 2. Now think of mixing all three as 3 x 2 x 2 rather than 3+2+2, as each substance potentiates the other, resulting in a greatly increased risk factor. Many users in the UK struggle to fund a habit legally and drift not only into offending behaviours, but seek to increase or maintain a satisfactory sedative effect as their tolerance increases, by using alcohol or benzodiazepines on top of heroin, also inviting a secondary/tertiary dependence.

If you use heroin, or know someone who does, you should be aware of 'Narcan' (Naloxone) initiatives. There may be a programme in your area which will provide both the drug, in injectable form, advice how to use it in the case of an emergency and learn how to do CPR, life-saving chest compressions if you are present at an overdose. You can ask your mates to do the same, spreading the message. Narcan is a short acting antagonist that reverses the effects of heroin and other opiates like morphine and can save lives.

If you use heroin, try and buy from one or two dealers who you trust. Try not to use every day. Try not to get into debt.

Heroin will reduce your appetite and you may find yourself nibbling sweet 'treats' instead of eating a proper meal. Many users become emaciated and vitamin and mineral deficient. Try and eat properly. Your appetite after using will be lessened, remember this when planning to score. As heroin reduces the force of your emotions, it will affect your responses and relationships and may inhibit your sex drive in particular. It is a solitary drug. There is also a connection between heroin use and sex working and the interruption of the menstrual cycle. This creates a dynamic that further isolates the user.

Some research suggests that chronic heroin users' display increased tolerance to the drug in locations where they are familiar with, when a user injects in a different location, this environment-conditioned tolerance does not occur, and the user may be more likely to overdose. It is suggested that heroin injectors do not use alone when possible [2].

  • Smoking heroin is less dangerous than injecting due to reduced risk of getting blood borne viruses including HIV, hepatitis B and hepatitis C. Those who take heroin are advised never to share any equipment,
  • If you choose to inject, don't do all your heroin in one go. Make sure you are with other people who can call an ambulance in case you overdose,
  • If injecting: only use clean supplies, use the smallest needle possible, only use clean equipment, rotate your sites, wash injecting sites/ hands and never share equipment!
  • Avoid other downers like alcohol, methadone, benzos or sleeping tablets as this will increase your risk of overdose,
  • Naloxone can reverse an opiate overdose - speak to your local drug service to find out more [39].


Those who inject heroin use a set of paraphernalia that includes hypodermic needles, small cotton balls used to strain the drug, spoons or bottle caps for 'cooking' (liquefying) the heroin, and a 'tourniquet' that the user wraps around his or her arm to make his or her veins protrude. Paraphernalia for sniffing or smoking heroin can include razor blades, straws, rolled dollar bills, and pipes. Also, balloons are used as a method of transporting and/or trafficking the drug [40].

  • needles or syringes not used for other medical purposes,
  • burned silver spoons,
  • aluminium foil or chewing gum wrappers with burn marks,
  • missing shoelaces (used as a tourniquet for injection sites),
  • straws with burn marks,
  • small plastic bags, with white powdery residue,
  • water pipes or other pipe [27].

If snorted

Razor blade, hard level surface (such as a mirror or glass), tube or rolled banknote [6].

If smoked

Tinfoil, matches or lighter, cigarette papers, tobacco [6].

If injected

Needle and syringe, water, citric acid, matches or lighter, spoon, tourniquet, swabs [6].


Several medical treatment options exist for heroin addiction. These treatments can be effective when combined with a medication compliance program and behavioral therapy. Methadone (Dolophine, Methadose), buprenorphine (Subutex, brand discontinued in U.S), buprenorphine combined with naloxone (Suboxone) and naltrexone (Depade, ReVia) are approved in the US to treat opioid dependence. These treatments work by binding fully or partially to opiate receptors in the brain and work as agonists, antagonists or a combination of the two. Agonists mimic the action of the opiate, and antagonists block and reverse the action of the opiate. Oral administration of these drugs may allow for a more gradual withdrawal from opiates. A long-acting intramuscular depot formulation of naltrexone (Vivitrol) is also available for use following opiate detoxification.

Methadone has been used for over a quarter century to treat heroin addiction. The use of methadone in opiate dependency is highly regulated in the US, and may differ between states. Oral methadone is approved for opiate detoxification and maintenance only in approved and certified treatment programmes, although certain emergency or inpatient care exceptions exist. Patients usually need to visit a centre daily for treatment and follow-up; however, special exceptions may be granted for Sunday, State and Federal holidays, and other times as determined by the Treatment Centre Medical Director [41].

Buprenorphine/naloxone, like methadone, has been shown in clinical trials to be effective in treating heroin dependence, and may have a lower risk for withdrawal effects upon discontinuation.

Naloxone (a pure opiate antagonist at receptor sites) is present to help prevent the intravenous abuse of the buprenorphine component. Buprenorphine/naloxone treatment takes place in an authorised physicians' office, and this may be more acceptable to patients. Buprenorphine is also available as a single agent and is used primarily for induction at treatment onset. Patients are usually switched to the combined buprenorphine/naloxone agent for outpatient maintenance therapy. A 2013 report by the Drug Abuse Warning Network (DAWN) highlights the fact that buprenorphine has become a popular drug of abuse itself. Emergency department visits involving buprenorphine increased substantially from 3,161 in 2005 to 30,135 in 2010 [42].

  • Naltrexone*, available orally and as an intramuscular depot injection is another treatment option, but patients must be opioid-free for at least 7 to 10 days prior to treatment. Naltrexone is a pure opioid antagonist and may result in withdrawal symptoms if the patient is not opioid-free [32].


While the synthesis of heroin can be dated to the close of the 19th century (originally 1874 in Paddington and commercially in 1899 by Bayer in Germany), opium has a long social and medical connection with humans (see Opium). There is a fascinating argument that suggests that the attempts to prevent opium use in cultures where it had been ingrained for many centuries merely succeeded in promoting heroin as an alternative. This not only introduced the drug without the cultural context that had grown over time, often many centuries, around opium use, but introduced injecting (opium is not injected, heroin as a salt can be) as a faster, 'cheaper by the dose' option for users with disastrous consequences, paticularly the spread of BBV's and increased incidence of overdose. It is frequently suggested that allowing the supply of the drug to be monopolised by profit-maximising criminals causes problems that cannot eradicate supply but merely compound the health, legal and social problems addicts face. The drug has been available for years in the UK on prescription and still is in terminal care and cases where a person is suffering chronic, severe pain, but doctors need a Home Office licence to supply heroin (diamorphine) for the treatment of addiction [2].

As long ago as 3400 B.C., the opium poppy was cultivated in lower Mesopotamia. The Sumerians called it as Hul Gil, the 'joy plant.' The Sumerians' knowledge of poppy cultivation passed to the Assyrians, the Babylonians, and ultimately, the Egyptians.

By 1300 B.C. the Egyptians were cultivating /opium thebaicum/, named for their capital city of Thebes. From Thebes, the Egyptians traded opium all over the Middle East and into Europe. Throughout this period, opium's effects were considered magical or mystical.

Some eight hundred years later, the Greek physician, Hippocrates, dismissed the idea that opium was 'magical'. Instead, he noted its effectiveness as a painkiller and a styptic.

Around 330 B.C. Alexander the Great introduced opium to the people of Persia and India, where the poppies later came to be grown in vast quantities. By A.D. 400, opium thebaicum was first introduced to China by Arab traders.

During the Middle Ages in Europe, when anything from the East was linked to the Devil, opium went unmentioned and unused in Europe. However, the surge of seafaring and exploring reintroduced the drug in the late 15th and early 16th centuries. Portuguese sailors are thought to have been the first to smoke opium, around 1500. As with any drug, smoking opium has an instantaneous effect, contrasted with eating or drinking the drug.

Laudanum, an alcoholic solution of opium, was first compounded by Paracelsus about 1527. The preparation was widely used up through the 19th century to treat a variety of disorders. The addictive property of opium (or laudanum) was not yet understood. A leading brand of laudanum, Sydenham's Laudanum, was introduced in England in 1680.

Purely recreational use of opium gained some prevalence in the early 1600's in Persia and India, where it was either eaten or drunk in various mixtures. The heavy traffic of trade and exploration by sea continued to spread the traffic of opium around the world during this period. Opium was traded everywhere from China to England. In fact, in 1606 ships chartered by Elizabeth I were instructed to purchase the finest Indian opium and transport it back to England.

The eighteenth century saw greater incursions of the opium trade into China, along with the practice of smoking the drug in pipes. The British undertook creating a demand for opium in China in order to create a trade balance for all of the tea from China they required. The opium problem became widespread enough to inspire a Chinese ban, in 1729, of the use of opium for anything other than licensed medical use. Beginning in the second half of the eighteenth century, the British East India Company dominated the opium trade out of Calcutta to China.

The amount of opium sold into China was approximately two thousand chests of opium per year by 1767, and by 1858, that number had risen to 70,000 chests of opium. By the end of the century, the British East India Company had a complete monopoly on the Indian opium trade. In 1799, all opium trade was banned in China, but by then millions of Chinese were addicted. In some coastal provinces, 90% of Chinese adults were opium addicts by the mid-1830's.

Not to be outdone, the British Levant Company began, in 1800, to purchase nearly half of all of the opium coming out of Smyrna, Turkey for export to Europe and the United States.

In 1803, Friedrich Sertuerner of Germany synthesised morphine (principium somniferum) for the first time, and discovered the active ingredient of the opium poppy, which Linnaeus had first classified in 1753 as papaver somniferum. The discovery of morphine was considered a milestone. The medical community declared that opium had been 'tamed'. Morphine's reliability, long-lasting effects, and safety were extolled. In fact, despite its potential for addiction, morphine is still the premier drug used for extreme pain in hospitals and for end-of-life care.

Following the 1799 ban on opium in China, opium smuggling began to be a crowded industry, with several well-known Americans entering the trade. Charles Cabot and John Cushing, of Boston, worked separately to amass opium-smuggling wealth. John Jacob Astor of New York City smuggled ten tons of opium into China under his American Fur Company banner, but later confined his opium selling to the English trade.

English artists, writers, and other luminaries were famously experimenting with and becoming addicted to opium in the early 19th century. By 1830, British use of opium for both medicinal and recreational purposes was at an all time high. 22,000 pounds of opium were imported from Turkey and India that year.

Laudanum continued to be popular, and was actually cheaper than beer or wine. Patent medicines (non-prescription 'cures' of all descriptions), and opium preparations such as Dover's Powder were readily available. The incidence of opium dependence grew steadily in England, Europe, and the United States during the first half of the 19th century by means of these treatments. Working-class medicinal use of products containing opium as sedatives for children was especially common in England. Those using opium for recreational purposes seem to have been primarily English literary and creative personalities, such as Thomas de Quincey, Byron, Shelley, Barrett-Browning, Coleridge, and Dickens.

The First Opium War between China and England began in 1839 as a result of a Chinese ban on opium traffic, and an order for all foreign traders to surrender their opium. In 1841, the British defeated the Chinese and took possession of Hong Kong as part of their bounty. The Second Opium War of 1856 finally made the importation of opium into China legal again, against the wishes of the Chinese government.

Dr. Alexander Wood of Edinburgh discovered the technique of injecting morphine with a syringe in 1843. The effects of injected morphine were instantaneous and three times more potent than oral administration.

Heroin (diacetylmorphine) was first synthesized in 1874 by English researcher, C.R. Wright. The drug went unstudied and unused until 1895 when Heinrich Dreser working for The Bayer Company of Germany, found that diluting morphine with acetyls produced a drug without the common morphine side-effects. Heroin was considered a highly effective medication for coughs, chest pains, and the discomfort of tuberculosis. This effect was important because pneumonia and tuberculosis were the two leading causes of death at that time, prior to the discovery of antibiotics. Heroin was touted to doctors as stronger than morphine and safer than codeine. It was thought to be nonaddictive, and even thought to be a cure for morphine addiction or for relieving morphine withdrawal symptoms. Because of its supposed great potential, Dreser derived his name for the new drug from the German word for 'heroic'.

After decades of promoting the consumption of opium, Britain in 1878 passed the Opium Act to reduce opium consumption in China, India, and Burma. Under the new regulation, the selling of opium was restricted to registered Chinese opium smokers and Indian opium eaters.

In 1886, the British acquired Burma's northeast region, the Shan state. Production and smuggling of opium along the lower region of Burma thrived despite British efforts to maintain a strict monopoly on the opium trade. To this day, the Shan state of Burma (now known as Myanmar) is one of the world's leading centers of opium production.

During the early years of the 20th century, the Chinese leadership worked in a variety of ways to stop the flow of opium into their country. In 1910, after 150 years of failed attempts to rid the country of opium, the Chinese were finally able to convince the British to dismantle the India-China opium trade.

Despite the 1890 U.S. law-enforcement legislation on narcotics, which imposed a tax on opium and morphine, consumption of the drugs, along with heroin, grew rapidly at the end of the 19th and beginning of the 20th centuries. Various medical journals of the time wrote of heroin as a morphine step-down cure. Other physicians argued, on the other hand, that their patients suffered from heroin withdrawal symptoms as severe as morphine withdrawal.

Finally, in 1905, the U.S. Congress banned opium. The following year, Congress passed the Pure Food and Drug Act, which required pharmaceutical companies to label their patent medicines with their complete contents. As a result, the availability of opiate drugs in the U.S. significantly declined. In 1909, Congress banned the import of opium. In 1914, Congress passed the Harrison Narcotics Act, which aimed to curb drug abuse and addiction. It requires doctors, pharmacists, and others who prescribed narcotics (cocaine and heroin) to register and pay a tax.

In 1923, the U.S. Treasury Department's Narcotics Division (the first federal drug agency) banned all legal narcotics sales, forcing addicts to buy from illegal street dealers. Soon, a thriving black market opened up in New York's Chinatown.

In the 1920's and 30's, the majority of illegal heroin smuggled into the U.S. came from China. In the 1940's, Southeast Asia, (Laos, Thailand and Burma, referred to as the Golden Triangle,) became a major player in the profitable opium trade. In fact, during World War II, the French occupiers of Southeast Asia encouraged Hmong farmers to expand their opium production so that the French could retain their opium monopoly. After the war, Burma gained its independence from Britain, and opium cultivation and trade began to flourish in the Shan state.

In the U.S., the heroin trade between 1948 and 1972 was dominated by Corsican gangsters and U.S. Mafia drug distributors. The raw Turkish opium was refined in Marseilles laboratories (the 'French Connection',) and sold to junkies on New York City streets. In the 1950's, the U.S. preoccupation with stopping the spread of Communism led to alliances with drug producing warlords in the Golden Triangle. The U.S. and France supplied the drug warlords and their armies with ammunition, arms, and air transport for the production and sale of opium. The result was an explosion in the availability and illegal flow of heroin into the United States and into the hands of drug dealers and addicts. During the U.S. war in Vietnam, the CIA set up a charter airline, Air America, to transport raw opium from Burma and Laos. During this period, the number of heroin addicts in the U.S. reached an estimated 750,000.

After the Vietnam War, the heroin epidemic in the U.S. subsided somewhat. Until 1978, Mexican Mud, temporarily replaced China White heroin as the most common source of heroin in the U.S. In 1978, the U.S. and Mexican governments cooperated to eliminate the source of Mexican opium. They sprayed the poppy fields with Agent Orange. The amount of Mexican Mud in the U.S. drug market declined rapidly. Another source of heroin cropped up in its wake, from the Golden Crescent area of Iran, Afghanistan, and Pakistan.

During the 1970's and 80's, officials tried to eradicate marijuana, coca, and opium poppy farms by introducing crop substitution programs in the Third World, but the technique produced very disappointing results.

In the late 80's, the establishment of a dictatorship in Burma increased the production of opium in that country. The world's single largest heroin seizure was made in 1988 in Bangkok. The 2,400-pound shipment of heroin, en route to New York City, was suspected to have originated in the region controlled by the Burmese drug warlord, Khun Sa. Khun Sa was indicted in the U.S. in 1990 on heroin trafficking charges, but was still at-large in Burma.

In 1992, Colombia's drug lords introduced a high-grade form of heroin into the United States at prices that severely undercut Asian sources. Despite a 1993 joint operation between the Thai army and U.S. Drug Enforcement Agency, among others, efforts to eradicate opium at its source remained unsuccessful in the mid-90's. The new U.S. focus adopted the approach of attempting to "[strengthen] democratic governments abroad, [to] foster law-abiding behavior and promote legitimate economic opportunity".

In 1995, the Golden Triangle region of Southeast Asia was the leader in opium production, yielding 2,500 tons annually. According to U.S. drug experts, there were new drug trafficking routes from Burma through Laos, to southern China, Cambodia, and Vietnam. In January 1996, the Burmese warlord Khun Sa 'surrendered' to the ruling junta of Burma. The junta allowed Khun Sa to retain control of his opium trade if he would end his 30-year-old revolutionary war against the government. In 1998, it appeared that approximately 18% of the heroin smuggled into the U.S. came from the Golden Triangle [28].

The opium poppy has had a long history. Our earliest knowledge of its cultivation dates back to the ancient Mesopotamian and Sumerian cultures, who passed it on to the Assyrians, Babylonians, and Egyptians. The Greeks introduced opium to Persia and India, where it was grown in mass quantities. In the eighteenth century, the British began exporting it to China, where they traded it for tea. Opium abuse reached epic proportions in China, where millions of people became addicted in the 1800's. When the Chinese government tried to ban all opium imports in 1839, The First Opium War began, ending in the British taking Hong Kong. The Second Opium War of 1856 made opium imports into China legal again, still against the wishes of the Chinese government. Heroin was synthesised from morphine in 1874 by the pharmaceutical company Bayer and was touted as a safer, non-addictive form of morphine. It became a widely used drug in cough medicines and a variety of other ailments. By the beginning of the twentieth century, heroin was understood to be highly addictive and in 1914 was banned as part of the Harrison Narcotics Act [40].


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