Everything you need to know about Heroin

Between April 2020 and the end of March 2021, there were 275,896 people in contact with drug and alcohol services. Of these, over half received treatment for an opiate drug problem, of which heroin is one such type of drug. Of course, not all drug users seek help and support, so the number of actual users of these substances is extremely likely to be much higher.

If we look at drug misuse statistics in the UK, approximately 1 in every 11 adults between the ages of 16 and 59 years old and around 1 in 5 of those between 16 and 24 years old reported that they had used drugs in the year ending June 2022. These staggering statistics equate to around 3 million adults in total or 18.6% of the adult population.

Of course, not all of these people will have taken the drug heroin. In fact, heroin is one of the rarer drugs that people tend to take. Taking heroin used to be more common. A large proportion of those receiving treatment for opiate addiction (of which heroin is one) likely started using during the 1980s and 1990s when there was a heroin epidemic.

For this reason, most heroin users tend to be over 40 years old. Indeed, according to government research, in the year ending 2018, 69% of people said they first used the drug before 2001 with only 9% saying they first tried it after 2011. Let’s take a closer look at what heroin is.

What is heroin?

Heroin is an illegal drug that is a processed form of morphine. It is derived from varieties of opium poppy plant seed pods that grow in countries in Asia as well as in Colombia and Mexico.

In appearance, heroin can look like a brownish or white powder or it may be sticky and black (black tar heroin). The powder is typically “cut” with starch, sugars, quinine or powdered milk. Pure heroin is a white powder and it has a bitter taste. The pure variety is smoked or snorted (this often makes it more appealing to users as it does not involve injection and the stigma that’s associated with it).

Black tar heroin is either hard in consistency resembling coal or is sticky like tar used in roofing. Black tar heroin tends to originate in Mexico and is often sold in the US on the west of the Mississippi River. The colour of this form of heroin is the result of crude processing where impurities are left behind. It is usually dissolved and injected into the body, either under the skin, in the muscles or directly into veins.

On the street, heroin has other names. It is known as H, skag, smack, gear, brown, horse, diamorphine, dope, sh*t, mud, junk, brown sugar, chive, raw, Captain Jack, Charley, China, big H, Harry, China white, Mr Brownstone and Dr Feelgood.

Can heroin be addictive?

Heroin is a highly addictive substance. It has the reputation of being one of the most addictive illegal drugs.

Some people wish to try heroin just once so that they can see what it is like. But it is a well-reported fact that its use doesn’t tend to stop after the first hit. The high a user receives is so pleasurable that those who’ve tried it just want to have those feelings back again. Some American research has highlighted that out of all the people who try heroin, almost a quarter of them will become addicted.

Those who use it regularly develop a tolerance to it. This means that they will need a higher dose or more frequent doses of the drug to achieve the same desired effects.

This is when the user is at risk of being dependent on the drug. Dependence on heroin is characterised by the body’s adaptation to the drug’s presence. The body feels like it needs heroin to function normally.

Someone who is dependent on heroin will crave it and will experience unpleasant withdrawal symptoms when they cannot use it. Seeking the “rush” and the high is no longer what taking the heroin is about; it’s become about avoiding withdrawal. This is the key indicator that a person is an addict.

Those addicted continue to take it out of “necessity”, even when they know that they are suffering from adverse effects of its continued use. This is known as a substance use disorder (SUD).

Heroin withdrawal

As mentioned, those addicted to heroin reach the point of having to take the drug to combat the withdrawal symptoms which are extremely unpleasant.

Withdrawal symptoms can start a mere few hours after someone last took the drug and they include:

• Extreme bone and muscle pain.
• Restlessness.
• Problems sleeping.
• Vomiting and diarrhoea.
• Cold flashes accompanied by goosebumps (this is where we get the phrase going “cold turkey” from).
• Uncontrollable movements in the legs (where “kicking the habit” comes from).
• Severe cravings for the drug.

Treating heroin addiction

There has been a lot of research into the effects of heroin and other opioids on the brain. Some studies have shown that the brain loses some white matter when taking heroin and this may affect a person’s ability to control their behaviour including decision-making and their response to stress. As such, a range of treatment methods is often applied to treating heroin addiction.

Methods of treatment include behavioural therapies and medicines to help with the withdrawal process. Medications include medicines that are opioids as well as ones to treat the symptoms.

These medicines are known to be effective and safe and they genuinely save lives. The reason that they work is due to the fact that they work on the very same receptors in the brain where heroin acts, but they do not give the same “rush” effects.

These medications include:

• Methadone.
  This is an opioid receptor “full agonist”. It attaches to opioid receptors and eases cravings and withdrawal symptoms.
• Buprenorphine.
  This is an opioid receptor “partial agonist”. This means that it attaches to the receptors and partially activates the receptors, easing cravings and withdrawal symptoms.
• Naltrexone.
  This is an opioid reception “antagonist”. This means that it prevents the heroin from attaching to the opioid receptors and blocks its effects.

Behavioural therapies are also used in conjunction with medication. Cognitive behavioural therapy helps by modifying the person’s expectations surrounding their drug use and their subsequent behaviours.

It helps to manage stress and triggers. Contingency management is another technique that is based on offering incentives and motivation such as rewards like cash or vouchers for staying drug-free. These behavioural therapies work best when used in combination with medications as a part of a detox programme.

What is heroin used for?

Heroin is a potent drug that is used recreationally for its euphoric effects. This accounts for the majority of its use globally.

However, heroin does have some medical uses. Medically, it is named diamorphine and is used in the UK as a strong pain medication. It is administered orally, by injection or IV.

It is prescribed to treat acute pain if there has been a severe physical trauma, heart attack, or for types of pain including post-surgical pain and chronic pain conditions, such as at the end-stage of terminal diseases. Other countries tend not to use diamorphine (heroin) and instead use other opioid preparations such as morphine.

In palliative care, it is usually administered subcutaneously via a syringe driver when patients can no longer swallow solutions containing morphine. Diamorphine is fat soluble (unlike morphine) and it is more potent by injection as smaller doses are needed yet give the same effect.

Medically it is also used as “maintenance therapy” to treat addiction in long-term IV heroin users. This is usually offered if other methods of addiction treatment have failed.

Why and how is heroin abused?

Because heroin is highly addictive, it is abused. To understand how and why it is abused, it’s important to understand why people start using heroin in the first place.

Withdrawal from prescription drugs

Many people are prescribed prescription painkillers after physical trauma. When the trauma has begun to subside, people often find it difficult to cope with the withdrawal from the prescription drugs and become addicted to them.

When medical teams stop prescribing the medication, some people are so desperate that they turn to illicit drug use and begin using heroin. In places like the US, heroin is often cheaper than prescription drugs, especially if they don’t have medical insurance.

Stress relief

People who are going through a difficult time or who have a psychological condition often try to cope with their condition by using substances. Often this is alcohol or other illicit drugs, but sometimes they turn to heroin. This may not be immediate. Typically, heroin is part of a pathway of increasingly potent substances that someone tries in order to manage their difficulties.

Socially

Believe it or not, sometimes heroin use starts as a result of peer pressure and a desire to fit in socially, particularly with younger people. It also makes the user feel less socially inhibited and is seen as a way of reducing a person’s social anxiety. People wrongly believe that it makes them feel braver and happier so that they can thrive in social settings.

Seeking euphoria

Many people try it just to experience the high. They are curious and bored. Those in rural areas who are isolated from activities and a social scene are more likely to succumb to heroin use for this reason.

Heroin use triggers

Essentially, every user’s journey with heroin begins with a “trigger”. These triggers can be environmental, social or emotionally based. Environmental triggers are typically those associated with the area in which a person lives but can include public places like certain bars and hotels or areas that are renowned for their drug use.

Social triggers tend to refer to the social situations that have created the desire to try heroin such as the loss of a job, relationship or opportunity, being in an abusive relationship or arguments and conflict. Emotional triggers include loneliness, depression, anxiety, fear and guilt. The triggers begin a cycle that turns into substance abuse.

Heroin abuse

Heroin is abused by sniffing, snorting, smoking or injecting heroin. People sometimes mix it with other drugs such as crack cocaine. Crack cocaine and heroin mixed together is known as speedballing.

What are the signs that someone is using heroin?

Given that heroin is a Class A drug, its use comes with the risk of severe penalties. This means that its use is often hidden and the full prevalence of its use can only be estimated. It’s not like in the films and TV shows where heroin addicts all have a typical appearance. However, there are signs that you can look out for if you are concerned that someone is vulnerable to using illicit drugs like heroin.

Physical signs of heroin use

• Drastic weight loss.
• Skin sores, itching and picking of the skin.
• Scars on the hands, arms, legs or toes.
• Constricted pupils.
• Vomiting and/or nausea.
• Mumbling of speech.

Emotional, social or behavioural signs of heroin use

• Disassociation.
• School or work issues.
• Family problems.
• Problems with friends.
• Aggression.
• No interest in normal or usual activities.
• Depression.
• Anxiety.
• Overly emotional.
• Fatigue.
• Irritability.
• Lack of concern for appearance and hygiene.
• Lying.
• Money problems.
• Legal problems or criminal behaviour.
• Loss of motivation.

If you think someone you care about is showing signs of heroin or other drug use, you must seek support with how to handle the situation. Quite often, the person is reluctant to seek help and won’t admit that there’s a problem.

How does heroin affect the body?

Heroin is a fast-acting drug and the speed of its action depends on the method by which it is used. Essentially, heroin binds to opioid receptors in the brain. These receptors are involved in how the body experiences pleasure and pain as well as contributing to controlling sleep, heart rate and breathing.

The specific receptors are called mu-opioid receptors or MORs. Our bodies produce natural neurotransmitters (chemicals) that bind to these receptors to help regulate hormone release, feelings of well-being and regulate pain. When they are activated in the brain’s reward centre, they stimulate the release of dopamine, another neurotransmitter, and it’s this that reinforces the drug-taking behaviour in heroin users.

The consequence of using heroin rather than the body’s natural chemicals depends on how much a person uses as well as where it binds in the body, how strong the bond is and how quickly it gets there.

When injected into a vein, heroin takes a mere seven seconds to work. An injection into the muscle takes between five and eight minutes whereas smoking or sniffing takes around 10 to 15 minutes. The heroin travels into the brain where it goes through several chemical reactions and changes into morphine.

When it rushes through the bloodstream it creates warmth and the limbs and extremities become relaxed and heavy. It slows the body’s functions. The intense euphoric feeling lasts between 45 seconds and a minute with the peak effects remaining for less than two hours. The effects generally completely wear off between three and five hours after use.

It’s typical for someone to report feeling “heroic” after their first dose of heroin. It’s been viewed as a “miracle drug” that can ease all pain. But this sense of empowerment is extremely short-lived and then leaves the person feeling much worse than before they took the drug. This is because opiates slowly destroy every cell in the body. They physically change the brain’s structure and function over time.

Heroin undergoes a first pass through the liver and has an extremely rapid half-life of only 2-6 minutes. It is eliminated via the urine. About 7% of it is excreted as unchanged morphine with about 50-60% excreted as glucuronides.

What are the risks of heroin?

Heroin is an extremely risky substance. The main risks associated with the drug are addiction, dependence, dangerous interactions, overdose (and perhaps death) and withdrawal.

Heroin overdose is one of the more dangerous risks but is extremely common. A heroin overdose happens when someone uses enough of the drug to threaten their life or cause their death. When people overdose on heroin, their breathing slows down considerably or even stops. They can enter a state of hypoxia which can have short- and long-term effects on the brain and nervous system including permanent brain damage or coma.

An Australian study in 2001 revealed that over half of injected drug users (54%) had experienced at least one non-fatal overdose in their life and a similar study in 1998 revealed that 11% of regular users had experienced an overdose within the last six months. Most of these overdoses (81%) happened in someone’s home with 88% happening when others were present. Surprisingly, almost three-quarters of those surveyed (73%) said that they never or rarely worried about overdosing.

Even if it’s the first time a person has taken heroin, they can still die from an overdose or by having an allergic reaction to an additive. For a first-time user, the predicted deadly dose ranges between 200mg and 500mg. Addicts can generally tolerate much higher doses up to about 1800mg without even suffering from vomiting.

However, experienced addicts still run the risk of overdose even though their bodies are extremely tolerant of the drug. This is because addicts can push their tolerance to extremes or because they may unintentionally buy heroin that is purer than what they usually use and take their usual dose. Even the most tolerant people can suffer from a sudden loss of their tolerance.

Treatment for overdose

If someone does use too much heroin, there are rescue medications that can be administered to try and counteract the effects. Naloxone is one such medicine that treats an overdose if it is given straight away.

It quickly binds to the opioid receptors and blocks the effect of heroin. Sometimes a second dose of Naloxone is required to get the person breathing again. Naloxone is administered via injection and there is a nasal spray too.

Legality

Another risk of heroin, aside from addiction, dependence, dangerous interactions, overdosing and withdrawal, is the legality (or rather illegality) of it. Heroin is a Class A drug.

This means that it is illegal to possess, distribute to others or sell. Even just possessing heroin can mean a person ends up with a jail sentence of up to seven years in length as well as an unlimited fine. If someone supplies heroin, even just to their friends, this can result in life imprisonment and an unlimited fine.

Even if it’s your first time, if the police find you with heroin they will always act. This could be a formal caution but is often arrest and prosecution. Convictions for drug-related offences are very serious. They can limit the jobs you can apply for as well as prevent you from travelling to some countries such as the United States.

Short-term and long-term effects of heroin

As mentioned, heroin has many effects on the body. Some of these are short-term effects that last from minutes to hours. Other effects are much longer lasting and may not be obvious at the outset.

Short-term effects

Essentially, the most talked-about short-term effect is the “rush” – the euphoric surge of pleasure that happens in the immediate aftermath of taking the drug. The intensity of this rush depends on the amount of heroin used and the method of using it. Injecting gives an almost immediate high, while smoking or snorting heroin takes a little longer to get into the system.

Aside from the pleasurable feeling, there are other common short-term side effects:

• A warm, flushed feeling on the skin.
• Dry mouth.
• Heavy-feeling arms and legs.
• Nausea and/or vomiting.
• Intense itching.
• Being “on the nod” – switching between being awake or semi-conscious.
• Foggy thinking.

After the initial effects, users will remain drowsy for the following few hours with mental impairment too. The heart rate and breathing slow, and sometimes this is enough to be considered life-threatening. This could lead to a coma and irreversible brain damage.

Long-term effects

For those who use heroin long term, there are other effects that may result:

• Collapsed veins from injecting.
• Insomnia.
• Damaged nose tissue if it is snorted.
• Infections in the heart valves and lining.
• Abscesses.
• Kidney and liver disease.
• Lung problems such as pneumonia.
• Depression.
• Other mental disorders such as personality disorders.
• Sexual dysfunction in men.
• Irregular menstrual cycles in women.

These effects are down to the fact that repeated use of heroin changes the brain’s physiology and physical structure which creates a long-term imbalance in hormonal and neuronal systems that are difficult to reverse.

Studies also indicate that white matter in the brain can deteriorate with long-term heroin use. This may make it more difficult for the user to make decisions or regulate their behaviour.

Of course, one long-term effect of heroin use is dependence, as discussed above. Withdrawal can then occur within a few hours after taking the drug. The major symptoms peak around 24 to 48 hours after the last dose. We discussed the symptoms of withdrawal earlier.

Additionally, heroin contains additives. These can clog up the blood vessels that lead to the liver, lungs, brain or kidneys and can cause permanent damage. Aside from this, sharing drug paraphernalia (particularly syringes) comes with the added risk of contracting an infectious disease such as hepatitis or HIV.

What are the different forms of heroin?

Heroin comes in several different forms: white heroin, black tar heroin, brown heroin, cheese heroin and heroin hydrochloride. Let’s take a look at the different forms in more detail as they come from different regions and have different purity levels.

White heroin

White heroin mostly comes from Southeast Asia. It is white, as its name suggests. This form of heroin is quite pure and comes in powder form that dissolves easily in water.

There are some adverse effects that are associated with white heroin including drowsiness, slurred speech, memory problems, attention difficulties, coma, increased likelihood of suicide, peripheral oedema, collapsed veins, increased risk of contracting HIV, hepatitis and TB, sexual dysfunction and depression.

Black tar heroin

As mentioned, black tar heroin is dark in colour and is hard and sticky. It is mostly made in Mexico and is less pure than white heroin. Its appearance is due to its low purity and the way it is processed. It is also typically cheaper than other forms of the drug.

It is no surprise that it contains additives that are often toxic. These additives clog the blood vessels, damaging internal organs. Aside from this, black tar heroin can cause wound botulism due to the presence of bacteria at the injection sites. This can result in paralysis or death. Abscesses are also common as well as necrotising fasciitis and gas gangrene.

Black tar heroin is much more common in the USA than it is in Europe. It can be smoked but is mostly injected.

Brown heroin

Brown heroin typically comes from Southwest Asia and is in a brown powdered form. It does not dissolve in water as easily as white heroin unless you add an acid to it. Despite its apparent differences, the health risks are very similar to those of white heroin.

Brown heroin is the typical form of heroin that is found in Europe. It is difficult to assess the potency of different forms of heroin and therefore there is an increased risk of overdose from one use to the next.

Cheese heroin

This is a fairly new form of heroin and has unfortunately claimed the lives of many young people as it’s a cheaper drug and is laced with diphenhydramine and acetaminophen. It is a lethal combination which depresses the heart rate and the person’s breathing until death occurs, often quite rapidly.

Heroin hydrochloride

This is not common in Europe but is the hydrochloride salt form of heroin. It is easily prepared for an injection as it dissolves in water. This can be snorted but does not work well in smoking as it doesn’t vaporise well.

The Takeaway

When you want to know everything there is to know about heroin, there are a few things you should remember:

• Heroin is an opioid, a drug made from morphine that is a naturally occurring substance derived from opium poppy seed pods.
• Heroin comes in different forms: white powder, brown powder, black tar heroin, cheese heroin and heroin hydrochloride.
• Heroin can be snorted, sniffed and injected. It can also be mixed with crack cocaine when speedballing.
• It enters the brain very quickly, binding to receptors in the brain that deal with feelings of pleasure and pain as well as controlling sleeping, heart rate and breathing.
• It causes many short-term and long-term effects and is extremely addictive.
• Overdoses are common.
• Heroin is a Class A drug and its use, possession and supply come with long prison sentences and hefty fines.
• There is a range of treatments to help people stop their use of heroin.

For support regarding heroin, many organisations can help:

• NHS Support.
• Talk to Frank.
• Narcotics Anonymous.
• SMART Recovery.
• Adfam.
• DrugFAM.
• Families Anonymous.
• Release.