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heroin

heroin (hĕ´rəwən), opiate drug synthesized from morphine (see narcotic). Originally produced in 1874, it was thought to be not only nonaddictive but useful as a cure for respiratory illness and morphine addiction, and capable of relieving morphine withdrawal symptoms. Later it was discovered to have the same pharmacologic effects as morphine and to be just as addictive. In many parts of the world, it is used as an analgesic (for relief of pain), particularly for the terminally ill. Although in the United States the manufacture and importation of the drug are prohibited and it is not used medically, heroin predominates in illicit narcotics traffic because it provides more potency for less bulk than morphine and is thus easier to smuggle.

See also drug addiction and drug abuse.

Effects and Addiction

Heroin is a central nervous system depressant that relieves pain and induces sleep. It produces a dreamlike state of warmth and well-being. It may also cause constricted pupils, nausea, and respiratory depression, which in its extremes can result in death. Heroin activates brain regions that produce euphoric sensations and brain regions that produce physical dependence—hence its notorious ability to produce both psychological and physical addiction. Its addictiveness is characterized by persistent craving for the drug, tolerance (the need for larger and larger doses to get the same results), and painful and dangerous withdrawal. Withdrawal symptoms include panic, nausea, muscle cramps, chills, and insomnia. Heroin use during pregnancy increases the risk of miscarriage and stillbirth. Infants exposed to heroin in the womb go through withdrawal at birth and exhibit various developmental problems. Besides the danger of overdose, addicts are susceptible to malnutrition, hepatitis, pneumonia, and AIDS.

Heroin Use

Heroin is usually injected intravenously, but may also be injected intramuscularly or under the skin, smoked, or sniffed; effects last three to six hours. In some cases addicts gather in places called "shooting galleries," often located in vacant buildings, which supply the necessary paraphernalia (e.g., hypodermic needle and spoon to heat and liquefy the heroin). Sharing of heroin needles significantly increases the risk of acquiring AIDS (from contaminated blood left in the syringe). Different distributors of heroin often assign "brand names" to their products to enhance rumors of their strength ( "Death Wish," "DOA" ) or effects ( "Evening's Delight," "Magic" ). Because the drug's strength and purity are unmonitored, each administration brings with it the possibility of overdose, illness from contaminants, or death. Multiple drug use involving heroin is increasingly common and results in many emergency-room visits. For example "speedballing," the use of heroin with cocaine intravenously, moderates the expected post-cocaine "crash." Instances of overdose are also increasing among the growing group of middle-class users that emerged in the 1990s as a potent powdered heroin became available.

Heroin Production

Most heroin originates from opium poppy farms in SW Asia (the "Golden Crescent," primarily Afghanistan and Pakistan), SE Asia (the "Golden Triangle," primarily in Myanmar), and Latin American (primarily Colombia). The opium gum is converted to morphine in labs near the fields and then to heroin in labs within or near the producing country. After importation, drug dealers cut, or dilute, the heroin (1 part heroin to 9 to 99 parts dilutor) with sugars, starch, or powdered milk before selling it to addicts; quinine is also added to imitate the bitter taste of heroin so the addict cannot tell how much heroin is actually present. It is sold in single-dose bags of 0.1 gram (0.03 oz.), each costing between $5 and $46 (1992). One pound of diluted heroin yields approximately 4,500 doses.

Heroin and Crime

Heroin use has long been associated with crime because its importation and distribution are illegal and because many addicted people turn to theft and prostitution to obtain money to buy the drug. In addition, violent competition between drug dealers has resulted in many murders and the deaths of innocent bystanders. From 1979 through 1990 arrests for heroin manufacture, sale, or possession in the United States held steady, but in the 1990s arrests rose as the drug's popularity began to increase once more.

The heroin trade can be enormously lucrative to those in the upper echelons. For decades the Mafia has been involved in heroin trafficking operations, including the "French Connection" of the 1950s and 1960s and the more recent "Pizza Connection," which used pizza parlors as fronts. Other trafficking groups are more loosely based on ethnic or national ties; for example, groups of Chinese, Thai, Nigerian, or Mexican nationals have operated in different parts of the country. In contrast to those in the higher tiers, many dealers on the street level are addicted or imprisoned frequently, and their financial gains are limited. U.S. laws and law enforcement efforts focus on interrupting the flow of heroin into the country as well as the arrest of distributors and persons who commit crimes to support their habits.

Treatment of Heroin Addiction

Treatment approaches vary with the motivation, background, and support system of the addict. Treatment of withdrawal may include palliative medication. Methadone maintenance is a controversial treatment that substitutes methadone for heroin then gradually decreases the dose until the user is drug free. Levomethadyl acetate (LAAM) and buprenorphine also have been approved for maintenance treatment of heroin addiction. Other treatment approaches may include psychological counseling, 12-step peer support groups such as Narcotics Anonymous, and educational and vocational services in residential or nonresidential settings.

Bibliography

See publications of the Drugs & Crime Data Center and Clearinghouse, the Bureau of Justice Statistics Clearinghouse, and the National Clearinghouse for Alcohol and Drug Information.

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heroin

heroin is a modified form of morphine obtained by acetylating morphine with acetic acid, so that both hydroxyl groups are modified. Chemically, therefore, it is diacetyl morphine. It is about three times more potent than morphine, and because of its increased lipid solubility it rapidly enters the brain. Addicts claim it gives a better ‘rush’ when injected intravenously. Heroin is now only rarely used to treat intractable pain, as appropriate dosing regimens can maintain analgesia using morphine or other drugs.

Alan W. Cuthbert


See addiction; analgesia; drug.

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heroin

heroin Drug derived from morphine. It produces similar effects to morphine, but acts more quickly and is effective in smaller doses. It is prescribed to relieve pain in terminal illness and severe injuries. Widely used illegally, it is more addictive than morphine. See also drug addiction

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heroin

heroin (diacetylmorphine) A narcotic compound that is a synthetic derivative of morphine (see opiate). The compound is easily absorbed by the brain, due to its lipid-like nature, and is used as a sedative and powerful analgesic. Highly addictive, it is abused by drug users.

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heroin

her·o·in / ˈherəwin/ • n. a highly addictive analgesic drug, C17H17NO(C2H302)2, derived from morphine, often used illicitly as a narcotic producing euphoria.

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heroin

heroin (h'e-roh-in) n. a white crystalline powder derived from morphine that is a highly addictive drug of abuse. Like morphine it is a powerful opioid analgesic (see diamorphine).

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heroin

heroin XIX. — G., of uncert, orig.; see -IN.

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heroin

heroinagin, akin, begin, Berlin, bin, Boleyn, Bryn, chin, chin-chin, Corinne, din, fin, Finn, Flynn, gaijin, gin, Glyn, grin, Gwyn, herein, Ho Chi Minh, in, inn, Jin, jinn, kin, Kweilin, linn, Lynn, mandolin, mandoline, Min, no-win, pin, Pinyin, quin, shin, sin, skin, spin, therein, thin, Tientsin, tin, Tonkin, Turin, twin, underpin, Vietminh, violin, wherein, whin, whipper-in, win, within, Wynne, yin •weigh-in • lutein • lie-in • Samhain •Bowen, Cohen, Owen, throw-in •heroin, heroine •benzoin •bruin, ruin, shoo-in •Bedouin • Islwyn •genuine, Menuhin •cabin, Scriabin •Portakabin • sin bin • swingbin •bobbin, dobbin, robin •haemoglobin (US hemoglobin) •Reuben • dubbin • dustbin • Jacobin •kitchen, lichen •Cochin • urchin

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Heroin

HEROIN

OFFICIAL NAMES: Heroin (diacetylmorphine)

STREET NAMES: H, horse, boy, smack, stuff, mud, dope, tar, black tar, dragon fire, king kong, cat woman, hat man, TNT, white skull, body bag, creeper, shake, treat, cap, spoon, slag, dragon, mac, heron, chiva, china white, monkey, magic, lady, tammy, manteca, diesel, turkey

DRUG CLASSIFICATIONS: Schedule I, narcotic


OVERVIEW

According to the U.S. Central Intelligence Agency, worldwide production of opium has doubled since the mid-1980s. The result has been easier and cheaper access to the drug and worsening social problems, such as crime, associated with its abuse. Derived from opium, heroin is a highly addictive drug, and its use is a serious and growing problem. Rising purity levels and lower prices have fueled heroin's popularity.

The widely held misconception that snorting or smoking it is "less addictive" than intravenous injection lures new young users. Any ingestion of heroin promotes tolerance and drug cravings that can, and frequently do, lead to addiction. Teens and young adults across the country are learning the hard way that heroin addiction can come just as easily in a pipe as a needle.

Opium production occurs in three source regions—Southeast Asia, Southwest Asia, and Latin America. While an undetermined amount of the opium is consumed in the producing regions, a significant amount of the drug is converted to heroin and sent to its major markets in Europe and North America.

Origin and production

Heroin is a narcotic derived from the opium poppy plant (Papaver somniferum). Opium poppy is grown primarily by destitute farmers in what is known as the Golden Crescent in Southwest Asia (encompassing Turkey, Iran, Afghanistan, and Pakistan) and the Golden Triangle in Southeast Asia (Burma, Thailand, Laos, and Vietnam). In the Americas, Columbia and Mexico are chief producers.

The poppy plant produces raw opium. Crude refineries modify the opium into a brown paste that is molded and dried into bricks. More sophisticated laboratories are found in Bangkok, Karachi, and Hong Kong. These labs change opium into what is known as number three heroin, a smokeable form. Purification of heroin to the "injectable" fourth stage (number four heroin) involves a volatile chemical combination that can result in catastrophic explosions.

History

The history of opium usage stretches back to 3400 b.c., where it was first cultivated in lower Mesopotamia. The Sumerians called the poppy Hul Gil or the "joy plant." The art of poppy cultivation spread from the Sumerians to the Assyrians, and from the Assyrians to the Babylonians and Egyptians.

The Egyptians applied proven agricultural methods to growing opium poppies, and the trade flourished throughout the ancient world. For the next 3,000 years, opium was an important trade item among civilizations clustered around the Mediterranean. Prized by merchants and traders, opium would find its way into markets in Greece, Carthage, India, Persia, and China.

As Europe began its slow emergence from the Dark Ages in the sixteenth century, opium began to reappear in medical journals on the continent. A century later, an English apothecary named Thomas Sydenham introduced "Sydenham's Laudanum," pills made from opium, sherry, and herbs. They were popular remedies for a variety of ills.

Portugese traders with routes to the East China Sea smoked opium with tobacco in long-stemmed pipes. They reintroduced the practice to the Chinese who had frowned on its use. The British East India Company assumed control of poppy-producing fields in India and dominated the opium trade. By the late 1700s, the East India Company had established a monopoly on its import into China, Europe, and the United States.

Opium had long been used by the Chinese to stop diarrhea, but in the seventeenth and eighteenth centuries, its recreational use exploded. In 1800, the Imperial government of Kia King banned its import and trade completely, but could not effectively enforce the ban. Opium dens flourished in the port cities and spread inward.

With its officials routinely bribed, China quickly became a haven for corruption, lawlessness, and addiction. In desperation, the imperial government made opium illegal in 1836 and took action against Chinese merchants and Western traders who continued to traffic in the drug. This and other trade disputes with the British led to the first of two Opium Wars.

By the time opium was banned by the U.S. Congress in 1905, the abuse of black market heroin had already taken hold. In 1910, Britain signed an agreement with China to dismantle the opium trade. But the profits made from its cultivation, manufacture, and sale were so enormous that no serious interruption would be felt until World War II closed supply routes throughout Asia. And although Bayer ended the manufacture of heroin for medicinal use in 1913, illicit importation and distribution networks in New York and San Francisco were already well established.

U.S. military involvement in Vietnam was credited with the next major surge in heroin smuggling into the United States. Political and economic turmoil in the region led to a surge in production from Southeast Asia's Golden Triangle. By the end of the U.S. war in Vietnam, there were some 750,000 heroin addicts on American streets.

Despite the billions of dollars spent to keep heroin off its streets, America's efforts have been unsuccessful. Heroin is not only more plentiful in the United States than it was 30 years ago, but it is also cheaper and at its point of sale almost 10 times as pure.

CHEMICAL/ORGANIC COMPOSITION

All drugs derived from opium poppy are called opiates. Of the opiates, heroin (diacetylmorphine) is the most potent and fast-acting. Though heroin is no longer used in medical settings, its less potent cousins—codeine, liquid morphine, pethidine, and methadone—are found in clinics and hospitals all over the world. But it wasn't until the early 1970s that scientists began to understand the real reasons behind heroin's propensity for abuse and addiction.

The chemical composition of opiates are remarkably similar to endorphins, chemicals produced by the brain in times of distress or injury to relieve pain or ease fear. There are three major types of endorphins: beta endorphins, located in the brain; and enkephalins and dynorphin, which are distributed throughout the brain and body.

These natural chemicals are small chain peptides that bind to opiate receptors distributed throughout the brain—including the limbic system, where their activation produces feelings of happiness, euphoria, serenity, and fearlessness.

The endorphins enkephalin and dynorphin possess natural analgesic (pain-relieving) qualities. When they bind to opiate receptors in the spinal cord, they suppress the ability of the brain to register pain. Heroin binds to these same opiate receptors in the brain and body.

Types of heroin

Most heroin is packaged and shipped in bricks of powder. Pure heroin is white, but the color when it reaches the user can vary from yellow to dark brown, owing either to impurities during the manufacturing process, the presence of powdered additives, or both.

Heroin is usually cut with baking soda, powdered milk, baby powder, sugar, starch, or quinine, but has also known to be cut with lidocaine, curry powder, strychi-nine, and even laundry detergent. Law enforcement officials in New York report the existence of heroin cut with a rat poison from Santa Domingo called Tres Pasos(meaning "three steps"). Three is the number of steps the mice take before dying after exposure to the poison.

Another form of heroin commonly distributed in the western and southwestern regions of the United States is called Black Tar or Mexican Brown. These varieties are produced in Mexico and—because they're manufactured crudely—have an either hard black coal or sticky, tar-like consistency. Purity rates range from 20–80%.

In 1980, the purity of heroin was somewhere in the 4% range. In 2002, the average bag sold by dealers in the United States was almost 40% pure, and sold for less than one-fifth the 1980 price.

INGESTION METHODS

Until very recently, the most common means of administering heroin was injection with a hypodermic needle, either intravenously (into a vein; called "mainlining"), subcutaneously (just under the skin; called "skin-popping") or intramuscularly (injected into muscle rather than a vein). Injection by regular users and addicts was preferred because the street drug was so diluted with fillers that injection was the most efficient way to get high.

Many first-time intravenous users of heroin have intensely negative reactions to the drug, including nausea and vomiting. For many, this is enough to turn them off heroin for good, but for others, social pressures and other factors compel them to keep trying until they find the high they anticipated.

With purity levels of packaged heroin increasing, the drug can now be snorted or smoked, severing for many people the negative associations heroin has with intravenous drug use. This has greatly expanded heroin's


pool of potential users and addicts, especially among young people.

According to a recent study by the National Institute on Drug Abuse (NIDA), smoking produces lower levels of heroin in the blood than injection, but the effects on the user are roughly similar. Smoking heroin also gives users more control over their intake of the drug without the burden of preparing another intravenous dose.

Snorting heroin is probably the least efficient means of taking the drug and has several immediate drawbacks, including strong stomach cramps and a constantly running nose. Many regular users of heroin began by snorting the drug on occasion. This kind of early heroin use is called "chipping." A high percentage of chippers eventually turn to injection of the drug before realizing they are hooked.

THERAPEUTIC USE

Because of its analgesic (painkilling) properties, opium and its derivatives have long been used for the treatment of ailments. Throughout the nineteenth century in England and the United States, opium was administered in plasters, pills, cough drops, lozenges, and many other applications dispensed by physicians and pharmacists.

In 1895, while working for the Bayer Company in Germany, Heinrich Dreser produced a drug he thought was as effective an analgesic as morphine, but without its harmful side effects. Bayer began mass production of diacetylmorphine, and in 1898 began marketing the new drug under the brand name "heroin" as a cough sedative.

Pharmacists in France, England, and the United States regularly marketed heroin as an excellent pain killer and a cure for disease, including respiratory ailments and diarrhea.

Several medical societies in the United States at that time offered heroin as a safe means of treating morphine addiction. Articles appearing in American medical journals early in the twentieth century spoke highly of heroin's ability to soothe the painful aches, shakes, and vomiting experienced by recovering morphine addicts, and it was widely used as a "step down" cure.

Within a decade, doctors realized they were merely substituting one opiate addiction for an even more powerful one.

Internationally, heroin's use as a medicine wasn't regulated until 1925 when the League of Nations adopted strict rules governing international heroin trade. The same body later stipulated that heroin producers could only manufacture quantities sufficient for medical use, though these guidelines were unenforceable and largely ignored.

USAGE TRENDS

Every government agency that has sought to quantify usage trends of heroin in the United States over the last several years has come to one inescapable conclusion: heroin use across the country is climbing dramatically, especially among young people.

In 2000, heroin was second only to cocaine in the number of drug-related emergency room episodes reported to a national registry run by the Drug Abuse Warning Network. Heroin, listed as a principal agent in respiratory and cardiac emergencies, went from 33,884 episodes nationwide in 1990 to 94,804 in 2000—an increase of nearly 180%.

Locally the numbers are even more dramatic. In a similar eight-year period (between 1991 and 1998), the rate of heroin-related incidents at area hospitals increased by 413% in Miami, 288% in Chicago, and 238% in St. Louis.

Scope and severity

The Office of National Drug Control Policy's (ONDCP) study of 21 major metropolitan areas in the United States revealed that the most likely user of heroin is over 30 years old. However, younger adults (18–30) comprise a substantial portion of those believed to be experimenting with heroin use. In the South, younger adults are more likely than adults over 30 to be regular users of the drug.

Figures compiled by the U.S. Department of Health and Human Services National Household Survey on Drug Abuse (NHSDA) estimate that there were approximately 104,000 new heroin users in 1999. Among these new users, 87,000 were between the ages of 12 and 25 and 34,000 of them were under age 18. The average age at first use among these new heroin users was 19.8 years.

The same study found that the number of people who had used heroin in the last month, an indication of more regular use, had climbed from 68,000 in 1993 to 208,000 in 1999.

Nationwide, the NHSDA released estimates in 1999 that said approximately 2.7 million Americans (1.2% of the population) are thought to have used heroin at least once in their lifetimes.

Age, ethnic, and gender trends

According to the National Institute on Drug Abuse (NIDA), among high-school-age teens, rates of heroin use remained relatively stable and low from the late 1970s until the start of 1990s.

After 1991, however, use began to rise among tenth-and twelfth-graders, and after 1993, among eighth-graders as well. In 1999, prevalence of heroin use was roughly the same for all three grade levels. Although the number of students who reported using heroin in the last year remain under 2% in 1999, the rates are about two to three times higher than those reported in 1991.

The NIDA released figures showing 1.7% of eighth graders, 1.7% of tenth graders, and 1.8% of high school seniors (twelfth graders) reported using heroin at least once. The results are remarkably static as respondents leave school and enter college, suggesting a strong adolescent culture of drug experimentation. Among college students, 1.7% reported using heroin at least once in their lifetime, while 1.8% of young adults aged 19–28 reported lifetime heroin use.

When asked about heroin use in the last 30 days,0.6% of eighth graders, 0.3% of tenth graders, and 0.4% of twelfth graders reported using heroin at least once, compared to 0.2% of college students and 0.1% of young adults.

In a separate report issued by the Centers for Disease Control (CDC), the indications of heroin experimentation among teens in high school were even higher. In the CDC report, 2.4% of sampled high school students reported having tried heroin at least once.

Drawing on data supplied by individual states, estimates of teen use varied between a low of 1.7% to a high of 5.2%. The CDC report also looked at specific metropolitan areas and these estimates mirrored state data; surveys pegged teen prevalence with a low of 1.0% and a high of 5.3%.

In a 2001 study entitled Epidemiologic Trends in Drug Abuse conducted by the Community Epidemiology Work Group (CEWG), a branch of NIDA, the number of men who abused heroin strongly outweighed the number of female users.

These trends appear to be established early on. Male high school students who report trying heroin, for example, outnumber female students in the CDC study by a ratio of almost three to one.

According to the ONDCP, which conducts in-depth drug usage profiles in 21 American cities, heroin users are most likely to be white and male. Whites and blacks are equally represented among heroin users in Birmingham, Alabama, and Columbia, South Carolina; and Hispanics are the dominant user group in El Paso, Texas, and Los Angeles, California. In Denver and Philadelphia, white users predominate, but Hispanics are overrepresented relative to their percentage of the general population. Similarly, in Boston, whites are more numerous among heroin users, but blacks are overrepresented.

MENTAL EFFECTS

The force of heroin's initial impact on the user, and the duration and intensity of the high, depends on the method of ingestion. If injected directly into the bloodstream, the euphoric "rush" hits the user in less than 10 seconds. Intramuscular or subcutaneous injection produces a much more gradual response as the drug takes longer (six to eight minutes) to filter into the bloodstream. Smoking heroin also produces less of an initial rush and a more gradual response to the dose, anywhere from 10 to 15 minutes.

It is the drug's sudden entry into the brain that accounts for the initial surge of energy. The rush is thought to last as long as it takes the brain and body to break heroin down into morphine, which is then absorbed by the body's opioid receptors. This stage finds the user going "on the nod," an alternatively wakeful and pleasurably drowsy state that lasts four to six hours.

Given that the morphine is artificially dosing the brain's opiate receptors, it is not surprising to hear users describe a powerful state of complete fulfillment and a tremendous sense of self-satisfaction while under the influence of the drug. Over time, because of the development of tolerance (needing higher doses more frequently to achieve the same effects felt at first use), heavy users and addicts lose the ability to get high and use the drug solely to counteract the effects of withdrawal.

PHYSIOLOGICAL EFFECTS

Heroin is a central nervous system depressant. The drug slows heart and breathing rates dramatically. During the "nod off" phase, consciousness may be lost. Any one of these effects is dangerous to the user; in combination, they are potentially life-threatening. Given the high incidence of nausea and vomiting associated with heroin use, for example, users who lose consciousness and then become sick are at risk of choking to death.

As is the case with other opiates, regular ingestion of heroin creates rapid tolerance in the user. Even over a relatively short period, weekend users may find themselves taking larger doses of the drug to achieve the same high. As many recovering addicts will attest, this is the often the first addictive hook heroin gets into recreational users.

The mechanics of tolerance are still not fully understood. One hypothesis suggests that when habitual heroin ingestion upsets the body's natural chemical equilibrium, the body attempts to compensate for it. More of the drug is then needed to overwhelm the body's attempt to suppress the drug's influence. This kind of tolerance is found with regular use of nearly all psychoactive substances.


Tolerance to heroin can vary greatly among individuals. A "regular" or "safe" dose for an experienced user can kill someone who has never tried it before. Even occasional users who build up some tolerance and take several weeks off from the drug can suffer an over-dose from their "usual" dose.

Depending on tolerance, and the amount and purity of the drug consumed, a lethal dose of heroin can range anywhere from 200 to 500 mg. Hardened addicts have survived doses three times that high.

The growing purity level of street heroin sold in American cities and suburbs is one of the most worrisome aspects of the drug's resurgence. Users accustomed to 25% purity can easily overdose if they use the same amount of the drug that is 50% or 70% pure.

A 2001 study conducted by the ONDCP found that Colombian heroin purity ranges from as low as 7% to as high as 95%. Purity of Mexican black heroin sold in South and West ranged from 14% to 58%—with both extremes reported in Seattle. These kinds of fluctuations can have deadly consequences for the user.

Harmful side effects

Heroin use can cause tragic complications during pregnancy, greatly increasing the chances of spontaneous miscarriage, breech deliveries, premature birth, or stillbirth. Research conducted by NIDA suggests that babies born to heroin-addicted mothers are at higher risk for sudden infant death syndrome (SIDS). Infants who do survive the pregnancy are often born addicted to heroin and exhibit severe withdrawal symptoms for a period of weeks and even months.

Heroin addicts are at a much higher risk for contracting HIV, hepatitis C, and bloodborne pathogens through the sharing and reuse of hypodermic syringes and other "works" associated with injection drug use. Government studies suggest that one-third of all HIV and more than half of all hepatitis C cases are the result of injection drug use.

Long-term health effects

Of course, one of the most debilitating effects of heroin use is dependence and addiction. Dependence follows the same trajectory as tolerance.

Eight to twelve hours after the addict's last dose, the user begins to experience the onset of flu-like symptoms: watery eyes, sneezing, muscle aches, weakness, and vomiting. The symptoms increase in severity over the next two to three days and include shivering, muscle spasms, paranoia, fear, hallucinations, and debilitating cramps in the stomach and extremities. Within a week, the body has corrected the imbalance created by the regular ingestion of heroin, and the symptoms subside. However, intense cravings for the drug last for a much longer period of time and often contribute to relapse.

Health consequences of chronic heroin abuse include scarred and collapsed veins, bacterial infections of the blood vessels and heart valves, boils, a variety of soft-tissue infections, kidney problems, and liver disease. Pneumonia, tuberculosis, and other lung diseases are also common among long-term users, which can be attributed to either poor nutrition and depressed respiratory function or both. Many of the additives heroin is cut with do not dissolve in the body and can block blood vessels, translating into higher risk of sudden death from stroke or heart attack.

Recovering heroin addicts often endure years of corrective dental work due to neglect and the side effects of regular drug use. Heroin addicts often have cavities along the gum-line and gum disease, because the drug causes a marked decrease in the production of saliva. Saliva protects the mouth by neutralizing acids that cause cavities and providing lubrication that reduces the retention of food debris.

A NIDA-supported study conducted by the University of Southern California Los Angeles examined the lives of some 587 heroin addicts admitted to criminals' addiction programs in the early 1960s. The researchers found their lives were marked by cycles of abstinence, relapse, crime, incarceration, chronic disease, and early death. By 1997, nearly half of the group had died. A full 40% of the survivors were still struggling with their addiction and reported using heroin in the last year. Fewer then 10% were in a working addiction program.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

Even experienced users caution mixing heroin with anything else: alcohol, amphetamines, and especially cocaine all greatly increase the dangers of using heroin by itself.

Ingesting heroin along while consuming alcohol is considered especially dangerous. Drinking alcohol increases the likelihood of vomiting and the dangers of choking. Also, both heroin and alcohol are central nervous system depressants and could slow the heart rate and breathing to dangerously low levels.

Combining cocaine and heroin, regardless of the ingestion method, is called "speedballing." Speedballing is extremely dangerous. For reasons that are not completely understood, the drugs enhance each other's effectiveness. Heroin enhances the electric high produced by cocaine, while cocaine elevates the mellowing aspects of heroin.

Physiologically, cocaine is a powerful stimulant that quickens the heartbeat, but it wears off much faster than heroin, which works to depress the heart rate. The stimulant effect of the cocaine and the depressant effect of heroin wreak havoc on the heart, which can lose its rhythm. Cocaine frequently masks how much heroin has been consumed, and when the cocaine's effects dissipate, heart failure can result. John Belushi and River Pheonix both died this way after taking speedballs.

In some parts of the western United States, particularly California where methamphetamine (crystal) is plentiful, speedballing a mix of heroin and methamphetamine, whether they are inhaled or injected, is increasing in popularity. In addition to methamphetamine, some heroin users take benzodiazepines—types of tranquilizers—to increase the effect of the opiate. Sources report that the use of MDMA (ecstasy) is increasing among heroin users, and that Rohypnol, a sleeping aid, is being taken to "soften the fall" when the effects of the drug combination begin to wear off.

TREATMENT AND REHABILITATION

A variety of treatments and treatment programs that are available to people addicted to heroin, though the treatment options available and the quality of the care provided greatly increase with the ability to pay. In a recent Rolling Stone interview, one anonymous addict said it cost his parents $150,000 for his two-year stay in a drug treatment center. Publicly subsidized treatment programs frequently have waiting lists and are forced to turn people away. The cold realities of drug treatment are even more troubling.

Despite progress, most studies post the failure rate of most treatment programs at or near 80%. Most addicts who try to abstain relapse at least once, and often several times before successfully kicking their drug addiction.

A common first step of treating heroin addiction is detoxification. The objective is to relieve withdrawal symptoms while allowing patients to adjust to life without heroin. "Detox," as it is sometimes called, is not an end in itself but a beginning that must also include broad therapeutic programs. Most successful programs of this type are in-patient residential regimens lasting three to six months.

Because any opiate derivative will suffice to soothe heroin cravings associated with withdrawal, methadone, a synthetic opiate that has no sedating side effects, has been an effective treatment for heroin and morphine addiction for more than 30 years. The medication is taken orally and suppresses narcotic withdrawal for a period of 24 to 36 hours. Methadone can be taken continuously for 10 years or longer with no harmful side effects.

Like methadone, LAAM (levo-alpha-acetylmethadol) is a synthetic opiate used to treat heroin addiction. LAAM can block the effects of heroin for up to 72 hours. This makes outpatient treatment much more convenient, given that patients need to dose only two to three times a week. Naloxone and naltrexone are new medications that are also effective at blocking the pleasurable effects of heroin, helping motivated individuals to abstain.

Buprenorphine (Temgesic, Subutex) is a new medication that has been shown to be even more effective in blocking the effects of heroin than methadone. Recent preclinical studies have shown that buprenorphine may also significantly reduce cravings associated with cocaine addiction.

Though drug-based treatment regimens can be helpful in conquering heroin addiction, integrating them with behavioral and therapeutic programs (both individual and group counseling) have consistently proven more effective at preventing relapse over the long term.

PERSONAL AND SOCIAL CONSEQUENCES

There is nothing glamorous, cool, or chic about heroin use. It is a personally and socially destructive compound that in imperceptible stages can reorient the user's priorities around its consumption.

Few, if any, heroin addicts set out to sacrifice their families, friends, and futures in service of their next fix, but that is what often happens. Heroin gradually sinks its hooks deeper into the user's psyche. What starts out as very occasional use can evolve in small steps to more frequent use. Monthly use can soon become weekly use. Before long, it is the drug that is dictating when it is consumed.

Heroin addiction is not easy or cheap to overcome. Many heroin addicts face a life of continual relapse, declining economic opportunity, broken families, and failing health. In a Rolling Stone interview, one user who failed in her attempt to stay clean likened the experience of sobriety to wanting to tear the muscle off her bones.

Heroin abuse has repercussions that extend far beyond the individual user and his or her family. The consequences of drug abuse and addiction carry a social price in festering criminality, violence, and disruptions to the workplace and educational environments that cost billions of dollars each year.

LEGAL CONSEQUENCES

Strict penalties are provided for drug convictions, including mandatory prison terms for many offenses. Federal law states that any conviction for possession, use, or distribution of illicit substances can result in loss of federal benefits, confiscation of property, fines, and jail sentences.

Persons convicted on federal charges of possessing any controlled substance face penalties of up to one year in prison and a mandatory fine of no less than $1,000 up to a maximum of $100,000. Second convictions are punishable by not less than 15 days but not more than two years in prison and a minimum fine of $2,500. Subsequent convictions are punishable by not less than 90 days but not more than three years in prison and a minimum fine of $5,000.

If death or serious bodily injury results from the use of an illegally distributed controlled substance, the person convicted of distributing that substance faces a mandatory life sentence and fines of up to $8 million.

Persons convicted on federal charges of drug trafficking within 1,000 feet of a university face penalties of prison terms and fines that are twice as high as the regular penalties for the offense, with a mandatory prison sentence of at least one year.

See also Cocaine; Methadone; Opium

RESOURCES

Books

Berridge, Virginia, and Griffith Edwards. Heroin, Opium and the People: Opiate Use in Nineteenth-Century England. New York: St. Martins Press, 1981.

Fernandez, Humberto. Heroin. Center City, NY: Hazelden Information Education, 1998.

Inciardi, James. The War on Drugs II: The Continuing Epic of Heroin, Cocaine, Crack, Crime, AIDS and Public Policy. Mountain View, CA: Mayfield Publishing Company, 1991.

Periodicals

European Union. European Monitoring Center for Drugs and Drug Addiction. Report on the Risk Assessment of Ketamine in the Framework of the Joint Action on New Synthetic Drugs. September 25, 2000.

U.S. Department of Health and Human Services. 2001 Monitoring the Future: National Results of Adolescent Drug Use. Washington, DC: U.S. Dept. of Health and Human Services, January 2002.

U.S. Department of Health and Human Services. National Institute on Drug Abuse. "Buprenorphine Proves Effective, Expands Options For Treatment of Heroin Addiction." NIDA Notes (May 2001).

U.S. Department of Health and Human Services. National Institute on Drug Abuse. "Heroin Snorters Risk Transition To Injection Drug Use And Infectious Disease." NIDA Notes (August 1999).

U.S. Department of Health and Human Services. National Institute on Drug Abuse. Heroin Update: Smoking, Injecting Cause Similar Effects; Usage Patterns May be Shifting. Washington, DC: U.S. Dept. of Health and Human Services, July/August 1995.

U.S. Department of Health and Human Services. National Institute on Drug Abuse. "33-Year Study Finds Lifelong Lethal Consequences of Heroin Addiction." NIDA Notes (October 2001).

U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. National Clearinghouse for Alcohol and Drug Information. Heroin Treatment Admissions Increase: 1993-1999. Washington, DC: U.S. Dept. of Health and Human Services, January 2002.

U.S. Department of Justice. National Drug Intelligence Center. National Drug Threat Assessment 2002. Washington, DC: U.S. Dept. of Justice, December 2001.

U.S. Office of National Drug Control Policy. "Pulse Check: Trends in Drug Abuse: Heroin." November 2001.

Other

U. S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. July 8, 2002. <http://www.samhsa.gov>. Accessed July 8, 2002.

U.S. Department of Justice. Drug Enforcement Administration. <http://www.usdoj.gov/dea>. Accessed July 8, 2002.

U.S. National Institute on Drug Abuse. June 27, 2002. <http://www.nida.nih.gov>. Accessed July 8, 2002.

U.S. Office of the National Drug Control Policy. July 5, 2002. <http://www.whitehousedrugpolicy.org>. Accessed July 8, 2002.

Christopher V.G. Barillas

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Heroin

Heroin

Heroin and morphine belong to a group of drugs called opiates. Opiates are derived from the opium poppy. Morphine was first identified as a painkiller in 1806. The problem with morphine was that people who took it often became addicted to it. They also experienced other undesirable side effects, such as nausea. At the end of the nineteenth century, a German scientist changed the molecules of morphine, hoping to produce a new drug that, like morphine, would relieve pain but that, unlike morphine, would not be addictive. This new drug was heroin. Within a year or two of its introduction, most of the medical community knew that heroin was not only stronger than morphine but that people who used it were even more likely to become addicted. By the 1920s, heroin had become the most widely abused of the opiates.

Medical Uses for Heroin

Heroin and morphine act in nearly identical ways on the body. Studies in cancer patients with severe pain show very little difference in the pain relief offered by the two drugs. They also produce similar feelings of euphoria (intense well-being). However, heroin may take effect more quickly, and it is two to three times stronger when injected. This is probably because heroin crosses from the blood into the brain more easily than does morphine. But when heroin is taken by mouth, its strength is the same as morphine's. Because heroin offers no major advantage over morphine in treating pain, heroin has no approved medical uses in the United States.

Street Heroin

Heroin is available and used only as an illegal "street" drug. The purity of street heroin varies greatly, and many other substances and drugs are "cut" (mixed with) street heroin. As a result, the user has no way to know what he or she is buying. This makes street heroin doubly dangerous.

Typically, heroin is injected into the veins (intravenously). The injection provides a rapid "rush," or an immediate feeling of euphoria. This rush is thought to be the important factor in the addictiveness of heroin. The drug can also be injected under the skin (subcutaneously) or deep into the muscle (intramuscularly). Swelling and redness of veins due to repeated injections are called track marks. These tracks are one of the signs that a person is abusing drugs. Less commonly, heroin can be inhaled or smoked in a cigarette.

According to the National Household Survey on Drug Abuse, in 2000 an estimated 308,000 people 12 and older used heroin within the past year. A survey of high school students conducted in 2001 showed that 1 percent of 8th graders and 0.9 percent of 10th and 12th graders reported using heroin at some point in the past year, representing a small but important decline from the previous year.

Heroin: Tolerance, Dependence, and Withdrawal

Users of heroin develop tolerance to its effects. Chronic, or long- term, users of the drug become less sensitive to its euphoric and analgesic (painkilling) actions, as well as to its rush. Once users develop tolerance, they need to increase doses of the drug to achieve the effects they desire. Heroin users also become physically dependent on the drug, and experience withdrawal symptoms if they stop taking it. Heroin's effects last for approximately four to six hours. As a result, addicts must take the drug several times a day to prevent the appearance of withdrawal symptoms. The need to continue taking the drug to avoid withdrawal is an important factor in heroin's addictiveness.

People who take opiate drugs for medical reasons can be taken off the drug gradually without withdrawal symptoms. The dose must be lowered by 20 to 25 percent daily for two or three days until all use is ended. However, abruptly stopping morphine or heroin has very different results. The withdrawal symptoms that occur after abruptly stopping heroin include:

  • eye tearing
  • yawning
  • sweating
  • restlessness
  • dilated pupils
  • irritability
  • diarrhea
  • abdominal cramps
  • waves of gooseflesh (the term "cold turkey" describes the goose- flesh that follows from abruptly stopping the drug)

The heroin withdrawal syndrome reaches a peak about two or three days after stopping the drug, and symptoms usually disappear within seven to ten days. Some low-level symptoms may last for many weeks.

Heroin use by a pregnant woman seriously affects the developing fetus. Babies of mothers dependent on heroin are born dependent. Special care must be taken to help them withdraw during their first weeks. Although withdrawal for the baby is miserable, heroin withdrawal is not usually life threatening.

Heroin Overdose

Overdosing is a common problem among heroin addicts. One reason for frequent overdoses is the varying purity of the street drug, which makes it difficult for the addict to judge the size of a dose. Also, some substances used to cut the drug may be toxic (poisonous) themselves, contributing to a drug overdose. Furthermore, as a user becomes tolerant to the heroin rush and the euphoria, he or she may increase the dose past the point of safety in an attempt to intensify these sought- after sensations.

When a person takes an overdose, he or she falls into a stupor . It is difficult to wake the person up. The pupils are typically small and the skin may be cold and clammy. Seizures may occur. Breathing becomes slow, and the lips may darken to a bluish color. This blueness indicates that there is not enough oxygen in the blood. Most dangerously, heroin overdose causes respiratory depression, or a slowed rate of breathing. As a result, blood pressure may then fall. Most people who die after a heroin overdose die because of this respiratory failure. Typically, the heroin user has also taken other drugs—whether on purpose or because they were mixed with the heroin—and/or drunk alcohol. The presence of other substances in the body makes the heroin overdose even more dangerous.

see also Addiction: Conceptsand Definitions; Heroin Treatment: Behavioral Approaches; Heroin Treatment: Medications; Opiateand Opioid Drug Abuse.


FICTION SPEAKS VOLUMES

Smack (1999), by Melvin Burgess, is the story of two teenagers who run away and become embroiled in heroin addiction. In a life filled with sex, drugs, and rock n roll, the two struggle to return to the real world and recover from their addictions.


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Heroin

Heroin


What Kind of Drug Is It?

Heroin is a powerful narcotic drug that is very habit-forming. It is derived from the opium poppy plant. Its sale and use are illegal in most parts of the world. However, this has not stopped the cultivation or farming of poppies and the creation of heroin in many countries in Southeast Asia, Southwest Asia, Central America, South America, and Mexico.

Highly addictive and quick-acting, heroin is a Schedule I controlled substance in the United States. The federal government does not believe that heroin has any medical value in treating illness, but it does consider heroin a very dangerous drug for recreational use or experimentation.

Production Soars

In December 2004, the Knight Ridder/Tribune News Service reported that prices for heroin being sold on the street had reached twenty-year lows, while the purity of illegal heroin had increased. The major reason this occurred was because opium poppy farmers in Afghanistan had started growing huge amounts of the plants again. The supply of opium out of Afghanistan greatly increased after the fall of the country's Taliban government in late 2001.

The Taliban government had tightly controlled opium production before being overthrown by U.S. troops and their allies during Operation Enduring Freedom. The United States and its allies invaded Afghanistan after terrorists flew airplanes into the World Trade Center in New York and the Pentagon in Washington, D.C., on September 11, 2001. The Taliban was suspected of allowing terrorists to train in Afghanistan. After the fall of the Taliban, poppy production soared, giving American drug dealers plentiful supplies of more affordable heroin to peddle to consumers.

Official Drug Name: Diacetylmorphine (DIE-uh-SEE-tuhl-MOR-feen); heroin

Also Known As: AIP, antifreeze, aries, Aunt Hazel, big H, big Harry, black pearl, black tar, bonita, bozo, brain damage, brick gum, brown sugar, bull dog, bundle, Charley, China white, diesel, H, Harry, manteca, Mexican mud, mud, nice and easy, noise, number 4, number 8, nurse, peg, sh#t, skag, smack, stuff, tootsie roll, white stuff

Drug Classifications: Schedule I; narcotic

Increased Purity

The increased purity meant that users could experience the heroin high without having to inject the drug into a vein. Typically, heroin users snort, smoke, or inject the drug just under the skin or into a muscle. Some people mistakenly believe that they will not become addicted to the substance if they do not inject it. Like all other natural and synthetic opiates, powdered heroin carries a high risk of producing dependence over a period of time. Dependence is the physical need for a drug in order to ward off withdrawal symptoms.

No one gets out of bed one day and decides on a whim to seek out a dark alley in a rundown neighborhood to buy a bag of heroin, convert it to a liquid, and then shoot it into a vein with a hypodermic needle. However, this is often the end result of continued recreational use of the drug. As the testimony of countless former addicts shows—as well as the number of emergency room visits—the drug can take hold of a user and destroy his or her life.

According to the Drug Abuse Warning Network (DAWN), between 1990 and 2000, emergency room visits related to heroin nearly tripled, from 33,884 in 1990 to 97,287 in 2000. DAWN statistics from the last half of 2003 showed that heroin was involved in 47,604 drug-related emergency department visits during that time. In addition, the California Department of Alcohol and Drug Programs reported that the average age of American heroin users dropped from 27.4 years to 17.6 years between 1988 and 1997. Heroin fatalities strike rich and famous users as well as poor and anonymous users. Itisan illegal substance that lures new addicts all over the world every year.

Heroin and Terrorism


According to a Washington Times report in December 2004, Mark Steven Kirk, a Republican congressman from Illinois, returned from Afghanistan with startling news. He reported that terrorist Osama bin Laden was using cash earned from heroin deals to pay for his personal bodyguards, weapons, and secret hiding places. Al Qaeda, the group Osama bin Laden heads, is said to pay Pakistani drug lords to help keep him hidden from U.S. troops.

Overview

Heroin is made from the fluid that drips out of opium poppy bulbs. The use of opium poppies for medication dates back more than 6,000 years. The first archaeological record of poppy use can be found in the ancient cultures of the Fertile Crescent (now the nations or Iraq and Iran). A document discovered in the ancient Egyptian city of Thebes, dated to 1552 bce, lists more than 700 illnesses for which opium was used. By the time of the great civilizations of ancient Greece and Rome, opium was well known for its painkilling properties—and for its effects on the brain. The Greek god Morpheus, god of dreams, is depicted in artwork carrying a bouquet of opium poppies.


Centuries-Long History

During the Middle Ages (c. 500–c. 1500), physicians experimented with opium for use in treating diarrhea and anxiety. Swiss scientist Paracelsus (1493–1541) mixed opium with alcohol and called the resulting tincturelaudanum, the Latin word for "to be praised." In the centuries that followed, opium would appear in a variety of widely dispensed medicines, even for teething babies. American inventor Benjamin Franklin (1706–1790) used opium to relieve the pain of gout and was believed to have been addicted to opium when he died.

In the nineteenth century, opium use was legal. In most cases it was socially acceptable and not considered any worse than smoking tobacco. Poets such as Samuel Taylor Coleridge (1772–1834) wrote under its influence, and wealthy women used it habitually for a variety of complaints. In 1803, a German pharmacist isolated the active ingredients in opium and was able to create morphine, which was named after the Greek god Morpheus. Stronger and faster-acting than opium, morphine quickly gained a following as a painkiller. Its habit-forming nature soon became evident, too. In 1848, the modern hypodermic needle was invented. This allowed surgeons to inject patients with liquid morphine to ease pain. This proved a boon during surgery and recovery, but it also created addicts. So many soldiers came home from the American Civil War (1861–1865) with morphine addiction that the condition was called "the soldiers' disease."

It was the search for a less habit-forming painkiller that led to the creation of heroin. In 1874, British chemist Alder Wright boiled morphine with an acid called acetic anhydride. The compound he produced, diacetylmorphine, at first seemed to be a miracle drug. It was a better painkiller than morphine, and it was quickly put to use for chronic coughs, especially in those suffering from tuberculosis. The German pharmaceutical company Bayer began marketing diacetylmorphine under the trade name "heroin" in 1898, principally as a cough suppressant.

At the beginning of the twentieth century, the medical community began to admit that opiate addiction had become a public health crisis. In his book Illegal Drugs: A Complete Guide to Their History, Chemistry, Use and Abuse, Paul M. Gahlinger wrote that an estimated 250,000 Americans in a population of 75 million (or 1 in 300) were morphine, heroin, or opium addicts. The most noticeable of these were the opium smokers, who frequented "opium dens" where they smoked the drug to get high.

But just as serious was the use of medicines that contained opium derivatives, most of which did not even list the ingredients. Cranky infants were given "soothing syrups" that contained morphine, codeine, or heroin. Sometimes they died of overdoses. Men and women from all economic levels depended on their "tinctures" and "elixirs." Even the fictional detective Sherlock Holmes, created by Scottish author Sir Arthur Conan Doyle (1859–1930), solved one of his cases by visiting an opium den.

Crackdowns on Use

In 1906 the Pure Food and Drug Act made it illegal to dispense medicine without listing the ingredients on the bottle. Less than ten years later, the Harrison Narcotic Act prohibited opium and its derivatives (including heroin) in all but prescription medications. The particular dangers of heroin singled it out


even further from its less powerful cousins, morphine and codeine. (Entries on morphine and codeine are available in this encyclopedia.) Heroin production in the United States was outlawed in 1924. For some time after that, doctors were able to obtain imported heroin for use as a painkiller. However, in 1956 the drug was completely outlawed, even for medical use. As such, heroin was one of the first drugs to go from being used in medicines to being classified as an illegal substance.

Outlawing heroin promoted its use as a recreational drug. A post-World War II generation of young people, resistant to authority and eager to try new things, began experimenting with heroin and other opiates. One of them, William S. Burroughs (1914–1997), would go on to describe his experiences as an addict in novels such as Junkie (1953) and The Naked Lunch (1959). Illegal heroin gained popularity as a recreational drug in the 1960s and 1970s, drawing many artists, musicians, and actors into its grip. Some of them, like comedian John Belushi (1949–1982) and singer/songwriter Kurt Cobain (1967–1994), died during heroin highs. Others, like musician Eric Clapton (1945– ), successfully battled addiction.

Heroin Chronology


c. 4000 bce      Opium poppies are cultivated in the Fertile Crescent by the ancient cultures of Mesopotamia.

1552 bce      An ancient Egyptian document lists 700 uses for opium.

800 bce      The poet Homer writes of a drug called nepenthe "to lull all pain" in The Iliad.

600-900     Arabic traders introduce opium to China.

1524      Swiss scientist Paracelsus mixes opium with alcohol and names the product laudanum.

1803      A German scientist isolates morphine as the most active ingredient in the opium poppy.

1848      The hypodermic needle is invented, allowing for quicker delivery of painkillers to the brain.

1874      British chemist Alder Wright creates diacetylmorphine (heroin), in an effort to produce a less addictive painkiller.

1898      Bayer Pharmaceuticals of Germany is the first company to market diacetylmorphine under the brand name "heroin."

1924      Heroin production is outlawed in the United States.

1953      William S. Burroughs writes Junkie, about his addiction to opiates.

1956      Heroin is completely outlawed in the United States.

1970      The Comprehensive Drug Abuse Prevention and Control Act names heroin a Schedule I controlled substance, carrying the highest criminal penalties if sold or possessed.

1982      Comedian and actor John Belushi is found dead in a hotel room after being injected with a "speedball" (mixture of heroin and cocaine).

1994      Rock singer/songwriter Kurt Cobain of the band Nirvana fatally shoots himself during a heroin high.

2004      The Office of National Drug Control Policy confirms that street prices for heroin have reached a twenty-year low.

In the early 1980s a new danger crept into heroin abuse. Addicts who injected heroin and shared needles already knew that they ran a greater risk of contracting hepatitis. But a new virus called AIDS (acquired immunodeficiency syndrome) was found to spread quickly through shared needles, too. AIDS is an infectious disease that destroys the body's immune system, leading to illness and death. By the mid-1980s, public health officials were warning that AIDS was spreading at higher rates among drug addicts than in other at-risk groups. The addition of AIDS to the heroin addict's list of dangers accounts for part of the rise in emergency room visits related to heroin in the 1980s and 1990s.

For a time, the risk of AIDS lowered the use of heroin in the United States. But the introduction of purer doses that could be snorted or smoked has brought the drug new users. These users do not run the risk of contracting AIDS by using dirty needles. However, heroin use can lead to risky behaviors, like having unprotected sex, which can lead to AIDS. In addition, users still face all the other dangers associated with heroin, including its tendency to promote dependence. As abusers build a tolerance to heroin over time, they become more likely to inject the drug, since this is the quickest way to achieve a high.

What Is It Made Of?

Heroin is simply an organic, or plant-derived, compound that combines morphine with acetic acid (vinegar) or acetic anhydride (an acid). It is processed from the same raw gum opium that can produce morphine, codeine, or thebaine. Farmers drain the sap from ripening opium poppies and boil it down into a sticky gum. The gum is treated in a water base with chemicals such as lime, ammonium chloride, activated charcoal, and hydrochloric acid. This causes the morphine to leach out of the gum.

When this product is dry, it is shaped into bricks. The bricks are then sent to other secret laboratories that mix the morphine with acetic anhydride, more activated charcoal, and sodium bicarbonate (baking soda). Once again the particles are allowed to settle in water. When the particles have dried, they are treated with hydrochloric acid, producing the heroin hydrochloride that is sold on the streets as a white powder.

Most of the white powder heroin sold in the United States comes from Vietnam, Afghanistan, and Pakistan. The product sold to users is never pure heroin. Instead the heroin is "cut" with a number of other water-soluble substances, including sugar, over-the-counter painkillers like acetaminophen (Tylenol), tranquilizers, baking soda, powdered milk, starch, and talcum powder. Some batches of heroin reportedly have been cut with rat poison or laundry detergent. cutting reduces the purity of the product and allows the dealer to stretch the supply. It also provides the user with an uncertain dosage that can range from 70 percent heroin to 20 percent heroin.

In Mexico, Central America, and South America, underground growers and chemists produce "tar heroin" that comes to the American black market as a sticky black or brown substance with an odor of vinegar.


How Is It Taken?

Heroin is popular because its effects can be felt almost immediately. This is because heroin is the most fat soluble of the natural opiates. This means that a highly fat-soluble drug enters the bloodstream faster and moves to the brain faster, no matter how it is taken.

The traditional picture of a heroin user is well known from photographs and films. A user buys powdered heroin from a dealer (usually a few doses at a time), dissolves the heroin in water, and then "cooks" the dose over heat. The user then draws up a dose into a hypodermic needle and injects it into a vein. Users must be careful to inject a vein and not an artery, because heroin injected into an artery can cause severe damage to a limb or an internal organ. Over time, veins subjected to repeated injections grow hard or collapse, and the user must find new veins in other parts of the body. Hard-core heroin use leaves tell-tale needle tracks in the arms.

Injected heroin causes a brief, intense rush of pleasure, followed by a four- to six-hour period of weariness and well-being. Breathing slows, and the user experiences no pain. However, he or she may experience skin irritation that is relieved by scratching. Heroin activates the part of the brain that governs vomiting, so users often throw up right after injecting. They sometimes use the force of their nausea to judge the strength of the dose.

Some users inject heroin right under the skin—a process called "chipping." Users also inject it into muscle tissue as well. Both of these processes delay the onset of the high by several minutes.

The increased purity of street heroin has led to two new delivery systems: smoking and snorting. Many first-time users snort the drug, confident that they are avoiding AIDS and other infections caused by


needle sharing. Some users may be under the impression that snorting or smoking heroin reduces the chances of dependence. This is not the case. Any method of heroin intake can expose the user to a cycle of increased usage, leading eventually to addiction and (in many cases) the use of needles to get the best high for the price.

Are There Any Medical Reasons for Taking This Substance?

Heroin was once used as a painkiller, but today that work is done by other medications, from morphine to the synthetic opioids such as fentanyl. (An entry for fentanyl is available in this encyclopedia.) Some doctors have lobbied for use of heroin in terminally ill cancer patients, for whom addiction is not an issue. But as of mid-2005, the drug had not been approved for this use.


In 2005 the Canadian government joined several European nations (most notably the Netherlands) in a pilot program to give free heroin to heroin addicts. Public health officials in Canada expressed the hope that those receiving free heroin would be able to live crime-free lives; would no longer be forced to share dirty needles; and would be more open to beginning the process of detoxification. The Canadian program works with the most dedicated addicts—people who have tried and failed at least twice to quit using the drug.

Those who support the plan say that, at the very least, giving addicts free heroin will reduce crime. They believe that such addicts will no longer need to steal or become prostitutes to earn enough for a fix. Those who oppose the plan—including officials in the U.S. government—say that the program encourages drug abuse. A reporter in The Economist wrote: "The hope is that if hard-core addicts no longer have to commit crimes to fund their habits they are more likely to become productive citizens and leave drugs behind."

The "free heroin" plans in Canada and parts of Europe are not necessarily just for the addicts, but also for the non-abusing public at large. Canadian officials hope to reduce crime and the costs of fighting it, as well as the spread of infectious diseases like AIDS and hepatitis.

Usage Trends

According to the National Survey on Drug Use and Health (NSDUH), in 2003 an estimated 19.5 million Americans age twelve and up used illicit (illegal) drugs. Of these, an estimated 119,000 teenagers between twelve and eighteen had tried heroin at least once.

The Drug That Does Not Discriminate

The image of a heroin user is typically a poor, unemployed, uneducated person who lives in an inner city. It is true that some poor, uneducated people do abuse heroin. However, there is no such thing as a "typical" heroin user. In 2004 for example, Colin Farrell, one of the year's top Hollywood actors, admitted to the press that he had tried the drug. The list of actors, artists, musicians, students, business executives, and politicians, among others, who have had a heroin habit is long. As such, heroin is abused by people from all segments of the population—young and old; rich and poor; uneducated and educated; employed and unemployed; and people living in the city, suburbs, and rural areas.

From 1995 until 1999, Dr. Lance L. Gooberman ran an "ultra rapid detox" facility for heroin abusers in a New Jersey-area suburb. According to Carol Ann Campbell in the Newark, New Jersey Star-Ledger, an investigation of Dr. Gooberman's practice "has shone a light into the hidden world of suburban heroin use." The reporter added: "Gooberman's clients included business executives, college students and parents who opened their checkbooks to get themselves or their children off drugs." In another Star-Ledger piece, Gooberman himself said he received 2,000 calls each week for his services. "We get all kinds—jail to Yale," he said. "We've had rock stars, an oil company heir, a Kuwaiti prince."

Heroin is not just a drug for the poor. It has found its way into the wealthiest neighborhoods in America. It is safe to say that heroin does not play a major role in the "club drug" scene. Under the influence of heroin, users become quiet and withdrawn. They tend to sit or lie in one place, nodding. Their speech becomes slurred. This sort of behavior does not fit the "rave" or dance party environment.

Kurt Cobain (1967–1994)


Kurt Cobain was the guitarist and lead singer of the Seattle-based band Nirvana. The band's "grunge" style music transformed rock music during the late 1980s and early 1990s. The group combined the sounds of punk and alternative rock with angry lyrics. The band's debut album, Bleach (1989), was popular with critics, but the release of the band's album Nevermind (1991) led Nirvana on a quick rise to fame.

The hit song "Smells Like Teen Spirit" remained at the top of pop charts for several weeks in 1991. Cobain and band members Krist Novoselic and Dave Grohl made millions of dollars from the sales of the album and became instant celebrities. In 1993 the band released the album In Utero, which also shot to the top of the charts. Songs like "All Apologies" and "Heart-Shaped Box" brought in more fans and more money.

As the front man for a band whose lyrics scorned popular success, Cobain was disturbed by the band's sudden fame. Cobain was also increasingly uncomfortable with the notoriety and pressures created by the band's popularity. He was particularly upset by media coverage of his controversial marriage to singer Courtney Love; the birth of their daughter, Frances Bean, in 1992; and the rumors of his and Love's drug use.

Cobain's journals, published in 2002, reveal that the singer battled depression for years prior to Nirvana's formation. He had also been in intense physical pain due to a chronic stomach condition that doctors had been unable to diagnose or treat for several years before his death. He began using heroin occasionally in 1990 in an attempt to self-medicate. In his journals, Cobain wrote about using heroin to treat his medical condition. He explained: "It was a stupid thing to do and I'll never do it again and I feel real sorry for anyone who thinks they can use heroin as a medicine because um, duh, it don't work."

Yet by 1993, after repeated attempts to stop using the drug, Cobain's heroin use


had turned into an addiction. Friends and family members attempted to assist him with an intervention and rehabilitation. In 1994, after several days in a drug rehabilitation center in Marina del Ray, California, Cobain left the facility. He was missing for several days, but his body was found on April 8, 1994.

Cobain's death was caused by a gunshot wound to the head, allegedly self-inflicted on April 5, after he injected himself with a large dose of heroin. The cause of death, officially ruled a suicide, has been controversial ever since. Some claim that the amount of heroin in Cobain's bloodstream was enough to have knocked him out. This would rule out the possibility that he could have pulled the trigger of the weapon that caused his death.

Nirvana's music and Kurt Cobain's influence on the rock music scene continue to live on among fans.

Can scientists identify a particular personality trait that may lead someone to experiment with heroin or abuse it? According to Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), neurobiology, the workings of the brain, do play a part in determining who may develop a heroin habit. Volkow told Psychology Today that addiction "may be a malfunction of the normal human craving for stimulation. … If you connect to the world in a meaningful way, and have more chances to get excited about natural stimuli, you're less likely to need an artificial boost." However, people who tend to look at the world in a dark way may be at a greater risk for drug addiction. This includes people who are easily bored or who feel bad about themselves, people who are stressed by work or school, or people who feel unpopular and disliked.

Heroin abuse and addiction is not just an American problem, either. Sohail Abdul Nasir in the Bulletin of the Atomic Scientists estimates that 4.5 million Pakistanis are addicted to the drug. Arrests for possession or sale of heroin have occurred on every continent except Antarctica, and some countries have extremely harsh penalties for those caught with the drug. The problem is so serious in the United Kingdom, Germany, and the Netherlands that those nations have established a few, carefully controlled "free heroin" clinics for addicts in hopes of reducing crime and the spread of illness.

The populations that show the least use of heroin are those where the poppies are actually grown. To many opium poppy farmers, growing the plants is just business—a way to provide for their families.

Effects on the Body

Whether injected, sniffed, or snorted, heroin speeds to the brain and spinal cord. Users feel an almost immediate rush, or "smack" of euphoria, especially when the drug is injected. This is because heroin turns to morphine in the brain and floods the brain's receptors that search for endorphins and enkephalins. The user's pleasure centers literally all fire at once, and the feeling is one of complete release from pain, anxiety, and unhappiness, replaced by a warm sensation of pleasure. After the immediate rush, the user settles into a "high" in which the pleasurable sensations continue, along with drowsiness and a general unwillingness to move or disrupt the dreamlike state. Users' heads may bob up and down. They may develop itchy skin from a mild allergic reaction to the heroin. They may become nauseated and vomit.

Within four to six hours, the heroin-turned-to-morphine slowly clears the brain. During the high, the body reacts to the opiate surge by causing slowed breathing, cessation (stopping) of coughing, and pinpoint pupils. Since all opiates work on the part of the brain that controls breathing, an overdose of any of them can cause a user to stop breathing. If the user is alone at the time of an overdose, he or she will die of suffocation. Cessation of breathing is one of the leading causes of death in heroin overdose cases.

Addiction, Cravings, and Withdrawal

Can a person become dependent on heroin after a single dose? In truth, heroin is less addictive than nicotine or cocaine. (Entries on nicotine and cocaine are available in this encyclopedia.) Some people can use it occasionally without developing a habit. But the fact remains that the intense rush of pleasure associated with a heroin high is quite seductive. The same is true of the longer-lasting sense of well-being and freedom from anxiety that follows the rush. If a user makes a point of seeking the drug a second time, that could indicate the onset of habitual behavior.

Smack


According to Sean Connolly in the book Just the Facts: Heroin, when heroin is injected directly into a vein with a hypodermic needle, it produces a high in seven to ten seconds. The nickname "smack" comes from this sudden rush of sensation.

Repeated use of heroin requires higher doses to achieve the high. This is known as "tolerance." Eventually, when dependence sets in, the user rarely achieves the same high that drew him or her to the drug the first time. Instead, the user seeks the drug to avoid with drawal symptoms. Life becomes a constant struggle to find the money to pay for another fix, to find the dealer and buy the fix, and to find a way to achieve the high.

Some experts estimate that as many as 80 percent of heroin addicts never free themselves from opiates. Once the habitual use is established, it is extremely difficult to stop.

Heroin withdrawal begins with a three- to five-day period of intense anxiety, insomnia, and a host of flu-like symptoms from uncontrolled coughing and yawning to stuffy nose, cramps, chills, sweating, diarrhea, and "goose bumps." Having goose bumps led to the origin of the phrase "quitting cold turkey." Additionally, muscles that have been relaxed by the drug tighten and twitch, causing severe pain and uncontrolled, reflexive motion ("kicking the habit"). A recovering addict named Joey Peets told Scholastic Choices: "It's the worst feeling. Most people say they'd rather be shot than be sick on drugs. … Being addicted and having to get off drugs is the worst experience. I wouldn't wish it on my worst enemy."

Yet, these desperate physical symptoms of withdrawal are not the worst aspect of opiate addiction. The addict experiences psychological cravings that are so intense that they become nearly impossible to fight. To quote Alfred Lubrano of the Knight Ridder/Tribune News Service: "The smell of burned matches, the sight of a $10 bill (the price for a 'dime bag' of drugs), even those 'Just Say No' anti-drug posters with a crossed-out needle, all act as potent cues that could bring even long-clean addicts to their knees, screaming for dope." Scientists have actually shown recovering addicts films of drug abuse while monitoring the drug users' brain activity. The results: Watching someone else use drugs, even on a film, spurs activity in the parts of the brain that govern motivation and craving.

Reactions with Other Drugs or Substances

"Speedballs" are a deadly combination of cocaine and heroin. "Hot rocks"—a combination of heroin and crack cocaine—are often fatal to users as well. Many other drugs enhance the dangers of heroin, including tranquilizers and alcohol. Taking amphetamines with heroin can cause an irregular heartbeat. (An entry on amphetamines is also available in this encyclopedia.)

One of the worst aspects of heroin use is that dosages vary. Dealers cut the pure heroin with fillers ranging from powdered milk to the ingredients found in rat poison. The purity of the heroin arriving from abroad can vary, too, depending on the health of the poppy crop and how the raw opium was processed. Those who use heroin never really know the strength of the product they are about to ingest. This can lead to overdose in even the most opiate-tolerant individuals.

Research has also shown that heroin addicts can have different reactions to the same dose of heroin if they take it in unfamiliar surroundings. A dose they can manage in a comfortable setting may become an overdose in a different setting. Scientists can offer no explanation for this particular reaction.

A person who has stopped taking heroin for some time, perhaps during detoxification or other therapy, can die of an overdose if he or she returns to the drug. Once the brain's chemical levels come closer to normal, doses that a user tolerated as an addict can become fatal. It was a return to heroin use after a period of detox that led to the death of the up-and-coming young American artist Jean-Michel Basquiat in 1988. Basquiat was just twenty-seven years old.

Treatment for Habitual Users

When heroin was first introduced to the medical community at the beginning of the twentieth century, it was used to help people overcome opium and morphine addiction. Heroin was considered a "step-down" drug. However, the cure was worse than the original addiction. It is no coincidence that heroin was the first opiate product declared illegal in the United States. Once a dependence is established, it is very difficult to end.

The "rapid detox" method used in New Jersey in the 1990s was declared illegal after nearly a dozen patients ended up in emergency rooms with life-threatening complications. Many of those who successfully completed the "rapid detox"—being put to sleep while an opiate antagonist, Narcan, was shot into the brain—returned to heroin use due to inadequate psychiatric follow-up. The dream of easy, pain-free detoxification from heroin has remained just that—a dream.

Typically, heroin addicts undergo several steps before seeking treatment. First, they come to recognize that the drug has altered their lives. This may happen when a marriage breaks up, when an addict resorts to crime to pay for drugs, when a friend dies of an overdose, or when an addict begins to have serious health problems related to drug use. At that point addicts might decide to continue to use heroin simply to avoid any withdrawal symptoms. In the next step, addicts may ask about the types of help they can expect and talk to health care workers about what might happen in an inpatient setting or a methadone clinic. (Methadone is a drug that is used to


help addicts overcome heroin addiction. An entry on methadone is available in this encyclopedia.) In the third step, addicts decide to accept help.

Drug Treatment for Heroin Addiction

Heroin addiction is treated with several other drugs. One of them is the opiate methadone, which is most often taken in liquid or pill form. It is released slowly into the body and keeps withdrawal symptoms away but does not provide the high of heroin. Ideally, recovering heroin addicts begin with high doses of methadone and gradually taper down until they are drug-free. They combine the medication with talk therapy and lifestyle changes. The course of methadone treatment is rarely smooth, however. Sometimes addicts return to heroin. Sometimes they abuse the methadone instead.


Nevertheless, at the beginning of the twenty-first century, methadone was still the medication of choice for treating opiate addiction.

Another drug, naloxone (Narcan), works differently. This substance quickly frees the pleasure centers of the brain from the opiate. Emergency room doctors use Narcan to revive victims of heroin overdose who have stopped breathing. However, naloxone causes violent withdrawal symptoms if administered by injection. Scientists are experimenting with a continuous release form of naloxone that would be implanted under the skin and would block the effects of heroin even if the user took a dose. Doctors are also prescribing buprenorphine (byoo-preh-NORR-feen), another drug found to block the absorption of heroin in the brain. Buprenorphine (Temgesic, Subutex) lasts longer than methodone—seventy-two hours rather than twenty-four. This allows recovering addicts to make fewer visits to clinics. It is still in the experimental stages.

People can overcome heroin addiction. Self-help groups such as Narcotics Anonymous (NA) provide group therapy and the experiences of other recovering users to bolster the addict's courage. The group provides emotional support during the difficult times. Recovering heroin users must also be willing to undergo counseling to understand what underlying feelings led them to experiment with the drug—and how to cope with the cravings when they occur. It is sometimes necessary to begin a "whole new life," separating from the friends, settings, and personal habits that the user employed during addiction. It is also necessary to realize that cravings for the high will continue, sometimes for years, especially in times of stress or on occasions when something reminds the user of the drug experience.

Consequences

Heroin addicts are at far greater risk than the general public for contracting HIV/AIDS, a deadly illness. Heroin users also run a greater risk of contracting any one of several hepatitis viruses, all of which attack the liver. These infectious illnesses are spread through the use of shared needles. If a heroin addict manages to avoid AIDS and hepatitis, long-term use of the drug can lead to: 1) damaged veins ("tracks"); 2) bacterial infections that damage blood vessels and the heart; 3) kidney and liver disease; 4) pneumonia; or 5) tuberculosis. Because heroin causes slower breathing, lung and brain damage can occur from repeated use. Sometimes those who inject heroin suffer strokes when some undissolved particle lodges in a blood vessel.

There are many health risks associated with injecting the substances that are used to cut the purity of heroin. Along with stroke, users might have breathing problems if the drug has been cut with tranquilizers, or irregular heartbeat if the drug contains amphetamines. Long-term use of heroin leads to tooth decay and gum disease, since the drug reduces the production of saliva.

One of the most destructive consequences of heroin use is loss of lifestyle. The American and international press is filled with accounts of parents who have lost custody of children because they neglected their kids while searching for more drugs. Some heroin habits climb to as much as $100 a day. People go through their life savings, sell their belongings, and eventually turn to crime to support their habits. Theft, drug dealing, and prostitution go hand-in-hand with heroin addiction. Such crimes can lead to jail time, where authorities are unlikely to help the addict manage his or her withdrawal symptoms.

Detoxification and rehabilitation in a clinical setting can be costly too. Few heroin addicts beat their dependence on the drug and still have a steady job or an intact marriage waiting for them. Recovering addicts often must deal with guilt over broken relationships, criminal records, and loss of peer respect.

The Law

Heroin is a Schedule I controlled substance in the United States. It is illegal to possess or sell even a small amount of it. Heroin is also illegal in every country in Europe, as well as in Mexico, Canada, and the countries of Central and South America. Even where it is grown, the drug is illegal and must be produced and refined without government knowledge.

A person convicted on U.S. federal charges of possessing a Schedule I substance faces prison terms and hefty fines. Those who manage to avoid prison on a first offense are subject to probation and random urine tests for drugs. Any detection of drugs during a test sends the user to jail. Other fines and sentences vary from state to state. For instance, in many places people can be arrested for possessing the pipes and needles used to ingest heroin—so-called "drug paraphernalia."

The penalties for second and third offenses are much greater and almost always involve as much as two years in prison. States with "three strikes" programs give life sentences to those convicted of a third instance of selling a controlled substance.

Heroin dependence carries with it many opportunities to run afoul of the law. Theft and prostitution both result in criminal records, possible jail time, and publicity. Many hard-core drug users turn to drug dealing to support their habits, thus increasing their chances of stiff sentences if they are arrested. People caught selling drugs within 1,000 feet of a school face the most serious sentences of all. Even first-time convictions carry minimum prison terms and double fines.

Some people and organizations have pressed to make some Schedule I drugs legal. However, no doctors, religious sects, or research scientists have asked that heroin be made available to anyone, for any reason. Opinion of the drug is universally low among those who understand its workings on the brain.

For More Information

Books

Burroughs, William S. Junkie. New York: Ace Books, 1953.

Connolly, Sean. Just the Facts: Heroin. Chicago: Heinemann Library, 2001.

Gahlinger, Paul M. Illegal Drugs: A Complete Guide to Their History, Chemistry, Use and Abuse. Las Vegas: Sagebrush Press, 2001.

Inciardi, James. The War on Drugs II: The Continuing Epic of Heroin, Cocaine, Crack, Crime, AIDS and Public Policy. Mountain View, CA: Mayfield Publishing Company, 1991.

Kuhn, Cynthia, Scott Swartzwelder, and Wilkie Wilson. Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy, 2nd ed. New York: W.W. Norton, 2003.

Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine. Boston: Houghton Mifflin, 1993, rev. 2004.

Periodicals

Bachelet, Pablo. "Report on Cocaine, Heroin Prices Suggests U.S. Is Losing War on Drugs." Knight Ridder/Tribune News Service (December 1, 2004).

Campbell, Carol Ann. "7th Death Linked to 2 Heroin Detox Doctors: State AG Charges That the Rapid Procedure, Involving Anesthesia, Is Medically Unsound." Star-Ledger (September 13, 2000): p. 13.

Campbell, Carol Ann, and Fredrick Kunkle. "State Curbs Doctor's Unique Heroin Detox." Star-Ledger (October 14, 1999): p. 1.

"Colin Farrell Admits Using Heroin." UPI NewsTrack (October 22, 2004).

Frank, Steven. "Fighting Heroin with … Heroin." Time (February 14, 2005): p. 14.

Frank, Steven. "Giving Addicts a Shot: A Controversial Program Will Supply Heroin to Heavy Users in Vancouver." Time Canada (February 14, 2005): p. 32.

Higham, William. "Heroin Supply: When More Is Better." New Statesman (October 25, 2004): p. 15.

Lewnes, Alexia. "The Downward Spiral Caused by a Drug Called Heroin." Scholastic Choices (November-December, 2004): p. 10.

Lubrano, Alfred. "Scientist Researches Cravings of Drug Addicts." Knight Ridder/Tribune News Service (December 3, 1997).

Man, Kingson. "U. Michigan Research Shows Effects of Cigarettes Similar to Heroin, Morphine." The Americas Intelligence Wire (November 9, 2004).

Marsden, Rachel. "Outside View: Free Heroin in Canada." UPI Perspectives (April 12, 2005).

McGowan, Kathleen. "Pay Attention to This: Heroin and Chocolate Cake Have a Nasty Way of Crowding out the Rest of the Universe." Psychology Today (November-December, 2004): p. 84.

Nasir, Sohail Abdul. "The Poppy Problem." Bulletin of the Atomic Scientists (September-October, 2004): p. 15.

"Proportion of Admissions to Substance Treatment Programs for Abuse of Narcotic Prescription Medications, Heroin, Marijuana, and Methamphetamine Has Increased in the Past 10 Years, While Those for Cocaine Abuse Declined." USA Today Magazine (February, 2005): p. 3.

Roosevelt, Ann. "Poppies the Problem in Afghanistan, Myers Says." Defense Daily (November 5, 2004).

Scarborough, Rowan. "Heroin Traffic Finances bin Laden: Cut Off Cash, Lawmaker Says." Washington Times (December 6, 2004).

Scott, Gale. "Jersey Wants to Ban Disputed Heroin Detox." Star-Ledger (January 12, 1997): p. 25.

"Under the Needle: Drugs in Canada." The Economist (February 12, 2005): p. 37.

Web Sites

"Cobain Journal Reveals Tortured Addict." CBS News, October 22, 2002. http://www.cbsnews.com/stories/2002/10/22/entertainment/main526584.shtml (accessed August 24, 2005).

"Drug Abuse Warning Network, 2003: Interim National Estimates of Drug-Related Emergency Department Visits." DAWN, 2003: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. http://DAWNinfo.samhsa.gov/ (accessed July 10, 2005).

"Facts and Figures on Youth Heroin Use" (July 2004). California Department of Alcohol and Drug Programs. http://www.adp.cahwnet.gov/FactSheets/Facts_and_Figures_on_Youth_Heroin_Use.pdf (accessed July 10, 2005).

"Heroin." Drug Abuse Help: Honest Drug Abuse Information. http://www.drugabusehelp.com/drugs/heroin/ (accessed July 10, 2005).

"Heroin." U.S. Department of Justice, Drug Enforcement Administration Diversion Control Program. http://www.deadiversion.usdoj.gov/ (accessed July 10, 2005).

"National Survey on Drug Use and Health (NSDUH)." Substance Abuse and Mental Health Services Administration (SAMHSA). http://www.drugabusestatistics.samhsa.gov (accessed July 10, 2005).

Wyman, Bill. "Kurt Cobain and a Dream about Pop." Salon.com, September 24, 2001. http://www.salon.com/ent/music/feature/2001/09/24/cobain/ (accessed August 24, 2005).

See also: Cocaine; Codeine; Fentanyl; Hydromorphone; Methadone; Morphine; Opium; Oxycodone

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