Heroin: The Killer Among Us!

8400 Westchester, Suite 220 Dallas, TX 75225
Phone: (214) 369-1155, Fax: (214) 369-1710
email: info@sosdallas.com
Web site: www.sosdallas.com

INTRODUCTION

This article discusses the current epidemic of heroin use and addiction. When I began researching and writing this article, I became very excited, driven, and most definitely, concerned. Excited because I believe I have an important message to communicate to you, driven because I believe this is the most challenged I have felt since I became an alcohol and drug abuse counselor in 1983, and concerned because of the deadly nature of heroin. In our treatment program, Solutions Outpatient Services, currently we have thirteen patients of which eight are heroin addicts. Five are Plano high school kids, two are SMU students, and one is a 28 year old male. Need I say more of my urgency to learn all I could? I have had to go to the Internet and library and get my hands on everything I could find on this drug. And guess what–I have learned more from the kids than the books. Isn’t that always the way it is? 

WHAT IS HEROIN?

Heroin is an illegal, highly addictive drug. It is both the most abused and most rapidly acting of the opiates. Heroin is processed from morphine, a naturally occurring substance extracted from the seedpod of certain varieties of poppy plants. It is typically sold as a white or brownish powder or as the black sticky substance known on the streets as "black tar heroin." Although purer heroin is becoming more common, most street heroin is "cut" with other drugs or with substances such as sugar, starch, powdered milk, or quinine. Street heroin can also be cut with strychnine or other poisons. Much of the heroin that is hitting the streets today is more powerful than the heroin of the 60’s and 70’s.

Heroin initially was marketed in 1898 by the Bayer Company of Germany. It was used as a cough remedy. Because morphine proved to be addictive, doctors began using heroin as a pain killer for surgery. However, heroin proved to be even more addictive than morphine–so much so that its use in medicine was stopped. And by 1925 heroin was branded as a dangerous drug nationally.

Like alcohol, heroin is a depressant that slows down all the body functions. But heroin differs from alcohol in two very significant ways. First, it is not "organotoxic." It does not destroy body organs, like the liver or kidney, the way alcohol does. That is why heroin dependency can last for years. Second, an abuser usually does not die from the symptoms experienced from the withdrawal although the violent retching is so unpleasant it drives many addicts back for another hit. The deaths associated with heroin are from overdosing rather than withdrawal. These so-called good differences are now being peddled to a new generation that has been bombarded with the negative effects of other addictive drugs like alcohol and cocaine.

HOW IS IT USED?

Heroin is usually injected, sniffed/snorted, or smoked. Typically, a heroin abuser may inject up to four times a day. Intravenous injection, "mainlining," provides the greatest intensity and most rapid onset of euphoria (7 to 8 seconds) while intramuscular injection produces a relatively slow onset of euphoria (5 to 8 minutes). "Skin-popping" is injecting the drug just under the skin. This way it gets into the blood through tiny blood vessels. When heroin is sniffed or smoked, peak effects are usually felt within 10 to 15 minutes. Although smoking or sniffing heroin does not produce a "rush" as quickly or as intensely as injecting intravenously, National Institute on Drug Abuse (NIDA) researchers have confirmed that all three forms of heroin administration are addictive.

There is no such thing as a typical first-time heroin user. However, studies show that most people who try it for the first time are between the ages of 16 and 24. Most people who use heroin have already tried some other drug. Experienced users like to combine heroin with other drugs. Mixed with tobacco or marijuana, heroin can be smoked. One of the most popular ways of using heroin among today’s youth is the injecting of "speedballs." "Speedballs" are a combination of heroin and cocaine (usually a "cap" each), "cooked" and injected intravenously.

Injection continues to be the predominant method of heroin use among addicted users seeking treatment. However, researchers have observed a shift in heroin use patterns, from injecting to sniffing and smoking. In fact, sniffing/snorting heroin is now a widely reported means of taking heroin among users admitted for drug treatment in Newark, Chicago, New York, and Detroit.

With the shift in heroin abuse patterns comes an even more diverse group of users. Older users (over 30 years old) continue to be one of the largest user groups in most national data. However, several sources indicate an increase in new, young users across the country who are being lured by inexpensive, high-purity heroin that can be sniffed or smoked instead of injected. Heroin has also been appearing in more affluent communities.

THE SCOPE OF HEROIN IN THE U.S., TEXAS, AND DALLAS

According to the 1996 National Household Survey on Drug Abuse, which may actually underestimate illicit opiate (heroin) use, an estimated 2.4 million people use heroin at some time in their lives, and nearly 216,000 of them reported using it within the month preceding the survey. The survey report estimates that there were 141,000 new heroin users in 1995, and that there has been an increasing trend in new heroin use since 1992. A large proportion of these recent new users were smoking, snorting, or sniffing heroin, and most were under the age 26. Estimates of usage for other age groups also increased, particularly among youths age 12 to 17: The incidence of first-time heroin use among this age group increased fourfold from the 1980’s to 1995.

The 1996 Drug Abuse Warning Network (DAWN), which collects data on drug-related hospital emergency department (ED) episodes from 21 metropolitan areas, estimates that 14% of all drug-related ED episodes involved heroin. Even more alarming is the fact that between 1988 and 1994, heroin-related ED episodes increased by 64% (from 39,063 to 64,013). Regardless of how users take the drug, an increase in the purity of heroin could be one reason for the increase in hospital ED visits. According to a report by the U.S. Drug Enforcement Administration, the purity of an ounce of heroin purchased on the street rose from 34% in 1990 to 66% in 1993. The greater purity of heroin could result in more overdoses and, in turn, more hospital visits.

Brandy Wismer, CEO of the Greater Dallas Council on Alcohol and Drug Abuse, states they are receiving more calls this year concerning heroin than ever before. In the spring of 1996, 3.9% of GDCADA calls were about heroin. That figure rose to 9.3% at the end of 1996. By May of 1997, almost 12% of the calls were related to heroin. Deaths from heroin overdoses have jumped in several of Texas’ most populous cities. The current street price of heroin is up 500% in Dallas since 1993. Richard Spence, an assistant deputy director of the state drug abuse commission, says, "A lot of times that is an indicator of demand. It costs more to get the same high."

SHORT-TERM EFFECTS

"Rush"

Depressed respiration

Clouded Mental Functioning

Nausea and Vomiting

Suppression of Pain

Spontaneous Abortion

 

Soon after injection (or inhalation), heroin crosses the blood-brain barrier. In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. Abusers typically report feeling a surge of pleasurable sensation, a "rush." The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the natural opioid receptors. Heroin is particularly addictive because it enters the brain so rapidly. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities, which may be accompanied by nausea, vomiting, and severe itching. After the initial effects, abusers usually will be drowsy for several hours. Mental function is clouded by heroin’s effect on the central nervous system. Cardiac functions slow. Breathing is also severely slowed, sometimes to the point of death. Heroin overdose is a particular risk on the street where the amount and purity of the drug cannot be accurately known.

LONG-TERM EFFECTS

Addiction

Infectious Diseases (HIV/AIDS, Hepatitis B and C)

Collapsed Veins

Bacterial Infections

Abscesses

Infection of the Heart Lining and Valves

Arthritis and Other Rheumatologic Problems

One of the most detrimental long-term effects of heroin is addiction itself. NIDA defines addiction as a chronic, relapsing disease characterized by compulsive drug seeking and usage, and by neurochemical and molecular changes in the brain. I prefer to define addiction as a pathological relationship with a mood and/or mind altering substance or behavior that renders one powerless and produces harmful consequences. Heroin produces profound degrees of tolerance and physical dependence which are also powerful, motivating factors for compulsive use and abuse. As with abusers of any drug, heroin abusers gradually spend more and more time and energy obtaining and using the drug. Once they are addicted, the heroin abuser’s primary purpose in life becomes seeking and using drugs. The drug literally changes their brains.

Physical dependence develops with higher doses of the drug. With physical dependence, the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced abruptly. Withdrawal may occur within a few hours after the last time the drug is taken. Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps ("cold turkey"), and leg movements. Heroin addicts will complain of their clothes hurting, that drinking water hurts, etc. Major withdrawal symptoms peak between 24 and 48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Heroin withdrawal is never fatal to otherwise healthy adults, but it can cause death to the fetus of a pregnant addict.

At some point during continuous heroin use, a person can become addicted to the drug. Sometimes addicted individuals will endure many of the withdrawal symptoms to reduce their tolerance for the drug so that they can again experience the rush. Physical dependence and the emergence of withdrawal symptoms were once believed to be the key features of heroin addiction. We now know this may not be the case entirely since craving and relapse can occur weeks and months after withdrawal symptoms are long gone. We also know that patients with chronic pain who need opiates to function (sometimes over extended periods) have few, if any, problems leaving opiates after their pain is resolved by other means. This may be because the patient in pain is simply seeking relief of pain and not the rush sought by the addict.

MEDICAL COMPLICATIONS OF CHRONIC HEROIN USE

Medical consequences of chronic heroin abuse include scarred and/or collapsed veins, bacterial infections of the blood vessels and heart valves, abscesses (boils) and other soft-tissue infections, and liver or kidney disease. Lung complications (including various types of pneumonia and tuberculosis) may result from the poor health condition of the abuser as well as from heroin’s depressing effects on respiration. Many of the additives in street heroin may include substances that do not readily dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection, or even death, of small patches of cells in vital organs. Immune reactions to these or other contaminants can cause arthritis or other rheymatologic problems.

Of course, the sharing of injection equipment or fluids can lead to some of the most severe consequences of heroin abuse–infections with hepatitis B and C, HIV, and a host of other blood-borne viruses, which drug abusers can then pass on to their sexual partners and children.

HEROIN WITHDRAWAL SYNDROME

Withdrawal symptoms have been discussed earlier in this article. Due to heroin withdrawal syndrome, a substantial portion of the physical symptoms seems to depend on the activity of a part of the brainstem called the locus coeruleus. The locus coeruleus is an important center in the brain’s fear-alarm system, and such hyperactivity would be consistent with the marked anxiety and agitation withdrawing addicts report. Fortunately for withdrawing addicts, other drugs besides the opiates can depress this region, and one of them is clonidine.

Clonidine is generally used as an anti-hypertensive agent, but in 1978 Gold and his colleagues reported that it could suppress or reverse the symptoms of opiate withdrawal. Subsequent work has shown that this reversal is by no means complete, but there seems to be no doubt that clonidine can make opiate withdrawal much more comfortable. Medical supervision and assistance is certainly now essential for successful withdrawal.

The duration of early abstinence depends on the drug’s rate of elimination. And in the cases of heroin, most major symptoms should be gone within seven to ten days. However, a protracted abstinence syndrome follows withdrawal from heroin. It lasts at least 31 weeks after withdrawal, and perhaps longer. Blood pressure, pulse rate, body temperature, and pupil diameter seem to be the main physiological variables affected. Behaviorally, the subject shows an increased propensity to sleep, and there are negative changes in mood and feeling state. Tolerance is a funny thing. Addicts have been known to die from their second shot of the day after dividing their daily amount into three piles. It would seem, therefore, that their tolerance had been reduced since the first shot. Someone conjectured that tolerance was partially a matter of place-conditioning, that addicts get conditioned so that their body begins to gear up for a shot when they go to their dealer or drug house, and, therefore, they have higher tolerance there. When they shoot up someplace else, their body is not ready and they OD.

TREATMENT OF HEROIN ADDICTION

Treatment of heroin addiction can be successful either on an outpatient or inpatient basis. As stated earlier, medical detoxification is not absolutely necessary; yet it does provide the patient less pain and discomfort. Contrary to popular opinion, heroin addicts can do just as well in a very structured, intense outpatient program. The key elements to a successful treatment program for heroin addicts is essentially the same as for any other addict and/or alcoholic. It is my opinion that we tend to glamorize treatment models in the same manner in which addicts have glamorized their addiction. Rather than focusing on the elements which help a heroin addict "get off" their drug, treatment needs to focus on the essential components which help the addict maintain recovery ("stay off" their drug).

Heroin is known to be the most pleasure producing drug, and it is also does the greatest damage to the user’s pain threshold. This is not just regarding physical pain, as discussed earlier, but addicts will also have little tolerance for either mental or emotional pain. Unpleasant truths will be avoided, and a patient will also have a tendency to not address any painful/emotional issues in their life. To the heroin addict who has been in a very infantile state for a period of time, such feelings and thoughts are overwhelming. The long-term use of heroin also produces a deadening of the feeling in the emotional side of the patient as well as the spiritual. This deadening of feelings and appreciation may be most intense for the first 9 to 12 months of recovery. During these 9 to 12 months, the patient has very little success in developing appreciation for day-to-day natural pleasures. They may experience difficulty applying the Twelve Steps of the AA or NA Program. Although this may be difficult, they need to still be required to work the Steps, all along being encouraged that "if they take the action, in time the feelings will follow." As the patient experiences abstinence for a period of time, and their feelings begin to gradually return, they will experience more of the promises of the AA program.

Heroin addicts also tend to lose any identity of self. They have become so centered on the drug, the procurement of the drug, and caught up in the ritual of the drug world, they lose any sense of inner self. As a result, they tend to be extremely manipulative with other people even though this tendency toward manipulation may be quite unconscious. They have long become someone who simply tries to please others and tries to avoid stress by pleasing others. They tend to mimic back what they believe the other person wants of them and very rarely stop to think about what they are feeling. Because heroin is such a powerful drug, there is also a tendency in the patient to blame the drug itself for the addiction rather than accepting the existence of a disease. The addict has the belief that any person who used heroin would, of course, become addicted, and that the primary mission in recovery is to simply stay away from the drug. This creates a sort of false recovery in the patient in which they have not really begun identifying themselves as having a disease that makes them susceptible to all mood-altering drugs. They will greatly minimize the threat of alcohol or other drugs. It can be said that heroin addicts sometimes need at least three treatments to begin accepting their addiction to heroin, then to other drugs, and then finally to alcohol itself.

Another issue involved in the treatment of heroin is that other drugs tend to stop producing a euphoric effect after a period of time. Generally, addicts will not get into recovery until their drug of choice no longer works for them. As long as some euphoria is still a part of the using pattern, the chemically dependent person will keep pursuing their drug use. As stated before, most drugs stop working at some point. The alcoholic, eventually through chronic use of their drug, will get to a period of "misery drinking." During this portion of a patient’s use, they are no longer experiencing any euphoria and may finally at that time, seek recovery. The same thing can be said about the effects of cocaine, marijuana, and other substances. However, the effect of heroin and other opioids tend to continue. Although the patient may become extremely disillusioned with the lifestyle around the drug use itself, the drug still produces a desired effect making that drug addict particularly susceptible to relapse.

Another issue involved in treatment is the patient’s development of "junkie pride." The heroin addict tends to believe that they are using both the best drug possible; yet, at the same time, they believe they are also the worst of the worst in some way also. The patient also has a fear of the recovery lifestyle perceiving it as something that will be boring, routine, and non-creative.

The heroin addict in treatment requires a lot of attention and confrontation. In fact, they seem to welcome it. The effect of the drug is to produce eventually a loss of self, and they tend to feel separated from other people. Therefore, they will welcome a lot of intense interactions with therapists and counselors and feel that the attention that they receive makes them important enough to start being cared about. The patient needs to be educated in the fact that they have the same disease as other addicts and alcoholics, which is chemical dependency. Their particular type of drug and drug use is different in some ways as stated earlier; however, the nature of the addict person is the same. Most everything which has been discussed regarding the heroin addict’s personality and attitudes can be said of alcoholics, marijuana addicts, cocaine addicts, and most any addict. Although the road to recovery for heroin addicts may be long and difficult, it is definitely rewarding and spiritually healing.

WHAT IS THE APPEAL OR SEDUCTIVENESS OF HEROIN?

Part of the appeal appears to be the "forbidden fruit" syndrome. That which one is forbidden to do, one wants to do more than ever, especially for addict type individuals. Those who have walked on the edge or pushed the envelope–the risk taker–finds heroin to be just another step along their path. There even seems to be an appeal towards the "needle." Years ago the "needle" was perceived as dirty and dangerous, and only for the "down and out." Today’s youth consider the "needle" as exciting and challenging. The high quality of heroin today is also inviting to the drug addict. When something is being marketed as the "best euphoria and high," most addicts become seduced by their own grandiosity. In the last few years, heroin use has gotten a mass media makeover. Heroin is "in." Today’s heroin users are often portrayed as chic models living the highlife in Manhattan, or street-wise guys in movies like Pulp Fiction and Trainspotting. For bored teens who wanted something new with which to experiment, heroin was the drug that had come back.

CONCLUSION

The manner in which I will conclude this article is to quote the Big Book of Alcoholics Anonymous. In this author’s opinion, the words contained in that book continue to be the most profound and revolutionary words of the 20^th Century:

REFERENCES

Alcoholics Anonymous, Alcoholics Anonymous, 3^rd ed. New York: AA World Services, Inc.,1976.

Bowersox, J.A. Heroin update: smoking, injecting cause similar effects; usage patterns may be shifting. NIDA Notes 10:8-9, 1995.

Cooper, J.R.; Altman, F.; Brown, B.S.; and Czechonwicz, D., eds. Research in the Treatment of Narcotic Addiction: State of the Art. National Institute on Drug Abuse Monograph, DHHS Pub.# (ADM) 83-1281, 1983.

Dole, V.P.; Nyswander, M.E.; and Kreek, M.J. Narcotic blockade. Arch Intern Med 118:304-309, 1966.

Goldstein, A. Heroin addiction: Neurology, pharmacology, and policy. J Psychoactive Drugs 23(2):123-133, 1991.

Hughes, P.H., and Rieche, O. Heroin epidemics revisited. Epidemiol Rev 17 (1):63-73, 1995.

Krivanek, J.A.. Heroin, myths and reality. NIDA Notes, pub. 1988, Allen & Unwin.

National Institute on Drug Abuse. Research Report Series. Heroin: abuse and addiction. NIDA, 1997.

McLaughlin, K. Drug safety why not say yes. Gateway Publishing Co., 1993.

Copyright © 1998 - 2003. All Rights Reserved.

Home Page

Licensed by

Texas Department of
State Health Services