opium smoking
Although the terms “opiate” and “opioid” are often used interchangeably they are different: Opiates refer to natural opioids such as heroin, morphine and codeine, which are derived from the opium poppy. Opioids refer to all natural, semisynthetic, and synthetic opioids and thus include fentanyl and OxyContin as well as heroin and morphine. Opium is often seen as a source of opiates and opiods rather than an opiate itself.

It is estimated that there was between 37 million and 78 million opioid users around the world in 2019, making opioids the second most used illicit drug globally after cannabis. Of these around 17 million use heroin. Many synthetic opioids exist, some of which can be prescribed for medicinal use, but are also widely used in the illicit drug trade and used for recreational purposes. In 2019, there were 49,860 opioid overdose deaths in the United States, of which 14,019 were deaths by heroin overdose. [M. Shahbandeh, Statista, December 15, 2021]

Opioids can: 1) depress breathing by changing neurochemical activity in the brain stem, where automatic body functions such as breathing and heart rate are controlled.; 2) reinforce drug taking behavior by altering activity in the limbic system, which controls emotions; block pain messages transmitted through the spinal cord from the body. [Source: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services, June 2018]

Websites and Resources: U.S. Drug Enforcement Administration (DEA) justice.gov/dea/concern ; Vaults of Erowid erowid.org ; United Nations Office of Drugs and Crime (UNODC) unodc.org ; Wikipedia article on illegal drug trade Wikipedia ; Frank’s A-to-Z on Drugs talktofrank.com ; Streetdrugs.org streetdrugs.org ; Illegal Drugs, country by country listing, CIA cia.gov/library/publications/the-world-factbook Books: “Buzzed” by Cynthia Kuhn Ph.D. Scott Swartzwelder, Ph.D., Wilkie Wilson Ph.D. of the Duke University Medical Center (Norton, 2003); “Consuming Habits: Drugs in Anthropology and History” by Goodman, Sharratt and Lovejoy; “Drug War Heresies: Learning from Other Vices, Times and Places” by Robert MacCoun and Peter Reuter (Cambridge University Press).

Opiate Use

Opiates have traditionally been used in medicine as painkillers and some are so strong they can even be used as anesthesia. Despite a great deal of time and research into the matter no other substances have been created that are as effective in treating severe pain.

Opium is still prescribed as a treatment for diarrhea, In the United States today, morphine and some synthetic and opiates remains widely used as painkillers; codeine is used as a cough treatment; and synthetic opiates are sometimes used to treat anxiety associated with shortness of breath. Diarrhea drugs like Lomotil use an opiate to temporally paralyze muscles in the intestines that help push digested food along. This stops the digestive process and stops diarrhea in its tracks. In the old days opiates were given as a treatment for severe depression and other psychiatric disorders but that is no longer the case..

Opiates used for recreation can be eaten, injected in a vein or under the skin, administered through the rectum or nasal membranes or smoked. Users sometimes experience an intense rush of pleasure when the use the drug — especially if it is injected — and then pass into pleasant drowsiness or dreamy state in which they have little sensitivity to pain. Heavy doses slow breathing, and cause the pupils to shrink to pinpoints and the skin becomes flush. Moderate doses make a user feel good but do not prevent him from functioning normally. First time user often feel nauseous.

Heroin Users

There are estimated to be 17 million heroin users worldwide. According to the UNODC: Global data on the prevalence of the use of opiates (heroin, morphine and opium) suggest that South Asia (most notably India) may be home to the largest number of opiate users worldwide (17 million people). or 39 percent of the global estimate in 2019, i.e., far more than in any other subregion) and may have experienced very strong increases in opiate use over the past two decades. Significant quantities of the opiates needed to meet domestic demand in South Asia are likely to be smuggled from Southwest Asia; for example, 40 percent of the total quantity of heroin seized in India in 2019 came from Southwest Asia. In 2019, India reported a particularly strong increase (157 per cent) in heroin shipments from Southwest Asia by sea. [Source: United Nations Office on Drugs and Crime (UNODC), World Drug Report 2021]

Although heroin use in the general population in the U.S. is rather low, the numbers of people starting to use heroin have been steadily rising since 2007. This may be due in part to a shift from misuse of prescription pain relievers to heroin as a readily available, cheaper alternative2-5 and the misperception that pure heroin is safer than less pure forms because it does not need to be injected. [Source: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services, June 2021]

The number of persons receiving treatment for heroin in the U.S. increased from 277,000 in 2002 to 618,000 in 2014. In addition, the number of heroin users in the United States jumped from about 404,000 in 2002 to 914,000 in 2014, and the number of those with heroin "dependence or abuse" more than doubled from 2002 to 2014, increasing from about 214,000 to 586,000.

In the U.S., people who began using heroin in the 1960s were predominantly young men from minority groups living in urban areas (82.8 percent; mean age at first opioid use, 16.5 years) whose first opioid of abuse was heroin (80 percent). Among people aged 12 or older in 2020, 0.3 percent (or about 902,000 people) reported using heroin in the past 12 months. In 2021, an estimated 0.2 percent of 8th graders, 0.1 percent of 10th graders, and 0.1 percent of 12th graders reported using heroin in the past 12 months. The greatest increase in heroin use is seen in young adults aged 18-25. [Sources: 2020 National Survey on Drug Use and Health, 2021 Monitoring the Future Survey]

In the U.S., Among people aged 12 or older in 2020, an estimated 0.2 percent (or about 691,000 people) had a heroin use disorder in the past 12 months. In 2020, approximately 13,165 people died from an overdose involving heroin. [Source: 2020 National Survey on Drug Use and Health, CDC WONDER Database]

Heroin Use

20120528-Heroin Chasing.jpg
Chasing the dragon
Heroin can be injected, smoked, or snorted, with injecting it being the fastest and most efficient way to get it the brain and smoking being the second fastest. When it is eaten or taking in pill form much of the drug is absorbed in the intestines and liver which delays and draws out the passage to the brain, resulting in a milder high.

Heroin converts to morphine in the brain. It’s potency is tied to fat solubility, which allows it pass easily through cells and get to the brain faster. Snorted heroin passes easily through cells in the mucous membranes of the nose (something not true with other opiates) and takes effect after about 10 to 15 minutes . Smoked heroin is felt almost immediately but the effect is less than if the drug is injected because less of it reaches the brain.

In the 1960s and 70s many potential heroin users were put off by the drug’s association with needles and blood. The availability of higher purity of heroin at cheaper prices in the 1980s and 1990s meant that users could get a good buzz by snorting or smoking the drug and no longer needed to inject it to get a powerful kick. In the United States and Europe, the number of recreational users, including middle class university and high school students, and addicts soared. In opium-producing counties, which in the past had many opium smokers but very few heroin addicts, the numbers of users and addicts smoking and injecting cheap heroin also soared, and they too began to have serious drugs problems.

Chasing the dragon — inhaling the fumes of heroin burned on a piece of aluminum foil — is one of the most common ways of taking heroin. Heroin is also sometimes added to cigarettes or marijuana cigarettes. Some users have the mistaken belief that if they smoke or snort heroin they won’t get addicted. The number of heroin drug overdoes and people seeking help for heroin addiction in the United States has roughly doubled between 1990 and 1994 from around 8,000 to 16,000 people.

Injecting Heroin

Heroin taken with a needle is mixed in a saline solution before it is injected. Heroin injected into the veins gives an intense high and rush within seven to eight seconds after it is injected. Heroin injected into the muscles take five to eight minutes to take effect. Users often begin by skin-popping. Injecting it just below the skin. Intravenous users often have tracks (needle marks) all over their arms. One of the biggest problems that addicts have is finding a vein. Some inject to remote places on the body.

Describing what is like to inject heroin, Barry Bearak wrote in the New York Times, "Mr. Kahn" empties "a tiny bag of heroin into a plastic bottle cap, adding water and heating it on a small flame, drawing the hypnotic broth into a syringe...Mr Khan, 30, and a helpmate search his arms, hands, feet and groin before settling on faint line in his right biceps...The shot was transporting. His head lowered sideways as if he was laying it on a platter."

According to PBS: The first intravenous injection of heroin can be extremely unpleasant, causing vomiting and nausea. Often this experience is enough to scare someone away, but social and psychological pressures may motivate a person to keep trying. After a few more uses, the beneficial effects are obvious. Some users have distinguished between the "rush" and the "high." The rush lasts only one or two minutes and is said to be caused by the injected heroin bathing the brain before it gets distributed by the bloodstream and changed into a more useable form of morphine. [Source: PBS, WGBH, Frontline 1998]

Buzz from Morphine and Heroin

20120528-Heroin -Injecting_Heroin.JPG
Heroin users often use the word “rush” to describe the intense pleasure and euphoria they feel after using the drug, something the late comedian Lenny Bruce said was "like kissing God." Afterwards the user fells pleasantly drowsy and often nods off (dozes off). Going "on the nod" is a back-and-forth state of being conscious and semiconscious. Users feels untroubled and have little desire for sex or anything else. They feel good until the effects wear off. After that long-time users and addicts get a craving for more and feel shitty until they get some.

Once heroin enters the brain, it is converted to morphine and binds rapidly to opioid receptors. 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 opioid receptors. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the arms and legs. Nausea, vomiting, and severe itching may also occur. After the initial effects, users usually will be drowsy for several hours; mental function is clouded; heart function slows; and breathing is also severely slowed. [Source: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services, June 2018]

According to PBS: The rush is often described as a heightened sexual orgasm, and a great relief of tension, which pervades the abdomen. After the rush, the high lasts for four or five hours and is caused by the morphine diffusing from the bloodstream into the brain. It is described as a warm, drowsy, cozy state. Addicts report a profound sense of satisfaction, as though all needs were fulfilled. There is also a pleasant state of mild dizziness that is not as impairing as alcohol's effects, and a sense of 'distancing' or apathy toward whatever is going on in the environment. Some addicts lose the effect of euphoria, and use heroin only for relief of unpleasant withdrawal symptoms. Since all opiates produce cross-tolerance, the use of codeine, opium or morphine can relieve the withdrawal symptoms of heroin. [Source: PBS, WGBH, Frontline 1998]

In the novel “Junkie” , William Burroughs wrote that the heroin rush: “hits the backs of the legs first, then the back of the neck, a spreading wave of relaxation slackening the muscle away from the bones so that you seem to float without outlines, like lying in warm salt water. As this relaxing wave spreads through my tissues, I experienced a strong feeling of fear. I had the feeling that some horrible image was just beyond the field of vision, moving, as I turned my head so that I never quite saw it. I felt nauseous. A series of pictures passed, like watching a movie: a huge neon-lighted cocktail bar that got larger and larger until streets, traffic and street repairs were included in it; a waitress carrying a skull on a tray; stars in the clear sky; the physical impact of the death; the shutting off of breath; the stopping of blood. I dozed off and woke up with a start of fear. The next morning I vomited and felt sick until noon.”

Effects of Heroin

The slowed breathing associated with heroin sometimes enough is to be life-threatening. Slowed breathing can also lead to coma and permanent brain damage. Repeated heroin use changes the physical structure and physiology of the brain, creating long-term imbalances in neuronal and hormonal systems that are not easily reversed. Studies have shown some deterioration of the brain’s white matter due to heroin use, which may affect decision-making abilities, the ability to regulate behavior, and responses to stressful situations.Heroin also produces profound degrees of tolerance and physical dependence. Tolerance occurs when more and more of the drug is required to achieve the same effects. With physical dependence, the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced abruptly. [Source: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services, June 2018]

Allen Ginsberg and William S. Burroughs
People who use heroin over the long term may develop: 1) insomnia; 2) collapsed veins for people who inject the drug; 3) damaged tissue inside the nose for people who sniff or snort it; 4) infection of the heart lining and valves; 5) abscesses (swollen tissue filled with pus); 6) constipation and stomach cramping; 7) liver and kidney disease; 8) lung complications, including pneumonia; 9) mental disorders such as depression and antisocial personality disorder; 10) sexual dysfunction for men; and 11 ) irregular menstrual cycles for women

Heroin often contains additives, such as sugar, starch, or powdered milk, that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage. Also, sharing drug injection equipment and having impaired judgment from drug use can increase the risk of contracting infectious diseases such as HIV and hepatitis

People who inject drugs such as heroin are at high risk of contracting the HIV and hepatitis C (HCV) virus. These diseases are transmitted through contact with blood or other bodily fluids, which can occur when sharing needles or other injection drug use equipment. HCV is the most common bloodborne infection in the Unites States. HIV (and less often HCV) can also be contracted during unprotected sex, which drug use makes more likely.

Heroin Overdoses and Deaths

Overdose is a dangerous and deadly consequence of heroin use. A large dose of heroin depresses heart rate and breathing to such an extent that a user cannot survive without medical help. Every year thousands of people die from heroin overdoses. In the Netherlands in the 2000s there were about 100 deaths a year from heroin but only one or two from cocaine or ecstasy. In the late 2000s an estimated 10,000 drug users globally died each year from overdoses involving heroin from Afghanistan. Probably double that number that die today.

In 2020 in the U.S. approximately 13,165 people died from an overdose involving heroin. The rate of heroin-involved overdose deaths increased from 0.8 deaths per 100,000 people in 2007 to 4.9 in 2016. Since then, the mortality rate has steadily declined to 4.1 deaths per 100,000 people — an estimated 13,200 heroin-involved overdose deaths in 2020. [Source: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services, June 2021]

A heroin overdose occurs when a person uses enough of the drug to produce a life-threatening reaction or death. Heroin overdoses have increased in recent years. When people overdose on heroin, their breathing often slows or stops. This can decrease the amount of oxygen that reaches the brain, a condition called hypoxia. Hypoxia can have short- and long-term mental effects and effects on the nervous system, including coma and permanent brain damage. [Ibid]

Because heroin is often injected, the upsurge in use also has implications for HIV, hepatitis C (HCV), and other injection-related illnesses. Intravenous heroin users risk getting HIV/AIDS or hepatitis. Some users share needles and engage in risky, unprotected sex with people that might have HIV/AIDS or hepatitis.

Heroin Use in the U.S.

Mexican heroin production increased from an estimated 8 metric tons in 2005 to 50 metric tons in 2009 — more than a six-fold increase in just 4 years. Domination of the U.S. market by Mexican and Colombian heroin sources, along with technology transfer between these suppliers, has increased the availability of easily injectable, white powder heroin. In a recent survey of patients receiving treatment for opioid abuse, accessibility was one of the main factors identified in the decision to start using heroin. [Source: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services]

One main factor that contributes to the popularity of a drug is availability. One key to prevention is reducing exposure. While efforts to reduce the availability of prescription opioid analgesics have begun to show success, the supply of heroin has been increasing. Prescription opioids and heroin have similar chemical properties and physiological impacts; when administered by the same method (i.e., ingested or injected), there is no real difference for the user.

It is not clear whether the increased availability of heroin is causing the upsurge in use or if the increased accessibility of heroin has been caused by increased demand. A number of studies have suggested that people transitioning from abuse of prescription opioids to heroin cite that heroin is cheaper, more available, and provides a better high. Notably, the street price of heroin has been much lower in recent years than in past decades.1 In addition to these market forces, some have reported that the transition from opioid pills to heroin was eased by sniffing or smoking heroin before transitioning to injection.2 In a recent survey of people in treatment for opioid addiction, almost all — 94 percent — said they chose to use heroin because prescription opioids were "far more expensive and harder to obtain."

Image Sources: Wikimedia Commons; Normal Opium Museum

Text Sources: 1) “Buzzed, the Straight Facts About the Most Used and Abused Drugs from Alcohol to Ecstasy” by Cynthia Kuhn, Ph.D., Scott Swartzwelder Ph.D., Wilkie Wilson Ph.D., Duke University Medical Center (W.W. Norton, New York, 2003); 2) National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services; 3) United Nations Office on Drugs and Crime (UNODC) and 4) National Geographic, New York Times, Washington Post, Los Angeles Times, Wikipedia, The Independent, Times of London, The New Yorker, Time, Newsweek, Reuters, Associated Press, AFP, , Lonely Planet Guides, and various books and other publications.

Last updated April 2022

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