What is heroin?

H

e roin is an illegal, highly

addictive drug. It is both 

the most abused and the

most rapidly acting of the opiates. Heroin is processed fro m

morphine, a naturally occurring

substance extracted from the

seed pod 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, powdere d

milk, or quinine. Street hero i n

can also be cut with strychnine

or other poisons. Because hero i n

abusers do not know the actual

s t rength of the drug or its true

contents, they are at risk of overdose or death. Heroin also poses

special problems because of the

transmission of HIV and other

diseases that can occur from

sharing needles or other injection

equipment. 

What is the scope 

of heroin use in

the United States?

A

ccording to the 1998

National Household Survey

on Drug Abuse, which may

actually underestimate illicit opiate (heroin) use, an estimated 

2.4 million people had used

h e roin at some

time in their

lives, and nearly

130,000 of them

reported using it

within the month

p receding the

survey. The survey report estimates that there

w e re 81,000

new hero i n

Abuse and

A d d i c t i o n

Although heroin abuse has

t rended downward during the past

couple of years, its prevalence is still

higher than in the early 1990s.

These relatively high rates of

abuse, together with the significant

h e roin abuse we are now seeing

among school-age youth, the glamorization of heroin in music and

films, changing patterns of drug

use, and heroin’s increased purity

and decreased prices, make it

imperative that the public have the

latest scientific information on this

t o p i c .

The National Institute on Drug

Abuse (NIDA) has developed this

publication to provide an overview

of the latest re s e a rch findings on

h e roin abuse and addiction.

H e roin is a highly addictive drug,

and its abuse has re p e rcussions that

extend far beyond the individual

u s e r. The health and social consequences of drug abuse–HIV/AIDS,

violence, tuberculosis, fetal eff e c t s ,

crime, and disruptions in family,

workplace, and educational 

e n v i ronments–have a devastating

impact on society and cost billions

of dollars each year.

Fortunately, the availability 

of treatments to manage opiate 

addiction and the promise of new

treatments from research provide

hope for individuals who suffer 

from addiction and for those

around them.

We hope this compilation of 

scientific information on heroin 

will help to inform readers about 

the harmful effects of heroin abuse

and addiction and will assist in 

p revention and treatment eff o r t s .

Alan I. Leshner, Ph.D.

D i re c t o r

National Institute on Drug Abuse

H E R O I N

U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s • N a t i o n a l I n s t i t u t e s o f H e a l t h

ResearchReport

N A T I O N A L I N S T I T U T E O N D R U G A B U S E

S E R I E S

Abuse and

A d d i c t i o n
2NIDA RESEARCH REPORT SERIES

users in 1997. A large pro p o r t i o n

of these recent new users were

smoking, snorting, or sniff i n g

h e roin, and most (87 perc e n t )

w e re under age 26. In 1992, 

only 61 percent were younger

than 26.

The 1998 Drug Abuse 

Wa rning Network (DAWN), 

which collects data on drugrelated hospital emerg e n c y

department (ED) episodes fro m

21 metropolitan areas, estimates

that 14 percent of all drug-re l a t e d

ED episodes involved hero i n .

Even more alarming is the fact

that between 1991 and 1996,

h e ro i n - related ED episodes more

than doubled (from 35,898 to

73,846). Among youths aged 

12 to 17, hero i n - related episodes

nearly quadrupled.

NIDA’s Community

Epidemiology Work Gro u p

(CEWG), which provides information about the nature and 

p a t t e rns of drug use in 21 cities,

reported in its December 1999

publication that heroin was 

mentioned most often as the 

primary drug of abuse in drug

abuse treatment admissions in

B a l t i m o re, Boston, Los Angeles,

Newark, New York, and San

F r a n c i s c o .

How is heroin used?

H

e roin is usually injected,

s n i ffed/snorted, or smoked.

Typically, a heroin abuser

may inject up to four times a day.

Intravenous injection provides the

g reatest 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). When heroin is sniffed or

smoked, peak effects are usually

felt within 10 to 15 minutes.

Although smoking and sniff i n g

h e roin do not produce a “rush”

as quickly or as intensely as 

intravenous injection, NIDA

researchers have confirmed 

that all three forms of heroin

administration are addictive.

Injection continues to be the

p redominant method of hero i n

use among addicted users seeking treatment; however,

researchers have observed a 

shift in heroin use patterns, 

from injection to sniffing and

smoking. In fact, sniff i n g / s n o r t i n g

h e roin is now the most widely

reported means of taking hero i n

among users admitted for drug

t reatment in Newark, Chicago,

and New York. 

With the shift in heroin abuse

p a t t e rns comes an even more

diverse group of users. Older

users (over 30) continue to be

one of the largest user groups in

most national data. However, the

i n c rease continues in new, young

users across the country who are

being lured by inexpensive, highpurity heroin that can be sniff e d

or smoked instead of injected.

H e roin has also been appearing

in more affluent communities. 

Route of Administration Among

Heroin Treatment Admissions in Selected Areas

100%

90

80

70

60

50

40

30

20

10

0

Baltimore

Percentage

Boston L.A. Newark New York St. Louis

Injecting

Sniffing/

snorting

Smoking 

and other

Source: Community Epidemiology Work Group, NIDA, December 1999
NIDA RESEARCH REPORT SERIES3

What are the 

immediate 

(short-term) effects

of heroin use?

S

oon 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 re p o r t

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 dro w s y

for several hours. Mental function

is clouded by heroin’s effect on

the central nervous system.

Cardiac function slows. Bre a t h i n g

is also severely slowed, sometimes to the point of death.

H e roin overdose is a particular

risk on the street, where the

amount and purity of the drug

cannot be accurately known. 

What are the 

long-term effects

of heroin use?

O

ne of the most detrimental

l o n g - t e rm effects of hero i n

is addiction itself. 

Addiction is a chronic, re l a p s i n g

disease, characterized by compulsive drug seeking and use, and by

n e u rochemical and molecular

changes in the brain. Heroin also

p roduces profound degrees of tolerance and physical dependence,

which are also powerful motivating factors for compulsive use and

abuse. As with abusers of any

addictive drug, heroin abusers

gradually spend more and more

time and energy obtaining and

using the drug. Once they are

addicted, the heroin abusers’ primary purpose in life becomes

seeking and using drugs. The

drugs literally change 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 re d u c e d

abruptly. Withdrawal may occur

within a few hours after the last

time the drug is taken. Symptoms

of withdrawal include re s t l e s sness, muscle and bone pain,

insomnia, diarrhea, vomiting, cold

flashes with goose bumps (“cold

turkey”), and leg movements.

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

Opiates Act on Many Places 

in the Brain and Nervous System

Opiates can change the 

limbic system, which 

controls emotions, to 

increase feelings of 

pleasure.

Opiates can block pain 

messages transmitted 

by the spinal cord from 

the body.

Opiates can

d e p ress bre a t h i n g

by changing 

n e u ro c h e m i c a l

activity in 

the brain 

stem, where 

automatic 

body 

functions 

a re contro l l e d .
4NIDA RESEARCH REPORT SERIES

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

r u s h .

Physical dependence and the

e m e rgence 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 chro n i c

pain who need opiates to function (sometimes over extended

periods) have few if any pro blems 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.

What are

the medical 

complications of

c h ronic heroin use?

M

edical consequences of

c h ronic 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 tuberc ulosis) may result from the poor

health condition of the abuser as

well as from heroin’s depre s s i n g

e ffects 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 rheumatologic problems. 

Of course, 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

b l o o d - b o rne viruses, which drug

abusers can then pass on to their

sexual partners and childre n .

Short- and Long-Term Effects of Heroin Abuse

S h o rt - Te rm Eff e c t s :

“ R u s h ”

Depressed 

r e s p i r a t i o n

Clouded mental 

f u n c t i o n i n g

Nausea 

and vomiting

Suppression 

of pain

Spontaneous 

a b o r t i o n

L o n g - Te rm Effects: 

A d d i c t i o n

Infectious diseases, 

for example, 

HIV/AIDS and 

hepatitis B and C

Collapsed veins

Bacterial 

i n f e c t i o n s

A b s c e s s e s

Infection of 

heart lining 

and valves

Arthritis 

and other 

rheumatologic 

p r o b l e m s
NIDA RESEARCH REPORT SERIES5

How does 

h e roin abuse affect 

p regnant women?

H

e roin abuse can cause serious complications during

p regnancy, including miscarriage and pre m a t u re delivery.

C h i l d ren born to addicted mothers are at greater risk of SIDS

(sudden infant death syndro m e ) ,

as well. Pre g n a n t

women should

not be 

d e t o x i f i e d

f rom opiates

because of

the incre a s e d

risk of spontaneous

abortion or pre m a t u re

delivery; rather, tre a tment with methadone 

is strongly advised.

Although infants born

to mothers taking

p re s c r i b e d

methadone may

show signs of physical dependence, they

can be treated easily 

and safely in the nursery.

R e s e a rch has demonstrated

also that the effects of 

in utero exposure to

methadone are re l a t i v e l y

b e n i g n .

Why are

heroin users 

at special risk 

for contracting

HIV/AIDS and 

hepatitis C?

H

e roin addicts are at risk 

for contracting HIV, hepatitis C, and other infectious

diseases. Drug abusers may

become infected with HIV,

hepatitis C, and other bloodb o rne pathogens through sharing and reuse of syringes

and injection paraphern a l i a

that have been used by

infected individuals.

They may also become

infected with HIV and,

although less often, to

hepatitis C thro u g h

u n p rotected sexual

contact with an

infected person.

Injection drug use

has been a factor

in an estimated

one-third of all

HIV and more

than half of all

hepatitis C

cases in the

N a t i o n .

N I D A -

f u n d e d

re s e a rch has

found that

drug abusers can

change the behaviors

that put them at risk 

for contracting HIV,

t h rough drug abuse tre a tment, prevention, and

community-based outreach programs. They

can eliminate drug use, drugrelated risk behaviors such as

needle sharing, unsafe sexual

practices, and, in turn, the risk of

e x p o s u re to HIV/AIDS and other

infectious diseases. Drug abuse

p revention and treatment are

highly effective in preventing the

s p read of HIV.

What are the

treatments for

heroin addiction?

A

variety of effective tre a tments are available for

h e roin addiction. Tre a t m e n t

tends to be more effective when

h e roin abuse is identified early.

The treatments that follow vary

depending on the individual, but

methadone, a synthetic opiate

that blocks the effects of hero i n

and eliminates withdrawal symptoms, has a proven record of 

success for people addicted to

h e roin. Other pharm a c e u t i c a l

a p p roaches, like LAAM (levoalpha-acetyl-methadol) and

b u p renorphine, and many behavioral therapies also are used

for treating heroin addiction.

D e t o x i f i c a t i o n

The primary objective of detoxification is to relieve withdrawal

symptoms while patients adjust to

a drug-free state. Not in itself a

t reatment for addiction, detoxification is a useful step only when

it leads into long-term tre a t m e n t

that is either drug-free (re s i d e n t i a l

or outpatient) or uses medications as part of the treatment. The

best documented drug-free tre a tments are the therapeutic community residential pro g r a m s

lasting at least 3 to 6 months. 
6NIDA RESEARCH REPORT SERIES

Methadone pro g r a m s

Methadone treatment has been

used effectively and safely to

t reat opioid addiction for more

than 30 years. Properly prescribed methadone is not intoxicating or sedating, and its eff e c t s

do not interf e re with ordinary

activities such as driving a car.

The medication is taken orally

and it suppresses narcotic 

withdrawal for 24 to 36 hours.

Patients are able to perceive pain

and have emotional re a c t i o n s .

Most important, methadone

relieves the craving associated

with heroin addiction; craving 

is a major reason for re l a p s e .

Among methadone patients, it

has been found that normal stre e t

doses of heroin are ineffective at

p roducing euphoria, thus making

the use of heroin more easily

e x t i n g u i s h a b l e .

Methadone’s effects last for

about 24 hours—four to six times

as long as those of hero i n — s o

people in treatment need to take

it only once a day. Also, methadone is medically safe even when

used continuously for 10 years or

m o re. Combined with behavioral

therapies or counseling and other

supportive services, methadone

enables patients to stop using

h e roin (and other opiates) and

re t u rn to more stable and 

p roductive lives.

Methadone dosages must be

c a refully monitored in patients

who are receiving antiviral therapy for HIV infection, to avoid

potential medication interactions.

LAAM and other medications

LAAM, like methadone, is a

synthetic opiate that can be used

to treat heroin addiction. LAAM

can block the

e ffects of heroin 

for up to 72 hours

with minimal side

e ffects when

taken orally. In

1993 the Food

and Drug

A d m i n i s t r a t i o n

a p p roved the 

use of LAAM for

t reating patients

addicted to hero i n .

Its long duration

of action perm i t s

dosing just thre e

times per week,

t h e reby eliminating the need for

daily dosing and

take-home doses

for weekends.

LAAM will be

i n c reasingly available in clinics that

a l ready dispense

methadone. 

Naloxone and

n a l t rexone are

medications that

also block the

e ffects of morphine, hero i n ,

and other opiates.

As antagonists, they are especially

useful as antidotes. Naltre x o n e

has long-lasting effects, ranging

f rom 1 to 3 days, depending on

the dose. Naltrexone blocks the

pleasurable effects of heroin and

is useful in treating some highly

motivated individuals. Naltre x o n e

has also been found to be successful in preventing relapse by

f o rmer opiate addicts re l e a s e d

f rom prison on pro b a t i o n .

Another medication to tre a t

h e roin addiction, bupre n o r p h i n e ,

may already be available by the

time this Research Report appears.

B u p renorphine is a particularly

attractive treatment because, comp a red to other medications, such

as methadone, it causes weaker

opiate effects and is less likely 

to cause overdose pro b l e m s .

B u p renorphine also produces a

lower level of physical dependence, so patients who discontinue the medication generally have

fewer withdrawal symptoms than

do those who stop taking

Treatments for Heroin Addiction

Methadone 

programs

LAAM, buprenorphine,

and other medications

Behavioral therapies
NIDA RESEARCH REPORT SERIES7

methadone. Because of these

advantages, buprenorphine may

be appropriate for use in a wider

variety of treatment settings than

the currently available medications. Several other medications

with potential for treating hero i n

overdose or addiction are 

c u r rently under investigation 

by NIDA.

Behavioral therapies

Although behavioral and 

p h a rmacologic treatments can 

be extremely useful when

employed alone, science has

taught us that integrating both

types of treatments will ultimately

be the most effective appro a c h .

T h e re are many effective behavioral treatments available for

h e roin addiction. These can

include residential and outpatient

a p p roaches. An important task is

to match the best tre a t m e n t

a p p roach to meet the particular

needs of the patient. More o v e r,

several new behavioral therapies,

such as contingency management

therapy and cognitive-behavioral

interventions, show particular

p romise as treatments for hero i n

addiction. Contingency management therapy uses a voucherbased system, where patients

e a rn “points” based on negative

drug tests, which they can

exchange for items that encourage healthy living. Cognitivebehavioral interventions are

designed to help modify the

patient’s thinking, expectancies,

and behaviors and to incre a s e

skills in coping with various life

s t ressors. Both behavioral and

p h a rmacological treatments help

to re s t o re a degree of norm a l c y

to brain function and behavior,

with increased employment rates

and lower risk of HIV and other

diseases and criminal behavior.

What are the 

opioid analogs and

their dangers?

D

rug analogs are chemical

compounds that are similar

to other drugs in their

e ffects but differ slightly in their

chemical structure. Some analogs

a re produced by pharm a c e u t i c a l

companies for legitimate medical

reasons. Other analogs, sometimes re f e r red to as “designer”

drugs, can be produced in illegal

laboratories and are often more

d a n g e rous and potent than the

original drug. Two of the most

commonly known opioid analogs

a re fentanyl and meperidine

(marketed under the brand name

D e m e rol, for example).

Fentanyl was introduced in

1968 by a Belgian pharm a c e u t i c a l

company as a synthetic narc o t i c

to be used as an analgesic in 

s u rgical pro c e d u res because of 

its minimal effects on the heart.

Fentanyl is particularly dangero u s

because it is 50 times more

potent than heroin and can 

rapidly stop respiration. This is

not a problem during surg i c a l

p ro c e d u res because machines 

a re used to help patients bre a t h e .

On the street, however, users

have been found dead with the

needle used to inject the drug 

still in their arm s .

Where can I get 

further scientific

information about

heroin abuse and

addiction?

T

o learn more about hero i n

and other drugs of abuse,

contact the National

Clearinghouse for Alcohol and

Drug Information (NCADI) at 

1-800-729-6686. Information 

specialists are available to assist

you in locating needed inform ation and re s o u rces. Inform a t i o n

can be accessed also through 

the NIDA World Wide Web site

(www.drugabuse.gov) or the

NCADI Web site (www.health.org ) .

Access information 

on the Intern e t

• W h a t ’s new on the 

NIDA Web site

• I n f o rmation on drugs 

of abuse

• Publications and 

communications 

(including N I D A N O T E S)

• Calendar of events

• Links to NIDA 

o rganizational units

• Funding inform a t i o n

(including program 

announcements and 

d e a d l i n e s )

• I n t e rnational activities

• Links to related Web sites

(access to Web sites of

many other org a n i z a t i o n s

in the field)

NCADI

Web Site: www.health.org

Phone No.: 1-800-729-6686

NIDA Web Sites

www.drugabuse.gov

www.steroidabuse.org

www.clubdrugs.org
8NIDA RESEARCH REPORT SERIES

G l o s s a ry

A d d i c t i o n : A chronic, relapsing disease, characterized by compulsive

d rug seeking and use and by neuro -

chemical and molecular changes in 

the brain.

A g o n i s t : A chemical compound that

mimics the action of a natural neuro -

t r a n s m i t t e r.

A n a l o g : A chemical compound that is

similar to another drug in its effects but

d i ffers slightly in its chemical stru c t u re .

A n t a g o n i s t : A drug that counteracts 

or blocks the effects of another dru g .

B u p re n o r p h i n e : A mixed opiate 

agonist-antagonist medication for the 

t reatment of heroin addiction.

C r a v i n g : A powerful, often uncontro llable desire .

D e t o x i f i c a t i o n : A process of allowing

the body to rid itself of a drug while 

managing the symptoms of withdrawal; often the first step in a drug 

t reatment pro g r a m .

F e n t a n y l : A medically useful opioid

analog that is 50 times more potent 

than hero i n .

L e v o - a l p h a - a c e t y l - m e t h a d o l

( L A A M ) : An FDA-approved medication

for heroin addiction that patients need to

take only three to four times a week.

M e p e r i d i n e : A medically approved 

opioid available under various brand

names (e.g., Demero l ) .

M e t h a d o n e : A long-acting synthetic

medication shown to be effective in 

t reating heroin addiction.

Physical dependence: An adaptive

physiological state that occurs with 

regular drug use and results in a withdrawal syndrome when drug use is

stopped; usually occurs with tolerance.

R u s h : A surge of euphoric pleasure that

rapidly follows administration of a dru g .

To l e r a n c e : A condition in which higher

doses of a drug are re q u i red to pro d u c e

the same effect as during initial use; often

leads to physical dependence.

Withdrawal: A variety of symptoms

that occur after use of an addictive drug 

is reduced or stopped.

References

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State of the Art. National Institute on Drug Abuse 

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blockade. A rch Intern Med 118:304-309, 1966.

Goldstein, A. Heroin addiction: Neuro l o g y, pharm a c o l o g y, 

and policy. J Psychoactive Dru g s 23(2):123-133, 

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3887. Washington, DC: Supt. of Docs., U.S. Govt. 

Print Off., 1991, pp. 32-52.

K reek, M.J. Rationale for maintenance pharmacotherapy of 

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K reek, M.J. Using methadone effectively: achieving goals by

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re s e a rch and by development of innovative programs. 

In: Pickens, R.; Leukefeld, C.; and Schuster, C.R., eds. 

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on Drug Abuse Research Monograph 106. 

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 

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Lewis, J.W., and Wa l t e r, D. Buprenorphine: background to 

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on Drug Abuse Research Monograph 121. DHSS Pub. 

No. (ADM) 92-1912. Washington, DC: Supt. of Docs., 

U.S. Govt. Print. Off., 1992, pp. 5-11.

Mathias, R. NIDA survey provides first national data on 

d rug abuse during pre g n a n c y. NIDA Notes 10:6-7, 

1 9 9 5 .

National Institute on Drug Abuse. Epidemiologic Trends 

in Drug Abuse: Vol. 1. Highlights and Executive

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NIH Pub. No. 00-4739. Washington, DC: 

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This publication was developed under Contract No.

NO1DA-4-2205 from the National Institute on 

D rug Abuse. 

NIH Publication Number 00-4165. 

Printed October 1997; Reprinted September 2000.

Feel free to reprint this publication.