What is heroin?

Heroin is an illegal, highly

addictive drug. It is both 

the most abused and the

most rapidly acting of the opiates. Heroin is processed from

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, powdered

milk, or quinine. Street heroin

can also be cut with strychnine

Heroin is a highly addictive drug,

and its abuse has repercussions that

extend far beyond the individual

user. The medical and social consequences of drug abuse—HIV/AIDS,

tuberculosis, fetal effects, crime, 

violence, and disruptions in family,

workplace, and educational environments—have a devastating impact 

on society and cost billions of dollars

each year.

Although heroin abuse has trended

downward during the past several

years, its prevalence is still higher

than in the early 1990s. These relatively high rates of abuse, especially

among school-age youth, and the

glamorization of heroin in music

and films make it imperative that 

the public has the latest scientific

information on this topic. Heroin 

also is increasing in purity and

decreasing in price, which makes it

an attractive option for young people.

Like many other chronic diseases,

addiction can be treated. Fortunately,

the availability of treatments to manage opiate addiction and the promise

from research of new and effective

behavioral and pharmacological

therapies provides hope for individuals

who suffer from addiction and for

those around them. For example,

buprenorphine, approved by the 

Food and Drug Administration

(FDA) in 2002, provides a less 

addictive alternative to methadone

maintenance, reduces cravings with

only mild withdrawal symptoms, 

and can be prescribed in the privacy

of a doctor’s office.

The National Institute on Drug

Abuse (NIDA) has developed this 

publication to provide an overview 

of the state of heroin abuse and

addiction. We hope this compilation

of scientific information on heroin

will help to inform readers about 

the harmful effects of heroin abuse

and addiction as well as assist in 

prevention and treatment efforts.

Nora D.Volkow, M.D.

Director

National Institute on Drug Abuse

from the director

HEROIN

U . S . Department of Health and Human Services • National Institutes of Health

ResearchReport

NATIONAL INSTITUTE ON DRUG ABUSE

SERIES

Abuse and

Addiction

or other poisons. Because heroin

abusers do not know the actual

strength 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?

According to the 2003

National Survey on Drug

Use and Health, which 

may actually underestimate illicit

opiate (heroin)

use, an estimated

3.7 million 

people had used

heroin at some

time in their

lives, and over

119,000 of them

reported using it

within the month 

preceding the

survey. An estimated 314,000

Americans used
2NIDA RESEARCH REPORT SERIES

heroin in the past year, and the

group that represented the highest number of those users were

26 or older. The survey reported

that, from 1995 through 2002, the

annual number of new heroin

users ranged from 121,000 to

164,000. During this period, most

new users were age 18 or older

(on average, 75 percent) and

most were male. In 2003, 57.4

percent of past year heroin users

were classified with dependence

on or abuse of heroin, and an

estimated 281,000 persons

received treatment for heroin

abuse.

According to the Monitoring

the Future survey, NIDA’s 

nationwide annual survey of 

drug use among the Nation’s 

8th-, 10th-, and 12th-graders,

heroin use remained stable from

2003 to 2004. Lifetime heroin 

use measured 1.6 percent among

8th-graders and 1.5 percent

among 10th- and 12th-graders.

The 2002 Drug Abuse Warning

Network (DAWN), which collects

data on drug-related hospital

emergency department (ED)

episodes from 21 metropolitan

areas, reported that in 2002, 

heroin-related ED episodes 

numbered 93,519. 

NIDA’s Community Epidemiology Work Group (CEWG), which

provides information about the

nature and patterns of drug 

use in 21 areas, reported in its

December 2003 publication that

heroin was mentioned as the 

primary drug of abuse for large

portions of drug abuse treatment

admissions in Baltimore, Boston,

Detroit, Los Angeles, Newark,

New York, and San Francisco.

How is heroin used?

Heroin is usually injected,

sniffed/snorted, or smoked.

Typically, a heroin abuser

may inject up to four times a

day. Intravenous injection 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). When heroin 

is sniffed or smoked, peak

effects are usually felt within 10

to 15 minutes. NIDA researchers

have confirmed that all forms 

of heroin administration are

addictive.

Injection continues to be 

the predominant method of 

heroin use among addicted 

users seeking treatment; in many

CEWG areas, heroin injection is

reportedly on the rise, while

heroin inhalation is declining.

However, certain groups, such 

as White suburbanites in the

Denver area, report smoking or

inhaling heroin because they

believe that these routes of

administration are less likely to

lead to addiction.

With the shift in heroin abuse

patterns comes an even more

diverse group of users. In recent

years, the availability of higher

purity heroin (which is more 

suitable for inhalation) and the

decreases in prices reported in

many areas have increased the

appeal of heroin for new users

who are reluctant to inject.

Heroin has also been appearing

in more affluent communities.

100

90

80

70

60

50

40

30

20

10

0 Atlanta

Percentage*

L.A. Miami/

South Florida

Minneapolis/

St. Paul

New York

City

San

Francisco

Source: Community Epidemiology Work Group, NIDA, December 2003, Vol. II.

*Includes first half 2003 data from treatment facilities.

Inhaled Injected

Route of Administration Among Heroin

Treatment Admissions in Selected Areas
NIDA RESEARCH REPORT SERIES3

What are the

immediate (shortterm) 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

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 function

slows. 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.

What are the 

long-term effects

of heroin use?

One of the most detrimental

long-term effects of heroin

use is addiction itself.

Addiction is a chronic, relapsing

disease, characterized by compulsive drug seeking and use,

and by neurochemical and 

molecular changes in the brain.

Heroin also produces 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 and

their behavior.

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. Major withdrawal

symptoms peak between 24 and

48 hours after the last dose of

heroin and subside after about a

week. However, some people

■ Opiates can depress breathing

by changing neurochemical 

activity in the brain stem, 

where automatic body 

functions are controlled.

■ Opiates can change the limbic system, 

which controls emotions, to increase 

feelings of pleasure.

■ Opiates can block pain messages 

transmitted through the spinal cord 

from the body.

Opiates Act on Many Places in the 

Brain and Nervous System
4NIDA RESEARCH REPORT SERIES

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.

What are 

the medical 

complications of

chronic heroin use?

Medical consequences of

chronic heroin injection

use 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 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 bloodborne viruses, which drug

abusers can then pass on to their

sexual partners and children.

How does heroin

abuse affect 

pregnant women?

Heroin abuse during pregnancy and its many associated environmental factors

(e.g., lack of prenatal care) have

been associated with adverse

consequences including low

birth weight, an important risk

factor for later developmental

delay. Methadone maintenance

combined with prenatal care and

a comprehensive drug treatment

program can improve many of

the detrimental maternal and

neonatal outcomes associated

with untreated heroin abuse,

although infants exposed to

methadone during pregnancy

typically require treatment for

withdrawal symptoms. In the

United States, several studies

have found buprenorphine to 

be equally effective and as safe

as methadone in the adult outpatient treatment of opioid

dependence. Given this efficacy

Short- and Long-Term Effects of Heroin Abuse

Short-Term Effects:

■ “Rush”

■ Depressed respiration

■ Clouded mental functioning

■ Nausea and vomiting

■ Suppression of pain

■ Spontaneous abortion

Long-Term Effects: 

■ Addiction

■ Infectious diseases, for 

example, HIV/AIDS and 

hepatitis B and C

■ Collapsed veins

■ Bacterial infections

■ Abscesses

■ Infection of heart lining 

and valves

■ Arthritis and other 

rheumatologic problems
NIDA RESEARCH REPORT SERIES5

among adults, current studies are

attempting to establish the safety

and effectiveness of buprenorphine in opioid-dependent 

pregnant women. For women

who do not want or are not able

to receive pharmacotherapy for

their heroin addiction, detoxification from opiates during 

pregnancy can be accomplished

with relative safety, although the

likelihood of relapse to heroin

use should be considered.

Why are heroin

users at special

risk for contracting

HIV/AIDS and

hepatitis B and C?

Heroin users are at risk for

contracting HIV, hepatitis C

(HCV), and other infectious

diseases, through sharing and

reuse of syringes and injection

paraphernalia that have been

used by infected individuals, 

or through unprotected sexual 

contact with an infected person.

Injection drug users (IDUs) 

represent the highest risk group

for acquiring HCV infection; 

an estimated 70 to 80 percent of

the 35,000 new HCV infections

occurring in the United States

each year are among IDUs.

NIDA-funded research has

found that drug abusers can

change the behaviors that put

them at risk for contracting HIV

through drug abuse treatment,

prevention, and communitybased outreach programs. They

can eliminate drug use, drugrelated risk behaviors such as

needle sharing, unsafe sexual

practices, and, in turn, the risk 

of exposure to HIV/AIDS and

other infectious diseases. Drug

abuse prevention and treatment

are highly effective in preventing

the spread of HIV.

What are the

treatments for

heroin addiction?

Avariety of effective treatments are available forheroin addiction. Treatment

tends to be more effective when

heroin abuse is identified early.

The treatments that follow vary

depending on the individual, but

methadone, a synthetic opiate

that blocks the effects of heroin

and eliminates withdrawal 

symptoms, has a proven record

of success for people addicted 

to heroin. Other pharmaceutical

approaches, such as buprenorphine, and many behavioral 

therapies also are used for treating

heroin addiction. Buprenorphine

is a recent addition to the array

of medications now available for

treating addiction to heroin and

other opiates. This medication 

is different from methadone 

in that it offers less risk of 

addiction and can be prescribed

in the privacy of a doctor’s

office. Buprenorphine/naloxone

(Suboxone) is a combination

drug product formulated to 

minimize abuse.

Detoxification

Detoxification programs aim 

to achieve safe and humane

withdrawal from opiates by minimizing the severity of withdrawal

symptoms and other medical

complications. The primary

objective of detoxification is to

relieve withdrawal symptoms

while patients adjust to a drugfree state. Not in itself a treatment

for addiction, detoxification is a

useful step only when it leads

into long-term treatment that is

either drug-free (residential or

outpatient) or uses medications

as part of the treatment. The best

documented drug-free treatments

are the therapeutic community

residential programs lasting 3 to

6 months. 

Opiate withdrawal is rarely

fatal. It is characterized by acute

States highlighted currently have 

CTN Nodes in place.

NIDA National Drug Abuse Treatment 

Clinical Trials Network

drugabuse.gov/CTN
6NIDA RESEARCH REPORT SERIES

withdrawal symptoms which

peak 48 to 72 hours after the last

opiate dose and disappear within

7 to 10 days, to be followed by a

longer term abstinence syndrome

of general malaise and opioid

craving.

Methadone programs

Methadone treatment has been

used for more than 30 years to

effectively and safely treat opioid

addiction. Properly prescribed

methadone is not intoxicating or

sedating, and its effects do not

interfere 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 reactions. Most

important, methadone relieves

the craving associated with heroin

addiction; craving is a major 

reason for relapse. Among

methadone patients, it has been

found that normal street doses 

of heroin are ineffective at producing euphoria, thus making

the use of heroin more easily

extinguishable.

Methadone’s effects last four 

to six times as long as those of

heroin, so people in treatment

need to take it only once a day.

Also, methadone is medically safe

even when used continuously 

for 10 years or more. Combined

with behavioral therapies or

counseling and other supportive

services, methadone enables

patients to stop using heroin

(and other opiates) and return to

more stable and productive lives.

Methadone dosages must be

carefully monitored in patients

who are receiving antiviral therapy

for HIV infection, to avoid 

potential medication interactions.

Buprenorphine and other

medications

Buprenorphine is a particularly

attractive treatment for heroin

addiction because, compared

with other medications, such as

methadone, it causes weaker

opiate effects and is less likely 

to cause overdose problems.

Buprenorphine 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

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

heroin overdose or addiction 

are currently under investigation

by NIDA.

In addition to methadone 

and buprenorphine, other drugs

aimed at reducing the severity of

the withdrawal symptoms can be

prescribed. Clonidine is of some

benefit but its use is limited due

to side effects of sedation and

hypotension. Lofexidine, a centrally acting alpha-2 adrenergic

agonist, was launched in 1992

specifically for symptomatic 

relief in patients undergoing 

opiate withdrawal. Naloxone 

and naltrexone are medications

that also block the effects of

Buprenorphine

A New Medication for Treating Opiate Addiction

■ First medication developed to treat opiate addiction in the

privacy of a physician’s office.

■ Binds to same receptors as morphine, but does not produce

the same effects. 

■ Offers a valuable tool for physicians in treating the nearly

900,000 chronic heroin users in the U.S.

■ As of March 2004, 3,951 U.S. physicians were eligible to

prescribe buprenorphine to patients.

The Story of Discovery

■ First synthesized as an analgesic in England, 1969.

■ Recognized as a potential addiction treatment by NIDA

researchers in the 1970s.

■ NIDA created Medications Development Division to focus

on developing drug treatments for addiction, 1990.

■ NIDA formed an agreement with the original developer to

bring buprenorphine to market in the U.S., 1994.

■ Buprenorphine tablets approved by the FDA, 2002.
NIDA RESEARCH REPORT SERIES7

morphine, heroin, and other 

opiates. As antagonists, they are

especially useful as antidotes.

Naltrexone has long-lasting

effects, ranging from 1 to 3 days,

depending on the dose.

Naltrexone blocks the pleasurable

effects of heroin and is useful in

treating some highly motivated

individuals. Naltrexone has also

been found to be successful in

preventing relapse by former

opiate addicts released from

prison on probation.

Behavioral therapies

Although behavioral and 

pharmacologic treatments can be

extremely useful when employed

alone, science has taught us that

integrating both types of treatments will ultimately be the 

most effective approach. There

are many effective behavioral

treatments available for heroin

addiction. These can include 

residential and outpatient

approaches. An important task 

is to match the best treatment

approach to meet the particular

needs of the patient. Moreover,

several new behavioral therapies,

such as contingency management

therapy and cognitive-behavioral

interventions, show particular

promise as treatments for heroin

addiction, especially when

applied in concert with pharmacotherapies. Contingency 

management therapy uses a

voucher-based system, where

patients earn “points” based 

on negative drug tests, which

they can exchange for items 

that encourage healthy living.

Cognitive-behavioral interventions are designed to help 

modify the patient’s expectations

and behaviors related to drug

use, and to increase skills in 

coping with various life stressors.

Both behavioral and pharmacological treatments help to restore

a degree of normalcy 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?

Drug analogs are chemical

compounds that are similar

to other drugs in their

effects but differ slightly in their

chemical structure. Some analogs

are produced by pharmaceutical

companies for legitimate medical

reasons. Other analogs, sometimes referred to as “designer”

drugs, can be produced in illegal

laboratories and are often more

dangerous and potent than the

original drug. Two of the most

commonly known opioid

analogs are fentanyl and meperidine (marketed under the brand

name Demerol, for example).

Fentanyl was introduced in

1968 by a Belgian pharmaceutical

company as a synthetic narcotic

to be used as an analgesic in 

surgical procedures because of

its minimal effects on the heart.

Fentanyl is particularly dangerous

because it is 50 times more

potent than heroin and can

rapidly stop respiration. This is

not a problem during surgical

procedures because machines

are used to help patients breathe.

On the street, however, users

have been found dead with the

needle used to inject the drug

still in his or her arm.

Where can I get

further scientific

information about

heroin abuse and

addiction?

T

o learn more about heroin

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 help

you locate information and

resources.

Fact sheets, including

InfoFacts, on the health effects 

of heroin, other drugs of abuse,

and other drug abuse topics are

available on the NIDA Web site

(www.drugabuse.gov), and 

can be ordered free of charge 

in English and Spanish from

NCADI at www.health.org.

Access information 

on the Internet

• What’s new on the NIDA Web site

• Information on drugs of abuse

• Publications and communications 

(including NIDA NOTES)

• Information on clinical trials through CTN

• Calendar of events

• Links to NIDA organizational units

• Funding information (including program

announcements and deadlines)

• International activities

• Links to related Web sites (access to

Web sites of many other organizations 

in the field)

NCADI

Web Site: www.health.org

Phone No.: 1–800–729–6686

NIDA Web Sites

www.drugabuse.gov

www.drugabuse.gov/CTN
8NIDA RESEARCH REPORT SERIES

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Supt. of Docs., U.S. Govt. Print. Off., 1992, pp. 12–27.

Glossary

Addiction: A chronic, relapsing disease, 

characterized by compulsive drug seeking and 

use and by neurochemical and molecular changes

in the brain.

Agonist: A chemical compound that mimics the

action of a natural neurotransmitter to produce a

biological response.

Analog: A chemical compound that is similar to

another drug in its effects but differs slightly in its

chemical structure.

Antagonist: A drug that counteracts or blocks

the effects of another drug.

Buprenorphine: A mixed opiate agonist/

antagonist medication for the treatment of heroin

addiction.

Craving: A powerful, often uncontrollable desire

for drugs.

Detoxification: 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 treatment program.

Fentanyl: A medically useful opioid analog that

is 50 times more potent than heroin.

Meperidine: A medically approved opioid available under various brand names (e.g., Demerol).

Methadone: A long-acting synthetic medication

shown to be effective in treating 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.

Rush: A surge of euphoric pleasure that rapidly

follows administration of a drug.

Tolerance: A condition in which higher doses of 

a drug are required to produce 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.

NIH Publication Number 05–4165.

Printed October 1997; Reprinted September 2000, 

Revised May 2005.

Feel free to reprint this publication.