To illustrate the rise in heroin related overdoses, let’s take a look at Massachusetts. In the year 2000, there were 379 confirmed opioid overdose deaths whereas in 2016, there were 2,083 confirmed opioid overdose deaths. This traces an upward curve in opioid overdose deaths which began escalating drastically in 2013. This follows the timeline of the drug fentanyl being introduced as a heroin adulterant, which was found by post-mortem toxicology screens in ~25% of opioid overdoses in fall of 2014, and had alarmingly reached ~90% by fall of 2017.
Beginning sometime around 2010 fentanyl, an extremely potent fully-synthetic opioid, has been added to heroin which drastically increases its potency as well as the risk of overdose. This is in part to reduce the costs of heroin manufacturers, as being fully-synthetic it can be made in a lab without the need for acres of opium poppies and no need to wait for harvest. Another reason is its extreme potency, which may result in it exhibiting higher potential for addiction (as if heroin needed any help in that regard).
We’ve outlined a detailed list of the top 5 dangers of heroin abuse below.
Due to the risk of overdose, heroin is one of the more deadly drugs known today. This is in part due to the frequent mode of IV use as well as the adulterants used by heroin manufacturers and distributors. As mentioned above, an IV drug user is capable of injecting a lethal dose in under a second; the amount of time it takes to push in the plunger. Heroin overdose is also more common in people who have stayed clean for a time and then relapse. The timelines vary greatly between people depending on genetic and physical health factors, but opioid tolerance can return to baseline after just weeks or months of abstinence. When someone goes to use heroin again and they use the same amount that they used after months or years of tolerance-building use, an overdose is typically the result.
Signs of a Heroin Overdose:
A heroin overdose can produce some, or all, of the following effects:
- Shallow or Depressed Breathing
- Unconsciousness (with an inability to wake up)
- Weak or Irregular Pulse
- Heart Failure
- Blue Tinged Lips or Extremities and Pale Skin (due to Hypoxia)
- Coma (with possible brain damage)
- Death (several of the above can lead to death)
Additionally, tolerance to euphoria increases much more rapidly than tolerance to respiratory depression so it is not uncommon for someone to use so much Heroin that they simply stop breathing.
Long Term Health Risks
Aside from the immediate risks or overdose and death, there are many long term and potentially fatal complications of heroin use as well. Some of these include¹:
- Endocarditis: Infection of the interior of the heart. Typically caused by Strep. or Staph. bacteria which are common in the mouth and can be introduced into the blood via IV drug use.
- Pulmonary Edema: Fluid buildup in the lungs. Can result in difficulty breathing, fatigue, chest pain, and cough.
- Septic Embolism: An infected piece of tissue that becomes dislodged and travels through the circulatory system. Typically originate from IV injection site. Can result in a variety of Metastatic Abscesses.
- Ischemic Stroke: Caused by a blockage in the circulatory system, resulting in a part of the brain being starved of oxygen. Can be caused by Septic Embolism or adulterants in injected heroin. Can cause permanent brain damage or death.
- Rhabdomyolysis: Caused by dead muscle tissue breaking down into the blood, causing Kidney damage or failure. Can be caused by repeated IV drug use and attendant tissue damage. Is potentially fatal and Kidney damage may be permanent. Getting Rhabdomyolysis once increases risk of subsequent occurrence.
- Liver Damage: Due to heroin metabolism as well as adulterants/contaminants in the drug. Also due to secondary effects of IV drug use such as Septic Embolism.
- Hepatitis B or C: Viral liver infection commonly acquired by IV drug users. Can progress to Cirrhosis of the liver.
- Kidney Damage: Due to adulterants/contaminants in heroin as well as secondary effects of IV drug use such as Rhabdomyolysis.
- HIV/AIDS: Autoimmune disorder commonly acquired by IV drug users. If untreated, it can result in pneumocystis pneumonia (PCP), toxoplasmosis, cryptococcal meningitis, esophageal candidiasis, and certain cancers such as Kaposi’s Sarcoma. Can also progress to NeuroAIDS or HIV-Associated Dementia.
Some of the more minor negative effects of chronic heroin use involve the gastrointestinal tract. These can include¹:
- Painful or Traumatic Bowel Movements: Due to Fecal Impaction and chronic constipation; can result in Rectal Prolapse and Hemorrhoids.
- Narcotic Bowel Syndrome: Caused by the effects of opioids on the gastrointestinal tract, the exact causes are unknown. Can produce abdominal pain (which can be immune to the analgesic effects of opioids), bloating, nausea, vomiting, abdominal distension and constipation.
- Gastroparesis: Due to opioid-induced GI paralysis the stomach cannot fully empty its contents into the intestines. This results in nausea, vomiting, and heartburn.
Some of the neurotoxic effects of long term heroin use include¹:
- Hyperalgesia: Increased sensitivity to pain.
- Tonic-Clonic Seizures: Loss of consciousness and muscle convulsions (sometimes violent).
- Myoclonus: Involuntary muscle spasms.
- Increased Agitation: Specifically to touch.
- Ataxia: Impaired coordination and balance. Frequently manifests as an off balanced walk.
As far as neurological issues caused by chronic heroin use, a buildup of M3G can lead to some serious issues. This is one of the major metabolites produced through heroin hydrolysis and although it does not appear to have a direct contribution in the high produced by heroin, it can produce negative long term effects. There is some evidence that M3G can increase the effect MOR has on users, although M3G does not appear to produce any euphoric effects on its own¹. M3G is known to persist in higher quantities, and for a longer duration than either 6-MAM or MOR. Because of this persistence, M3G can build to neurotoxic levels with the user being unaware.
Deadly Drug Interactions
Heroin is capable of many dangerous drug to drug interactions which can act to amplify or degrade the effects of both heroin and the other drug being used. Some of the more dangerous drugs interactions include¹:
- Alcohol: Using Heroin in tandem with alcohol can slow the blood elimination rates for both drugs, leading to higher toxicities. Alcohol has a similar effect of depression on vital functions and because of this can dramatically increase the risk of death¹.
- Benzodiazepines: Especially alprazolam (Xanax) and diazepam (Valium). These drugs also act as a CNS depressant and the combined effects of a Benzo with heroin can result in such severe breathing depression that it is potentially fatal. Fatalities have been directly linked to dual heroin and xanax use¹.
- Stavudine (Zerit): An antiretroviral drug for HIV treatment, the decreased gastrointesinal peristalsis produced by heroin leads to longer exposure to stomach acid which degrades the drug substantially and results in sub-therapeutic blood concentrations.
- Zidovudine (Retrovir): Another antiretroviral drug for HIV treatment, the decreased gastrointestinal function actually increases absorption of this drug, leading to toxicity and produces symptoms similar to opioid withdrawal.
- Dextromethorphan (Robitussin): Can produce delirium when mixed with opioids, especially heroin.
- Quetiapine (Seroquel): Dual use can lead to increased morphine blood concentration.
- Buprenorphine (Subutex): Due to the μ-Opioid receptor partial agonist action produced by buprenorphine, depression of vital functions (breathing in particular) can easily reach dangerous levels resulting in coma or death.
- Diphenhydramine (Benadryl) & Promethazine (Phenergan): Both antihistamines, dual use of either with heroin can enhance the CNS depressant effects of both drugs to a dangerous extent.
- Anticonvulsants (Carbamazepine, Phenytoin, and Phenobarbital): These drugs have the effect of inducing morphine metabolism and can cause precipitated withdrawal (rapid and intense withdrawal symptoms).
Aside from drug-drug interactions, if you shoot up heroin, there are elevated risks associated with that particular route of intake. Historically, about 25% of all new HIV cases in America are a direct result of IV drug use. Even more alarming, over 60% of all new Hepatitis C infections in America come from injecting drugs including Heroin¹.
Heroin Cutting Agents
Many heroin manufacturers, and more often the distributors will add adulterants or cutting agents into heroin to increase profits. In this way they can increase the apparent amount and weight of their product by adding much cheaper, and usually legal, alternative materials. Some of these can be harmless but others are dangerous enough in their own right, and when combined with heroin can be fatal. Some of the more harmless heroin cutting agents include:
- Lactaid Pills
- Powdered Milk
- Acetominophen (Tylenol)
- Quinine/Quinidine: An anti-malarial medication.
- Levamisole: A drug used to treat parasitic worm infections.
Some of the more dangerous heroin cutting agents include:
- Xylazine: A horse and deer tranquilizer, it is not a controlled substance or Scheduled by the DEA in America and only requires a veterinarians license to buy. It is a powerful sedative which has been a common cutting agent in Puerto Rico for years, and is finally showing up on the US mainland, mostly in the Northeast. Due to its powerful sedative properties, it can amplify the depressant effects of heroin and dramatically increase risk of coma or death.
Fentanyl: A fully-synthetic opioid, it can be manufactured wholesale in unregulated laboratories. While there is pharmaceutical-grade fentanyl, the fact that fentanyl prescription levels have remained steady throughout the sharp rise in fentanyl related deaths implies the presence of illicitly produced fentanyl in a majority of these cases. The typical strength of pharmaceutical-grade fentanyl is 54.1 times more potent than Morphine¹.
The presence of illicit fentanyl is worrying because of the lack of quality control in manufacturing. This means that the potency of fentanyl can vary wildly between sources. Also, there are many analogues of fentanyl which are vastly more potent. Some of these are 3-Methylfentanyl (between 48.5-569 times more potent than Morphine), Sufentanil (between 625-4,000 times more potent than Morphine)¹, and Carfentanil (roughly 10,000 times more potent than Morphine)¹. Any of these analogues could be present in heroin and there is no way to know the potency of the cutting agent.
Legal Consequences of Heroin Use
While opium was used for millennia, it wasn’t until 1874 that a chemist named Charles Wright first synthesized heroin in London. This was used as a wonder drug and cure-all for many years and in 1898, Bayer Pharmaceuticals began mass production of heroin. After being popularized by prescribing physicians and the ample supply available, its widespread use soon proved that heroin had a massive potential for addiction which resulted in a corresponding rise in Heroin overdoses and violent crime. After about 1913 production dropped sharply and in June of 1924 the United States Congress passed the “Heroin Act” banning the import of opium for the production of heroin and making heroin possession a crime. While domestic production ceased at this point, there were still plenty of people smuggling heroin in from Canada and Mexico (one of the major opium exporters at the time and a primary US heroin supplier today along with Columbia¹).
In 1970, the “Controlled Substances Act” was passed and heroin was listed as a Schedule 1 Narcotic. A Schedule 1 drug is one that has no currently accepted medical use and has a high potential for abuse. Schedule 1 drugs carry the highest penalties of any other Schedule class, as they are considered the most dangerous. After the formation of the DEA in 1973 prosecution became much more vigorous for drug possession or trafficking charges, especially heroin.
While charges vary from state to state, the federal mandatory minimum for 1st offense heroin trafficking (100 to 999 grams) is 5 years. For 1st offense of 1 kilogram (1,000 grams) or more, the penalty is a minimum 10 year prison sentence. For a 1st offense simple possession (any amount of heroin) charge, the mandatory minimum is 15 days to no more than 1 year in prison, a $1,000 fine, or both.