Heroin is an extremely dangerous drug by any measure. Overdoses are unfortunately very common, both due to the potency of heroin as well as the fact that many people inject heroin for a stronger effect. It is also possible to suffer serious health complications from heroin use without actually overdosing. Chronic heroin use poses its own set of risks which can be either short or long-term issues.
We’ve outlined a detailed list of the top 5 dangers of heroin abuse below:
Danger #1: Heroin Overdoses
Due to the risk of overdose, heroin is one of the more deadly drugs known today. The fact that heroin is often injected has led to overdoses for many decades and the increasing presence of fentanyl in heroin has only increased the number of overdoses. Sadly, overdosing from heroin is more common in people who have stayed clean for a time and then relapsed. Depending on the person, heroin tolerance can return to baseline after just weeks or months of abstinence. When someone goes to use heroin again, they often use the same amount that they used last time and an overdose is typically the result.
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. More recently 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 the fall of 2014 and had alarmingly reached ~90% by the fall of 2017.
Signs of a Heroin Overdose:
The signs of a heroin overdose can include:
- Shallow or Depressed Breathing
- Unconsciousness (with an inability to wake up)
- Weak or Irregular Pulse
- Heart Failure
- Blue or Gray Skin and Face (due to lack of oxygen)
- Coma (indicative of brain damage)
- Death (several of the above can lead to death)
Aside from overdoses directly related to heroin itself, mixing heroin with other drugs can greatly increase the risk of death or serious negative consequences. This can happen accidentally as there are a number of other drugs or “fillers” used as cutting agents which the user may not know about prior to use.
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.
Danger #2: Long-Term Health Risks From Heroin Use
Aside from the immediate risks of overdose and death, there are many long-term and potentially fatal complications of heroin use as well. Some of these may include:
- Endocarditis: Infection of the interior of the heart. Typically caused by bacteria found on the skin or in the mouth and introduced into the blood through IV heroin 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 becomes dislodged and travels through the circulatory system. Typically originates from a heroin injection site. May be fatal.
- 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 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 subsequent tissue damage. Is potentially fatal and kidney damage may be permanent. Getting rhabdomyolysis once increases the risk of subsequent occurrence.
- Liver Damage: Due to heroin metabolism as well as adulterants or 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 use. Can progress to cirrhosis of the liver.
- Kidney Damage: Due to adulterants or contaminants in heroin as well as secondary effects of IV drug use such as rhabdomyolysis.
- HIV/AIDS: Autoimmune disorder commonly acquired by IV drug use. If untreated it can result in a variety of illnesses, pneumocystis pneumonia, and finally death.
- Hyperalgesia: Increased sensitivity to pain.
Some of the more minor negative effects of chronic heroin use involve the gastrointestinal tract. These can include:
- Constipation and Painful Bowel Movements: Due to the paralytic effects of heroin on the intestines, this 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 intestinal paralysis the stomach cannot fully empty its contents into the intestines. This results in nausea, vomiting, and heartburn.
Danger #3: Deadly Drug Interactions with Heroin
Heroin is capable of many dangerous drug interactions that can amplify the effects of heroin. Some of the more dangerous drugs interactions include:
- Alcohol: Using heroin with alcohol can slow the blood elimination rates for both drugs, leading to higher toxicities. Alcohol has a similar depressive effect on vital functions and using them together can dramatically increase the risk of death.
- Benzodiazepines: Especially alprazolam (Xanax) and diazepam (Valium). These drugs also act as powerful depressants and the combined effects of a benzodiazepine with heroin can result in severe breathing depression. Fatalities have been directly linked to dual heroin and Xanax use.
- Stavudine (Zerit): An antiretroviral drug for HIV treatment, the decreased digestive function produced by heroin leads to longer exposure to stomach acid which degrades the drug 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 an increased blood concentration of heroin.
- Buprenorphine (Subutex): Also an opioid, using buprenorphine with heroin can intensify breathing depression and 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 depressant effects of both drugs to a dangerous degree.
- 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 someone injects 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 heroin. 2
Danger #4: Cutting Agents Used in Heroin
Many heroin manufacturers, but more often the distributors or dealers, will add adulterants or cutting agents into heroin to increase profits. This is done to increase the apparent amount and weight of their product by adding much cheaper 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
- Acetaminophen (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 veterinarian’s license to buy. It is a powerful sedative that 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 the 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 25 to 40 times more potent than heroin. 3
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 include 3-Methylfentanyl (between 48.5-569 times more potent than morphine), Sufentanil (between 625-4,000 times more potent than morphine), and Carfentanil (roughly 10,000 times more potent than morphine). Any of these analogues could be present in heroin and there is no way to know the potency of the cutting agent.
Danger # 5: Legal Consequences of Heroin Use
In 1970, the “Controlled Substances Act” was passed and heroin was listed as a “Schedule 1” narcotic. Schedule 1 substances are drugs that have no currently accepted medical use and a high potential for abuse. These drugs carry the highest penalties out 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.
The legal repercussions vary between states as far as the minimum sentence for heroin possession is concerned. For example, in Georgia, there are some very harsh mandatory minimum sentences for heroin possession. Possession of 4 or more grams of heroin is a felony in Georgia and the mandatory minimum sentences are quite severe. They are subdivided by the amount of heroin that was found, and include:
- Possession of 4 to 14 grams: 5 years in prison and a $50,000 fine.
- Possession of 14 to 28 grams: 10 years in prison and a $100,000 fine.
- Possession of 28 or more grams: 25 years in prison and a $500,000 fine.
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.
- The American Journal on Addictions: Drug Interactions of Clinical Importance among the Opioids, Methadone, and Buprenorphine, and other Frequently Prescribed Medications – A Review
- Clinical Infectious Diseases: Hepatitis C Virus Infection as an Opportunistic Disease in Persons Infected with Human Immunodeficiency Virus
- Frontiers in Pharmacology: Metabolic Pathways and Potencies of New Fentanyl Analogs
- Future Medicinal Chemistry: Fentanyl-related Compounds and Derivatives – Current Status and Future Prospects for Pharmaceutical Applications