September 14, 2011

Revered by Sumerians, Egyptians, Greeks, and other ancient civilizations for its ability to ease pain, the opium poppy has yielded a number of chemical compounds that have revolutionized the control of pain as well as contributed to problems of addiction in modern societies. Morphine, one of the most powerful pain relievers known, was isolated from opium by a German pharmacologist in 1803. In 1874, a British chemist experimenting with morphine produced diacetylmorphine, a semisynthetic opiate marketed in 1898 by Bayer and Company under the name “heroin” (from the German word, heroisch, meaning “heroic” or “powerful”) as a medicine for coughs, pneumonia, tuberculosis, and other ailments. Shortly after its introduction, the addictive nature of heroin became evident to the medical community.

Several waves of heroin addiction have been identified in the United States. For about the first two decades after its introduction, most heroin addiction was iatrogenic, sometimes associated with its prescription for morphine addiction. The Harrison Act of 1914 strictly regulated the use of heroin, and the legal sale of heroin was prohibited. Due to increasing problems surrounding heroin addiction, the U.S. Public Health Service opened narcotic hospitals in Lexington, Kentucky (1935) and in Fort Worth, Texas (1938). After World War II, African Americans and Hispanics in inner cities, in particular, were most affected by a second wave of heroin addiction. A third wave of heroin addiction began in the 1960s and continued throughout much of the Vietnam War era. The National Institute on Drug Abuse was established in 1973, partly in response to increases in heroin abuse during this period. Most data indicate that the United States is in the midst of a fourth wave of heroin addiction that began in the early 1990s in some areas of the country. In this latest wave, many new heroin users have been young (18-25) whites of middle-class background.

United Nations estimates suggest there were about 8 million heroin users worldwide in 2000, with almost 1 million “hard-core” (weekly use or more) users in the United States. Major sources of heroin in the United States include Mexico, Southeast Asia, Southwest Asia, and, more recently, Colombia and South America. While heroin typically is sold in powdered form, some Mexican heroin is a tar-like substance. Depending on its purity and form, heroin can be snorted (inhaled through the nasal passages), smoked, injected under the skin (“skin-popping”), or injected intravenously. Intravenous injection of heroin was rare until about 1930.

Whatever the route of administration, heroin produces a “rush” characterized by exhilarating feelings of euphoria, well-being, energy (at least initially), and power, followed by somnolescence—the “nod.” This is why it is referred to on the streets as “boy,” the “king” of drugs, in contrast to cocaine, or “girl,” the weaker of the two. Use of heroin several times a day for several weeks results in physical dependence. Dependent heroin users experience painful, flu-like withdrawal symptoms when they cannot use the drug. Although not often life threatening, withdrawal symptoms are extremely unpleasant. At this stage, more frequent and/or larger doses of heroin are needed just to remain feeling “normal.” The daily cost of a heroin habit can exceed $200. Physical withdrawal symptoms often motivate some heroin users to engage in illegal activities such as shoplifting, theft, fraud, prostitution, and other crimes to obtain the money needed to purchase enough of the drug. Importantly, some people experiment with heroin and never become dependent, but the number of experimenters is unknown. In addition, some people use heroin occasionally over long periods of time without becoming dependent.

Since the early to mid-1990s, depending on geographic region, the purity and availability of heroin in the United States has increased significantly. Cost has decreased as well. Higher purity heroin can be administered efficiently by smoking or snorting. Although many recent, new heroin users initiated use of the drug by snorting or smoking, many users who become dependent eventually turn to injection. At least initially, dependent heroin sniffers can inject smaller quantities of heroin at a comparatively lower cost.

Heroin injectors are at risk for a wide range of health problems, including—but not limited to— infection at the injection site, endocarditis, hepatitis B and hepatitis C infection, HIV infection, overdose, and addiction. Women who inject heroin are often at greater risk of experiencing some of these health problems for a variety of reasons. For example, women often assume subordinate roles compared to men in injection settings. Consequently, women often inject after men and therefore may inject with syringes that have been used previously. In addition, given limited options for work, some women addicted to heroin may turn to prostitution to obtain the money necessary to buy daily supplies of the drug. Women heroin users who engage in sex work have a greater risk of being exposed to HIV and other sexually transmitted diseases. Heroin users who engage in prostitution are also at risk for experiencing violence, including sexual assault.

Substance abuse treatment modalities for heroin and other opioid dependence include the use of a number of therapeutic agents for detoxification and maintenance. The most widely used is methadone, a synthetic narcotic developed during World War II by the Germans as a substitute for morphine. In adequate doses, methadone that is taken orally can ease withdrawal symptoms and can block the physical craving for opiates as well as the euphoric effects. Women who use heroin often experience greater problems accessing drug abuse treatment services, particularly when they are mothers. Few drug abuse treatment programs provide child care services, thus creating a barrier to treatment access.

There is evidence that some women who abuse heroin may experience amenorrhea, anovulation, and infertility. It is not clear if this is due specifically to heroin or other lifestyle issues, such as poor nutrition. Finally, the fetus of a pregnant woman who abuses heroin is at substantial health risks, including dependence.

SEE ALSO: Acquired immunodeficiency syndrome, Addiction, Cocaine, Hepatitis, Injection drug use, Sexually transmitted diseases, Substance use

Suggested Reading

  • Carlson, R. G. (1999). “Boy” and “girl”: The AIDS risk implications of heroin and cocaine symbolism among injection drug users. Anthropology and Medicine, 6(1), 59—77.
  • Inciardi, J. A., & Harrison, L. D. (Eds.). (1998). Heroin in the age of crack-cocaine. Thousand Oaks, CA: Sage.
  • Musto, D. F. (1987). The American disease: Origins of narcotic control. New York: Oxford University Press.
  • Rosenbaum, M. (1981). Women on heroin. New Brunswick, NJ: Rutgers University Press.
  • Stephens, R. C. (1991). The street addict role. Albany: State University of New York Press.

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