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{{Otheruses|Mavericks and sgtbody bag pwns(disambiguation)}}

{{drugbox |
| IUPAC_name = (5α,6α)-7,8-didehydro-4,5-epoxy-<br>17-methylmorphinan-3,6-diol diacetate (ester)
| image = Heroin-2D-skeletal.png
| image2 = Heroin-3D-balls.png
| CAS_number = 561-27-3
| ATC_prefix = N02
| ATC_suffix = AA09
| PubChem = 3592
| DrugBank =
| C=21 | H=23 | N=1 | O=5
| molecular_weight = Mavericks and sgtbody bag pwns
| bioavailability = Mavericks and sgtbody bag pwns%
| protein_bound = 0% (] metabolite 35%)
| metabolism = ]
| elimination_half-life = 2-3 hours
| excretion = 90% ] as ]s, rest ]
| pregnancy_category =
| legal_AU = S9
| legal_CA = Schedule I
| legal_UK = Class A
| legal_US = Schedule I
| legal_status =
| dependency_liability =Extremely High
| routes_of_administration = Inhalation, Transmucosal, Intravenous, Oral, Intranasal, Rectal, Intramuscular}}

'''Heroin''' (]: '''diacetylmorphine''', ]: '''diamorphine''') is an ] processed directly from the extracts of the ], ''Papaver somniferum'', originally intended to break ] addictions. It is the 3,6-] derivative of ] (hence ''diacetylmorphine'') and is processed by ]. The white crystalline form is commonly the hydrochloride salt '''diacetylmorphine hydrochloride'''. Upon crossing the ], which occurs soon after introduction of the drug into the bloodstream, heroin is converted into morphine, which mimics the action of ]s, creating a sense of well-being; the characteristic euphoria has been aptly described as an "orgasm" centered in the gut. One of the most common methods of heroin use is via ].

Due to heroin's mimicry of endorphins, it is used both as a ] and a ]. Frequent administration has a high potential for causing ] and may quickly lead to tolerance; however, occasional use may not lead to symptoms of withdrawal. If a continuous, sustained use of heroin for as little as three days is stopped abruptly, withdrawal symptoms can appear. This is much shorter than other common painkillers such as ] and ].<ref>{{cite journal|author=David Shewan, Phil Dalgarno|title=Evidence for controlled heroin use? high levels of negative health and social outcomes among non-treatment heroin users in Glasgow|url=http://www.gcal.ac.uk/news/downloads/heroin_use.pdf|journal=British Journal of Health Psychology|year=2005|doi=10.1348/135910704X14582|pages=33-48|volume= 10}}</ref><ref>{{cite news|author=Hamish Warburton, Paul J Turnbull, Mike Hough|title=Occasional and controlled heroin use: Not a problem?|url=http://www.jrf.org.uk/bookshop/details.asp?pubID=747|date=2005}}</ref>

Internationally, heroin is controlled under Schedules I and IV of the ].<ref>{{cite web
| year = December 2004| url = http://www.incb.org/pdf/e/list/46thedition.pdf
| title = Yellow List: List of Narcotic Drugs Under International Control| format = PDF
| publisher = ]
| accessdate = May 5| accessyear = 2006
}} ''Referring URL = http://www.incb.org/incb/yellow_list.html''</ref> It is illegal to manufacture, possess, or sell heroin in the ] and the UK. However, under the name '''diamorphine''', heroin is a legal prescription drug in the ]. Popular street names for heroin are ''gear'', ''diesel'', ''smack'', ''B'', ''boy'', ''skag'', ''Harry'', ''Bobby'', '']'', ''horse'', ''honk'', ''munge'', ''junk'', ''brok'', ''jack'', ''jenny'', ''blow'', ''brown'', ''brown sugar'', ''brownstone'', ''dark'', ''sweaty'', ''dope'', ''pof'', ''sam'', ''waccocco'', ''lovage'', ''dragon'', ''bitch'', ''skurge'', ''ron'', ''ice cube'', ''jim'', ''moop'', ''sweet lady H'' and ''H''.
<!--
Please do not add more names to the above short list (which came from www.erowid.org) - consider adding to "List of street names of drugs" article instead
--><!-- Does this need to be in the introduction? Can't we move to some less important position in the article? -->

==History==

] Heroin.]]
]

The ] was cultivated in lower ] as long ago as 3400 BC.<ref>{{cite web
|url=http://www.pbs.org/wgbh/pages/frontline/shows/heroin/etc/history.html
|title=Opium Throughout History
|publisher=PBS Frontline
|accessdate=2006-10-22
}}</ref> The chemical analysis of opium in the 19th century revealed that most of its activity could be ascribed to two ingredients, ] and ].

Heroin was first ] in 1874 by ], an English chemist working at ] Medical School in London, England. He had been experimenting with combining morphine with various acids. He boiled anhydrous morphine alkaloid with acetic anhydride over a stove for several hours and produced a more potent, acetylated form of morphine, now called ''diacetylmorphine''. The compound was sent to F.M. Pierce of Owens College in Manchester for analysis, who reported the following to Wright:

:''Doses ... were ] into young dogs and rabbits ... with the following general results ... great prostration, fear, and sleepiness speedily following the administration, the eyes being sensitive, and pupils constrict, considerable ] being produced in dogs, and slight tendency to ]ing in some cases, but no actual emesis. ] was at first quickened, but subsequently reduced, and the heart's action was diminished, and rendered irregular. Marked want of coordinating power over the muscular movements, and loss of power in the pelvis and hind limbs, together with a diminution of temperature in the rectum of about 4° (rectal failure)''.<ref>{{cite web
|url=http://adhpage.dilaudid.net/heroin.html
|title=On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
|last = Wright
|first = C.R.A.
|date=]
|archiveurl=http://web.archive.org/web/20040606103721/http://adhpage.dilaudid.net/heroin.html
|archivedate=2004-06-06
}} Note: this is an annotated excerpt of {{cite journal
| last = Wright
| first = C.R.A.
| year = 1874
| title = On the Action of Organic Acids and their Anhydrides on the Natural Alkaloids
| journal = ]
| volume = 27
| pages = 1031-1043
}}</ref>

Wright's invention, however, did not lead to any further developments, and heroin only became popular after it was independently re-synthesized 23 years later by another chemist, ]. Hoffmann, working at the ] pharmaceutical company in ], was instructed by his supervisor Heinrich Dreser to acetylate morphine with the objective of producing ], a natural derivative of the opium poppy, similar to morphine but less potent and less addictive. But instead of producing codeine, the experiment produced a substance that was actually 1.5-2 times more potent than morphine itself. Bayer would name the substance "heroin", probably from the word ''heroisch'', German for heroic, because in field studies people using the medicine felt "heroic".<ref>owden, Mary Ellen. Pharmaceutical Achievers. Philadelphia: Chemical Heritage Foundation, 2002.</ref>

From 1898 through to 1910 heroin was marketed as a non-addictive morphine substitute and cough medicine for children. Bayer marketed heroin as a cure for morphine addiction before it was discovered that heroin is converted to morphine when metabolized in the liver. The company was somewhat embarrassed by this new finding and it became a historical blunder for Bayer.<ref>{{cite web
|year=1998
|month=September 13
|url=http://opioids.com/heroin/heroinhistory.html
|title= How aspirin turned hero
|publisher=Sunday Times
|accessdate=2006-10-22
}}</ref>

As with aspirin, Bayer lost some of its trademark rights to heroin following the German defeat in ].
<ref>{{cite web
|url=http://history.sandiego.edu/gen/text/versaillestreaty/all440.html
|date=]
|title=Treaty of Versailles
|accessdate=2007-05-05
|pages=Part X, Section IV, Annex, paragraph 5
}}</ref>

In the United States the ] was passed in 1914 to control the sale and distribution of heroin. The law did allow heroin to be prescribed and sold for medical purposes. In particular, recreational users could often still be legally supplied with heroin. In 1924, the United States Congress passed additional legislation banning the sale, importation or manufacture of heroin in the United States. It is now a Schedule I substance, and is thus illegal there.

<br>

==Usage and effects==
{{Expert-verify|date=April 2007}}
{| bgcolor="#ffffff" border="1" cellpadding="3" cellspacing="0" align="right" width="167px" style="border-collapse: collapse; clear: right; margin: 0 0 0 0.5em"
|-
|'''Indicated for:'''<br/>
*Relief of Extreme Pain

'''] uses:'''<br/>
*]
*]

'''Other uses:'''<br/>
*] relief
*]
*anti-]l
|-
|''']s:'''<br/>
*]
*]s and ]
*]s
*Other ]s (depends heavily on tolerance)
|-
|''']'''{{Fact|date=July 2007}}
<div style="background: #ffcc99">
'''''{{red|Severe:}}'''''
*], ], ], death
*]

</div>

</div>
''''']:'''''
*]
*]
*]

'''''] & ]:'''''
*Lowered ]
*]
*]
*]
*]
*Respiratory depression

'''''], ], ], and ]:'''''
*Dry mouth
*] ("pinpoint pupils")
*]

''''']:'''''
*]
*] (protracted)
*]
*]

''''']:'''''
*]

''''']]:'''''
*]
*]
*]

''''']:'''''
*]
*]

''''']:'''''
*]
*]
*]
*]
*]

''''']:'''''
*Itching
*Flushing/Rash

]
|}

Heroin is used as a recreational drug for its intense ], which often disappears with increased ]. It is believed that heroin's popularity with recreational users, compared to morphine or other opiates, comes from its somewhat different perceived effects.<ref>{{cite journal
| author = Tschacher W, Haemmig R, Jacobshagen N.
| year = 2003
| title = Time series modeling of heroin and morphine drug action.
| journal = ]
| PMID = 12404073
| url = http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12404073&query_hl=23&itool=pubmed_DocSum
}}</ref> This belief has not been supported by clinical research. In studies comparing the physiological and subjective effects of heroin and morphine administered intravenously in post-addicts, subjects showed no preference for one or the other of these drugs when administered on a single injection basis. Equipotent intravenous doses had comparable action courses. There was no difference found in their ability to produce feelings of "euphoria," ambition, nervousness, relaxation, drowsiness, or sleepiness.<ref>W. R. Martin 1 and H. F. Fraser 1</ref> Data acquired during short-term addiction studies did not support the statement that tolerance develops more rapidly to heroin than to morphine. These findings have been discussed in relation to the physicochemical properties of heroin and morphine and the metabolism of heroin. When compared to other opioids -- ], ], ], and ], post-addicts showed a strong preference to heroin and morphine over the others, suggesting that heroin and morphine are more liable to abuse and addiction. Morphine and heroin were also much more likely to produce feelings of "euphoria", and other subjective effects when compared to most other ] analgesics.<ref>1 National Institute of Mental Health, Addiction Research Center, U. S. Public Health Service Hospital, Lexington, Kentucky</ref><ref>Journal of Pharmacology And Experimental Therapeutics, Vol. 133, Issue 3, 388-399, 1961</ref> Heroin can be ] in a number of ways, including ]ing and ]. It may also be smoked by inhaling the vapors produced when heated (known as "]").

Some users mix heroin with ] in a so-called "speedball" or "snowball", which is usually injected intravenously although it can be smoked or dissolved in water and snorted. This causes a more intense rush than heroin alone but is more dangerous because the combination of the short-acting stimulant with the longer-acting depressant increases the risk of overdosing on one or both drugs.

Once in the brain, heroin is rapidly ] into morphine by removal of the acetyl groups, therefore, it is known as a ]. It is the morphine ] that then binds with opioid receptors and produces the subjective effects of the heroin high.

The onset of heroin's effects is dependent on the method of administration. Taken orally, heroin is totally metabolized ] into morphine before crossing the blood-brain barrier; so the effects are the same as oral morphine. Snorting heroin results in an onset within 10 to 15 minutes. Smoking heroin results in an almost immediate, though mild effect which strengthens the longer it is used. Intravenous injection results in rush and euphoria within 7 to 8 seconds; while intramuscular or subcutaneous injection takes longer, having an effect within 5 to 8 minutes.

Heroin is a μ-opioid (]) ]. It acts on ] ]s that are spread in discrete packets throughout the ], ] and ] in almost all ]s. Heroin, along with other ], are ] to four endogenous ]. They are ], ], ], and ]. The body responds to heroin in the brain by reducing (and sometimes stopping) production of the endogenous opioids when heroin is present. Endorphins are regularly released in the brain and nerves, attenuating pain. Their other functions are still obscure, but are probably related to the effects produced by heroin besides analgesia (], ]). The reduced endorphin production in heroin users creates a dependence on the heroin, and the cessation of heroin results in extremely uncomfortable symptoms including pain (even in the absence of physical trauma). This set of symptoms is called ] syndrome. It has an onset 6 to 8 hours after the last dose of heroin.

Large doses of heroin can be fatal. The drug can be used for suicide or, as in the case of ], physician-assisted suicide. <!-- {{fact}}? I read this on ], so it must be true. ;) --> Heroin can also be used as a murder weapon. The serial killer Dr. ] used it on his victims as did Dr. ] (]). Dealers can also supply unwanted customers with unusually pure heroin, or heroin cut with other dangerous drugs such as fentanyl, resulting in a fatal overdose. It can sometimes be difficult to determine whether a heroin death was an accident, suicide or murder. The death of ] was such a case. <ref>http://www.timesonline.co.uk/article/0,,11069-2329203,00.html</ref><!-- more information needed! -->

==Regulation==

In Canada heroin is a controlled substance under Schedule I of the ] (CDSA). Every person who seeks or obtains heroin without disclosing authorization 30 days prior to obtaining another prescription from a practitioner is guilty of an indictable offense and liable to imprisonment for a term not exceeding seven years. Possession for purpose of trafficking is guilty of an indictable offense and liable to imprisonment for life.

In Hong Kong, heroin is regulated under Schedule 1 of ] Chapter 134 ''Dangerous Drugs Ordinance''. It can only be used legally by health professionals and for university research purposes. It can be given by pharmacists under a prescription. Anyone who supplies heroin without prescription can be fined $10000(HKD). The penalty for trafficking or manufacturing heroin is a $5,000,000 (]) fine and life imprisonment. Possession of heroin for consumption without license from the Department of Health is illegal with a $1,000,000 (HKD) fine and/or 7 years of jail time.

In the ], heroin is available by prescription, though it is a restricted ]. According to the ] (BNF) edition 50, diamorphine ] may be used in the treatment of acute pain, ], acute ], and ]. The treatment of chronic non-] pain must be supervised by a specialist. The BNF notes that all opioid analgesics cause dependence and tolerance but that this is "no deterrent in the control of pain in terminal illness". When used in the ] of cancer patients, heroin is often injected using a ].

In ] heroin is not available for therapeutic purposes.

==Production and trafficking==
]
===Manufacturing===
Heroin is produced for the black market through processes of opium refinement. While the production of drugs like ] requires considerable expertise in ] and access to constituents which are now tightly controlled, the refinement of the first three grades of heroin from opium is a relatively simple process requiring only moderate technical expertise and common chemicals. The final grade of heroin favoured in the ] is more difficult to produce and involves a potentially dangerous chemical procedure.

First, morphine is isolated from crude opium by being dissolved in water, reacted with ] fertilizer such that the morphine precipitates out, and then reacted again with ]. What remains is then mechanically filtered to yield a final product of morphine weighing about 90% less than the original quantity of opium. The morphine is reacted with ] — a chemical also used in the production of aspirin — in a five-step process used by most refineries in the ]. The first step is to cook the morphine at 85 °C (185 °F) for six hours with an equivalent weight of acetic anhydride. In the second, a treatment of water and hydrochloric acid then purifies the product moderately. When the chemists add ], the particulates settle. Step four involves heating the heroin in a mixture of ] and ] until the alcohol evaporates. The fifth step is optional, as it only changes the heroin into a finer white powder, more easily injectable; this so-called "no. 4 heroin" is principally exported to the Western markets. In this last, most dangerous step, the heroin (after being dissolved in alcohol), precipitates out in tiny white flakes when a mixture of ] and ] is injected; this step is dangerous because the ether may explode, leveling or severely damaging the refinery (as has happened to a number of such facilities).

The purity of the extracted morphine determines in large part the quality of the resulting heroin.

Heroin is also rarely made from ] by first demethylating with ] followed by acetylation with acetic anhydride. The resulting product is an impure mixture of heroin and ] known as ].

===History of heroin traffic===

{{original research|section}}

The origins of the present international illegal heroin trade can be traced back to laws passed in many countries in the early 1900s that closely regulated the production and sale of opium and its derivatives including heroin. At first, heroin flowed from countries where it was still legal into countries where it was no longer legal. By the mid-1920s, heroin production had been made illegal in many parts of the world. An illegal trade developed at that time between heroin labs in China (mostly in Shanghai and Tianjin) and other nations. The weakness of government in China and conditions of civil war enabled heroin production to take root there. Chinese ] gangs eventually came to play a major role in the heroin trade.

Heroin trafficking was virtually eliminated in the U.S. during ] due to temporary trade disruptions caused by the war. Japan's war with China had cut the normal distribution routes for heroin and the war had generally disrupted the movement of opium. After the second world war, the Mafia took advantage of the weakness of the postwar Italian government and set up heroin labs in Sicily. The Mafia took advantage of Sicily's location along the historic route opium took from Iran{{Fact|date=July 2007}} westward into Europe and the United States. Large scale international heroin production effectively ended in China with the victory of the communists in the civil war in the late 1940s. The elimination of Chinese production happened at the same time that Sicily's role in the trade developed.

Although it remained legal in some countries until after World War II, health risks, addiction, and widespread abuse led most western countries to declare heroin a controlled substance by the latter half of the 20th century.

Between the end of World War II and the 1970s, much of the opium consumed in the west was grown in ]{{Fact|date=July 2007}}, but in the late 1960s, under pressure from the U.S. and the ], Iran{{Fact|date=July 2007}} engaged in anti-opium policies. While opium production never ended in Iran{{Fact|date=July 2007}}, the decline in production in those countries led to the development of a major new cultivation base in the so-called "]" region in South East Asia. In 1970-71, high-grade heroin laboratories opened in the Golden Triangle. This changed the dynamics of the heroin trade by expanding and decentralizing the trade. Opium production also increased in Afghanistan due to the efforts of Turkey and Iran{{Fact|date=July 2007}} to reduce production in their respective countries. Lebanon, a traditional opium supplier, also increased its role in the trade during years of civil war.{{Fact|date=July 2007}}

Soviet-Afghan war led to increased production in the Pakistani-Afghani border regions. It increased international production of heroin at lower prices in the 1980s. The trade shifted away from Sicily in the late 1970s as various criminal organizations violently fought with each other over the trade. The fighting also led to a stepped up government law enforcement presence in Sicily. All of this combined to greatly diminish the role of the country in the international heroin trade. {{Fact|date=July 2007}}

===Dr. Alfred W. McCoy's account of the history of the heroin trade===

Although it was beginning to become more prevalent by the 1930s, Asian historian and drug traffic expert Dr. Alfred W. McCoy reports that heroin trafficking was virtually eliminated in the U.S. during World War II due to temporary trade disruptions caused by the war. McCoy contends the Mafia was able to gain control of the heroin trade thanks in large measure due to the ] of a covert deal between top Mafia leader ] and American military intelligence. The deal resulted in a large increase in Mafia influence in Sicily after the 1943 American invasion. {{Fact|date=February 2007}}

In southeast Asia, the governments of most countries and many colonial officials had been involved in the opium trade for a very long time. Thanks to ] connections in the former French colony of Vietnam, Luciano was able to begin to develop South-east Asia as a new source of Opium. The ] and ] operations in Laos had the unintended consequence of first opening up many areas of South-east Asia to modern transportation and then presenting a ready-made market for the drug among the U.S. military personnel stationed in the region. {{Fact|date=February 2007}}

The major turning point came in 1970-71 when the first high-grade heroin laboratories opened in the Golden Triangle. Prior to this, the chemical skills for refinement had existed only in Europe. This gave the opium producers control over the creation of the final product. The hundreds of thousands of American servicemen in Vietnam provided a perfect market for the heroin producers, and heroin use among soldiers rapidly increased. In 1971 the first large consignments of South East Asian heroin were intercepted in Europe and America, and by the mid-1970s heroin addiction fulfilled its promise as a serious social problem in the United States, Australia, the United Kingdom, and many other nations.{{Fact|date=February 2007}}

===Trafficking===
:''See also: ]''

Traffic is heavy worldwide, with the biggest producer being Afghanistan.<ref>{{cite web
| last =Nazemroaya
| first =Mahdi Darius
| year =2006
| month =October 17
|url=http://www.globalresearch.ca/index.php?context=viewArticle&code=NAZ20061017&articleId=3516
|title=The War in Afghanistan: Drugs, Money Laundering and the Banking System
|publisher=GlobalResearch.ca
|accessdate=2006-10-22
}}</ref> According to U.N. sponsored survey,<ref>{{cite web
|url=http://www.unodc.org/pdf/afg/afghanistan_opium_survey_2004.pdf
|title=Afghanistan opium survey - 2004
|publisher=
|accessdate=2006-10-22
}}</ref> as of 2004, Afghanistan accounted for production of 87 percent of the world's heroin.<ref>{{cite web
| last =McGirk
| first =Tim
| year = 2004
| month =August 2
| url =http://www.time.com/time/asia/magazine/printout/0,13675,501040809-674806,00.html
| title =Terrorism's Harvest: How al-Qaeda is tapping into the opium trade to finance its operations and destabilize Afghanistan
| publisher =Time Magazine Asia
| accessdate =2006-10-22
}}</ref> Opium production in that country has increased rapidly since, reaching an all-time high in 2006. War once again appeared as a facilitator of the trade.<ref>{{cite web
| last =Gall
| first =Carolotta
| year =2006
| month =September 3
| url =http://www.nytimes.com/2006/09/03/world/asia/03afghan.html?ex=1314936000&en=77aca21e09c8576e&ei=5088&partner=rssnyt&emc=rss
| title =Opium Harvest at Record Level in Afghanistan
| publisher =New York Times - Asia Pacific
| accessdate =2006-10-22
}}</ref>

At present, opium poppies are mostly grown in ], and in ], especially in the region known as the Golden Triangle straddling ], ], ], ] and ] province in the ]. There is also cultivation of opium poppies in the ] region of ] and in ]. The majority of the heroin consumed in the United States comes from Mexico and Colombia{{Fact|date=February 2007}}. Up until 2004, Pakistan was considered one of the biggest opium-growing countries. However, the efforts of Pakistan's ] have since reduced the opium growing area by 59% ]{{Fact|date=February 2007}}. Some suggest that the decline in Pakistani production is inversely proportional to the rise of Afghani production, and that rather than anti-narcotics activity, the decline in Pakistan is due more to changed market forces.{{Fact|date=February 2007}}

Conviction for trafficking in heroin carries the death penalty in most ] and some ] and ] countries (see ] for details), among which ], ] and ] are the most strict. The penalty applies even to citizens of countries where the penalty is not in place, sometimes causing controversy when foreign visitors are arrested for trafficking, for example the arrest of ] or the hanging of ]n citizen ] in Singapore, both in 2005.

] has written an autobiography covering her experience of getting caught with Heroin at a Thai airport.

==Risks of non-medical use==
{{Not verified|date=May 2007}}

]
* For ] users of heroin (and any other substance), the use of non-sterile needles and syringes and other related equipment leads to the risk of contracting blood-borne ] such as ] and ], as well as the risk of contracting bacterial or fungal ] and possibly venous sclerosis.
* Poisoning from ] added to "]" or dilute heroin
* Chronic ]
* Heroin-induced ]<ref>http://www.cmaj.ca/cgi/content/full/162/2/236</ref><ref>http://www.medscape.com/viewarticle/554308_7</ref><ref>http://jnnp.bmj.com/cgi/content/abstract/76/7/1014</ref> (very rare, smokers only, the causal reason is currently unknown)
* ] and constantly growing tolerance. Like all opiates and opioids, long term use can lead to physical addiction.
* Decreased kidney function. (although it is not currently known if this is due to adulterants used in the cut)<ref>http://cat.inist.fr/?aModele=afficheN&cpsidt=15612648</ref><ref>http://kidneyfoundation.ab.ca/Be_Active/preserving_function.htm</ref><ref>http://www.kidney.ab.ca/health/index.html</ref><ref>http://www.kidney.org/kidneydisease/howkidneyswrk.cfm</ref><ref></ref>
Many countries and local governments have begun funding programs that supply ] needles to people who inject illegal drugs in an attempt to reduce these contingent risks and especially the contraction and spread of blood-borne diseases. The Drug Policy Alliance reports that up to 75% of new AIDS cases among women and children are directly or indirectly a consequence of drug use by injection. But despite the immediate ] benefit of ]s, some see such programs as tacit acceptance of illicit drug use. The United States federal government does not operate needle exchanges, although some state and local governments do support needle exchange programs. Needle exchanges have been instrumental in arresting the spread of HIV/AIDS in many communities with a significant heroin using population,{{Fact|date=February 2007}} Australia being a leader due to its early inception of needle exchanges. Needle exchange programs have also been attributed to saving the public significant amounts of tax money by preventing medical costs which would have been required otherwise for the treatment of diseases spread through the practice of sharing and reusing needles.

A heroin ] is usually treated with an opioid ], such as ] (]), which has a high affinity for ] but does not activate them. This blocks heroin and other opioid antagonists and causes an immediate return of consciousness and the beginning of ] symptoms when administered intravenously. The ] of this antagonist is usually much shorter than that of the opiate drugs it is used to block, so the antagonist usually has to be re-administered multiple times until the opiate has been metabolized by the body.

Depending on drug interactions and numerous other factors, death from overdose can take anywhere from several minutes to several hours due to anoxia because the breathing reflex is suppressed by µ-opioids. An overdose is immediately reversible with an ] injection. Heroin overdoses can occur due to an unexpected increase in the dose or purity or due to diminished opiate tolerance. However, most fatalities reported as overdoses are probably caused by interactions with other ] drugs like alcohol or ]s.<ref>{{cite journal | author=Shane Darke, Deborah Zador|title=Fatal Heroin 'Overdose': a Review|url=http://www.lindesmith.org/library/darke2.cfm|journal=Addiction|year=1996|volume = 91|issue =12|pages= 1765-1772 }}</ref>

The ] for a physically addicted person is prohibitively high,{{Fact|date=June 2007}} to the point that there is no general medical consensus on where to place it. Several studies done in the 1920s gave users doses of 1,600&ndash;1,800&nbsp;mg of heroin in one sitting, and no adverse effects were reported. This is approximately 16&ndash;18 times a normal recreational dose.{{Fact|date=June 2007}} Even for a non-user, the LD<sub>50</sub> can be placed above 350&nbsp;mg{{Fact|date=June 2007}} though some sources give a figure of between 75 and 375&nbsp;mg for a 75 kg person.<ref>personhttp://lincoln.pps.k12.or.us/lscheffler/ToxicSubstances%20in%20water.htm</ref>

Street heroin is of widely varying and unpredictable purity. This means that the user may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, those who use the drug after a period of abstinence have tolerances below what they were during active addiction. If a dose comparable to their previous use is taken, an effect greater to what the user intended is caused, in extreme cases an overdose could result.

It has been speculated that an unknown portion of heroin related deaths are the result of an overdose or allergic reaction to ], which may sometimes be used as a cutting agent.

A final source of overdose in users comes from ]. Heroin use, like other drug using behaviors, is highly ritualized. While the mechanism has yet to be clearly elucidated, it has been shown that longtime heroin users, immediately before injecting in a common area for heroin use, show an acute increase in metabolism and a surge in the concentration of ]-metabolizing ]s. This acute increase, a reaction to a location where the user has repeatedly injected heroin, imbues him or her with a strong (but temporary) ] to the toxic effects of the drug. When the user injects in a different location, this place-conditioned tolerance does not occur, giving the user a much lower-than-expected ability to metabolize the drug. The user's typical dose of the drug, in the face of decreased tolerance, becomes far too high and can be toxic, leading to overdose.

A small percentage of heroin smokers may develop symptoms of ]. This is believed to be caused by an uncommon ] that is only active when heated. Symptoms include slurred speech and difficulty walking.

==Harm reduction approaches to heroin==
Proponents of the ] philosophy seek to minimize the harms that arise from the recreational use of heroin. Safer means of taking the drug, such as smoking or nasal, oral and rectal insertion, are encouraged, due to the higher risks of overdose, infections and blood-borne viruses associated with ].
Where the strength of the drug is unknown, users are encouraged to try a small amount first to gauge the strength, to minimize the risks of overdose. For the same reason, poly drug use (the use of two or more drugs at the same time) is discouraged. Users are also encouraged to not use heroin on their own, as others can assist in the event of an overdose.
Heroin users who choose to inject should always use new needles, syringes, spoons/steri-cups and filters every time they inject and not share these with other users. Governments that support a harm reduction approach often supply new needles and syringes on a confidential basis, as well as education on proper filtering prior to injection, safer injection techniques, safe disposal of used injecting gear and other equipment used when preparing heroin for injection may also be supplied including citric acid sachets/vitamin C sachets, steri-cups, filters, alcohol pre-injection swabs, sterile water ampules and tourniquets (to stop use of shoe laces or belts).

==Withdrawal==
]]]

The withdrawal syndrome from heroin may begin starting from within 6 to 24 hours of discontinuation of sustained use of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose. Symptoms may include: ], ], ], ], persistent and intense penile erection in males (]), extra sensitivity of the genitals in females, general feeling of heaviness, cramp-like pains in the limbs, ] and ], sleep difficulties (]), cold sweats, chills, severe muscle and bone aches not precipitated by any physical trauma; nausea and ], diarrhea, ], ], and ].<ref>http://www.drugaddictiontreatment.info/heroin.htm</ref><ref>http://www.med.umich.edu/1libr/aha/aha_subabu_bha.htm </ref> Many users also complain of a painful condition, the so-called "itchy blood", which often results in compulsive scratching that causes bruises and sometimes ruptures the skin, leaving scabs. Abrupt termination of heroin use causes muscle spasms in the legs of the user (]). Users taking the "]" approach (withdrawal without using symptom-reducing or counteractive drugs), or induced withdrawal with opiate antagonist drugs, are more likely to experience the negative effects of withdrawal in a more pronounced manner.

Two general approaches are available to ease the physical part of opioid withdrawal. The first is to substitute a longer-acting opioid such as ] or ] for heroin or another short-acting opioid and then slowly taper the dose.

In the second approach, ]s such as ] (Valium) may temporarily ease the often extreme anxiety of opioid withdrawal. The most common benzodiazepine employed as part of the detox protocol in these situations is ] (Serax). Benzodiazepine use must be prescribed with care because benzodiazepines have an addiction potential, and many opioid users also use other central nervous system ], especially alcohol. Also, though unpleasant, opioid withdrawal seldom has the potential to be fatal, whereas complications related to withdrawal from benzodiazepines, ] and alcohol (such as epileptic ], ], and ]) can prove hazardous and are potentially fatal.

Many symptoms of opioid withdrawal are due to rebound hyperactivity of the ], which can be suppressed with ] (Catapres), a centrally-acting alpha-2 agonist primarily used to treat ]. Another drug sometimes used to relieve the "restless legs" symptom of withdrawal is ], a ]. Diarrhea can likewise be treated symptomatically with the peripherally active opioid drug ].

] is one of the substances most recently licensed for the substitution of opioids in the treatment of users. Being a partial opioid agonist/antagonist, it develops a lower grade of tolerance than heroin or methadone due to the so-called ceiling effect. It also has less severe withdrawal symptoms than heroin when discontinued abruptly, which should never be done without proper medical supervision. It is usually administered every 24-48 hrs. Buprenorphine is a kappa-opioid receptor antagonist. This gives the drug an anti-depressant effect, increasing physical and intellectual activity. {{Fact|date=February 2007}} Buprenorphine also acts as a partial agonist at the same μ-receptor where opioids like heroin exhibit their action. Due to its effects on this receptor, all patients whose tolerance is above a certain level are unable to obtain any "high" from other opioids during buprenorphine treatment except for very high doses.

Researchers at ] have been testing a sustained-release "depot" form of buprenorphine that can relieve cravings and withdrawal symptoms for up to six weeks.<ref>{{cite web
| last = Thomas| first = Josephine| year = May 2001
| url = http://www.nida.nih.gov/PDF/NNCollections/NNHeroin.pdf
| title = Buprenorphine Proves Effective, Expands Options For Treatment of Heroin Addiction
| format = PDF| work = NIDA Notes: Articles that address research on Heroin| pages = 23
| publisher = ]
| accessdate = May 5| accessyear = 2006
}}</ref> A sustained-release formulation would allow for easier administration and adherence to treatment, and reduce the risk of diversion or misuse.

Methadone is another μ-opioid agonist most often used to substitute for heroin in treatment for heroin addiction. Compared to heroin, methadone is well (but slowly) absorbed by the gastrointestinal tract and has a much longer duration of action of approximately 24 hours. Thus ] avoids the rapid cycling between ] and withdrawal associated with heroin addiction. In this way, methadone has shown some success as a "less harmful substitute"; despite bearing about the same addiction potential as heroin, it is recommended for those who have repeatedly failed to complete withdrawal or have recently relapsed. As of 2005, the μ-] ] ] is also being used to manage heroin addiction, being a superior, though still imperfect and not yet widely known alternative to methadone. Methadone, since it is longer-acting, produces withdrawal symptoms that appear later than with heroin, but usually last considerably longer and can in some cases be more intense. Methadone withdrawal symptoms can potentially persist for over a month, compared to heroin where significant physical symptoms would subside in 4 days.

Three opioid ] are known: ] and the longer-acting ] and ]. These medications block the effects of heroin, as well as the other opioids at the receptor site. Recent studies have suggested that the addition of naltrexone may improve the success rate in treatment programs when combined with the traditional therapy. {{Fact|date=February 2007}}

The ] undertook preliminary development of a heroin vaccine in ] during the 1970s, but it was abandoned. There were two main reasons for this. Firstly, when immunized monkeys had an increase in dose of x16, their ] became ] and the monkey had the same effect from heroin as non-immunized monkeys. Secondly, until they reached the x16 point immunized monkeys would substitute other drugs to get a heroin-like effect. These factors suggested that immunized human users would simply either take massive quantities of heroin, or switch to other drugs, which is known as ].

There is also a controversial treatment for heroin addiction based on a ]-derived African drug, ]. Many people travel abroad for ibogaine treatments that generally interrupt substance use disorders for 3-6 months or more in up to 80% of patients.<ref> H.S. Lotsof. Ibogaine in the Treatment of Chemical Dependence Disorders: Clinical Perspectives. MAPS Bulletin 1995 V(3):19-26 </ref> Relapse may occur when the person returns home to their normal environment however, where drug seeking behavior may return in response to social and environmental cues.{{Fact|date=February 2007}} Ibogaine treatments are carried out in several countries including Mexico and Canada as well as, in South and Central America and Europe. Opioid withdrawal therapy is the most common use of ibogaine. Some patients find ibogaine therapy more effective when it is given several times over the course of a few months or years. A synthetic derivative of ibogaine, ] was specifically designed to overcome cardiac and neurotoxic effects seen in some ibogaine research but, the drug has not yet found its way into clinical research..

== Heroin prescription ==
The UK Department of Health's Rolleston Committee report in 1926 established the British approach to ] to users, which was maintained for the next forty years: dealers were prosecuted, but doctors could prescribe heroin to users when withdrawing from it would cause harm or severe distress to the patient. This "policing and prescribing" policy effectively controlled the perceived heroin problem in the UK until the 1960s. Attitudes eventually began to change, however: in 1964 only specialized clinics and selected approved doctors were allowed to prescribe heroin to users. Eventually, from the 1970s, the emphasis shifted to abstinence and the prescription of methadone, until now only a small number of users in the UK are prescribed heroin.<ref>{{cite web
| last =Goldacre
| first =Ben
| year =1998
| url =http://www.badscience.net/?p=327
| title =Methadone and Heroin: An Exercise in Medical Scepticism
| accessdate =2006-12-18
}}</ref>

In 1994 Switzerland began a trial program featuring a heroin prescription for users not well suited for withdrawal programs&mdash;e.g. those that had failed multiple withdrawal programs. The aim is maintaining the health of the user in order to avoid medical problems stemming from low-quality street heroin. Reducing ] was another goal. Users can more easily get or maintain a paid job through the program as well. The first trial in 1994 began with 340 users and it was later expanded to 1000 after medical and social studies suggested its continuation. Participants are prescribed to inject heroin in specially designed pharmacies for about US $13 per dose.<ref>{{cite web
| last =Nadelmann
| first =Ethan
| year =1995
| month =July 10
| url =http://www.drugpolicy.org/library%5Ctlcnr.cfm
| title =Switzerland's Heroin Experiment
| publisher =Drug Policy Alliance
| accessdate =2006-10-22
}}</ref>

The success of the Swiss trials led German, Dutch,<ref>{{cite web
| year = 2005
| month =June 5
| url =http://news.bbc.co.uk/2/hi/health/4607233.stm
| title =Heroin prescription 'cuts costs'
| publisher =BBC News
| accessdate =2006-10-22
}}</ref> and Canadian<ref>{{cite web
| url =http://www.naomistudy.ca/
| title =About the study
| publisher =North American Opiate Medication Initiative
| accessdate =2006-10-22
}}</ref> cities to try out their own heroin prescription programs.<ref>{{cite web
| last =
| first =
| coauthors = Carlos Nordt, Rudolf Stabler
| year = 2006
| month ='''367''', 1830-4,
| url =http://www.cesda.net/downloads/lancet1.pdf
| title =Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis
| format =PDF
| publisher =The Lancet
| language =
| accessdate =2006-10-22
}}</ref> Some Australian cities (such as Sydney) have trialed legal heroin injecting rooms, in line with other wider ] programs. Heroin is unavailable on prescription however, and remains illegal outside the injecting room, and effectively decriminalized inside of the injecting room. {{Fact|date=February 2007}}

==Drug interactions==
Opioids are strong ] depressants, but regular users develop ] allowing gradually increased dosages. In combination with other central nervous system depressants, heroin may still kill even experienced users, particularly if their tolerance to the drug has reduced or the strength of their usual dose has increased.

] studies of heroin-related deaths reveal frequent involvement of other central nervous system depressants, including alcohol, benzodiazepines such as diazepam (]), and, to a rising degree, methadone. Ironically, benzodiazepines are often used in the treatment of heroin addiction while they cause much more severe withdrawal symptoms.

] sometimes proves to be fatal when used in combination with heroin. Though "]" (when injected) or "]" (when smoked) are a popular mix of the two drugs among users, combinations of ] and depressants can have unpredictable and sometimes fatal results. In the United States in early 2006, a rash of deaths was attributed to either a combination of ] and heroin, or pure fentanyl ] as heroin particularly in the Detroit Metro Area; one news report refers to the combination as 'laced heroin', though this is likely a generic rather than a specific term.<ref>{{cite news
|first=Robin
|last=Brown
|title=Heroin's Hell
|publisher=]
|pages=A1,A12
|date=]
}}</ref>

==Culture==
Heroin has inspired countless writers, musicians and other artists over the past century of use. However, its influence is often misunderstood or unfairly assumed; many creative people have used or been addicted to heroin, but the extent to which the drug affected their creativity is debatable. Relatively few artists with great talent have credited heroin use with major epiphanies. The 1996 ] film '']'', based on the book by ], depicts heroin users in the areas around ] in ]. Other movies that deal with heroin users include the 1955 ] film '']''; the 1971 ] film, '']''; the 2000 film '']''; '']''; and the 1998 television movie '']'' starring ] about drug-addicted supermodel ].

==See also==
{{wiktionary}}
{{wikinewspar| 2005 Afghan opium harvest begins}}
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==References==
{{reflist|2}}

^ Bowden, Mary Ellen. Pharmaceutical Achievers. Philadelphia: Chemical Heritage Foundation, 2002.

==Literature==

*''Heroin'' (1998) ISBN 1-56838-153-0
*''Heroin Century'' (2002) ISBN 0-415-27899-6
*''This is Heroin'' (2002) ISBN 1-86074-424-9
*''The Heroin User's Handbook'' by ] (paperback 2004) ISBN 1-55950-216-9
*''The Little Book of Heroin'' by Francis Moraes (paperback 2000) ISBN 0-914171-98-4
*''Heroin: A True Story of Addiction, Hope and Triumph'' by Julie O'Toole (paperback 2005) ISBN 1-905379-01-3

==External links==
{{Commons|Heroin}}

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Revision as of 06:18, 2 September 2007

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