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p id="cite_ref-70" class="reference">[66]

Chronic use of heroin and other opioids, has been shown to be a potential cause of hyponatremia, resultant because of excess vasopressin secretion.


Oral use of heroin is less common than other methods of administration, mainly because there is little to no "rush", and the effects are less potent.[67] Heroin is entirely converted to morphine by means of first-pass metabolism, resulting in deacetylation when ingested. Heroin's oral bioavailability is both dose-dependent (as is morphine's) and significantly higher than oral use of morphine itself, reaching up to 64.2% for high doses and 45.6% for low doses; opiate-naive users showed far less absorption of the drug at low doses, having bioavailabilities of only up to 22.9%. The maximum plasma concentration of morphine following oral administration of heroin was around twice as much as that of oral morphine.[68]


Injection, also known as "slamming", "banging", "shooting up", "digging" or "mainlining", is a popular method which carries relatively greater risks than other methods of administration. Heroin base (commonly found in Europe), when prepared for injection will only dissolve in water when mixed with an acid (most commonly citric acid powder or lemon juice) and heated. Heroin in the East coast United States is most commonly found in the hydrochloride salt form, requiring just water (and no heat) to dissolve. Users tend to initially inject in the easily accessible arm veins, but as these veins collapse over time, users resort to more dangerous areas of the body, such as the femoral vein in the groin. Users who have used this route of administration often develop a deep vein thrombosis. Intravenous users can use a various single dose range using a hypodermic needle. The dose of heroin used for recreational purposes is dependent on the frequency and level of use, thus a first-time user may use between 5 and 20 mg, while an established addict may require several hundred mg per day. As with the injection of any drug, if a group of users share a common needle without sterilization procedures, blood-borne diseases, such as HIV or hepatitis, can be transmitted. The use of a common dispenser for water for the use in the preparation of the injection, as well as the sharing of spoons and/or filters can also cause the spread of blood borne diseases. Many countries now supply small sterile spoons and filters for single use in order to prevent the spread of disease.[69]


Smoking heroin refers to vaporizing it to inhale the resulting fumes, not burning it to inhale the resulting smoke. It is commonly smoked in glass pipes made from glassblown Pyrex tubes and light bulbs. It can also be smoked off aluminium foil, which is heated underneath by a flame and the resulting smoke is inhaled through a tube of rolled up foil, This method is also known as "chasing the dragon" (whereas smoking methamphetamine is known as "chasing the white dragon").


Another popular route to intake heroin is insufflation (snorting), where a user crushes the heroin into a fine powder and then gently inhales it (sometimes with a straw or a rolled up banknote, as with cocaine) into the nose, where heroin is absorbed through the soft tissue in the mucous membrane of the sinus cavity and straight into the bloodstream. This method of administration redirects first pass metabolism, with a quicker onset and higher bioavailability than oral administration, though the duration of action is shortened. This method is sometimes preferred by users who do not want to prepare and administer heroin for injection or smoking, but still experience a fast onset. Snorting heroin becomes an often unwanted route, once a user begins to inject the drug. The user may still get high on the drug from snorting, and experience a nod, but will not get a rush. A "rush" is caused by a large amount of heroin entering the body at once. When the drug is taken in through the nose, the user does not get the rush because the drug is absorbed slowly rather than instantly.


Little research has been focused on the suppository (anal insertion) or pessary (vaginal insertion) methods of administration, also known as "plugging". These methods of administration are commonly carried out using an oral syringe. Heroin can be dissolved and withdrawn into an oral syringe which may then be lubricated and inserted into the anus or vagina before the plunger is pushed. The rectum or the vaginal canal is where the majority of the drug would likely be taken up, through the membranes lining their walls.


In the Netherlands, diacetylmorphine is a List I drug of the Opium Law. It is available for prescription under tight regulation exclusively to long-term addicts for whom methadone maintenance treatment has failed. It cannot be used to treat severe pain or other illnesses.[70]

In the United States, diacetylmorphine is a schedule I drug according to the Controlled Substances Act of 1970, making it illegal to possess without a DEA license.[71] Possession of more than 100 grams of diacetylmorphine or a mixture containing diacetylmorphine is punishable with a minimum mandatory sentence of 5 years of imprisonment in a federal prison.

In Canada, diacetylmorphine is a controlled substance[72] under Schedule I of the Controlled Drugs and Substances Act (CDSA).[73] Any person seeking or obtaining diacetylmorphine without disclosing authorization 30 days prior to obtaining another prescription from a practitioner is guilty of an indictable offense and subject to imprisonment for a term not exceeding seven years. Possession of diacetylmorphine for the purpose of trafficking is an indictable offense and subject to imprisonment for life.

In Hong Kong, diacetylmorphine is regulated under Schedule 1 of Hong Kong's Chapter 134 Dangerous Drugs Ordinance. It is available by prescription. Anyone supplying diacetylmorphine without a valid prescription can be fined $10,000 (HKD). The penalty for trafficking or manufacturing diacetylmorphine is a $50,000 (HKD) fine and life imprisonment. Possession of diacetylmorphine without a license from the Department of Health is illegal with a $10,000 (HKD) fine and/or 7 years of jail time.[74]

In the United Kingdom, diacetylmorphine is available by prescription, though it is a restricted Class A drug. According to the 50th edition of the British National Formulary (BNF), diamorphine hydrochloride may be used in the treatment of acute pain, myocardial infarction, acute pulmonary oedema, and chronic pain. The treatment of chronic non-malignant 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 palliative care of cancer patients, diacetylmorphine is often injected using a syringe driver.[75]

Production and trafficking


Diacetylmorphine is produced from acetylation of morphine derived from natural opium sources. Numerous mechanical and chemical means are used to purify the final product. The final products have a different appearance depending on purity and have different names.[76]

Heroin grades

Heroin purity has been classified into four grades. No.4 is the purest form – white powder (salt) to be easily dissolved and injected. No.3 is "brown sugar" for smoking (base). No.1 and No.2 are unprocessed raw heroin (salt or base).[77]


International drug routes

Traffic is heavy worldwide, with the biggest producer being Afghanistan.[78] According to a U.N. sponsored survey,[8] in 2004, Afghanistan accounted for production of 87 percent of the world's diacetylmorphine.[79] Afghan opium kills around 100,000 people annually.[80]

The cultivation of opium in Afghanistan reached its peak in 1999, when 350 square miles (910 km2) of poppies were sown. The following year the Taliban banned poppy cultivation, a move which cut production by 94 percent. By 2001 only 30 square miles (78 km2) of land were in use for growing opium poppies. A year later, after American and British troops had removed the Taliban and installed the interim government, the land under cultivation leapt back to 285 square miles (740 km2), with Afghanistan supplanting Burma to become the world's largest opium producer once more.[81][82] Opium production in that country has increased rapidly since, reaching an all-time high in 2006. War in Afghanistan once again appeared as a facilitator of the trade.[83] Some 3.3 million Afghans are involved in producing opium.[84]

At present, opium poppies are mostly grown in Afghanistan, and in Southeast Asia, especially in the region known as the Golden Triangle straddling Burma, Thailand, Vietnam, Laos and Yunnan province in China. There is also cultivation of opium poppies in the Sinaloa region of Mexico and in Colombia. The majority of the heroin consumed in the United States comes from Mexico and Colombia. Up until 2004, Pakistan was considered one of the biggest opium-growing countries.

Conviction for trafficking heroin carries the death penalty in most Southeast Asian, some East Asian and Middle Eastern countries (see Use of death penalty worldwide for details), among which Malaysia, Singapore and Thailand 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 nine Australians in Bali, the death sentence given to Nola Blake in Thailand in 1987, or the hanging of an Australian citizen Van Tuong Nguyen in Singapore.

Trafficking history

Primary worldwide producers of heroin

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 triad gangs eventually came to play a major role in the illicit heroin trade. The French Connection route started in the 1930s.

Heroin trafficking was virtually eliminated in the U.S. during World War II because of 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 World War II, 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 westward into Europe and the United States.[85]

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 recreational use led most western countries to declare heroin a controlled substance by the latter half of the 20th century.

In late 1960s and early 1970s, the CIA supported anti-Communist Chinese Nationalists settled near the Sino-Burmese border and Hmong tribesmen in Laos. This helped the development of the Golden Triangle opium production region, which supplied about one-third of heroin consumed in US after the 1973 American withdrawal from Vietnam. In 1999, Burma, the heartland of the Golden Triangle, was the second largest producer of heroin, after Afghanistan.[86]

The Soviet-Afghan war led to increased production in the Pakistani-Afghan border regions, as U.S.-backed toner cartridge that had been modified into an improvised explosive device, the resultant increased level of airfreight scrutiny led to a major shortage (drought) of heroin from October 2010 until April 2011. This was reported in most of mainland Europe and the UK which led to a price increase of approx 30% in the cost of street heroin and an increased demand for diverted methadone. The number of addicts seeking treatment also increased significantly during this period. Other Heroin droughts (shortages) have been attributed to cartels restricting supply in order to force a price increase and also to a fungus that attacked the opium crop of 2009. Many people thought that the American Government had introduced pathogens into the Afghanistan atmosphere in order to destroy the opium crop and thus starve insurgents of income.

On 13 March 2012, Haji Bagcho, with ties to the Taliban was convicted, by a U.S. District Court of conspiracy, distribution of heroin for importation into the United States and narco-terrorism.[87][88][89][90][91][91] Based on heroin production statistics[92] compiled by the United Nations Office on Drugs and Crime, in 2006, Bagcho's activities accounted for approximately 20% of the world's total production for that year.[88][89][90][91]

Street price

The European Monitoring Centre for Drugs and Drug Addiction reports that the retail price of brown heroin varies from €14.5 per gram in Turkey to €110 per gram in Sweden, with most European countries reporting typical prices of €35–40 per gram. The price of white heroin is reported only by a few European countries and ranged between €27 and €110 per gram.[93]

The United Nations Office on Drugs and Crime claims in its 2008 World Drug Report that typical US retail prices are US$172 per gram.[94]

Harm reduction

Comparison of the perceived harm for 20 popular recreational drugs from a poll among medical psychiatrists specialized in addiction treatment. Diacetylmorphine is ranked as the most addictive and most harmful of twenty popular recreational drugs.[95]

Harm reduction is a public health philosophy that seeks to reduce the harms associated with the use of diacetylmorphine. One aspect of harm reduction initiatives focuses on the behaviour of individual users. This includes promoting safer means of taking the drug, such as smoking, nasal use, oral or rectal insertion. This attempts to avoid the higher risks of overdose, infections and blood-borne viruses associated with injecting the drug. Other measures include using a small amount of the drug first to gauge the strength, and 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. Injecting diacetylmorphine users are encouraged to use new needles, syringes, spoons/steri-cups and filters every time they inject and not share these with other users. Users are also encouraged to not use it on their own, as others can assist in the event of an overdose.

Governments that support a harm reduction approach usually fund needle & syringe exchange programmes, which 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 diacetylmorphine 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).

Another harm reduction measure employed for example in Europe, Canada and Australia are safe injection sites where users can inject diacetylmorphine and cocaine under the supervision of medically trained staff. Safe injection sites are low threshold and allow social services to approach problem users that would otherwise be hard to reach.[96] In the UK the Criminal Justice System has a protocol in place that requires that any individual that is arrested and is suspected of having a substance misuse problem, be offered the chance to enter a treatment program. This has had the effect of drastically reducing an area's crime rate as individuals arrested for theft in order to supply the funds for their drugs are no longer in the position of having to steal to purchase Heroin because they have been placed onto a Methadone program, quite often quicker than would have been possible had they not been arrested. This aspect of harm reduction is seen as being beneficial to both the individual and the community at large, who are then protected from the possible theft of their goods.[97][98]

During the late 1980s and early 1990s, Swiss authorities ran the ZIPP-AIDS (Zurich Intervention Pilot Project), handing out free syringes in the officially tolerated drug scene in Platzspitz park.

Popular culture

Heroin is mentioned in hundreds of films. Sometimes the use or trafficking of the drug is the central theme of the film but many times it is almost incidental as part of a crime in a police drama, for example.

  • The 1959 play The Connection by Jack Gelber, and the 1961 film adaptation of it, concern a group of addicts, some of whom are jazz musicians, waiting for their dealer.
  • The film The Panic in Needle Park starring Al Pacino and Kitty Winn is the story of a young woman who falls in love with a heroin addict in New York. It was one of Pacino's first roles.
  • The film, American Gangster, is loosely based on real life drug dealer Frank Lucas, who sold heroin. Lucas was portrayed by Denzel Washington.[99]
  • The film Gia, based on a true story of model Gia Carangi, is about her addiction and use of heroin and how it affected her.[100]
  • The film Christiane F. – Wir Kinder vom Bahnhof Zoo (We the children of Bahnhof Zoo) is about heroin use and street culture in West Berlin in the 1970s, centering on a 13-year-old girl's decision to experiment with the drug.
  • The film Trainspotting chronicles the exploits of a group of heroin addicts in Edinburgh, Scotland, during the late 1980s.
  • The film Requiem for a Dream, tells the story of four drug addicts (mainly heroin) who can only witness their disastrous habits spiral out of control into the darkest, ugliest and dirtiest sides of humanity.[101]
  • In season three of the American television series 24, the show's protagonist Jack Bauer is seen battling a heroin addiction after having spent months undercover working with a drug lord family in Mexico.
  • The film The Basketball Diaries follows protagonist Jim Carrol's addiction to heroin and getting off heroin. Leonardo Dicaprio portrayed Carroll.
  • The film Pulp Fiction featuring John Travolta as Vincent Vega shows IV use of the drug, and Uma Thurman's character Mia Wallace overdoses.
  • The television series Breaking Bad features Jane Margolis, Jesse Pinkman's girlfriend/landlady who is in rehab for heroin usage, but gets back into using it and introduces Jesse to it, but later dies due to the combination of an overdose and Walter White's refusal to save her life.
  • The film Rush (1991) starring Jennifer Jason Leigh, Jason Patric, Sam Elliott and Gregg Allman is a fictionalized depiction of a heroin-trade-based corruption scandal that wracked the Tyler, Texas, US Police Department in the late seventies; undercover detective characters played by Ms. Leigh and Mr. Patric inadvertently become heroin addicts in the process of attempting to gather evidence against the local drug dealer played by Mr. Allman.

Use of heroin by jazz musicians in particular was prevalent in the mid-twentieth century, including Billie Holiday, sax legends Charlie Parker and Art Pepper, guitarist Joe Pass and piano player/singer Ray Charles; a "staggering number of jazz musicians were addicts".[102] It was also a problem with many rock musicians, particularly from the late 1960s through the 1990s. Pete Doherty is also a self-confessed user of heroin.[103] Nirvana frontman Kurt Cobain's heroin addiction was well documented.[104] Pantera frontman, Phil Anselmo, turned to heroin while touring during the 1990s to cope with his back pain.[105]


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Further reading

  • Diary of a Drug Fiend by Aleister Crowley (1922)
  • Junkie by William S. Burroughs (1953) ISBN 0-14-200316-6
  • Heroin (1998) ISBN 1-56838-153-0
  • Heroin Century (2002) ISBN 0-415-27899-6
  • Thick As Thieves by Steve Geng (2007) ISBN 0805080562
  • This is Heroin (2002) ISBN 1-86074-424-9
  • The Heroin User's Handbook by Francis Moraes (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
  • The Heroin Diaries: A Year in the Life of a Shattered Rockstar by Nikki Sixx (2007) ISBN 978-0-7434-8628-6
  • Heroin: The Myths and the Facts by Richard Ashley (1972), St. Martin's Press, Library of Congress No. 72-89417
  • "The Death Proclamation of Generation X: A Self-Fulfilling Prophesy of Goth, Grunge and Heroin" by Maxim W. Furek, M. (2008), i-Universe. ISBN 978-0-595-46319-0
  • Seeds of Terror: How Heroin is Bankrolling the Taliban and Al Qaeda, by Gretchen Peters, publ. Thomas Dunne Books (2009)
  • Forbes, Andrew ; Henley, David (2011). Traders of the Golden Triangle. Chiang Mai: Cognoscenti Books. ASIN: B006GMID5K

External links

  • UNODC – United Nations Office on Drugs and Crime – Afghan Opium Survey 2009
  • NIDA InfoFacts on Heroin
  • ONDCP Drug Facts
  • Heroin news page – Alcohol and Drugs History Society
  • Protocols of the Learned Experts on Heroin Thomas Szasz M.D.
  • U.S. National Library of Medicine: Drug Information Portal – Heroin
  • Geopium: Geopolitics of Illicit Drugs in Asia, especially opium and heroin production and trafficking in and around Afghanistan and Burma (Articles and maps and French and English)
  • National Alliance of Advocates for Buprenorphine Treatment – non-profit education website for treatment of Heroin addiction
  • United States Department of State fact sheet: anti-narcotics efforts in Pakistan – dated 7 June 2002
  • BBC Article entitled 'When Heroin Was Legal'. References to the United Kingdom and the United States
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