Boy, brown, china white, dragon, gear, H, horse, junk, skag, smack, diamorphine, morphine, methadone, opium, codeine, pethidine, dihydrocodeine (DF118), palfium, diconal, temgesic, physeptone
What is heroin?
Heroin (diamorphine) is one of a group of drugs called ‘opiates’. These drugs are derived from opium, the dried milk of the opium poppy. Opium contains morphine and codeine, both effective painkillers. Heroin is a semi-synthetic derivative made from morphine and in its pure form is a white powder.
Today street heroin usually comes as an off white or brown powder since it is cut with other substances. Medical heroin is usually formulated as tablets or an injectable liquid.
Other opiates can be naturally occurring like morphine, codeine and thebaine, synthetic such as methadone (Often prescribed as a substitute in the treatment of heroin addiction), dihydrocodeine (DF 118s), pethidine (often used in childbirth), tramadol, nitazenes, diconal, palfium, temgesic and fentanyl. And also semi-synthetic derivatives, including hydrocodone, oxycodone and buprenorphine.
Methods of use
Heroin can be smoked on foil (‘chasing the dragon’), divided into lines and snorted or prepared for injection. In order to be injected it is usually dissolved in a heated solution of citric acid (vitamin C). Medical opioids may be used by heroin users who cannot get hold of heroin. Methadone is usually prescribed as a drinkable syrup.
The UK situation
According to DrugScope’s street drug trends survey of 2016, the cost of a 0.1g bag of heroin was £10.
Prevalence of heroin use has fallen considerably in the UK and Europe. According to a gov.uk report published in 2019 only 0.1% of adults aged 16-59 in England and Wales had used heroin in the last year. The figure was smaller still for 16-24 year olds.
The ONS Deaths related to drug poisoning in England and Wales: 2020 registrations report shows that rates of deaths involving opiates have been trending upwards. For deaths registered in 2020, a total of 2,263 drug poisoning deaths involved opiates; this was 4.8% higher than in 2019 (2,160 deaths) and 48.2% higher than in 2010 (1,527 deaths. Opiates were involved in just under half (49.6%) of drug poisonings registered in 2020 – and these numbers could be higher as the drug type is sometimes not specified.
The latest annual United Kingdom drug situation 2019: Focal Point report showed in 2018 the UK opioids were mentioned in around 80% of drug related deaths and that heroin was involved in more than half of all opioid-related deaths in England, Wales and Scotland (35% in Northern Ireland). The next most common opioid involved in drug related deaths was Methadone. Methadone was involved in 47% of drug related deaths in Scotland, a much higher percentage than the rest of the UK (20% in England, 10% in Wales and 13% in Northern Ireland).
In the European Drug Report 2023 it’s suggested that heroin use in Europe remained stable in 2021 compared with previous years. It is estimated that around 1 million people in Europe (0.33%) used opioids in 2021.
The UNODC World Drug Report 2023 suggests global use of opiates is also stable in 2021. An estimated 60 million people used opioids in 2021, representing 1.2% of the global adult population. Of those using opioids in 2021, an estimated 31.5 million used opiates, mainly heroin.
Heroin and other opiates are sedative drugs that depress the nervous system. They slow down body functioning and are strong painkillers. The effect is usually to give a feeling of warmth, relaxation and detachment with a lessening of anxiety. Effects start quickly and can last several hours but this varies with dose and how the drug is taken.
“It is probably one of the most pleasurable experiences I’ve had. All the pain goes. All the anger is gone. I was lying on the sofa floating happily. It makes you feel safe and warm like being wrapped up in a blanket.”
Initial use can result in dizziness, nausea and vomiting but these unpleasant reactions fade with regular use. With high doses sedation takes over and people become drowsy. Excessive doses can produce stupor and coma and even death from respiratory failure.
The physical effects of long term heroin use are rarely serious in themselves but may include chronic constipation, irregular periods for women and possibly pneumonia and decreased resistance to infection. This can be made worse by poor nutrition, self neglect and bad housing.
Opiate use during pregnancy tends to result in smaller babies who may suffer withdrawal symptoms after birth. These can usually be managed with good medical care. Opiate withdrawal during pregnancy can be dangerous for the baby, so the preferred option is often to maintain the mother on low doses until the birth of the child.
Tolerance and withdrawal
With regular use tolerance to heroin develops so that more is needed to get the same effect. Physical dependence can also result from regular use. Withdrawal can produce unpleasant flu like symptoms which may include aches, tremor, sweating, chills and muscular spasms. These fade after 7-10 days but feelings of weakness may last longer. Whilst many people do successfully give up long term heroin use, coming and staying off heroin can be difficult.
“You can get addicted pretty quickly and start feeling you have to have it all the time. It’s cut with all sorts of rubbish but you don’t really care. The only goal in life became getting more. It kind of took all my feelings away”.
Overdose and purity
Fatal overdoses can occur, especially when users take their normal dose after a break during which their tolerance has faded. Overdoses may also happen when opiate use is combined with the use of other depressant drugs such as an alcohol, tranquillisers or other opiates. There is also a risk of death through inhaling vomit.
It is often difficult to know exactly what is being taken because the purity of street heroin varies and it is often mixed with adulterants, though these additives have rarely been found to be harmful. Street purity is usually around 30%-40%, however, occasionally heroin may be sold that is unexpectedly pure and this can lead to accidental overdosing.
Injecting increases risks of overdosing and also puts users at risk of a range of infections including hepatitis and HIV if the injecting equipment is shared.
Regular injectors may also suffer health problems such as damaged arteries and veins, heart and lung disorders.
Treatment and prevention
There are several schools of thought on treatment for heroin dependency ranging from abstinence to maintenance.
Methadone is the leading drug for substitute prescribing and can be used to maintain or detox.
Buprenorphine can also be prescribed by GPs as a substitute drug. This is marketed under the trade name Subutex and may be useful when methadone is not the best choice, for example when a person is in the early stages of dependency.
Methadone and buprenorphine help to:
- stabilise drug use
- stop people using illegal drugs
- change risky behaviour, such as injecting and sharing needles and equipment
- stop the need to commit crimes to fund a heroin habit
In addition to substitute drugs, those receiving treatment for heroin use may also be offered counselling.
When the patient is ready to come off their substitute drug completely they will be given the choice of a community or inpatient detox.
With community detox the dose of methadone or buprenorphine is reduced gradually over a period of time thereby minimising uncomfortable withdrawal symptoms. The patient may then be offered a drug called naltrexone. Naltrexone can stop patients relapsing by blocking the effects of drugs like heroin and reducing the desire to use them.
Inpatient detox involves a two-to-three-week stay in a hospital or residential rehab centre with detox facilities. It allows the patient to reduce their substitute dose more quickly.
It is important that people are supported after detox. If they start using heroin again, the chances of an overdose are much higher than before detox.
Numbers in treatment
The Adult substance misuse treatment statistics 2019 to 2020: report from Public Health England showed that between April 2019 and March 2020 the number of people in treatment for opiates was 140,599 (slightly up from 139,845 in the previous year. 52% of the adults in treatment were there for problems with opiates.
As mentioned above it is better not to use heroin with other depressant drugs. It is also better never to use drugs alone but to be with a person you trust.
Injecting is the most dangerous way to take drugs but needle exchanges can help mitigate some of the problems such as blood borne diseases. The first needle exchange opened around 1987. There is now 100% coverage across. Injecting drug users hand in their used needles and syringes in return for sterile injecting equipment.
Drug consumption rooms
Drug consumption rooms take this a step further. They are places where illicit drugs can be used under the supervision of trained staff. These facilities primarily aim to reduce the acute risks of disease transmission through unsafe injecting, prevent drug-related overdose deaths and connect high-risk drug users with addiction treatment and other health and social services.
Naloxone is a medicine which can temporarily reverse the effects of an overdose caused by opiates and opioids such as heroin, methadone or morphine.
The main life-threatening effect of opiates is to slow down and stop breathing and naloxone blocks this effect and reverses the breathing difficulties.
Now, anyone involved in delivering drug treatment services can carry naloxone and make it available to others without a prescription. This includes friends and family of people who use heroin.
Heroin and other opiates are controlled under the Misuse of Drugs Act making it illegal to possess them or to supply them to other people without a prescription. Heroin is treated as a Class A drug where the maximum penalties are 7 years imprisonment and a fine for possession and life imprisonment and a fine for supply.
Morphine, opium, methadone, pethidine and diconal are also Class A drugs under the Act. Codeine and dihydrocodeine (DF118) are Class B drugs and temgesic and distalgesic are Class C drugs.
Only a very few specially licensed doctors can prescribe heroin to ‘maintain’ a drug user. Methadone is much more commonly prescribed. Heroin can, however, be prescribed by doctors to relieve severe pain and has been found very effective with terminally ill cancer patients. According to a freedom of information request by Release, in 2017-2018, 280 people received a prescription for diamorphine (medical-grade heroin).
Methadone can be taken abroad in some circumstances, provided you have a prescription and sometimes an export permit for the drug. See the gov.uk website for full details on what controlled drugs you can and can’t take out of the country.
Cultivation and production
The World Drug Report from 2021 states that opium production is highly concentrated, with 97% of estimated production coming from 3 of the 50 countries worldwide where opium production is reported over the period 2015–2019. The country in which the largest amount of opium is produced continues to be Afghanistan. Afghanistan accounted for an estimated 83% of global opium production between 2015–2020. 2021 was the fifth year that Afghanistan’s production is at historic highs of more than 6,000 tons, potentially yielding up to 320 tons of pure heroin (Drug Situation in Afghanistan 2021).
Global opium production has shown a long-term upward trend but remained largely stable in 2020 compared with the previous year. But the production of 7,410 tons is almost a 60% increase than a decade earlier. The highest reported production was for 2017 at 10,240 tons. Taking opium consumption into account, the estimated global opium production in 2020 would have been sufficient to potentially manufacture 454–694 tons of heroin, similar to the level reported in the previous year (474–722 tons).
The earliest reference to use of opium is amongst Sumerian people in the Middle East 6,000 years ago. It was used as a medicine and recreational drug amongst the Ancient Greeks and by the 7th or 8th century AD commonly used in Chinese medicine.
Use in China became widespread and caused great concern to the Emperor and authorities. Most Chinese opium was imported into China from India by the East India Company. In other words a British company was the main supplier to China using opium grown in conquered lands in India and the British government benefited greatly from the tax revenue. The Chinese introduced harsh laws to try and stop their people using opium. When this did not work in 1839 the Chinese authorities in Canton seized opium from British ships and flushed it into the sea. The British sent in troops and the Chinese authorities backed down.
In 1856 a similar incident led to a second ‘Opium War’ with the British navy shelling Canton and opening up other ports. The opium trade increased again so that up to 15 million Chinese became regular opium smokers. The Chinese authorities made opium use legal and began to grow their own poppies. Within a few decades Chinese opium production outstripped the Indian grown supplies and British sales and influence declined. In time China became a main supply for opium use in Europe.
Opium was used in the UK (and the rest of Europe) in medicines from the 1550s and by the 17th century drugs like laudanum – a mixture of opium and alcohol – were used for all sorts of ailments including to kill pain, aid sleep, for coughs, diarrhoea, period pains and for toothache and colic in babies. This trend continued well into the 19th century with the availability of many opium-based medicines bought from grocery stores and use of opium by many famous writers and poets. Concerns about the rising number of infant deaths through opium overdose resulted in the first controls on sales of opium in 1868.
Morphine was first synthesised from opium in 1805 by a German chemist and was advertised as a new wonder medicine that was non-addictive and could even be used for the treatment of opium dependence. About 1850, the hypodermic syringe came into use and at that time people believed that smoking opium, rather than injecting opiates led to dependence. Thousands of soldiers in the American Civil War came home addicted to morphine given to them to ease the pain of their injuries. In 1874, again in Germany, heroin was first made from morphine – again it was advertised as non-addictive, this time as a substitute for morphine.
Although many people in the USA were addicted to medical opiates, all the press attention was focused on the Chinese community and their use of opium in opium dens. The Chinese were accused of fostering addiction and luring especially young women into white slavery through opium; the evil Fu Manchu image of the Chinese became a standard racist stereotype in both the USA and Britain.
Non-medical use of opiates was not an offence in the UK until after the First World War but doctors were still allowed to prescribe them (mainly morphine) to people who had become dependent. Not many people used morphine or heroin and most who did obtained it from doctors. Diversion of heroin from doctors saw the number of users increase in the 1960s and all but a few specialist doctors were stopped from prescribing it.
The mid 1970s saw the beginnings of a significant market in imported illegally manufactured ‘chinese’ heroin from Hong Kong. In the mid 1980s the number of users of heroin and other opiates increased dramatically, particularly in inner city deprived areas. this heroin came from the so called golden cresent countries of Iran, Pakistan and Turkey. This type of heroin was originally produced for smoking rather than injecting and followed the rise in Iranian refugees to the UK after the fall of the Shah in 1979.
The government responded by developing new community based drug services and running anti- heroin media campaigns as well as needle exchange schemes to reduce needle sharing and the incidence of HIV.
Updated August 2023