Heroin Drug of the Month: download
Transcript and Sources
What exactly is it? Where does it come from in nature, how is it turned into useable form? How is it consumed?
And now it’s time for the Drug of the Month, where we take a closer look at the background, science, history, and recent trends in a different drug each month. For our last drug of the month, we talked about caffeine, a legal drug that is actually the most widely consumed psychoactive substance in the world. This month, we’ll be examining an increasingly popular drug that has been unfortunately making headlines across the country, often paired with words like “crisis” or “epidemic.” While this drug is highly illegal as a Schedule I controlled substance, its close chemical cousins are often-prescribed and often-much-more expensive pharmaceutical painkillers. This month, of course, we’ll be discussing Heroin.
It seems like these days, Sam and I talk about heroin almost every episode, often in connection to harm reduction measures implemented to combat the heroin epidemic and opioid overdose crisis spreading across the country. We often talk about how overprescription of painkillers is leading to an opiate addiction among even unlikely drug users, and that sadly translates to many of these new addicts switching to heroin, which is cheaper, more potent, and more easily accessible than prescription opioids. So in today’s episode, we’ll explore the nature of heroin, what it is, and where it comes from.
Heroin is itself by definition an opioid painkiller and chemically similar to morphine. It was originally synthesized by an English chemist in the late 1800s in London by adding two acetyl groups to a morphine molecule. Internationally, it is generally illegal to manufacture, possess, or sell heroin without a license. In the United States, as a Schedule 1 drug, the government does not recognize any medical uses of heroin, and considers it highly addictive. In contrast, in the UK, heroin is often prescribed under the generic name diamorphine as a strong pain medication which is administered via subcutaneous, intramuscular, intrathecal (which means injected into the base of the spine) or intravenous routes. Heroin can also be prescribed as a cough suppressant or as an anti-diarrhea treatment.
Recreationally, heroin is used for the intense euphoria and blissful apathy it induces. Anthropologist Michael Agar, who wrote the book “Dope Double Agent” calls heroin “the perfect whatever drug.” For example, in his book, he describes a moment in which he broke his leg, and then thought “Whatever, I’ll be fine.” Sociologists believe that many users turn to the drug to escape from extreme stresses that the user does not have the emotional, social, or financial support to deal with. In fact, one of our very first guests on this show, Lisa Raville, who is executive director of the Harm Reduction Action Center, believes that trauma is the real gateway drug.
Heroin is of course highly addictive. Tolerance develops quickly, and increased doses are needed in order to achieve the same effects. Short-term addiction studies demonstrated that, when compared to other opioids like hydromorphone, fentanyl, and oxycodone, former addicts showed a stronger preference for heroin and morphine, suggesting that heroin and morphine are particularly susceptible to abuse and addiction. Most often administered intravenously by injection, heroin is two to four times more potent than morphine and is faster in its onset of action. Illicit heroin is sometimes available in a matte-white powder freebase form, which is smokable.
So where does heroin come from? In 2004, Afghanistan produced roughly 87% of the world’s supply of illicit raw opium. After regularly producing about 70% of the world’s opium, Afghanistan decreased production by more than 90 percent under a ban by the Taliban in 2000. A year later, however, after American and British troops invaded Afghanistan, removed the Taliban and installed the interim government, the land under cultivation leapt back to 285 square miles, and Afghanistan overcame Burma to become the world’s largest opium producer once more. However, the production rate in Mexico increased 500% from 2007 to 2011, making Mexico now the second largest opium producer in the world.
Opium is the dried latex that comes from opium poppies. Now contrary to common usage, latex is not just the thin plastic used in surgical gloves or condoms. It is a broader term referring to a sap-like substance that some plants excrete. Opium latex contains alkaloid morphine, the molecule that is then synthesized into heroin. Incidentally, opium latex also produces another analgesic opioid, codeine. But not all little opium poppies grow up to one day produce heroin. Opium latex from common, household varieties of poppy contain approximately 12% of morphine or codeine, compared to plants that are selectively bred for eventual drug manufacture which may contain 90% or more of the potent alkaloids.
When poppies are grown for opium production, the skin of the ripening pods are routinely scored with a sharp blade so that its white, milky latex seeps out. Incisions are made three or four times at intervals of two to three days, and each time the “poppy tears,” which dry to a sticky brown resin, are collected the following morning. One acre harvested in this way can produce three to five kilograms of raw opium.
Raw opium may be sold to a merchant or broker on the black market, but it usually does not travel far from the field before it is refined into morphine base, because raw opium is very strong-smelling and also jelly-like so it’s harder to smuggle. Crude laboratories in the field are capable of refining opium into morphine base by a simple acid-base extraction, similar to the process employed to transform coca into cocaine. The morphine is then acetylated to become heroin.
As I’ve already mentioned, intravenous injection is the most popular route of administration since it is the fastest-acting. 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 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 which is a major vein in the groin. Users who have used this route of administration often develop a deep vein thrombosis, which is a blood clot inside a deep vein. Additionally, intravenous use of heroin is the riskiest method because of frequent re-use and sharing of needles, which has led to an epidemic of blood-borne diseases such as HIV or hepatitis in some parts of the United States.
There are other less common and less effective means of consuming heroin, including by smoking it which is actually vaporizing it. In such cases, it is usually 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 often known in pop culture as “chasing the dragon.”
So that’s it for today’s segment of Drug of the Month, where we learned about heroin, what it is, where it comes from, and how people use it. Next week, Sam will be back to chat about the science of heroin, how it interacts with the body, and some of its potential side effects.
What is the science behind how it interacts with the body? What receptors does it influence? What are the medical effects of it, potential side effects?
And now it’s time for our drug of the month, which for February, is heroin, also known by its scientific name, Diamorphine or Diacetylmorphine. This week, I’ll be diving into the science of this almost universally vilified drug: how it interacts with the body, its immediate and long-term effects, and some of its recreational and medical uses.
As we explained in the introduction and is probably familiar to most people, the most common route of administration for heroin is injection, though it can also be snorted or smoked, and in medical settings it is either done by IV or administered in pill form. The reason that injection is so popular, both recreationally and medicinally, is bioavailability, or the proportion of an administered dose of a drug that reaches your bloodstream unchanged. By definition, a drug that’s injected intravenously has 100% bioavailability, since it’s going straight into your bloodstream. In comparison, snorting heroin only has about 45% bioavailability and taking it orally is only about 35%. For addicts and other regular users, cost is a big factor, and injecting’s bioavailability gives more “bang for the buck” since it is more efficient.
Snorting and smoking also both effect the body quite quickly, but they differ in how intense they are, and how long they last, so while most people inject, some still prefer snorting or smoking despite them being less efficient. For medical purposes, diamorphine is often prescribed in pill form since that does not come with an immediate rush of euphoria, and instead spreads its effects over a longer period of time, making it more effective for pain management and less likely to lead to addiction.
Depending on the route of administration, heroin interacts with the body in different ways. When taking orally – and by that I mean ingested, rather than smoked – diamorphine goes through a process called deacetylation, which is just the removal of acetyl groups. Since all heroin is is morphine with two acetyl groups — which is the reason it’s referred to as Diacetylmorphine — this means that your body strips off these two acetyl groups, transforming the heroin into morphine, which then enters the bloodstream. So when taken orally, heroin is really just a prodrug for morphine, but the reason it’s used instead is because it’s much more bioavailable – the concentration of morphine in your blood after ingesting heroin orally is actually about twice the concentration as when ingesting oral morphine.
In contrast, when injected, heroin skips this first-pass metabolism, allowing it to rapidly cross the blood-brain barrier where it then goes through deacetylation, turning into 6-monoacetylmorphine and then into morphine. These bind with mu-opioid receptors, which cause heroin’s characteristic effects. This is a very quick process, with users feeling effects within minutes. The biological half-life of heroin is only 2-3 minutes, but some effects are still felt for 4 or 5 hours afterwards.
Heroin has a few major effects on the body, the most notable of which is intense euphoria, which is what most recreational users are seeking when they consume it. It also dulls pain and anxiety, causing users to feel very relaxed, often leading to “the nod” where users are alternately alert and drowsy, as if they’re nodding off to sleep. Breathing slows down and muscles are weaker than they’d normally be, and users will often also get dry mouth and a warm flushed feeling on their skin.
As is well-known, heroin comes with a high risk of fatal overdose, which are usually caused by the body’s respiratory system shutting down. This is caused in part by the pharmacology of heroin, since it’s more potent than other drugs like morphine, but it’s also caused by prohibition – people who consume street heroin are unlikely to know the purity of the drug, as it’s almost always cut with other things in order to make more money, often being cut at each stage of the supply chain, making it even harder to know. Sometimes, heroin is even cut with other, more potent opioids like fentanyl, which can cause even experienced users to overdose. Also, the risk of overdose is greatly increased when heroin is combined with alcohol, which is a depressant.
People who use heroin frequently will quickly build up a tolerance, which is more pronounced than many other recreational drugs: a first-timer may use a 10 or 20 milligram dose, while a daily user might consume hundreds of milligrams per day. This amplifies the risk of overdose, as someone who goes off heroin for a while will lose their tolerance, making it very dangerous for them to use the same amount they were previously used to. Along with the tolerance comes a high risk of dependence, with NIDA estimating that 23% of people who try heroin will become addicted. Of course, as we’ve discussed in other episodes, there are also a lot of environmental factors at play in addiction, which should not be over-simplified into a mere chemical reaction. It’s also important to note that this means 77% of people who try heroin will NOT become addicted, contrary to fear-mongering claims that everyone who tries it will immediately be turned into an addict for the rest of their lives.
But if someone does become dependent, trying to quit will lead to intense withdrawals, which, while not as dangerous as potentially fatal alcohol withdrawals, can make quitting incredibly difficult. Some symptoms of heroin withdrawal include sweating, anxiety, depression, insomnia, severe muscle and bone aches, nausea, vomiting, diarrhea, cramps, and fever. While difficult to get through, withdrawal symptoms typically subside within about a week, but can last two or three weeks in some cases.
With its long list of potential side effects, high potential for abuse, and demonization in the media, it may surprise our listeners – especially our American ones – that heroin has many recognized medical uses as well. While US doctors tend to prefer morphine, UK doctors prescribe diamorphine as an analgesic, cough suppressant, and an antidiarrhoeal. Many countries like the UK and Switzerland also have heroin maintenance programs, where people trying to wean themselves off of recreational heroin can get government-tested or even government-made heroin, administered under medical supervision to help lessen withdrawal symptoms.
There’s obviously a lot more to heroin than we can fit in this segment, but I hope that helped clear up some misconceptions and add a bit of scientific understanding to this drug that is so often misunderstood. Tune in next week to hear Rachelle give a lesson on the history of heroin.
When did people start using it? Who uses it now? How have the laws and societal attitudes about it evolved over time?
And now it’s time for Drug of the Month, where we take a closer look at a different drug each month. For February, we’ve been learning more about heroin, and last week, Sam talked about the science behind heroin and how it interacts with the human body. On today’s episode, I’ll be discussing the history of heroin, the origins of its use, and evolving societal attitudes towards heroin users.
As I mentioned in the introductory episode, heroin was first synthesized by an English chemist in 1874. For me though, one of the most interesting historical events related to heroin actually occurred about 30 years before heroin was even invented or discovered, and is actually much more about heroin’s natural precursor, opium. But since I don’t foresee us doing an Opium episode any time, and as a co-host of the show, I can actually guarantee we won’t, much of my history on heroin will actually focus on opium today. Apologies to our more pedantic listeneres who only wanted to learn about heroin today.
So, as with so many other plant-derived pschoactive substances, humanity has had thousands of years of history of using opium as a medical, spiritual, and food product. There is evidence of opium cultivation as far back as 3400 BC, during the Neolithic Era or the New Stone Age, a time when humans first began domesticating crops and animals. Many ancient empires, including the Egyptians, Greeks, Romans, and Indians all made widespread use of opium, and opium is even mentioned in the some of the most important ancient medical texts. It was the most potent form of pain relief then available, allowing ancient surgeons to perform prolonged surgical procedures.
In China, the use of opium for medicinal purposes was introduced around the 7th century. It wasn’t until a thousand years later, during the 17th century, when the practice of mixing opium with tobacco became widespread for recreational use. Around this time, there was a major trade imbalance between the Chinese Empire and certain European countries, especially Great Britain, where Chinese products like silk, porcelain and especially tea, were becoming extremely popular. For our regular listeners, you may remember during one of the Caffeine episodes, Sam talked about tea being so popular among the British that the government imposed a high tax on its importation in an effort to reduce use and that led to the creation of a black market for tea. Well that was during this same era too. This is an incredibly fascinating story to me because seemingly, addiction to one drug, tea, led to a deliberate effort to cause addiction among a different population to a different drug, in order to correct a trade imbalance.
So to connect the dots here, basically Britain was importing a ton of tea from China to feed its caffeine addicted fiends, and European manufactured goods weren’t very popular in China, so China would only accept silver in trade, and the British were tired of being the losers in that deal, as presidential candidate Donald Trump would put it. So by 1817, the British realized they could reduce the trade deficit by encouraging the use of opium among the Chinese population, which they could cultivate in their colonies in India and sell to China through the British East India Company. Between 1821 and 1837, the sales of opium in China increased 500%. By then, the trade imbalance had (successfully for the British) been reversed, with the Chinese now exporting more silver than they were importing. Long story long, the Chinese government tried to reduce the use of opium among its people through regulation and control of imports. When that didn’t work, a Chinese official actually confiscated and destroyed nearly 3 million pounds of opium from the British East India Company, and that upset the British enough to start what is known as the First Opium War. China lost that war, and now on a personal note, that’s why Hong Kong, the Chinese island where my parents are from, was a British colony until 1997. After the wars, (unfortunately for the Chinese) opium use continued to increase with now widespread domestic production in China. By 1905, an estimated 25% of the male population were regular consumers of the drug.
Around that same time, over here in the United States, opium became the target of what would be the first in a long history of discriminatory race-based drug laws in the US. At the time, there were no legal restrictions on the importation or use of opium in the United States, and no international treaties yet limiting international drug trade. In 1875, San Francisco passed the Opium Den Ordinance, which banned dens for public smoking of opium, a measure fueled entirely by anti-Chinese immigration sentiments, and the perception that White People were starting to frequent the dens. For those who are more familiar with the origins of marijuana prohibition, you’ll recognize the parallels between this and the fear-mongering against Mexicans and Blacks who smoke the devil’s weed and would corrupt white children or white women.
Okay, so back to heroin for the last two minutes of the segment. English chemist Alder Wright synthesizes heroin for the first time in 1874. It was then known by its scientific name, diamorphine, and didn’t become popular for any use, either medical or recreational, until 23 years later, when it was re-synthesized by accident by another chemist in Germany for the pharmaceutical company Bayer. This guy, Felix Hoffman, was trying to produce codeine from opium poppies, a substance pharmacologically similar to morphine but less potent and less addictive. Instead, the experiment produced an acetylated form of morphine one and a half to two times more potent than morphine itself. The new drug was named heroin, based on the German word for “heroic or strong.” Bayer, the German pharmaceutical company, may not have been the first to discover heroin, but they developed techniques for larger scale production, and this led to the first commercialization of the drug. From 1898 through to 1910, diamorphine was marketed under the trademark name Heroin as a non-addictive morphine substitute and cough suppressant. World War I then broke out, and after the war, as a German company, Bayer lost its trademark rights to heroin under the Versailles Treaty, as it had for Aspirin.
So I know that was a lot about opium and not as much about heroin as it maybe should have been. I promise that next episode, when we talk about recent news and trends, we’ll get back more into modern-day usage and trafficking of heroin, and also how societal attitudes towards users is finally shifting from stigmatization and criminalization towards a focus on harm reduction, compassion, and public health.
News & Trends
And now it’s time for Drug of the Month, where we take a closer look at a different drug each month. Last week, we discussed the history of Heroin, going in-depth on the Opium Wars between China and the British Empire, and then exploring how the drug was first synthesized and then popularized. This week, in our fourth and final installment about Heroin, we’ll take a look at more recent news and trends surrounding the drug, and particularly, at how the treatment of heroin users has evolved over the past few decades.
As our regular listeners have heard over and over since our very first episode, America is in the midst of a countrywide heroin epidemic. But this isn’t the first time this country has experienced an opiate addiction epidemic, or even the second, or third time. In the 1870s to 1880s, when heroin was still considered a legal pharmaceutical, the rate of opiate addiction was nearly triple the rate of opiate addiction in the 1990s. And even more noteworthy, is that surveys show between 56% – 71% of addicts were middle- to upper-middle class white women who had purchased the drug legally. Sound familiar? Oftentimes these women became addicted to heroin after being prescribed laudanum, a tincture containing morphine, that was frequently prescribed to society women to treat aches and pains and settle coughs. Contributing to the problem was a widespread practice of physicians prescribing opiates for menstrual and menopausal disorders. In many ways, women’s addiction to opiates was taken for granted and was even encouraged by the fact that women drinking alcohol was frown upon. So while husbands went to saloons and drank, wives stayed at home and took opium. This was a quiet crisis that didn’t gain much attention because it wasn’t something that was spoken about in polite society. Of course, this was around the same time that opium dens were first banned in San Francisco, drawing a distinct line between white people’s permissible use and abuse of legal pharmaceuticals, and scary ethnic Chinese people smoking opium in dens.
By the early 1900s, illicit heroin use had made its way across the country. The Bellevue Hospital in New York City, the oldest public hospital in the United States, admitted its first patient for heroin addiction in 1910. Two years later, the Hague International Opium Convention of 1912 was signed by 13 countries led by the United States, becoming the first international agreement to regulate and limit the international drug trade. This gave way to an illicit market that became the only source of heroin. In 1915, the same Bellevue Hospital in New York admitted 425 heroin addicts, who were, according to the Psychiatric Bulletin of the New York State Hospitals, ‘in many instances members of gangs who congregate on street corners particularly at night, and make insulting remarks to people who pass.’ These early heroin users were mostly between seventeen and twenty-five years old, but already you can see a shift in the tone used when discussing the addicts. This was no longer a hush-hush family problem that we don’t discuss with company, but rather considered to be anti-social behavior, and the users judged for being immoral deviants. During the 1920s, heroin addicts became known for supporting their habit by collecting and selling scrap metal from junkyards, hence the derogatory term for heroin users “junkie.”
Fast-forward to the 1970s and the Vietnam War, when a congressional report found that nearly 15 percent of US Servicemen in Vietnam were actively addicted to heroin. Compare that to the 0.3% of the current US population that is addicted to heroin, in the midst of a “heroin epidemic.” This was at the height of the Golden Triangle’s dominance as the world’s opium producers. The Golden Triangle refers to three countries in South-East Asia, which together comprised the largest heroin-producing region in that era. The three countries were Myanmar, formerly known as Burma, Thailand, and Laos. If you look at a map of South-East Asia, Vietnam is basically spooning that area, and thus the source of cheap, high-grade heroin to US soldiers stationed. Despite the alarming rates of use of heroin among Vietnam War soldiers, this crisis is better known for its outcome than the problem. After the congressional report was released, President Nixon implemented a program prohibiting enlisted men from returning home until they were “dry.” When the soldiers who had been identified as addicted did finally return home, they were tracked and data on their progress was collected at regular intervals. What researchers found was that shockingly only 5% of returning soldiers relapsed. That means 95% of soldiers who identified as addicted while in Vietnam did not become re-addicted once back in the United States. This is a complete reversal of soldiers addicted to heroin who were treated in the United States after they returned home, in which 95% relapsed. This led to the very first theories that the “setting” of addiction treatment is just as or more important than the intent to overcome addiction. Because the soldiers were no longer surrounded by the same environment, the same activities, and the same people as they were while they were using heroin, they no longer felt the compulsion or fell into the habit of using.
In the meantime, heroin addiction was sweeping through and destroying inner cities across America, particularly in the Bronx in New York, Philadelphia, and Chicago. For millions of impoverished, hopeless, urban-dwelling Latinos and African-Americans, heroin was both a paycheck and a checkout from reality. Heroin was blamed for the rise of violent crime, and users were themselves criminalized and incarcerated. This epidemic tragically only ended when a new crisis began in the 1980s, the rise of crack cocaine.
In the 1990s, heroin chic came into fashion. This was an esthetic characterized by emaciated models with pale skin, dark circles beneath their eyes, and angular bone structure. Heroin chic was embodied in British supermodel Kate Moss. The popular image of heroin emerged as hip and trendy at that time for several reasons. The price of heroin had decreased, and its purity had increased dramatically. In the 1980s, the AIDS epidemic had made injecting heroin with unclean needles increasingly risky. Available heroin had become more pure, and inhalation became a more common mode of heroin use. These changes decreased the stigma surrounding the drug, allowing heroin to find a new market among the middle-class and the wealthy, in contrast to its previous base of the poor and marginalized. Heroin also infiltrated pop culture through a string of films released in the mid-1990s that examined heroin use and drug culture, including Trainspotting, Pulp Fiction, and The Basketball Diaries. The era of heroin chic ended with the rise of Brazilian supermodel Gisele Bundchen and Vogue’s pronouncement in 1999 of the “return of the sexy model.”
That brings us to today, with the return of the heroin epidemic. Between 2006 and 2013, the number of first-time heroin users nearly doubled, from 90,000 to 169,000. The rate of deadly heroin overdoses nearly quadrupled from 2002 to 2013. But this time around, society’s response has been a gentler, more compassionate one. The focus is not on violent crime or the mass incarceration of users. Rather, a truly inspiring number of harm reduction measures and drug policy reforms have been implemented in recent years, including Good Samaritan policies, which allows callers to report a potential overdose without risk of legal repercussion, needle exchange programs, and access to naloxone. Overall, the treatment of heroin addiction as a public health problem rather than a criminal justice issue has a positive development. But experts and researchers point to one disturbing factor in this more enlightened treatment: Race. Nearly 90 percent of people who tried heroin for the first time in the past decade are white.
Andrew Cohen of The Marshall Project has written the best piece on this topic that I have read anywhere. We’ll link to it on our website, and I encourage you all to check it out. A lot of what comes next comes directly from Cohen’s piece, so instead of going “quote/end quote” every time I quote him which is more or less for the rest of this segment, I will just strongly direct you to reading his piece in its entirety.
The response to the rise in heroin use follows patterns we’ve seen over decades of drug scares. When the perception of the user population is primarily people of color, then the response is to demonize and punish. When it’s white, then we search for answers. Think of the difference between marijuana attitudes in the “reefer madness” days of the 1930s when the drug was perceived to be used in the “racy” parts of town, and then the 1960s when white college towns exploded in use.
Heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women in their late 20s living outside of large urban areas. The cause for this may be simple. White people addicted to prescription opiates, the sorts of drugs they could conveniently get from a friendly doctor or pharmacist, are finding heroin an obvious (and cheap) substitute now that law-enforcement officials have cracked down on those opiates. The hottest fronts in this war now can be seen in rural states like Vermont and in suburban areas that largely missed the ravages of the crack craze.
While the takeaway should absolutely be that these harm reduction measures and more sensible drug policies are a positive step for society overall, and a much-needed demonstration of compassion and humanity towards people struggling with addiction, it would behoove us as drug policy reformers to never forget that our progress is not truly progress if it not for all of us.