Heroin is an illicit, schedule 1 drug because it is considered to have no accepted medical use and a high potential for abuse.
Illicit drugs that can only be purchased through black markets carry with them many dangers. The main risk associated with illicit drugs is that no one can be sure of their true contents unless they undergo chemical analysis.
This is particularly the case with street heroin, which contains an estimated 7%-10% to a maximum of 20% pure heroin [1]. It is estimated that no heroin found on the streets is fully pure, despite the recent increase in demand for a purer product.
Unfortunately, the presence of adulterants in heroin makes it significantly more dangerous, as it can lead to someone unknowingly taking a synthetic opioid like fentanyl that is many magnitudes more powerful than heroin.
From 2012-2014, overdose deaths from synthetic opioids more than doubled in the U.S. As of 2015, there were 2.5 million opioid users in America, and synthetic opioids have been causing more overdose deaths than heroin.
Now, opioids are responsible for more overdoses than any other drug, with heroin and fentanyl-related deaths rising worldwide. Drug overdose deaths are up 327% in Canada, 64% in the United Kingdom, and 61% in Australia [2].
With the number of opioid-related deaths increasing around the world, contaminated heroin has become a public health crisis of increasing worldwide concern.
Heroin is a semi-synthetic illicit street drug that is made from the unripened seed pods of the opium poppy plant and morphine. Also known as diacetylmorphine or diamorphine, heroin belongs to the opioid family of drugs that are primarily used to relieve pain and induce anaesthesia.
Once heroin enters the brain, it rapidly binds to pain receptors and other opioid receptors that play a central role in reward. When heroin binds to the reward pathway, it triggers the release of the neurotransmitter dopamine, causing feelings of intense euphoria, happiness, and relaxation.
These euphoric effects can be incredibly helpful for users in terms of temporarily relieving distress. However, they are also responsible for heroin’s addictive potential, which ultimately leads to physical and psychological dependence and a wide range of potentially life-threatening issues.
Much of street heroin consists of diluents that are added so that more of the product can be made at less expense. This addition of diluents, or fillers, as they are sometimes called, is referred to as “cutting”.
Cutting heroin with these substances dilutes the drug somewhat, thus decreasing its potency. Using cheap, available substances that are legal and not pharmacologically active increases profits for sellers at all levels of the distribution chain.
On the other hand, “lacing” heroin refers to the practice of adding consciousness-altering adulterants with the purpose of increasing heroin’s potency and intensifying the euphoric effects. When the drug is more powerful, it becomes more desirable for users.
Because heroin comes in three different forms, black tar heroin, brown heroin, and white powder heroin, it is easy to add similar-looking substances that may include to cover up a potentially poor-quality product.
Some heroin manufacturers use diluents that have similar properties to heroin also. For example, griseofulvin has a bitter taste like heroin, and paracetamol has similar analgesic properties [3]. Furthermore, diluents and adulterants added to heroin have similar boiling points to ensure that the cutting process is smooth.
Oftentimes diluents and adulterants are added to make the administration of the drug more efficient. For example, caffeine, procaine, and the highly toxic pesticide strychnine vaporise at lower temperatures, and so facilitate ease of smoking [4].
Most producers and sellers of heroin are adamant that their product remains desirable to ensure they continue to attract new customers. Therefore, they are eager to keep up to date with the latest methods of administration [5].
Most heroin dealers are businessmen who want to maintain a steady customer base, so it would make no sense to lace heroin with harmful substances. Only inexperienced, malicious, or unlearned dealers would ever cut heroin with substances that could dangerously increase the risk of overdose or death for users [6].
Heroin is cut before exportation or right after importation to the intended destination [7].
Diluents used to cut heroin are relatively harmless compared to potentially poisonous adulterants. Diluents may include, but are not limited to the following:
In the 60s and 70s in Europe, caffeine, quinine, lactose, and mannitol were used more than any other substances for the purposes of cutting heroin [8].
Throughout the 80s, quinine was detected much less in street heroin whereas the use of a local anaesthetic drug called procaine increased, as did the use of caffeine and paracetamol.
It had been surmised for many years that the paracetamol added to heroin is illicit paracetamol, which was discoloured to look like base heroin. Large quantities of paracetamol and caffeine mixtures associated with heroin trafficking have been seized across Europe.
From the 90s onwards, caffeine and paracetamol were detected in heroin more than any other substances across Europe, with most studies reporting the presence of both in over 90% of samples.
Nowadays, glucose, sucrose, lactose, mannitol, and quinine are the most used diluents in street heroin [9].
Heroin is often referred to as “brown sugar” on the street, which may be due to the use of actual brown sugar in the manufacturing of the product. Brown sugar is a type of sucrose sugar that gets its colour from the presence of molasses.
Sucrose is often used in the making of black tar heroin in particular and is responsible for its sticky texture.
Sucrose has been detected in up to 65% of heroin samples in parts of Europe, and in up to 21% of samples collected in the U.S.
Pure heroin comes as a white powder, and so lactose, or powdered milk as it is otherwise known, is added to heroin to make it look like it is of high quality to buyers and users.
Lactose is also quite cheap to buy and allows for large quantities of the drug to be produced at a much lower expense to suppliers.
Studies have reported the presence of lactose in up to 33% of collected heroin samples in Europe, and 17% of samples collected in the U.S.
Mannitol is a type of sugar alcohol derived from corn starch that is usually used as a low-calorie sweetener or as a medication. As a medication, mannitol is used to treat pressurised eyes in people with glaucoma, or to relieve pressure inside the skull.
Mannitol is also used as a diuretic when testing for asthma.
Similar to lactose, mannitol is white and powdery and is most likely used to give buyers and users the impression of high purity.
It is estimated that mannitol is present in approximately 38% of heroin samples.
Quinine is a natural substance derived from the bark of the cinchona tree native to the tropical Andean forests of South America. Quinine comes in powdered form that is brown in colour.
Originally developed as a treatment for malaria, quinine also used to be prescribed to treat cramping of the legs before the Food and Drug Administration issued a series of warnings against its use. Small amounts of quinine are also used in the making of Indian tonic water, due to its distinguishing bitter taste.
Quinine is detected in up to 68% of collected samples across the U.S.
Adulterants are added to heroin either to mimic the effect of heroin or make the drug more powerful by intensifying its euphoric effects. The most commonly used adulterants may include, but are not limited to the following:
In rare cases, uncommon and quite strange substances are added to heroin with devastating consequences.
A study reported the case of a woman who developed nasty necrotic lesions on her forearms in the aftermath of injecting heroin. It was found that the heroin she had injected had been cut with “rizzy” powder, which is ordinarily used to keep flowers fresher for longer [10].
Incredibly potent opioids and synthetic opioids are often added to heroin to make it more powerful.
The prevalence of fentanyl in street heroin has increased by over 1400% since 2013, largely because it is relatively inexpensive to purchase, easy to make, and easier to traffic. Since 2015, fentanyl has been the most commonly found synthetic opioid in street heroin.
Synthetic opioids like fentanyl are particularly concerning as they can be lethal in very small doses. For example, fentanyl is said to be approximately 50 times more potent than heroin, so it vastly increases the chances of abuse, dependence, and fatal or non-fatal overdose [11].
With the increased supply and demand of heroin, incidences of fentanyl-related overdose deaths have more than doubled [12]. Furthermore, fentanyl is now the main cause of death in more than half of all overdose fatalities [13].
Another particularly dangerous substance often detected in heroin is carfentanil, a synthetic opioid analgesic that is used to anaesthetise large animals. Carfentanil can be up to 100 times more potent than fentanyl, which gives you an indication of just how deadly it can be.
After fentanyl or carfentanil-laced heroin hits a particular area, there is usually a short-term increase in overdoses and deaths. Fentanyl and carfentanil are so powerful that first responders have to wear personal protective equipment when they arrive at the scene of a suspected overdose.
Fentanyl test strips, which are used to test for the presence and absence of fentanyl and fentanyl analogs in street drugs, can be very effective in preventing fentanyl-related overdose.
A study that investigated the effectiveness of fentanyl test strips found that they had a 96-100% success rate at detecting fentanyl and a 90-98% success rate at detecting its absence [14].
Furthermore, the use of fentanyl test strips and receiving a positive test result has been associated with improvements in drug use behaviour and perceptions of overdose safety.
Evidence of test strips’ efficacy suggests that they may be a very effective harm-reduction tactic, especially when used in conjunction with other evidence-based prevention methods [15].
Unfortunately, test strips are incapable of measuring the quantity or potency of fentanyl should it be present in a sample of heroin.
Heroin can also be contaminated by substances that are unintentionally added during the production stage. Heroin that comes into contact with other substances during packaging may also become contaminated.
Contaminants may include:
Unfortunately, it is extremely difficult if not impossible to determine if harmful adulterants or diluents have been added to heroin merely by looking at it.
Again, this is because most dealers use cutting agents that have similar properties, like colour, for example, to remove any doubt about the product’s quality.
There are however some signs to watch out for that may be indicative of the presence of a potentially toxic substance. If you suspect that the product smells a bit funny or the colour is slightly off, this could be an indication that it has been cut with a potentially harmful cutting agent.
For example, heroin that is cut with laundry detergent may have different colours running through it or have a sparkly quality.
Deaths due to illicit drug overdose have reached an all-time high. According to the Centres for Disease Control and Prevention, overdose-related deaths rose by almost 30% from 2020 to 2021, with annual deaths now exceeding those due to motor vehicle accidents and gun violence [16].
Listed below are signs of a heroin-related overdose:
Anyone who overdoses on an opioid requires immediate medical attention. If a person comes upon a suspected case of opioid overdose, they should:
Naloxone, an opioid receptor antagonist drug that blocks and reverses the effects of heroin, should be administered at this time. Naloxone can be administered by emergency service professionals in the UK.
In the U.S., naloxone can be purchased from a pharmacy without a prescription under the brand name “Narcan”.
Naloxone may need to be administered more than once if someone has overdosed on a more potent opioid than heroin, like fentanyl or carfentanil [17].
The safety and efficacy of naloxone have been well-established in the scientific literature. Naloxone has an almost 100% success rate at reversing heroin overdose in clinical trials, with both intranasal and injected naloxone displaying similar efficacy [18].
Naloxone has no potential for abuse, no potential for overdose, and it is extremely inexpensive to make.
People who use heroin on a regular basis eventually develop a tolerance. Drug tolerance, or drug insensitivity as it is sometimes called, refers to the reduced reaction to the drug as a consequence of repeated use.
Heroin users have to take more and more of the drug to combat the effects of tolerance.
After continued use, people may become physically and/or psychologically dependent on heroin, which means that they will begin to experience distressing withdrawal symptoms if they don’t use it.
Due to heroin’s relatively short half-life, withdrawal symptoms typically set in just 6-12 hours after a person’s last uses, and last for 5-10 days in total.
The severity of heroin withdrawal is contingent upon the following factors:
Heroin withdrawal is typically characterised by the following psychological effects:
Recovering from heroin addiction can be quite challenging without proper medical assistance. That is why people who wish to stop using heroin are encouraged to enrol in inpatient or outpatient rehabilitation treatment programmes.
A more comprehensive overview of inpatient and outpatient rehab programmes is provided below:
Inpatient rehab is also known as residential rehab because patients who enrol live in a residential facility for the duration of their treatment. Patients may stay in residential treatment for 6 months to a year.
At inpatient rehab, patients are welcomed into a healthy environment wherein staff members do all they can to support recovery. Staff members are fully focused on helping patients to make the transition from a life blunted by heroin addiction, to a more fulfilling, drug-free life post-treatment.
Advantages of inpatient rehab include:
Inpatient rehab may be particularly helpful for people with comorbidities such as co-occurring mental health conditions.
Potential drawbacks associated with inpatient rehab to consider:
As an alternative to inpatient rehab, people may prefer to opt for the less intense option of outpatient rehab.
Patients do not live in a residential facility as part of outpatient rehab, rather, they travel to receive daily treatment at a rehab facility. This allows patients to continue living at home where they can meet familial, professional, or educational responsibilities.
The majority of outpatient programmes include the same access to group or individual therapy sessions. However, there is a step-down approach employed meaning that the therapy sessions become less intense as patients advance in their recovery.
Advantages of outpatient rehab include:
Disadvantages of outpatient rehab to consider:
[1] https://pubmed.ncbi.nlm.nih.gov/26635443/
[2] https://www.hri.global/files/2016/11/14/GSHR2016_14nov.pdf
[3] https://benthamopen.com/ABSTRACT/TOFORSJ-2-16
[4] https://pubmed.ncbi.nlm.nih.gov/1039284/
[5] https://journals.sagepub.com/doi/abs/10.1177/009145099702400204
[7] https://www.sciencedirect.com/science/article/abs/pii/S0379073811003124
[8] https://journals.sagepub.com/doi/abs/10.1177/002204260603600310
[9] https://www.sciencedirect.com/science/article/abs/pii/S037907381630055X
[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6666922/#REF2
[11] https://www.sciencedirect.com/science/article/abs/pii/S0376871616310596
[12] https://pubmed.ncbi.nlm.nih.gov/27996932/
[13] https://www.sciencedirect.com/science/article/abs/pii/S0955395917301330
[14] https://docs.house.gov/meetings/IF/IF02/20190716/109817/HHRG-116-IF02-20190716-SD003.pdf
[15] https://www.sciencedirect.com/science/article/pii/S0955395918302135
[16] https://www.sciencedirect.com/science/article/abs/pii/S0736467917303694
[17] https://pubmed.ncbi.nlm.nih.gov/25865597/
[18] https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2009.02724.x
Boris is our editor-in-chief at Rehab 4 Addiction. Boris is an addiction expert with more than 20 years in the field. His expertise covers a broad of topics relating to addiction, rehab and recovery. Boris is an addiction therapist and assists in the alcohol detox and rehab process. Boris has been featured on a variety of websites, including the BBC, Verywell Mind and Healthline. You can connect with Boris online at LinkedIn or X.com.
