Heroin is a fascinating drug. But perhaps the most engaging thing about it to me is the depth of misconceptions about it that run rampant in our War on Drugs society. Even among the post-D.A.R.E. pro-drugs crowd, there are huge and gaping holes in the knowledge about how dangerous heroin is and why it's dangerous. And I believe that those misconceptions are the single biggest danger surrounding heroin usage.

Before I get into the reasons why, let me say the following: heroin is a dangerous drug that can ruin your life and/or kill you. There is no doubt about that. I don't advocate the use of heroin; I know people who have and do use heroin; I know people who have died as a result of heroin usage. It's a good way to fuck up your life. it's a good way to put yourself right in the path of a speeding Hepatitis C train. It's a good way to contract HIV. However, most of those problems are unneccesary consequences of heroin use. That's my story and I'm stickin' to it.

Let's tackle some of the most common myths about the dangers of heroin usage:

Heroin is so addictive that drug dealers give free samples to get people hooked.
The physical addiction (tolerance and presence of withdrawal symptoms in the absence of the drug) that society associates with opiate addiction sets in very gradually. While moderate tolerance can be observed fairly quickly the physical dependance that produces withdrawal symptoms only sets in after a period of weeks or months of continuous daily usage. What is more, tolerance appears to be situationally specific -- give a regular user a fix in his usual surroundings, he's fine, but give him the same dose in an unfamiliar settings and the chances of an overdose skyrocket.

What is more of a problem is psychological dependancy (that term is not meant to suggest that there isn't a chemical component like dopamine or other mechanisms involved) and socialization. Studies suggest that for many street users of heroin, being an 'addict' may frequently or even usually involve sub-physically-addictive dosages and dosage intervals. At issue there is both classical psychological dependancy (a la cocaine addiction), which is certainly one of the major dangers of the drug, but also a social state -- the idea being that these people are addicts because they are part of heroin culture, not because they need the drug. They use because their friends use; they use as a diversion from the shitty reality of living on the street; and they use because in their minds they are addicts. However, it is not uncommon for people in these circumstances to stop using abruptly, and without significant consequences. Middle- and upper-class users who use regularly but without developing habits are called chippers and are much less likely to identify as addicts, even if they use as regularly as street users.

Heroin is very, very bad for you.
Actually, there is very little to suggest that heroin per se is harmful. Medically speaking, middle- and upper-class users tend to be in average physical condition. There are documented cases of people with opiate-dependencies spanning decades without significant health problems as a result. There are four ways that heroin users tend to harm themselves, and none of them except overdosing is a direct result of diacetylmorphine itself. They are: overdose (which is vastly less common than popularly thought, but more on that below); adulterant toxicity; malnutrition; and damage caused by needle usage (diseases like HIV and hepatitis, vein damage, etc). Overdose, adulterants, and needle problems are all solvable and for the most part have fairly obvious solutions (which, ironically, the War on Some Drugs discourages). Malnutrition is more a problem for street users than more well off users, and causes most of the physical characteristics associated with "heroin chic" -- emaciation, sunken eyes, etc.

Consider, as well, the use of long-term methadone use as a treatment for heroin addiction. Methadone is a long acting opiate which actually has worse (and longer) withdrawal symptoms than heroin. In maintenance methadone treatment users are given regular doses in order to keep off withdrawal. They effectively substitute one addiction for the other. This treatment can last indefinitely. It's useful because methadone doesn't have the euphoric kick that heroin does, so users are disinclined to elevate doses or dosing intervals. Methadone is otherwise very similar to heroin and other narcotic opiates and body toxicity would make it a poor choice for prolonged treatment (I know this doesn't prove that heroin isn't harmful to the body, but that fact is well documented; I'm just trying to give common sense support to that notion).

Heroin withdrawal is so horrible that a junkie will do anything to avoid it.
While it is true that heroin withdrawal produces shivers, vomiting and cold sweats, short term withdrawal symptoms have been wildy exaggerated in the media. The experience for a hardcore user (someone who is using multiple times a day for months at a time) is likened to a somewhat nasty flu and lasts only 48-72 hours. Many long-term junkies will periodically abstain for a while, choosing to go through withdrawal in order to reduce their tolerance. Others are forced to kick abruptly when their connection dries up, they run out of money, they end up in jail, etc. This withdrawal period is far less intense, uncomfortable or dangerous than alcohol or barbituate withdrawal, which in some settings can kill the user.

There is a long-term withdrawal, lasting 20-40 weeks, however, that many users have a harder time with. Primary symptoms are an increased appetite for sleep and dysthymia (long-term, low grade depression).

However, as mentioned before, heroin use, even regular and long term usage, doesn't immediately imply the presence of these symptoms when a user kicks. And again, a more difficult factor is setting and socialization.

Most people who use heroin eventually overdose and die; they eventually misjudge a dosage and are dead in minutes
There is some documentation to support the notion that heroin purity has gone up, and it is true that this factor makes overdosing more likely. But the popular notion of what happens in a heroin overdose is radically wrong, and though statistics on the matter are hard to come by, it would seem that the majority of deaths attributed to "heroin overdose" are actually a result of one or two other factors.

A heroin overdose causes the respiratory and cardiac systems to slow for a period of 4-6 hours until eventually respiration ceases entirely. For most of this period it is possible to reverse the effects of the overdose by stimulating the central nervous system. This is most effectively done with a drug like naloxone (trade name Narcan) which stimulates the CNS and blocks opiate receptors. However, due to general paranoia about criminal repercussions, many overdoses are either treated late or not at all. It appears that a quarter to a third of I.V. heroin deaths are caused solely from acute morphine intoxication (heroin is metabolized to morphine, which is then responsible for the effects on the body -- it is more powerful than morphine only because it is able to cross the blood-brain barrier much more rapidly).

The other causes of heroin deaths attributed to 'overdose' appear to be quinine intoxication and interaction with other CNS depressants such as alcohol and barbiturates. The incidence of sudden death in heroin users was only reported after 1939, when quinine began appearing as a cut in heroin (possibly as a result of a malaria outbreak among users, though this may be apocryphal). Quinine is also bitter and has a similar texture to heroin, making it a good candidate for an adulterant. Alcohol and barbiturates both have the properties of being cheap and alleviating the discomfort of withdrawal somewhat. Together these explanations seem to cover the two-thirds to three-quarters (some researchers claim the figure is higher and potentially accounts for nearly all heroin deaths). In many 'overdose cases there is little to suggest that the user had taken enough heroin to cause an overdose in even an opiate-naive person. Many of these cases exhibit pulmonary edema and sometimes cerebral edema, which can be explained via the quinine theory. Other studies show that heroin tolerance drops dramatically with the presence of alcohol in the bloodstream, and while barbituates don't seem to show the strength of the drop that alcohol does, any CNS depressant will place the user at higher risk. Sociological studies of heroin users show that most regular users don't drink much while they are using, but those that do undoubtedly put themselves at a far greater risk than nondrinkers.

An assessment of the relationship of the harms outlined above to the manner in which the War on Drugs attempts to control heroin usage isn't very encouraging. The government has fought against needle exchange programs, which are an obvious and well-substantiated way to control the spread of HIV and hepatitis. The emphasis on punishment over treatment means that it is difficult for street addicts (those most likely to be caught in the war) to escape the social setting of other heroin users. And the primary dangers of shooting up -- 'overdose' in it's different guises, can be avoided by giving users easier access to Narcan; by making available methods to clean up heroin of adulterants (a fairly simple process; and what a strange irony that this substance, considered incredibly dangerous, would be considerably less dangerous if it was always pure!); and by educating people about the danger of polydrug abuse. Heroin deaths could drop drastically. Unfortunately the primary mechanism of action in the WOD is to make drugs so dangerous that people won't want to use them; the casualties that come as a result, regardless of how preventable they are, are simply collateral damage that feeds back into the next year's D.A.R.E. statistics handout.

Further information for those interested in reading about how the War on Drugs is killing people:

  • Heroin withdrawal : http://www.heroin-information.org/heroin/pages/how_bad_withdrawal.html
  • Fatal heroin 'overdose': a review : http://www.lindesmith.org/library/darke2.html
  • The heroin problem: an overview : http://www.druglibrary.org/schaffer/heroin/opiates.htm
  • The "heroin overdose" mystery : http://www.druglibrary.org/schaffer/Library/studies/cu/cu12.htm
  • Ethanol abuse in the etiology of heroin-related deaths : http://www.hoboes.com/html/Politics/Prohibition/Notes/Heroin-Ethanol_Abuse.html
  • Drug War Facts - Heroin : http://www.drugwarfacts.org/heroin.htm
  • The persistent, Dangerous Myth of the Heroin Overdose : http://www.peele.net/lib/heroinoverdose.html
  • Heroin, Myths and Reality, Jara A. Krivanek
  • The Hardest Drug, John Kaplan
  • Careers in Dope, D. Walden