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<div class='wkToc'><table bgcolor='#000000' cellpadding='1' cellspacing='0'><tr><td><table bgcolor='#eeeeee' class='wkCTb'><tr><td><h4>Contents</h4><ul><li><a href='#hd1'>History</a><br/><li><a href='#hd2'>Usage and effects</a><br/><li><a href='#hd3'>Production and trafficking</a><br/><li><a href='#hd4'>Risks of non-medical use</a><br/><li><a href='#hd5'>Withdrawal</a><br/><li><a href='#hd6'>Heroin prescription</a><br/><li><a href='#hd7'>Drug interactions</a><br/><li><a href='#hd8'>Culture</a><br/><li><a href='#hd9'>See also</a><br/><li><a href='#hd10'>References</a><br/><li><a href='#hd11'>Literature</a><br/><li><a href='#hd12'>External links</a><br/></ul></td></tr></table></td></tr></table></div>
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In the United Kingdom heroin is available on prescription, though it is a restricted Class A drug. According to the British National Formulary (BNF) edition 50, diamorphine hydrochloride may be used in the treatment of acute pain, myocardial infarction, acute pulmonary edema, 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, heroin is often injected using a syringe driver. In comparison to morphine, it may cause less nausea, hypotension, sedation, euphoria and can be dissolved in a smaller quantity of liquid.
Heroin is also widely and illegally used as a powerful and addictive drug that produces intense euphoria, which often disappears with increasing tolerance. It is thought that heroin's popularity with recreational users, compared to morphine or other opiates, comes from its somewhat different perceived effects
First morphine is isolated from the crude opium (through being dissolved in water, reacted with lime fertilizer such that it precipitates out, and then reacted again with ammonia; what is left is then mechanically filtered to yield a final product of morphine weighing about 90% less than the original quantity of opium). The morphine is reacted with acetic anhydride â€" a chemical also used in the production of aspirin â€" in the complicated five-step process used by most refineries in the Golden Triangle. The first step is to cook the morphine at 85°C (185°F) for six hours with an equivalent weight of acetic anhydride. In the second, a treatment of water and hydrochloric acid then purifies the product moderately. When the chemists add sodium carbonate, the particulates settle. Step four involves heating the heroin in a mixture of alcohol and activated charcoal until the alcohol evaporates. The fifth step is optional, as it only changes the heroin into a finer white powder, more easily injectable; this so-called "no. 4 heroin" is principally exported to the Western markets. In this last, most dangerous step, the heroin (after being dissolved in alcohol), precipates out in tiny white flakes when a mixture of ether and hydrochloric acid is injected; this step is dangerous due to the fact that the ether may explode, leveling or severely damaging the refinery (as has happened to a number of such facilities).
The purity of the extracted morphine determines in large part the quality of the resulting heroin. Most black market heroin is highly impure due to contaminants left after refinement of opium into morphine which then remain in the final product; even if the final product is in the upper range of purity (80â€"99% pure), once it reaches the consumer, it typically has been cut multiple times.HistoryThe 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 Tietsin) 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 heroin trade.
Heroin trafficking was virtually eliminated in the U.S. during World War II due to 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 the second world war, 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 from Iran westward into Europe and the United States. 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 abuse led most western countries to declare heroin a controlled substance by the latter half of the 20th century.
Between the end of World War II and the 1970s, much of the opium consumed in the west was grown in Iran, but in the late 1960s, under pressure from the U.S. and the United Nations, Iran engaged in anti-opium policies. While opium production never ended in Iran, the decline in production in those countries led to the development of a major new cultivation base in the so-called "Golden Triangle" region in South East Asia. In 1970-71, high-grade heroin laboratories opened in the Golden Triangle. This changed the dynamics of the heroin trade by expanding and decentralizing the trade. Opium production also increased in Afghanistan due to the efforts of Turkey and Iran to reduce production in their respective countries. Lebanon, a traditional opium supplier, also increased its role in the trade during years of civil war.
After the overthrow of the Shah of Iran, the new Iranian regime was much more tolerant of opium production. At the same time, the Soviet-Afghan war lead to increased production in the Pakistani-Afghani border regions. Both events led to increased international production of heroin at lower prices in the 1980s. The trade shifted away from Sicily in the late 1970s as various criminal organizations violently fought with each other over the trade. The fighting also led to a stepped up government law enforcement presence in Sicily. All of this combined to greatly diminish the role of the country in the international heroin trade.Dr Alfred W. McCoy's account of the history of the heroin tradeAlthough it was beginning to become more prevalent by the 1930s, Asian historian and drug traffic expert Dr Alfred W. McCoy reports that heroin trafficking was virtually eliminated in the U.S. during World War II due to temporary trade disruptions caused by the war. McCoy contends the Mafia was able to gain control of the heroin trade thanks in large measure due to the unintended consequences of a covert deal between top Mafia leader Lucky Luciano and American military intelligence. The deal resulted in a large increase in Mafia influence in Sicily after the 1943 American invasion.
In southeast Asia, the governments of most countries and many colonial officials had been involved in the opium trade for a very long time. Thanks to Corsican Mafia connections in the former French colony of Vietnam, Luciano was able to begin to develop Southeast Asia as a new source of Opium even as Iranian production declined. The Vietnam War and C I A operations in Laos had the unintended consequence of first opening up many areas of Southeast Asia to modern transportation and then presenting a ready-made market for the drug among the U.S. military personnel stationed in the region.
The turning point came in 1970-71 when the first high-grade heroin laboratories opened in the Golden Triangle. Prior to this, the chemical skills for refinement had existed only in Europe. This gave the opium producers control over the creation of the final product. The hundreds of thousands of American servicemen in Vietnam provided a perfect market for the heroin producers, and heroin use among soldiers rapidly increased. In 1971 the first large consignments of South East Asian heroin were intercepted in Europe and America, and by the mid-1970s heroin addiction fulfilled its promise as a serious social problem in the United States, Australia, the United Kingdom, and many other nations.TraffickingSee also: Opium production Traffic is heavy worldwide, with the biggest producer being Afghanistan. According to U.N. sponsored survey [1], as of 2004, Afghanistan accounted for production of 87 percent of the world's heroin. It is thought that such organizations as Al-Qaeda and Taliban are largely funded by heroin trafficking. [2] [3] | Heroin concealed under the clothes of a drug smuggler. |
Some observers, particularly political conservatives in the United States, have accused China of being a leading producer of heroin. Dr. Alfred W. McCoy has claimed that the C.I.A. secretly collaborated with Asian drug syndicates and was complicit in the expansion of the global heroin trade from 1970 to 1973 in order to prosecute the Cold War. While the Vietnam War brought modern transportation to remote opium areas, McCoy himself does not claim that the CIA set up the drug labs in Southeast Asia or created the trade.
Heroin is one of the most profitable illicit drugs since it is compact and easily concealed. At present, opium poppies are mostly grown in the Middle East, Pakistan, and Afghanistan, and in Asia, especially in the region known as the Golden Triangle straddling Myanmar, 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. However, the efforts of Pakistan's Anti-Narcotics Force have since reduced the opium growing area by 59% as of 2001. Some suggest that the decline in Pakistani production is inversely proportional to the rise of Afghani production, and that rather than anti-narcotics activity, the decline in Pakistan is due more to changed market forces.
Conviction for trafficking in heroin carries the death penalty in most Southeast Asia and some East Asia, southern Asia and Middle East 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 or the hanging of Australian citizen Van Tuong Nguyen in Singapore, both in 2005.* Overdose, possibly causing death
* For intravenous users of heroin, the use of non-sterile needles and syringes and other materials leads to the risk of contracting blood-borne pathogens such as HIV and/or hepatitis infections as well as the risk of contracting bacterial or fungal endocarditis
* Poisoning from contaminants added to "cut" or dilute heroin
* Chronic constipation
* Venous sclerosis
* Tolerance leading to larger doses to achieve the same effect
* Heroin-induced leukoencephalopathy (smokers only)
Many countries and local governments have begun funding programs to supply sterile needles to people who inject illegal drugs, in an attempt to reduce some of these contingent risks including the contraction and spread of blood-bourne diseases. The Drug Policy Alliance reports that up to 75% of new AIDS cases among women and children are directly or indirectly a consequence of injection drug use. But despite the immediate public health benefit of needle exchanges, some see such programs as tacit acceptance of illicit drug use. The United States does not support needle exchanges federally by law, and although some state and local governments do support needle exchange programs, they continue to face harassment by police in most areas. Needle exchanges have been instrumental in arresting the spread of HIV/AIDS in many communities with a significant heroin using population, Australia being a leader due to its early inception of needle exchanges. Needle exchange programs have also been attributed for saving the public significant amounts of tax dollars by preventing medical costs which would have been required otherwise for the treatment of diseases spread through the practice of sharing/re-using needles.
A heroin overdose is usually treated with an opioid antagonist, such as naloxone (Narcan) or naltrexone, which have a high affinity for opioid receptors but do not activate them. This blocks heroin and other opioid agonists and causes an immediate return of consciousness and start of withdrawal symptoms when administered intraveneously. The half-life of these antagonists is usually much shorter than that of the opiate drugs they are used to block, so the antagonist usually has to be re-administered multiple times until the opiate has been metabolized by the body.
A heroin overdose is not fast-acting, it very often takes many hours to die. An overdose is immediately reversible with an opioid antagonist injection. Heroin overdoses can occur due to an unexpected increase in the dose or purity or due to diminished opiate tolerance. However, many fatalities reported as overdoses are probably caused by interactions with other depressant drugs like alcohol or benzodiazepines.
The LD50 for a person already addicted is prohibitively high, to the point that there is no general medical consensus on where to place it. Several studies done in the 1920s gave addicts doses of 1,600–1,800 mg of heroin in one sitting, and no adverse effects were reported. This is approximately 160–180 times a normal recreational dose. Even for a non-addict, the LD50 can be credibly placed above 350 mg.
Street heroin is of widely varying and unpredictable purity. This means that an addict may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, relapsing addicts after a period of abstinence have tolerances below what they were during active addiction. If a dose comparable to their previous use is taken an overdose often results.
A final source of overdose in addicts comes from place conditioning. Heroin use, like other drug abuse behaviors is highly ritualized. While the mechanism has yet to be clearly elucidated, it has been shown that longtime heroin users, immediately before injecting in a common area for heroin use, show an acute increase in metabolism and a surge in the concentration of opiate-metabolizing enzymes. This acute increase, a reaction to a location where the addict has repeatedly injected heroin, imbues the addict with a strong (but temporary) tolerance to the toxic effects of the drug. When the addict injects in a different location, this place-conditioned tolerance does not occur, giving the addict a much lower-than-expected ability to metabolize the drug. The user's typical dose of the drug, in the face of decreased tolerance, becomes far too high and can be toxic, leading to overdose.
A small percentage of heroin smokers may develop symptoms of leukoencephalopathy. This is believed to be caused by an uncommon adulterant that is only active when heated. Symptoms include slurred speech and difficulty walking. Contrary to popular rumor, aluminum foil probably has nothing to do with the development of leukoencephalopathy in heroin users.The withdrawal syndrome from heroin (or any other short-acting opioid) can begin within 6 hours of discontinuation of sustained use of the drug, however this time frame can fluctuate with degree of dependency and tolerance. Symptoms include: sweating, malaise, anxiety, depression, persistent and intense penile erection in males (priapism), general feeling of heaviness, cramp-like pains in the limbs, yawning and lacrimation, sleep difficulties, cold sweats, chills, severe muscle and bone aches not precipitated by any physical trauma, nausea and vomiting, diarrhea, gooseflesh (hence, the term "cold turkey"), cramps, and fever occur. Many addicts also complain of a painful condition, the so-called "itchy blood", which often results in compulsive scratching that causes bruises and sometimes ruptures the skin leaving scabs. Abrupt termination of heroin use causes muscle spasms in the legs of the user (restless leg syndrome), hence the term "kicking the habit". Users seeking to take the "cold turkey" (without any preparation or accompaniments) approach are generally more likely to experience the negative effects of withdrawal in a more pronounced manner.
Two general approaches are available to ease opioid withdrawal. The first is to substitute a longer-acting opioid such as methadone or buprenorphine for heroin or another short-acting opioid and then slowly taper the dose. The other approach, which can be used alone or in combination, is to relieve withdrawal symptoms with non-opioid medications.
In the second approach, benzodiazepines such as diazepam (Valium) ease the often extreme anxiety of opioid withdrawal. The most common benzodiazepine employed as part of the detox protocol in these situations is oxazepam (Serax). Benzodiazepine use can also lead to a dependence, and many opiate addicts also abuse other central nervous system depressants including benzodiazepines and barbiturates. Also, though unpleasant, opiate withdrawal seldom has the potential to be fatal, whereas complications related to withdrawal from benzodiazepines, barbiturates and alcohol (such as seizures, cardiac arrest, and delirium tremens) can prove hazardous and potentially fatal. Many symptoms of opioid withdrawal are due to rebound hyperactivity of the sympathetic nervous system, and this can be suppressed with clonidine (Catapres), a centrally-acting alpha-2 agonist primarily used to treat hypertension.
Buprenorphine is one of the most recent opioid agonist/antagonist used for treating addiction. It develops tolerance much more slowly than heroin or methadone. It also has a withdrawal many times softer than heroin and other opioids. It can be administered up to every 24-48 hrs. By itself buprenorphine has low overdose dangers. Buprenorphine is a kappa-opioid receptor antagonist. This gives the drug an anti-depressant effect, increasing physical and intellectual activity. Buprenorphine also acts as a partial agonist at the same μ-receptor illicit opiates such as Heroin initiate from. Due to its effects on this receptor, patients are unable to obtain any "high" from other opiates during buprenorphine treatment.
Researchers at Johns Hopkins University have been testing a sustained-release "depot" form of buprenorphine that can relieve cravings and withdrawal symptoms for up to six weeks.
The University of Chicago undertook preliminary development of a heroin vaccine in monkeys during the 1970s, but it was abandoned. There were two main reasons for this. Firstly, when immunised monkeys had an increase in dose of x16, their antibodies became saturated and the monkey had the same effect from heroin as non-immunised monkeys. Secondly, until they reached the x16 point immunised monkeys would substitute other drugs to get a heroin-like effect. These factors suggested that immunised human addicts would simply either take massive quantities of heroin, or switch to other hard drugs, which is known as cross-tolerance.
There is also a controversial treatment for heroin addiction based on a plant-derived Africanpsychedelic drug, ibogaine. Many people travel abroad for ibogaine treatments thatgenerally interrupt the addiction for 3 - 6 months or more in up to 80% of patients. Relapse often occurs when the person returns home to their normal environment however, where drug seeking behaviour may return in response to social and environmental cues. Ibogaine treatments are carried out in several countries in South America and in Europe but can be dangerous. Some addicts find the ibogaine therapy most effective when it is given several times over the course of a few months or years, but this can be very expensive. A synthetic derivative of ibogaine, 18-methoxycoronaridine is in phase 2 trials in humans as an anti-addictive drug.In 1994 Switzerland began a trial program featuring a heroin prescription for addicts not well suited for withdrawal programs--e.g. those that had failed multiple withdrawal programs. The aim is maintaining the health of the addict in order to avoid medical problems stemming from low-quality street heroin. Reducing drug-related crime is another goal. Addicts can more easily get or maintain a paid job through the program as well. The first trial in 1994 began with 340 addicts and it was later expanded to 1000 after medical and social studies suggested its continuation. Participants are prescribed to inject heroin in specially designed pharmacies for about US $13 per dose.
The success of the Swiss trials led German, Dutch, Canadian [4] and Australian cities to trial their own heroin prescription programs.Drugpolicy.org on Swiss trials, Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis by Carlos Nordt, Rudolf Stabler. The Lancet 367, 1830-4 (2006), BBC online on Dutch trialsOpiates are strong central nervous system depressants, but regular users develop physiological tolerance allowing gradually increased dosages. In combination with other central nervous system depressants, heroin may still kill experienced users, particularly if their tolerance to the drug has reduced or the strength of their usual dose has increased.
Toxicology studies of heroin-related deaths reveal frequent involvement of other central nervous system depressants, including alcohol, benzodiazepines such as diazepam (valium), and occasionally methadone. Ironically, benzodiazepines and methadone are often used in the treatment of heroin addiction.
Cocaine also proves to be often fatal when used in combination with heroin. Though "speedballs" (when injected) or "moonrocks" (when smoked) are a popular mix of the two drugs among users, combinations of stimulants and depressants can have unpredictable and sometimes fatal results. In the United States in early 2006, a rash of deaths have been attributed to either a combination of fentanyl and heroin, or pure fentanyl masquerading as heroin particularly in the Detroit Metro Area; one news report refers to the combination as 'laced heroin', though this is likely a generic rather than a specific term.[Heroin has inspired countless writers, musicians and other artists over the past century of use.]
*Black Tar Heroin
*Cheese (recreational drug)
*Hillbilly heroin
*China White
*Drugs and prostitution
*Methadone
*Recreational drug use
*Psychoactive drug
*Scag
*List of people known to be addicted to opiates
*List of famous drug smugglers
*Opium
*PoppyHeroin (1998) ISBN 1-568-38153-0
Heroin Century (2002) ISBN 0-415-27899-6
This is Heroin (2002) ISBN 1-860-74424-9
The Heroin User's Handbook by Francis Moraes (paperback 2004) ISBN 1-559-50216-9
The Little Book of Heroin by Francis Moraes (paperback 2000) ISBN 0-914-17198-4
Heroin: A True Story of Addiction, Hope and Truimph by Julie O'Toole (paperback 2005) ISBN 1-905-37901-3
*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)
*Heroin Helper
*[https://www.cia.gov/cia/publications/heroin/flowers_to_heroin.htm From Flowers to Heroin], CIA publication.
*The mismanagement of methadone
*Harrowing Heroin by Geoff Morton
*National Alliance of Advocates for Buprenorphine Treatment - non-profit education website for treatment of Heroin addiction
*NIDA InfoFacts on Heroin
*ONDCP Drug Facts
*Role of Government of Pakistan in Narcotics Control
*United States Department of State fact sheet: anti-narcotics efforts in Pakistan - dated June 7, 2002
*BBC Article entitled 'When Heroin Was Legal'. References to the United Kingdom and the United States
*Heroin Facts
* Information on heroin and other illicit drugs
*Can poppy seeds make you test positive for heroin?
*Heroin news page - Alcohol and Drugs History Society
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