Dorothy and Toto slipped into a deep sleep when they traipsed through a field of red poppies in the Wizard of Oz. Those who wander into the realm of opium-derived drugs outside of Oz, however, are likely to face demons more dangerous than sleepiness and flying monkeys.
When used for medical purposes, opiates are extremely powerful and effective painkillers. But opium and its derivatives -- heroin, fentanyl, hydrocodone, morphine, oxycodone, and codeine -- are also extremely addictive drugs, with potentially hazardous side effects. These drugs can cause serious health problems such as collapsed veins, skin abscesses and massive scarring (when injected), painful withdrawal symptoms, and even death.
What are opiates?
The term narcotic comes from the Greek word "narkotikos," which means "to make numb," and is the name of the group of drugs that includes opium and its derivatives. References to opium date back to 3,000 B.C. and its popularity for both medicinal and recreational use created a bustling trade between East and West. It played a major role in the so-called Opium Wars in China in 1839.
Certain varieties of poppy plants contain opium, a raw narcotic extracted from the plant in liquid form and then processed into a brownish powder known as refined opium. It is then sold to drug manufacturers to make morphine and codeine; black market manufacturers alter morphine to produce heroin. Taken into the body, opiates plug into endorphin receptors in the brain, where they mimic the body's natural proteins that help regulate pain, pleasure and emotion. There, narcotics slow down the central nervous system and often produce a short but powerful sensation of euphoria and well-being.
What are the medical uses of narcotics?
In medicine, opiates have long been used to kill and control pain as well as suppress terrible coughing, induce sleep, and prevent diarrhea.
Doctors have widely prescribed the opium derivative codeine as a pain and cough reliever over the years, although its use as a cough suppressant has waned in the face of new, less addictive drugs.
Today the growing opioid epidemic across the United States has many worried. Many people are addicted to OxyContin (oxycodone) and Vicodin (hydrocodone) opioids commonly prescribed for chronic pain management. Similar to morphine, oxycodone can be addictive if not taken as directed.
Historically, medicine's best-known opiate is morphine, which is 10 times stronger than codeine. Morphine's incredible analgesic qualities make it invaluable in hospitals and in the treatment of chronic pain. It's a tricky situation, however -- dependence occurs so easily that addiction caused by medical treatment is very common, according to Dr. Amanda Gruber, a psychiatrist at the Harvard-affiliated McLean Hospital and an expert in addiction. Almost all patients on morphine, codeine, or other prescription opiates develop dependence and go through some level of withdrawal upon discontinuing use.
Relatively minor withdrawal symptoms may include runny nose, sweating and anxiety. Morphine's side effects can also include incoherence, vomiting, and suppression of the immune system, along with irregular or shallow breathing. Respiratory failure is sometimes the cause of death in morphine overdoses.
Along with their pain-killing qualities, opiates are also the most successful type of drug for treating severe diarrhea. The popular over-the-counter drug Imodium (loperamide), for example, is an opiate, but because it never enters the central nervous system it causes none of the addictive symptoms that morphine does.
Which opiates are most likely to be abused?
Drug abuse can fall into two categories: prescription drugs and street drugs. The most common opioid prescriptions likely to be abused include oxycodone, codeine, fentanyl and hydrocodone. Although they come in pill form, they can be crushed and swallowed, snorted or injected.
Around 2000, recreational drug users discovered that prescription OxyContin tablets can be crushed and then injected or snorted, which produces a euphoric, heroin-like high. (The ability to get high by crushing the pill was announced as a "warning" on the drug's label.) This practice quickly turned the medication into a highly addictive drug.
Addicted users often sought out doctors who would write oxycodone or hydrocodone prescriptions without thoroughly checking their medical histories. They sought out the drug on the streets, robbed summer cabins, and even raided medicine cabinets or stole prescription drugs from pharmacies. However, under pressure from federal agencies, the manufacturer changed the formulation in 2000 so that crushing the pills would not produce a euphoric high, and many addicted users went on to heroin instead, according to Science Daily.
Fentanyl -- known by its street names China White, Apache or TNT -- is a synthetic form of heroin that is drastically more potent. Originally developed as an anesthetic in 1968 and used by doctors to control severe pain, fentanyl appeared on the street when illicit labs began producing it in the 1980s. Another synthetic derivative of heroin closely related to fentanyl is meperidine, more widely known by its trade name Demerol; an illegal chemical variation of Demerol appeared on the street as MPPP. All of these synthetic forms of heroin are usually injected, but can also be sniffed or taken orally.
Heroin, also called "smack," "H," or "junk," is the most notorious of injected drugs, and is illegal in the United States (although still legal for medical use in Great Britain, Canada, and several other countries). It is typically sold as white or brownish powder, or as the black sticky substance known on the streets as black tar heroin. Both types of heroin are usually injected, sniffed, or smoked. Intravenous injection ("shooting up," "fixing," or "mainlining") causes the most intense and rapid onset (about seven seconds) of euphoria. Intramuscular injection ("muscling") produces a slower onset (five to eight minutes). Smoking and snorting heroin produce relatively less intense and slower reactions to the drug. While some people believe that you're safe as long as you don't inject it, researchers have found that smack is highly addictive any way you take it.
What are the risks of taking heroin or other opiates?
The hazards include:
- Disease. Needle use carries many health risks, especially if needles are shared and/or reused. Collapsed veins are common among needle users; HIV infection is a huge risk, as are hepatitis and other bacterial infections passed through dirty needles. San Francisco has been plagued by a "flesh eating" bacteria spread through needles used to inject black tar heroin. The infection causes horrific abscesses and can lead to amputations.
- Overdose. Many users OD, or overdose, after obtaining high quality heroin without knowing it. Pure heroin causes an overdose more easily than the adulterated kind, and according to the Drug Enforcement Administration (DEA), heroin has reached up to a 70 percent purity level, reflecting a steady climb since 1980, when the purity level was just 3.6 percent.
- When used with alcohol, opioids can also slow your heart rate and breathing so low that it can lead to coma or death.
- Both novice and experienced users are at risk for overdose. Having not developed a tolerance to the drug, a first-time user may OD by shooting a dose an experienced user can easily handle. And a veteran user, thinking they're cooking up a routine fix, may run into a more potent batch than they've encountered before, and overdose despite shooting their usual amount. Heroin is usually cut (mixed) with other drugs such as amphetamines, poisons such as strychnine, or less harmful substances such as sugar or powdered milk. This allows dealers to make more money, but makes heroin even more dangerous because the buyer never knows the actual strength of the drug or its real contents.
- Addiction. Opiates are extremely addictive, both physically and psychologically -- that is, you have to use increasing amounts of the drug in order to achieve the same high, which can create a constant craving for the drug. Withdrawal for regular users is agonizing -- it can cause convulsions and even death. This is why you hear so many stories of heroin "junkies" stealing from their families and friends to support their habit.
- Withdrawal. Symptoms include nausea, watery eyes, runny nose, yawning, cramps, loss of appetite, irritability, tremors, panic, chills, and sweating.
- Death. Heroin and synthetic heroin overdoses depress your respiratory and central nervous system and can cause convulsions, coma, and death.
How can I tell if someone I know is on opioid drugs?
People on heroin and other opiates appear sleepy even though inside they may be feeling intense euphoria. Look for droopy eyelids, slow and deliberate movements or a loose-limbed walk, slow or halting speech, and nausea. They may also "nod off" continually. People who inject drugs will have needle marks or "tracks," usually on their arms.
Physiological effects include constricted (pinpoint) pupils, dry mouth, reduced appetite, constipation, itching, and sweating. Regular users, however, may show few outward signs of being high. Symptoms of overdose include slow and irregular breathing, clammy skin, and convulsions. Call for an ambulance immediately if you suspect you or someone else has had an overdose of opiates. It's important to note that most users won't feel or show many negative effects during their first six months on heroin, says Gruber. This may prevent friends from aggressively trying to get them to stop, and might even encourage them to begin using, too. Only after people have been on it longer than six months and begin to develop serious tolerance, dependence, and physical symptoms and start to appear unhealthy, do others realize the danger and new use begins to decrease. In this sense, says Gruber, heroin use can be very cyclical and go through many peaks and lows.
Is it safe to smoke or snort heroin?
No. Too many people have died accidentally from using heroin, including the actor Philip Seymour Hoffman, who died in 2014 after he combined heroin with cocaine and other drugs. Rock and roll musicians Jimi Hendrix, Janis Joplin, and Jim Morrison all died at age 27 from heroin overdoses. Unfortunately, heroin use continues to grow. Between 2002 and 2015 the number of deaths from heroin use alone increased sixfold. Nearly 13,000 people died of heroin in 2015 alone.
If old enough, people may remember the Neil Young song about heroin addiction ("I've seen the needle and the damage done/A little part of it in everyone/But every junkie's like a setting sun"). But not everyone realizes that smoking or snorting heroin or other opiates can be highly addictive and potentially fatal -- even for a first-time user.
Although snorting and smoking heroin carries a lower overdose risk (because the rate of intake is slower), tolerance will eventually develop and the people often move on to injecting the drug, says Gruber. Heroin with a high level of purity is easier to smoke and snort, and the widespread increase in purity in the last 20 years (mentioned earlier) may in part explain the surge in heroin use over the past fifteen years.
Also, for some people, snorting and smoking erase the social stigma of shooting up and avoid the dangers of diseases such as HIV/AIDS and hepatitis, which are transmitted to users through dirty needles.
How can I get treated for opiate addiction?
There is a range of treatment options for heroin and opiate addiction. For users who aren't yet addicted, treatment usually consists of intervention and counseling, psychotherapy, and support groups, and an emphasis on finding a supportive living situation in which drugs aren't easily available. In addition, doctors will often prescribe opiate antagonists such as Naltrexone -- these are medications that blunt the high when someone relapses into opiate use.
For users who are addicted to opiates, the discussion usually focuses on heroin, which has proven to be one of the toughest addictions to cure.
What about methadone and buprenorphine treatments for heroin addiction?
These synthetic opiates, taken orally, are designed to treat heroin addiction in two ways. First, they lessen withdrawal symptoms and drug cravings so that addicts can overcome their physical addiction. Secondly, for people who aren't able to stay off opiates after going through withdrawal treatment, methadone and buprenorphine are prescribed as "maintenance therapy." In addition to preventing withdrawal symptoms and cravings, maintenance therapy prevents addicts from getting a high from heroin if they do falter and use it.
Methadone has historically been the most common treatment. Because of the potential for abuse, it is administered daily in special clinics. Buprenorphine (Subutex) and buprenorphine with naloxone (Suboxone) are milder narcotics that stay in the system longer, so they are generally given every two to three days. Buprenorphine is the first addiction treatment narcotic that can be prescribed in a doctor's office, making it more convenient than methadone. There is concern, however, that it has the potential to be diverted and abused for non-medical purposes. Another synthetic opioid medication, LAAM (Levomethadyl hydrochloride acetate), was discontinued in 2004 after numerous cases of heart trouble were reported in patients taking the drug.
People often question the logic of giving opiate addicts more opiates, and this is a point of considerable controversy. Methadone, albeit a milder form of opiate than the drugs patients are trying to kick, is still an addictive drug. Some studies and articles have come out in support of the treatment, and after a year or two some users are able to slowly wean themselves off the methadone and go opiate-free. However, according to Gruber, the majority of users either continue to use other opiates and other drugs, and many stay on methadone all their lives. Patients staying on methadone usually never completely regain the level of functioning they had when they were drug-free. Most suffer from mild but chronic cravings, as well as other effects of opiate use: constipation, dry mouth, decreased appetite, and difficulty concentrating and thinking clearly.
For these reasons, says Gruber, the growing consensus is that opiate users should strive to discontinue use entirely. Many areas don't even have methadone maintenance programs anymore, and many detox centers now use non-narcotic drugs like clonidine to ease their patients' withdrawal.
National Institute on Drug Abuse. Commonly Abused Drugs. https://www.drugabuse.gov/drugs-abuse/commonly-abused-drugs-charts
Oxycontin formula change has many abusers switching to heroin. Science Daily. July 11, 2012. https://www.sciencedaily.com/releases/2012/07/120711205857.htm
National Institute on Drug Abuse. Overdose Death Rates. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
Centers for Disease Control and Prevention. Heroin Overdose Data. https://www.cdc.gov/drugoverdose/data/heroin.html
National Institute on Drug Abuse, National Institutes of Health. InfoFacts: Prescription Drugs and Pain Medications.
National Drug Intelligence Center, Department of Justice, "OxyContin Fast Facts."
Office of National Drug Control Policy.
Clark, HW, et al. Buprenorphine in the Treatment of Opioid Addiction: Balancing Medication Access with Quality Care. SAMHSA.