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Subsection Links:
Description, Prevalence and Use Indicators
Physiological and Psychological Effects
Criminal Justice System
Overdose Prevention and Reversal: Naloxone
Other Research
Heroin Treatment - See related chapters below

Related Chapters:
Addictive Properties
Causes of Death
Diversion of Pharmaceutical Drugs
HIV-AIDS & Injection Drug Use
Methadone and Opioid Substitution Therapy
Pain Management & Prescription Drugs
Pharmacotherapy Using Injectable Diacetylmorphine (Heroin)
Safe Injection Facilities
Syringe Exchange
Treatment Overview

Note: If you're looking for more than just information, if you feel that you or someone you care about needs help because of a substance use, addiction, or mental health issue, this Behavioral Health Treatment Services Locator provided by the Substance Abuse and Mental Health Services Administration is a confidential and anonymous source of information for persons seeking treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems.

Note 2: Andrew Byrne, MD, is a general practitioner in New South Wales, Australia, who is approved to prescribe methadone for addiction treatment. His book Addict In The Family provides answers to many questions about drug addiction, in a manner that is both straightforward and clear. As Dr. Byrne writes, "The discovery of unequivocal proof of drug use may be devastating. Reactions vary from rejection and hostility to even further denial of the problem. With time, patience and understanding, most of these tensions can be overcome and previous harmonious relationships restored and even improved."

Note 3: Maia Szalavitz is a journalist and author specializing in addiction and psychopharmacology. DWF editor Doug McVay interviewed her for radio about her book Unbroken Brain: Unbroken Brain: A Revolutionary New Way of Understanding Addiction, wherein she contends that by treating addictions as learning disorders, we can transform treatment, prevention and policy for the better.

Note 4: The Chicago Recovery Alliance provides this excellent training video and other materials regarding Naloxone and opiate overdose reversal.

Note 5: Common Sense for Drug Policy has run several public service advertisements highlighting the pain management issue, including "Chronic Pain & Opioids: Debunking The Myths."

  1. Overview

    (Possible Reasons for Increasing Rates of Heroin Use and Opioid Overdose in the US) "A key factor underlying the recent increases in rates of heroin use and overdose may be the low cost and high purity of heroin.45,46 The price in retail purchases has been lower than $600 per pure gram every year since 2001, with costs of $465 in 2012 and $552 in 2002, as compared with $1237 in 1992 and $2690 in 1982.45 A recent study showed that each $100 decrease in the price per pure gram of heroin resulted in a 2.9% increase in the number of hospitalizations for heroin overdose.46"

    Wilson M. Compton, M.D., M.P.E., Christopher M. Jones, Pharm.D., M.P.H., and Grant T. Baldwin, Ph.D., M.P.H. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med 2016; 374:154-163. January 14, 2016. DOI: 10.1056/NEJMra1508490

  2. (Factors in the Transition from Prescription Opiate Use to Heroin Use) "Multiple studies that have examined why some persons who abuse prescription opioids initiate heroin use indicate that the cost and availability of heroin were primary factors in this process. These reasons were generally consistent across time periods from the late 1990s through 2013.34-41 Some interviewees made reference to doctors generally being less willing to prescribe opioids as well as to increased attention to the issue by law enforcement, which may have affected the available supply of opioids locally.38,40"

    Wilson M. Compton, M.D., M.P.E., Christopher M. Jones, Pharm.D., M.P.H., and Grant T. Baldwin, Ph.D., M.P.H. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. N Engl J Med 2016; 374:154-163. January 14, 2016. DOI: 10.1056/NEJMra1508490

  3. (Methadone Maintenance as a Treatment for Opioid Dependence) "Methadone is a long-acting μ-opioid receptor agonist, introduced in the 1960s, after being developed in Germany at the end of World War II.60 It has an onset of action within 30 minutes61-63 and an average duration of action of 24 to 36 hours. Its oral bioavailability is excellent and approaches 90%. These unique pharmacologic properties ideally lend themselves to once-daily dosing for maintenance therapy, although, when used to treat chronic pain, methadone is generally dosed 3 times daily. When the dosage is judiciously titrated, methadone treated patients generally do not experience euphoria or sedation, nor do they suffer impairment in the ability to perform mental tasks. One of the most important advantages of methadone is that it relieves narcotic craving, which is the primary reason for relapse. Similarly, methadone blocks many of the narcotic effects of heroin,64 which helps reinforce abstinence. Once a therapeutic dose is achieved, patients frequently can be maintained for many years with the same dose.65
    "Methadone hydrochloride is available in 5- and 10-mg tablets as well as a 40-mg dispersible wafer. However, it is most frequently used for maintenance in a 10-mg/mL liquid concentrate. An intravenous solution is also available but has been linked with bradycardia when administered for sedation."

    Mori J. Krantz, MD; Philip S. Mehler, MD, "Treating Opioid Dependence: Growing Implications for Primary Care," Archives of Internal Medicine, (Chicago, IL: American Medical Association, February 2004), Vol. 164, p. 279.

  4. Basic Data

    (Description of Heroin) "Heroin is an opiate drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as 'black tar heroin.'"

    National Institute on Drug Abuse, DrugFacts: Heroin (Rockville, MD: US Department of Health and Human Services, Revised March 2010), last accessed Jan. 12, 2013.

  5. (Prevalence of Heroin Use in the US, 2013)
    "• The number and percentage of persons aged 12 or older who were current heroin users in 2013 (289,000 or 0.1 percent) were similar to those in 2008 to 2012 (ranging from 193,000 to 335,000 or 0.1 percent for all 4 years) (Figure 2.4). The number of current heroin users in 2013 was higher than the number of users in 2002 to 2005 (ranging from 119,000 to 166,000) and in 2007 (161,000). The number of persons aged 12 or older who were past year heroin users in 2013 also was higher than the numbers in 2002 to 2005, 2007, and 2008 (ranging from 314,000 to 455,000). (See Section B.2.3 in Appendix B for additional discussion of the estimated numbers of past year and past month heroin users in 2006.)"

    Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014, pp. 81-83.

  6. (Proof of Efficacy of Heroin-Assisted Treatment) "Over the past 15 years, six RCTs [Randomized Controlled Trials] have been conducted involving more than 1,500 patients, and they provide strong evidence, both individually and collectively, in support of the efficacy of treatment with fully supervised self-administered injectable heroin, when compared with oral MMT, for long-term refractory heroin-dependent individuals. These have been conducted in six countries: Switzerland (Perneger et al., 1998); the Netherlands (van den Brink et al., 2003); Spain (March et al., 2006); Germany (Haasen et al., 2007), Canada (Oviedo-Joekes et al., 2009) and England (Strang et al., 2010).
    "Across the trials, major reductions in the continued use of ‘street’ heroin occurred in those receiving SIH [Supervised Injectable Heroin] compared with control groups (most often receiving active MMT). These reductions occasionally included complete cessation of ‘street’ heroin use, although more frequently there was continued but reduced irregular use of ‘street’ heroin, at least through the trial period (ranging from 6 to 12 months). Reductions also occurred, but to a lesser extent, with the use of a range of other drugs, such as cocaine and alcohol. However, the difference between reductions in the SIH group and the various control groups was not as great (compared with major reductions in the use of ‘street’ heroin)."

    European Monitoring Centre for Drugs and Drug Addiction, "EMCDDA INSIGHTS No. 11: New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond" (Luxembourg: Publications Office of the European Union, April 2012), doi: 10.2810/50141, p. 11.

  7. (Undertreated Chronic Pain and Development of Substance Dependence) "In our study, there was greater evidence for an association between substance use and chronic pain among inpatients than among MMTP [Methadone Maintenance Treatment Program] patients. Among inpatients, there were significant bivariate relationships between chronic pain and pain as a reason for first using drugs, multiple drug use, and drug craving. In the multivariate analysis, only drug craving remained significantly associated with chronic pain. Not surprisingly, inpatients with pain were significantly more likely than those without pain to attribute the use of alcohol and other illicit drugs, such as cocaine and marijuana, to a need for pain control. These results suggest that chronic pain contributes to illicit drug use behavior among persons who were recently using alcohol and/or cocaine. Inpatients with chronic pain visited physicians and received legitimate pain medications no more frequently than those without pain, raising the possibility that undertreatment or inability to access appropriate medical care may be a factor in the decision to use illicit drugs for pain."

    Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, pp. 2376-2377.

  8. (Health Risks from Heroin Use) "Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, and liver or kidney disease. Pulmonary complications, including various types of pneumonia, may result from the poor health of the abuser as well as from heroin’s depressing effects on respiration. In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs."

    National Institute on Drug Abuse, DrugFacts: Heroin (Rockville, MD: US Department of Health and Human Services, Last Revised March 2010), last accessed Jan. 12, 2013.

  9. (Community Epidemiology Working Group Indicators of Heroin Use in the US, 2013) "Sixteen of 19 CEWG area representatives reported stable or increasing heroin indicators for the 2013 reporting period, compared with 2012. Indicators, including mainly mortality, primary treatment admissions, and some law enforcement indicators, were observed as increasing in Atlanta, Baltimore City and Maryland, Boston, Cincinnati, Denver/Colorado, Maine, Minneapolis/St. Paul, New York City, San Francisco, Seattle, South Florida/Miami-Dade and Broward Counties, and Texas. Heroin levels were described as high relative to other drugs and indicators as relatively stable by area representatives from Chicago, Detroit, St. Louis, and San Diego. Heroin indicators were reported by area representatives as mixed (with some indicators decreasing, some stable, and some increasing) in two CEWG areas — Los Angeles and Phoenix. Trends for heroin were unclear in Philadelphia in this reporting period, according to the area representative. None of the 19 CEWG area representatives reported declining indicators for heroin for 2013."

    "Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group, Highlights and Executive Summary, June 2014" (Bethesda, MD: National Institute on Drug Abuse, September 2014), p. 20.

  10. (Law Enforcement and Treatment Indicators of Heroin Use in the US, 2013)
    "Other Highlights – Younger Heroin Users:
    "• Eight CEWG area representatives noted either increases in primary heroin treatment admissions for young adults (age 18–25) or high proportions of admissions for this age group compared with other age groups. A younger heroin user population was reported in treatment data in Denver and Colorado, Detroit and Michigan, Los Angeles, Minneapolis/St. Paul, St. Louis, San Diego (based on 2012 treatment data), Seattle, and Texas. The area representative from Chicago reported an increase in heroin use by young suburbanites as a key finding for 2013.
    "Other Highlights – Cross-Area Data Sources
    "Treatment Admissions:
    "• Primary heroin treatment admissions ranked first in proportions of total treatment admissions in 2013 in 6 of 17 CEWG reporting areas—Baltimore City, Boston, Detroit, Maryland, St. Louis, and San Francisco—and they ranked second in 2 areas: Cincinnati and Seattle (table 1). Boston (56.6 percent) and Baltimore City (49.5 percent) had the highest proportions of primary heroin treatment admissions in 2013; Atlanta had the lowest, at 6.1 percent (table 8; figure 5).
    "• Injection was the most frequently reported mode of heroin administration in 12 of 16 reporting CEWG areas in 2013. Proportions of heroin admissions injecting the drug ranged from 15.0 percent in Atlanta to 87.1 percent in South Florida/Broward County (table 9). Inhalation or intranasal use was the most frequent mode of heroin administration reported by heroin admissions in 2 of 17 areas: Baltimore City, at 57.0 percent, and Detroit, at 59.8 percent. However, this mode was relatively rarely reported among treatment admissions in Phoenix and Denver (at 3.8 and 4.3 percent, respectively). Smoking was reported by less than 2.0 percent of the heroin admissions in 9 of 16 CEWG areas reporting. Phoenix had the highest proportion of heroin treatment admissions whose primary mode of administration was smoking, at 28.1 percent (table 9)."

    "Epidemiologic Trends in Drug Abuse: Proceedings of the Community Epidemiology Work Group, Highlights and Executive Summary, June 2014" (Bethesda, MD: National Institute on Drug Abuse, September 2014), p. 21.

  11. (Global Opiate Consumption) "The world consumes some 3,700 tons of illicit opium per year (1/3 raw and 2/3 processed into heroin) and seizes 1,000 tons."

    United Nations Office on Drugs and Crime, "Addiction, Crime and Insurgency: The transnational threat of Afghan opium" (Vienna, Austria: October 2009), p. 7.

  12. Heroin

    (Estimated Prevalence of Current Heroin Use in the US, 2014) "Because heroin use is not as common as the use of other illicit drugs, monitoring both past month and past year heroin use provides additional context for interpreting the trends. For past year use, 0.3 percent of people aged 12 or older in 2014 had used heroin (Figure 13), which represents about 914,000 people.
    "Despite the dangers associated with heroin use, its use has increased in the population. The estimate of current heroin use in 2014 among people aged 12 or older was higher than the estimates for most years between 2002 and 2013. However, this difference represents a change from 0.1 percent in 2002 to 2013 to 0.2 percent in 2014. Data from future survey years would be useful for monitoring whether this increase in 2014 signals the start of a change in the trend, or if the percentage goes back down.
    "The estimate of past year heroin use in 2014 (0.3 percent) also was greater than the estimates from 2002 to 2013 (ranging from 0.1 to 0.3 percent). This rise in heroin use among people aged 12 or older may reflect increases in heroin use by adults aged 26 or older and, to a lesser extent, increases in heroin use among young adults aged 18 to 25."

    Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50), pp. 11-12.

  13. (Mortality from Heroin Use) "The majority of drug deaths in an Australian study, conducted by the National Alcohol and Drug Research Centre, involved heroin in combination with either alcohol (40 percent) or tranquilizers (30 percent)."

    Peele, Stanton, MD (1998), "The persistent, dangerous myth of heroin overdose," published in DPFT News (Drug Policy Forum of Texas), August, 1999, p. 5, from The Stanton Peele Addiction Website, last accessed June 8, 2013.

  14. (Opioid Overdose Deaths in the US, 1999-2005) "There can be no doubt, however, that fatal opioid overdose, long a chronic health problem in the United States, is now a rapidly growing one.71 National surveillance data suggest that almost 83,000 Americans died from this form of overdose between 1999 to 2005, with over 16,000 fatalities in 2005 alone.72 Opioid overdose death has seen a sharp increase over the last decade, especially in the category of overdose from prescription medications.73 Because of gaps in the surveillance system, the actual figure is likely to be substantially higher."

    Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 284.

  15. (Heroin Toxicity or Overdose) "The main toxic effect is decreased respiratory rate and depth, which can progress to apnea. Other complications (eg, pulmonary edema, which usually develops within minutes to a few hours after opioid overdose) and death result primarily from hypoxia. Pupils are miotic. Delirium, hypotension, bradycardia, decreased body temperature, and urinary retention may also occur.
    "Normeperidine, a metabolite of meperidine, accumulates with repeated use (including therapeutic); it stimulates the CNS and may cause seizure activity."

    "Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Feb. 16, 2013.

  16. (Heroin Toxicity, Adulterants, and Overdose Potential) "If it is not pure drugs that kill, but impure drugs and the mixture of drugs, then the myth of the heroin overdose can be dangerous. If users had a guaranteed pure supply of heroin which they relied on, there would be little more likelihood of toxic doses than occur with narcotics administered in a hospital.
    "But when people take whatever they can off the street, they have no way of knowing how the drug is adulterated. And when they decide to augment heroin's effects, possibly because they do not want to take too much heroin, they may place themselves in the greatest danger."

    Peele, Stanton, MD, (1998), "The persistent, dangerous myth of heroin overdose." Last accessed Jan. 12, 2013.

  17. (Opioid Withdrawal Syndrome) "The withdrawal syndrome usually includes symptoms and signs of CNS hyperactivity. Onset and duration of the syndrome depend on the specific drug and its half-life. Symptoms may appear as early as 4 h after the last dose of heroin, peak within 48 to 72 h, and subside after about a week. Anxiety and a craving for the drug are followed by increased resting respiratory rate (> 16 breaths/min), usually with diaphoresis, yawning, lacrimation, rhinorrhea, mydriasis, and stomach cramps. Later, piloerection (gooseflesh), tremors, muscle twitching, tachycardia, hypertension, fever and chills, anorexia, nausea, vomiting, and diarrhea may develop. Opioid withdrawal does not cause fever, seizures, or altered mental status. Although it may be distressingly symptomatic, opioid withdrawal is not fatal.
    "The withdrawal syndrome in people who were taking methadone (which has a long half-life) develops more slowly and may be less acutely severe than heroin withdrawal, although users may describe it as worse. Even after the withdrawal syndrome remits, lethargy, malaise, anxiety, and disturbed sleep may persist up to several months. Drug craving may persist for years."

    "Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Jan. 12, 2013.

  18. (Heroin Trafficking and Seizures in the Americas, 2012) "According to the United States, in 2012, the availability of heroin continued to increase in that country, likely due to high levels of heroin production in Mexico and Mexican traffickers expanding into 'white heroin' markets.117 Some metropolitan areas in the United States experienced an increase in heroin overdose deaths. Apart from heroin originating in Latin America, heroin from South-West Asia may be reaching the North American market in larger quantities. Canada, which continues to identify Pakistan and India as being among the prominent countries of provenance for heroin reaching its market, mentioned an increase in the number of heroin seizures from couriers on commercial airlines in the latter part of 2012 and in early 2013, and reported that this could be due to a resurgence in the use of heroin across Canada, as well as possible export to other countries, such as the United States.118 However, the United States has not reported a significant flow of heroin from Canada. India and the United States both indicated that there was a flow of heroin from India to the United States; it is plausible that the flow of heroin reaching North America from India, while probably still small in relation to the size of the North American consumer market, is of South-West Asian origin (as discussed above).
    "In Latin America, despite illicit cultivation of opium poppy in some countries and the manufacture of heroin in Colombia and Mexico, destined mainly for the United States, the prevalence of opiate use is relatively low. South America, Central America and the Caribbean collectively accounted for less than 3 per cent of global seizures of heroin in 2012."

    United Nations Office on Drugs and Crime, World Drug Report 2014 (United Nations publication, Sales No. E.14.XI.7), p. 31.

  19. (Data Limitations Make Estimating Demographics of Heroin Users in the US Difficult) "The prevalence of heroin use is extremely difficult to estimate despite the fact that harm to society associated with heroin marketing and use is substantial. A disproportionate number of heroin users are part of the nonsampled populations in general prevalence surveys (persons with no fixed address, prison inmates, etc.) Also, heroin users are believed to represent less than one half of one percent of our total population, making heroin usage a relatively rare event. Sample surveys are not sensitive enough to measure rare events reliable. Data from the National Household Survey on Drug Abuse (which is considered to produce conservative estimates), indicated that 1.9 percent of blacks, 1.6 percent of Hispanics, and 1.4 percent of whites had ever tried heroin. As will be noted later in this report, the data available from hospital emergency rooms and from drug abuse treatment programs indicated that heroin use is a more serious problem among blacks than whites and Hispanics."

    Andrea N. Kopstein and Patrice T. Roth, "Drug Abuse Among Racial/Ethnic Groups" (Rockville, MD: National Institute on Drug Abuse, 1993), p. 13.

  20. (Global Heroin Seizures, 2012) "Globally, seizures of heroin and illicit morphine went down 19 per cent in 2012. The main declines in opiate seizures were reported in South-West Asia and Western and Central Europe, where seizures declined by 29 per cent and 19 per cent, respectively (from 117 tons in 2011 to 82 tons in 2012 in South-West Asia, and from 6 tons in 2011 to 4.85 tons in 2012 in Western and Central Europe). A substantial increase in heroin seizures, however, was reported in Eastern and South-Eastern Europe (15.98 tons in 2012 compared with 9.88 tons in 2011), mainly as a result of increased quantities reported seized in Turkey. Heroin seizures also increased substantially in Australia and New Zealand (1.09 tons in 2012 compared with 0.61 tons in 2011) and in South Asia (1.3 tons in 2012 compared with 0.723 tons reported in 2011). In North America, heroin seizures declined by 58 per cent in Mexico but increased in the United States, to 5.5 tons in 2012, compared with 4.8 tons in 2011. However, overall heroin seizures in North America have remained stable over the previous year."

    United Nations Office on Drugs and Crime, World Drug Report 2014 (United Nations publication, Sales No. E.14.XI.7), pp. 21-22.

  21. (HIV and IDUs in Russia and Central Asia) "In terms of absolute numbers, the Russian Federation is particularly affected with its 1.5 million addict population. The hugely damaging threat of HIV/AIDS is directly related to heroin injection. To date, there are over a quarter of a million registered HIV cases (although the number of unregistered cases is estimated to be much higher than this) in the Russian Federation. Of these, over 80% are intravenous drug users. In the CARs [Central Asian Republics], nearly 15 years of continuous heroin transit has created a local market of 282,000 heroin users, consuming approximately 11 mt of heroin annually. Local opium consumption is estimated at approximately 34 mt (although demand in Turkmenistan may be underestimated). This puts some Central Asian states on par with countries with the highest global opiate abuse prevalence."

    UNODC, World Drug Report 2010 (United Nations Publication, Sales No. E.10.XI.13), pp. 52-53.

  22. "A striking finding from the toxicological data was the relatively small number of subjects in whom morphine only was detected. Most died with more drugs than heroin alone 'on board', with alcohol detected in 45% of subjects and benzodiazepines in just over a quarter. Both of these drugs act as central nervous system depressants and can enhance and prolong the depressant effects of heroin."

    Zador, Deborah, Sunjic, Sandra, and Darke, Shane, "Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances," The Medical Journal of Australia, 1996; 164 (4): 204-207.

  23. "The disadvantage of continuing to describe heroin-related fatalities as 'overdoses' is that it attributes the cause of death solely to heroin and detracts attention from the contribution of other drugs to the cause of death. Heroin users need to be educated about the potentially dangerous practice of concurrent polydrug and heroin use."

    Zador, Deborah, Sunjic, Sandra, and Darke, Shane, "Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances," The Medical Journal of Australia, 1996; 164 (4): 204-207.

  24. (Effectiveness of Heroin-Assisted Treatment Compared With Methadone Maintenance) "Diacetylmorphine was found to be a dominant strategy over methadone maintenance treatment in each time horizon studied (Table 2). Over a lifetime horizon, people in the methadone cohort lived 14.54 years on average following entry into the model, spending 8.79 years (60% of their remaining life) in treatment and 5.52 years in relapse. They accumulated 7.46 discounted QALYs and generated a societal cost of $1.14 million. People in the diacetylmorphine cohort lived 15.45 years on average, spending 10.41 years (67% of their remaining life) in treatment (2.34 years of which was in post-diacetylmorphine methadone treatment) and 4.05 years in relapse. They accumulated 7.92 discounted QALYs and generated a societal cost of $1.10 million. Based on these findings in the baseline model, over a lifetime horizon the provision of diacetylmorphine in the hypothetical cohort provided greater incremental health benefits and reduced the total costs to society compared with methadone maintenance treatment."

    Bohdan Nosyk PhD., et al., "Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid dependence refractory to treatment," Canadian Medical Association Journal, April 3, 2012, 184(6):E317-E328.

  25. (Global Heroin Treatment Need and OD Deaths) "More than 60 per cent of drug treatment demand in Asia and Europe relate to opiates that are, especially heroin, the most deadly drugs. Deaths due to overdose are, in any single year, as high as 5,000-8,000 in Europe, and several times this amount in the Russian Federation alone."

    United Nations Office on Drugs and Crime, "Addiction, Crime and Insurgency: The transnational threat of Afghan opium" (Vienna, Austria: October 2009, p. 7.

  26. (Trends in Treatment Admissions for Heroin Addiction and in Opioid Substitution Treatment in the US, 2003-2013) "General measures of heroin abuse among treatment admissions aged 12 and older were relatively consistent from 2003 through 2011, accounting for 13 to 15 percent of TEDS admissions in those years, but rose to 16 percent in 2012 and 19 percent in 2013 [Table 1.1b]. In 2013, injection was the preferred route of administration for 71 percent of primary heroin admissions, inhalation for 23 percent, and smoking for 4 percent [Table 2.4]. The majority of primary heroin admissions from 2003 to 2013 were 20 to 34 years of age (41 to 43 percent from 2003 through 2007 and 58 percent in 2013) [Table 3.5].
    "However, these measures conceal substantial changes in the age, race/ethnicity, and route of administration of some subpopulations among heroin-using admissions.
    "Table 3.5 and Figure 21. TEDS data show an increase in heroin admissions among young non-Hispanic White adults. Among non-Hispanic Blacks, however, admissions have declined except among older admissions.
    "• In 2003, 1 in 4 heroin admissions (25 percent) were non-Hispanic White aged 20 to 34. By 2013, almost half of primary heroin admissions (48 percent) belonged to this subgroup. The proportion of primary heroin admissions who were non-Hispanic White aged 35 to 44 decreased from 12 percent to 10 percent in the same period, while the proportions of non-Hispanic White admissions aged 12 to 19 and older than 45 remained constant, at 2 to 3 percent and 7 to 8 percent, respectively.
    "• In contrast, the proportion of primary heroin admissions that were non-Hispanic Black aged 20 to 34 fell from 5 percent to 2 percent between 2003 and 2013, while the proportion aged 35 to 44 fell from 11 percent to 3 percent. However, the proportion of non-Hispanic Black admissions aged 45 and older remained between 8 and 11 percent from 2003 through 2013. Non-Hispanic Black admissions aged 12 to 19 accounted for one tenth of 1 percent or less of all primary heroin admissions in the same time period.
    Table 3.6 and Figure 22.
    "• In 2003, 1 in 4 primary heroin admissions (26 percent) were injectors aged 20 to 34 and nearly 1 in 5 (18 percent) were injectors aged 35 to 44. By 2013, almost one half of primary heroin admissions (46 percent) were injectors aged 20 to 34, but the proportion that were injectors aged 35 to 44 had dropped to 12 percent.
    "• The proportion of primary heroin admissions who were inhalers aged 20 to 34 fell from 12 percent in 2003 to 9 percent in 2013, while the proportion who were inhalers aged 45 and older fluctuated between 8 percent to 10 percent from 2003 through 2013."

    Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2003-2013. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-75, HHS Publication No. (SMA) 15-4934. Rockville, MD: Substance Abuse and Mental Health Services Administration, December 2015, pp. 32-33.

  27. Impact of Treatment on Drug Use

    (Treatment Effectiveness at Reducing Levels of Drug Use) "During the course of treatment, many treatment seekers stopped using the drugs that they reported using at entry to the study. Lower rates of drug use were recorded at each follow-up. Furthermore, those that continued to use tended to use less. Most of the changes observed occurred by first follow-up. For most forms of drug use, no particular treatment modality was more associated with cessation than any other and the route into treatment (CJS or non-CJS) did not influence drug-use outcomes.
    "The proportion using each drug reduced significantly between baseline and follow-up (Figure 5). Most of this change occurred by first follow-up; indeed use of some drug types increased marginally, and levels of abstinence from all drugs decreased between first and second follow-up.
    "The proportion of treatment seekers using heroin, crack, cocaine, amphetamine or benzodiazepines decreased between baseline and follow-up by around 50 per cent; the proportion using non-prescribed methadone or other opiates such as morphine, decreased by considerably more; but the proportion using cannabis or alcohol decreased by considerably less.The proportion who reported each drug to be causing problems fell substantially for all drug types, suggesting that continued use was often, in the client’s view, non-problematic."

    Andrew Jones, et al., "Research Report 24: The Drug Treatment Outcomes Research Study (DTORS): Final Outcomes Report" (London, England: UK Government, Home Office Ministry, Research, Development & Statistics Directorate, December 2009), p. 10.

  28. (Estimated Global Opium Production, 2015) "The main areas of opiate production are in three subregions. Countries in South-West Asia (mostly Afghanistan) supply markets in neighbouring countries and in countries in Europe, the Near and Middle East, Africa and South Asia, with small proportions going to East and South-East Asia, North America and Oceania. Countries in South-East Asia (mostly Myanmar and, to a lesser extent, the Lao People’s Democratic Republic) supply markets in East and South-East Asia and in Oceania, with smaller proportions going to South Asia. Countries in Latin America (mostly Mexico, Colombia and Guatemala), supply markets in countries in North America (except Canada, which is predominantly supplied by opiates originating in Afghanistan) and the more limited markets in South America. In addition, in a number of countries, important quantities of opium poppy are cultivated for the domestic market (for example, in India). Thus, opium is illicitly produced in nearly 50 countries worldwide.
    "In 2015, the total area under opium poppy cultivation worldwide decreased by 11 per cent from the level of the previous year, to around 281,000 hectares (ha); that decline is primarily a reflection of a drop in cultivation reported by Afghanistan (-19 per cent), although, at 183,000 ha, Afghanistan still accounted for almost two thirds of the total area under illicit opium cultivation. Myanmar accounted for 20 per cent (55,500 ha) of the total, Mexico accounted for 9 per cent and the Lao People’s Democratic Republic for 2 per cent.
    "Global opium production in 2015 fell by 38 per cent from the previous year, to some 4,770 tons144 (i.e. to the level of the late 1990s). The decrease was primarily the result of a decline in opium production in Afghanistan (-48 per cent compared with the previous year), mainly attributable to poor yields in the country’s southern provinces."

    United Nations Office on Drugs and Crime, World Drug Report 2016 (United Nations publication, Sales No. E.16.XI.7), p. 26.

  29. (Estimated Global Opium Production, 2012) "Afghanistan maintained its position as the lead producer and cultivator of opium globally. With a global total of over 236,000 hectares under cultivation, illicit cultivation of opium poppy reached peak levels in 2012, surpassing the 10-year high recorded in 2007. This was mainly the result of increases in Afghanistan and Myanmar (the two main producers). A preliminary assessment of opium poppy cultivation trends in Afghanistan in 2013 revealed that such cultivation is likely to increase in the main opium growing regions, which would be the third consecutive increase since 2010.62 Mexico remained the largest grower of opium poppy in the Americas. An overview of global potential production of opium and manufacture of heroin, as well as country data on opium poppy cultivation and eradication and opium production can be found in Annex II.
    "The fluctuations which characterized opium production in Afghanistan in recent years, also affected Europe, the main market for opiates. Heroin use decreased in Western and Central Europe, which can be ascribed to a change in the structure of the market, which has seen decreased supply, increased law enforcement activity and an ageing user population, combined with an increase in the availability of treatment. However, the same does not apply to the non-medical use of prescription opioids."

    UNODC, World Drug Report 2013 (United Nations publication, Sales No. E.13.XI.6), p. 30.

  30. Opiate Overdose Prevention and Treatment: Naloxone

    (Note: For an excellent training video and other materials regarding Naloxone and overdose prevention, check out this resource from the Chicago Recovery Alliance,

    (Naloxone As Overdose Prevention) "The heart of the challenge is the possibility that things could be different: overdose is a public health problem that can be solved. Unlike many of the other leading causes of death, death from opioid overdose is almost entirely preventable,21 and preventable at a low cost.22 Opioids kill by depressing respiration, a slow mode of death that leaves plenty of time for effective medical intervention.23 Overdose is rapidly reversed by the administration of a safe and inexpensive drug called naloxone. Naloxone strips clean the brain’s opioid receptors and reverses the respiratory depression causing almost immediate withdrawal.24 A growing number of harm reduction organizations in the United States are offering overdose prevention programs that provide injection drug users with resuscitation training and take-home doses of naloxone.25"

    Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 277.

  31. (Feasibility of Naloxone Distribution to Injection Drug Users (IDUs)) "This pilot trial is the first in North America to prospectively evaluate a program of naloxone distribution to IDUs to prevent heroin overdose death. After an 8-hour training, our study participants' knowledge of heroin overdose prevention and management increased, and they reported successful resuscitations during 20 heroin overdose events. All victims were reported to have been unresponsive, cyanotic, or not breathing, but all survived. These findings suggest that IDUs can be trained to respond to heroin overdose by using CPR and naloxone, as others have reported. Moreover, we found no evidence of increases in drug use or heroin overdose in study participants. These data corroborate the findings of several feasibility studies recommending the prescription and distribution of naloxone to drug users to prevent fatal heroin overdose."

    Seal, Karen H., Robert Thawley, Lauren Gee, Joshua Bamberger, Alex H. Kral, Dan Ciccarone, Moher Downing, and Brian R. Edlin, "Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study," Journal of Urban Medicine (New York, NY: New York Academy of Medicine, 2005), Vol. 82, No. 2, p. 308.

  32. (Benefits from Naloxone Distribution) "Naloxone distribution to heroin users would be expected to reduce mortality and be cost-effective even under markedly conservative assumptions of use, effectiveness, and cost. Although the absence of randomized trial data on naloxone distribution and reliance on epidemiologic data increase the uncertainty of results, there are few or no scenarios in which naloxone would not be expected to increase QALYs [Quality-Adjusted Life-Years] at a cost much less than the standard threshold for cost-effective health care interventions. Ecological data, in fact, suggest that naloxone distribution may have far greater benefits than those forecast in this model: Reductions in community-level overdose mortality from 37% to 90% have been seen concordant with expanded naloxone distribution in Massachusetts (7), New York City (11), Chicago (10), San Francisco (9, 67, 68), and Scotland (69). Such a result is approached in this model only by maximizing the likelihood of naloxone use or by assuming that naloxone distribution reduces the risk for any overdose. Preliminary data showing that naloxone distribution is associated with empowerment and reduced HIV risk behaviors (70, 71) suggest that future research is needed to test these hypotheses."

    Coffin, Phillip O., MD, and Sullivan, Sean D. PhD, "Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal," Annals of Internal Medicine 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.

  33. (Rapid Effect of Naloxone)"Heroin is particularly toxic because of high lipid solubility, which allows it to cross the blood–brain barrier within seconds and achieve high brain levels.10
    "Naloxone is also lipid soluble and enters the brain rapidly. Reversal of respiratory depression is evident 3–4 minutes after IV and 5–6 minutes after subcutaneous administration.11"

    Etherington, Jeremy; Christenson, James; Innes, Grant; Grafstein, Eric; Pennington, Sarah; Spinelli, John J.; Gao, Min; Lahiffe, Brian; Wanger, Karen; Fernandes, Christopher, "Is early discharge safe after naloxone reversal of presumed opioid overdose?" Canadian Journal of Emergency Medicine (Ottawa, ON: Canadian Association of Emergency Physicians, July 2000), p. 160.

  34. (Barriers to Naloxone Access) "A more prosaic, but no less important, legal barrier to widespread naloxone access is the Food and Drug Administration’s (FDA) classification of naloxone as a prescription drug. This means that public health and harm reduction agencies cannot distribute naloxone like condoms or sterile syringes. Instead, naloxone must be prescribed by a properly licensed health care provider after an individualized evaluation of the patient. Because health care providers have to be involved, naloxone programs must deal with concerns about liability, which among doctors can be powerful even when they are not wellfounded in fact.31 The prescription status raises the cost of naloxone distribution and makes it illegal to give naloxone to lay people willing to administer the drug to others suffering an overdose."

    Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 278.

  35. (Effectiveness of Naloxone Against Opiate Overdoses) "Treatment with naloxone can reverse respiratory failure within a few minutes (Darke and Hall, 1997; Physician’s Desk Reference, 2000). Naloxone is an opiate antagonist, and is thought to displace heroin at the Mu2 receptors. Physicians and emergency personnel treat patients suspected of heroin overdose by administering an initial dose of naloxone parenterally. While 2 mg are almost always sufficient to revive a patient, additional doses can be administered if the desired improvement does not occur, and smaller doses are often used to minimize the discomfort of sudden heroin withdrawal (Physician’s Desk Reference, 2000). In adults, naloxone has a half-life of between 30 and 81 minutes (Physician’s Desk Reference, 2000). Therefore, repeated administration could be necessary to reverse the effect of particularly large or long-lasting doses of heroin. (Sporer, 1999; Physician’s Desk Reference, 2000). In practice, however, a single 2 mg does is almost always sufficient. If a patient has not taken opioids, naloxone has no pharmacological effect (Darke and Hall, 1997).
    "While administration of naloxone may produce acute withdrawal symptoms in patients with heroin dependence (Physician’s Desk Reference, 2000), the drug does not have long-term or life threatening adverse effects when it is administered at therapeutic doses (Strang, et al, 1996). Naloxone has been associated with complications such as seizures and arrhythmia, (Physician’s Desk Reference, 2000) but more recent research suggests that complications are exceedingly rare, that past reports of complications may have been erroneous (Goldfrank and Hoffman, 1995), or that complications occur, if at all, in patients with pre-existing heart disease (Goldfrank and Hoffman, 1995). Naloxone is not addictive, and has no psycho-pharmacological effects."

    Burris, Scott; Norland, Joanna; and Edlin, Brian, "Legal Aspects of Providing Naloxone to Heroin Users in the United States," International Journal of Drug Policy, 2001, Vol. 12, pp. 237-48.

  36. (Cost-Effectiveness of Naloxone Distribution) "Naloxone distribution was cost-effective in our base-case and all sensitivity analyses, with incremental costs per QALY [Quality-Adjusted Life-Year] gained much less than $50 000 (Table 2 and Appendix Figure 3, available at; see Appendix Table 3, available at, for detailed results of selected analyses). Cost-effectiveness was similar at starting ages of 21, 31, and 41 years; the greater QALY gains of younger persons were roughly matched by higher costs. In scenarios where naloxone administration reduced reliance on EMS, naloxone distribution was cost-saving and dominated (that is, less costly and more effective than) the no-distribution comparison. Cost-effectiveness was somewhat sensitive to the efficacy of lay-administered naloxone and the cost of naloxone but was relatively insensitive to the breadth of naloxone distribution, rates of overdose and other drug-related death, rates of abstinence and relapse, utilities, or the absolute cost of medical services. Naloxone was no longer cost-effective if the relative increase in survival was less than 0.05%, if 1 distributed kit cost more than $4480, or if average emergency care costs (as a proxy for downstream health costs) exceeded $1.1 million. A worst-case scenario, in which the likelihood of an overdose being witnessed, the effectiveness of naloxone, and the likelihood of naloxone being used were minimized and the cost of naloxone was maximized, resulted in an incremental cost of $14,000 per QALY gained. A best-case scenario, in which naloxone distribution reduced the risk for overdose, was dominant."

    Coffin, Phillip O., MD, and Sullivan, Sean D. PhD, "Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal," Annals of Internal Medicine 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.

  37. (Impact Of Good Samaritan Laws On Arrests) "Ninety-three percent of police respondents had attended a serious opioid overdose (defined in the survey) in their career, with 64 % having attended one in the past year. While 77 % of officers felt it was important they were at the scene of an overdose to protect medical personnel, a minority, 34 %, indicated it was important they were present for the purpose of enforcing laws. Arrest during the last overdose officers encountered was rare, with only 1 % of overdose victims and 1 % of bystanders being arrested. In cases in which no arrest was made, 25 % reported confiscating drugs or paraphernalia.
    "The majority, 62 %, indicated the law would not change their behavior at a future overdose because they would not have arrested anyone at the scene of an overdose anyway. Smaller proportions indicated they would be less likely to arrest (14 %), did not know what they would do (20 %), or would continue to arrest people at the scene of an overdose (4 %)."

    Banta-Green C J, Beletsky L, Schoeppe JA, Coffin PO, Kuszler PC. Police officers’ and paramedics' experiences with overdose and their knowledge and opinions of Washington State's drug overdose-naloxone-Good Samaritan law. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2013;90(6):1102-;11.

  38. (911 Calls, Good Samaritan Laws, And Opiate Overdoses) "Among heroin users, research indicates fear of police response as the most common barrier to not calling 911 during overdoses.12,13 In a Baltimore study, 37 % of injection drug users who did not call 911 during an overdose endorsed concerns about police as the most important reason they did not call.13 Several states have enacted laws, commonly called Good Samaritan laws, to encourage calling 911 during overdoses on controlled substances; these laws are in part modeled on college campus alcohol Good Samaritan policies.14 Overdose Good Samaritan laws had been adopted in ten states as of the end of 2012, but they have not yet been evaluated.15 Generally, the laws include provisions that provide immunity from criminal prosecution for drug possession to overdose victims and to those who seek medical aid. Eight states have passed laws that ease access to take-home-naloxone by allowing the prescription of naloxone (an opioid antagonist or antidote) to persons at risk for having or witnessing an overdose, enabling bystanders to quickly respond in the event of an overdose.3,15 Previous research suggests that police are sometimes under-informed, and often ambivalent to public health laws, especially those based in a risk reduction framework.16,17"

    Banta-Green C J, Beletsky L, Schoeppe JA, Coffin PO, Kuszler PC. Police officers’ and paramedics' experiences with overdose and their knowledge and opinions of Washington State's drug overdose-naloxone-Good Samaritan law. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2013;90(6):1102-;11.

  39. (Effectiveness of Enforcement) "Similar evidence of the drug war’s failure is provided by US drug surveillance data. For example, from 1981 to 2011, the budget of the US Office of National Drug Control Policy increased by more than 600 percent (inflation-adjusted). However, despite increasing annual multibillion dollar investments in drug control, US government data suggest an approximate inflation- and purity-adjusted decrease in heroin price of 80 percent, and a greater than 900 percent increase in heroin purity between 1981 and 2002, clearly indicating that expenditures on interventions to reduce the supply of heroin into the United States were unsuccessful."

    "The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic," Global Commission on Drug Policy (Rio de Janeiro, Brazil: June 2012), p. 11.

  40. (Non-Injection Means of Ingestion As A Reason For Growth in Heroin Use Among Youth) "We do think that the expansion in the world supply of heroin, particularly in the 1990s, had the effect of dramatically raising the purity of heroin available on the streets, thus allowing for new means of ingestion. The advent of new forms of heroin, rather than any change in respondents’ beliefs about the dangers associated with injecting heroin, very likely contributed to the fairly sharp increase in heroin use in the 1990s. Evidence from this study, showing that a significant portion of the self-reported heroin users in recent years are using by means other than injection, lends credibility to this interpretation. The dramatic decline in LSD use in the early to mid-2000s is also not explainable by means of concurrent changes in perceived risk or disapproval; but availability did decline sharply during this period and very likely played a key role in reducing the use of that drug."

    Johnston, L. D., O’Malley, P. M., Bachman, J. G., Schulenberg, J. E. & Miech, R. A. (2014). Monitoring the Future national survey results on drug use, 1975–2013: Volume I, Secondary school students. Ann Arbor: Institute for Social Research, The University of Michigan, p. 462.

  41. Effects

    (Acute Effects of Opioids) "Acute intoxication is characterized by euphoria and drowsiness. Mast cell effects (eg, flushing, itching) are common, particularly with morphine. GI [gastro-intestinal] effects include nausea, vomiting, decreased bowel sounds, and constipation."

    "Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Jan. 12, 2013.

  42. (Chronic Effects) "Tolerance develops quickly, with escalating dose requirements. Tolerance to the various effects of opioids frequently develops unevenly. Heroin users, for example, may become relatively tolerant to the drug's euphoric and respiratory depression effects but continue to have constricted pupils and constipation.
    "A minor withdrawal syndrome may occur after only several days' use. Severity of the syndrome increases with the size of the opioid dose and the duration of dependence.
    "Long-term effects of the opioids themselves are minimal; even decades of methadone use appear to be well tolerated physiologically, although some long-term opioid users experience chronic constipation, excessive sweating, peripheral edema, drowsiness, and decreased libido. However, many long-term users who inject opioids have adverse effects from contaminants (eg, talc) and adulterants (eg, nonprescription stimulant drugs) and cardiac, pulmonary, and hepatic damage due to infections such as HIV infection and hepatitis B or C, which are spread by needle sharing and nonsterile injection techniques (see Drug Use and Dependence: Injection Drug Use)."

    "Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Jan. 12, 2013.

  43. (Long-Term Health Risks of Heroin Use) "Unlike alcohol or tobacco, heroin causes no ongoing toxicity to the tissues or organs of the body. Apart from causing some constipation, it appears to have no side effects in most who take it. When administered safely, its use may be consistent with a long and productive life. The principal harm comes from the risk of overdose, problems with injecting, drug impurities and adverse legal or financial consequences."

    Byrne, Andrew, MD, "Addict in the Family: How to Cope with the Long Haul" (Redfern, NSW, Australia: Tosca Press, 1996), pp. 33-34, available on the web at

  44. (Wholesale Price of Heroin) In 2010, a kilogram of heroin typically sold for an average wholesale price of $2,527.60 in Pakistan. The 2010 wholesale price for a kilogram of heroin in Afghanistan ranged around $2,266. In Colombia, a kilogram of heroin typically sold for $10,772.3 wholesale in 2010. In the United States in 2010, a kilogram of heroin ranged in price between $33,000-$100,000.

    UN Office on Drugs and Crime, World Drug Report 2012 (United Nations publication, Sales No. E.12.XI.1), Opioids: Retail and wholesale prices by drug type and country (2010 or latest available year)

  45. Krokodil

    (The Emergence of 'Krokodil') "In the last three to five years an increasing number of reports suggest that people who inject drugs (PWID) in Russia, Ukraine and other countries are no longer using poppies or raw opium as their starting material, but turning to over-the-counter medications that contain codeine (e.g. Solpadeine, Codterpin or Codelac). Codeine is reportedly converted into desomorphine (UNODC, 2012; Gahr et al., 2012a, 2012b, 2012c; Skowronek, Celinski, & Chowaniec, 2012). The drug is called Russian Magic, referring to its potential for short lasting opioid intoxication or, more common, to its street name, krokodil. Krokodil refers both to chlorocodide, a codeine derivate, and to the excessive harms reported, such as the scale-like and discolored (green, black) skin of its users, resulting from large area skin infections and ulcers. At this point, Russia and Ukraine seem to be the countries most affected by the use of krokodil, but Georgia (Piralishvili, Gamkrelidze, Nikolaishvili, & Chavchanidze, 2013) and Kazakhstan (Ibragimov & Latypov, 2012; Yusopov et al., 2012) have reported krokodil use and related injuries as well."

    Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013),

  46. (Krokodil Production) "In considering the drug krokodil, two aspects are of importance, its pharmacology and its chemistry. The short half-life, limited high after the impact effect and, in particular the need for frequent administration may narrow the attention of users on the (circular) process of acquiring, preparing and administering the drug, leaving little time for matters other than avoiding withdrawal and chasing high, as reported in several popular magazines (e.g. Shuster, 2011; Walker, 2011). However, when the layers of bootleg chemistry and attribution are peeled off, what’s left is an opioid analogue (or several ones) that, besides the variations in half-life, behaves pharmacologically not very different than heroin or Hanka (Haemmig, 2011). There are various paths to synthesize desomorphine from codeine, but the chemical process most commonly reported to be used by PWID in Russia and Ukraine is very similar to that of home-produced methamphetamine or Vint (Grund, Zábransky, Irwin, & Heimer, 2009; Zábransky, 2007) – a rudimentary version of a simple chemical reduction. The illicit production of krokodil reportedly involves the processing of codeine into the opiate analogue desomorphine (UNODC, 2012; Gahr et al., 2012a, 2012b, 2012c; Skowronek et al., 2012). Desomorphine (Dihydrodesoxymorphine-D or PermonidTM ) is an opiate analogue first synthesized by Small in 1932 (Small, Yuen, & Eilers, 1933). The analgesic effect of desomorphine is about ten times greater than that of morphine (and thus stronger than heroin), whereas its toxicity exceeds that of morphine by about three times (Weill & Weiss, 1951). The drug’s onset is described as very rapid but its action is of short duration, which may lead to rapid physical dependence and frequent administration."

    Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013),

  47. (Harms Associated with Krokodil Use) "In recent years, harm reduction and drug treatment services from Russia, Ukraine, Georgia and Kazakhstan began reporting severe health consequences associated with krokodil injecting. Although serious localized and systemic harms have previously been associated with injecting homemade opiates and stimulants in the region (Grund, 2002; Volik, 2008), the harms associated with krokodil injecting are extreme and unprecedented. The most common complications of krokodil appear to be serious venous damage and skin and soft tissue infections, rapidly followed by necrosis and gangrene (Gahr et al., 2012a, 2012b, 2012c; Skowronek et al., 2012). Our research further identified an impressive, undoubtedly incomplete, list of injuries and symptoms (Table 1), reported in the media (e.g. Shuster, 2011; Walker, 2011) and identified in YouTube clips and photographs on the internet. Importantly, this list includes several parts of the body that are not typically used as sites for injecting drugs. This suggests that the ill effects of krokodil are not limited to localized injuries, but spread throughout the body (Shuster, 2011; UNODC, 2012), with neurological, endocrine and organ damage associated with chemicals and heavy metals common to krokodil production (Lisitsyn, 2010).
    "It is important to note that the described harms seem to become manifest relatively shortly after krokodil injecting is initiated. Present accounts of krokodil related harms often concern young people presenting in emergency rooms and surgeries with extreme and advanced complications. According to NGOs that work with people who inject krokodil, these young people have relatively short histories of using the drug. Mortality rates among young krokodil users are reportedly high (Akhmedova, 2012; Shuster, 2011; Walker, 2011), with official reports associating krokodil use with half of all drug-related deaths in at least two Oblasts (Walker, 2011)."

    Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013),

  48. (Prevalence of Krokodile Use) "The estimated number of PWID in Russia was close to 2 million in 2008 (Mathers et al., 2008). 2.3% of the Russian population uses opioids annually and 1.4% heroin, compared to an annual prevalence of 0.4% opioid use in Western and Central Europe (UNODC, 2012). While actual epidemiological data is not available, a number of academic and media reports suggest that 5% or more of Russian drug users (approximately 100,000 PWID) may be injecting krokodil (Walker, 2011), while 'various official estimates' place the numbers of Russian PWID using krokodil as high as one million (Shuster, 2011). Epidemiological data is critical to evaluating claims that the use of krokodil is reaching epidemic proportions in Russia (Walker, 2011), and potentially, the Ukraine. There are an estimated 290,000 to 375,000 PWID in Ukraine (Mathers et al., 2008). A recent national survey found that 7% of PWID have used krokodil in 2011 (Balakireva, 2012), suggesting that around 20,000 PWID in Ukraine may have used krokodil that year. Balakireva and colleagues furthermore found statistically significant differences in krokodil use between the cities in the study, with most krokodil use reported in Uzhhorod (35.6%), Simferopol (26.9%), Kyiv (21.7%), Chernivtsi (15.5%) and Donetsk (12.6%). Estimates from other countries are not available. Outside of the former Soviet region, krokodil has been reported in Germany (Der Spiegel, 2011) and in Tromsø in northern Norway (Lindblad, 2012)."

    Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013),

  49. (Krokodil - Reasons and Risks) "In sum, these observations suggest that the relatively limited availability of black market opiates and stimulants and the relative ease of harvesting legal precursors to powerful analogues from the countryside and pharmacies inspired and sustained a Soviet-style homemade drug culture in the Eastern European region that remains radically different from those observed in countries where narco-traffickers dominate the production and distribution of drugs (Booth, Kennedy, Brewster, & Semerik, 2003; Grund et al., 2009; Grund, 2005; Subata & Tsukanov, 1999; Zábransky, 2007).
    "The physical and logistical exigencies of home production; its locus in networks of drug injecting friends and the high degree of cooperative action involved (in foraging for, producing and using the drugs); the multiple roles and ambiguous status of injecting paraphernalia; the routine occurrence of well-known risk behaviours (e.g. syringe sharing, frontloading) and those currently less well understood, such as the slapdash nature of the bootleg drug synthesis and its unpredictable outcomes in terms of actual drug product, purity and pollution— indeed all of these factors contribute to and interact within the vastly complex high risk environment of home drug production in the region."

    Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013),

  50. (Stigmatization and Inhumane Treatment of Krokodil Users) "In Russia and many other post-Soviet countries, the old ideology lingers on in narcological institutes, out of sync with modern public and mental health concepts (Grund et al., 2009). Many narcologists continue to view addiction as criminal or moral deviance and not as a disease. Narcological dispensaries continue to share information with law enforcement (Mendelevich, 2011). The threat of removal of child custody rights may impede women’s access to health care in particular (Shields, 2009). Stigma and discrimination, hostile treatment and lack of confidentiality are persistent in the treatment of PWID and must be viewed as important barriers to timely seeking medical care (Beardsley & Latypov, 2012; Mendelevich, 2011; Wolfe et al., 2010). PWID have therefore strong incentives to avoid narcological facilities and, by association, other state health services. In their personal 'hierarchy of risk,' seeking help for significant health problems is subordinated by the need to stay under the radar of the authorities (Connors, 1992). Several of the YouTube clips on the internet furthermore document not only the gravity of harms among krokodil users, but also poor and inhumane treatment of those hospitalized with krokodil related injuries. In one video a man’s leg is sawn off under the knee with a lint saw in what seems not to be a surgical unit, but perhaps a common hospital ward. The man sits wide-awake in an ordinary wheelchair and holds his leg himself above a bucket, which was lined with a garbage bag just before. These videos and case reports (Asaeva et al., 2011; Daria Ocheret, personal communication, 2012; Sarah Evans, personal communication, 2012) suggest that the care provided to those with krokodil related injuries may be (grossly) substandard, sometimes exacerbated by improper diagnosis and faulty clinical decisions."

    Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013),

  51. Laws and Policies

    (Sentences) Possible federal sentences for heroin possession include:
    Amount: 1 kilogram or more of a mixture or substance containing a detectable amount of heroin.
    Sentence: Not less than 10 years or more than life. No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment.
    Amount: 100 grams or more of a mixture or substance containing a detectable amount of heroin.
    Sentence: Not less than 5 years and not more than 40 years. No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment.

    "Title 21 United States Code (USC) Controlled Substances Act, From the U.S. Code Online via GPO Access [] [Laws in effect as of January 3, 2007]" (21USC841), last accessed June 4, 2013.

  52. In November 1997, the National Institutes of Health (NIH) convened a Consensus Panel on Effective Medical Treatment of Heroin Addiction. The panel of national experts concluded:
    "• Vigorous and effective leadership is needed within the Office of National Drug Control Policy (ONDCP) (and related Federal and State agencies) to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.
    "• Society must make a commitment to offering effective treatment for opiate dependence to all who need it.
    "• The panel calls attention to the need for opiate-dependent persons under legal supervision to have access to MMT [methadone maintenance treatment]. The ONDCP and the U.S. Department of Justice should implement this recommendation.
    "• The panel recommends improved training of physicians and other health care professionals in diagnosis and treatment of opiate dependence. For example, we encourage the National Institute on Drug Abuse and other agencies to provide funds to improve training for diagnosis and treatment of opiate dependence in medical schools.
    "• The panel recommends that unnecessary regulation of MMT and all long-acting agonist treatment programs be reduced.
    "• Funding for MMT should be increased.
    "• We advocate MMT as a benefit in public and private insurance programs, with parity of coverage for all medical and mental disorders.
    "• We recommend targeting opiate-dependent pregnant women for MMT.
    "• MMT must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.
    "• Patients, underrepresented minorities, and consumers should be included in bodies charged with policy development guiding opiate dependence treatment.
    "• We recommend expanding the availability of opiate agonist treatment in those States and programs where this treatment option is currently unavailable."

    "Effective Medical Treatment of Opiate Addiction," NIH Consensus Statement 1997, Nov 17-19 (Washington, DC: National Institutes of Health), 15(6), p. 24.

  53. (Naloxone Programs) "Naloxone distribution programs in the US are ongoing in Chicago, Baltimore, San Francisco, New Mexico and New York City. Additional community-based organizations interested in minimizing the adverse consequences of drug use in several cities in the US, including Los Angeles, Providence, Pittsburgh and Boston, are in the process of planning and developing naloxone administration programs for drug users."

    Tinka Markham Piper, Sasha Rudenstine, Sharon Stancliff, Susan Sherman, Vijay Nandi1 Allan Clear and Sandro Galea. "Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City," Harm Reduction Journal (January 25, 2007).

  54. (Pain Patients in Methadone Treatment) "Pain was very prevalent in representative samples of 2 distinct populations with chemical dependency, and chronic severe pain was experienced by a substantial minority of both groups. Methadone patients differed from patients recently admitted to a residential treatment center in numerous ways and had a significantly higher prevalence of chronic pain (37% vs. 24%). Although comparisons with other studies of pain epidemiology are difficult to make because of methodological differences, the prevalence of chronic pain in these samples is in the upper range reported in surveys of the general population. The prevalence of chronic pain in these chemically dependent patients also compares with that in surveys of cancer patients undergoing active therapy, approximately a third of whom have pain severe enough to warrant opioid therapy."

    Rosenblum, Andrew, PhD, Herman Joseph, PhD, Chunki Fong, MS, Steven Kipnis, MD, Charles Cleland, PhD, Russell K. Portenoy, MD, "Prevalence and Characteristics of Chronic Pain Among Chemically Dependent Patients in Methadone Maintenance and Residential Treatment Facilities," Journal of the American Medical Association (Chicago, IL: American Medical Association, May 14, 2003), Vol. 289, No. 18, p. 2376.

  55. (Heroin Assisted Treatment vs Methadone Maintenance) "The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

    Naber, Dieter, and Haasen, Christian, Centre for Interdisciplinary Addiction Research of Hamburg University, "The German Model Project for Heroin Assisted Treatment of Opioid Dependent Patients -- A Multi-Centre, Randomised, Controlled Treatment Study: Clinical Study Report of the First Study Phase," January 2006, p. 122.

  56. (Effectiveness of Heroin-Assisted Treatment [HAT] and Overview of Research) "A few key conclusions and discussion points regarding the state and future of HAT (heroin-assisted treatment) can be offered based on the above review of completed or ongoing studies.
    "First, although the basic goal of the different HAT studies is similar, each of the studies is distinct in key aspects, thus limiting direct comparisons and meta-analyses.40 Although this might be a desirable goal for science, it should be noted that heroin addiction and its consequences occur in distinct real-life environments (including unique cultural and system factors), and interventions need to be devised, measured, and evaluated within these to have authentic relevance for policy and practice.33,41
    "Second, the discussed studies above have demonstrated in several different contexts that the implementation of HAT is feasible, effective, and safe as a therapeutic intervention.21,24,26,30 This should not be seen as a conclusion that could be taken for granted because many observers expected disastrous consequences from the provision of medical heroin prescription.
    "Third, even within the contexts of relevant methodological constraints, e.g., the Swiss study relying purely on prospective observational data, and most of the other RCTs comparing HAT outcomes against a control intervention (MMT), which participants have previously either rejected by choice or proven to be ineffective, 32,42 the reviewed HAT studies have demonstrated rather robust and consistently positive therapeutic outcomes on the various indicators chosen for a population of high-risk heroin addicts for whom currently no effective alternative therapies are available. Clearly, this demonstrated effectiveness is at this point limited to short-term outcomes, and long-term examinations ought to follow (albeit Swiss follow-up data present initial positive evidence in this regard).43 It may very well emerge that HAT's main long-term benefit does not materialize through life-long maintenance, but by stabilizing and readying many of its patients for other simpler therapeutic interventions or even abstinence.
    "Fourth, also given the current expansion and diversification of alternative oral opioid maintenance therapies (e.g., buprenorphine and morphine) and considering the complex logistics (on both providers and patients_ ends), high costs, and sociopolitical controversy around (especially injection) HAT, the most sensible role of HAT is likely that of an exceptional 'last resort' option for heroin addicts who cannot be effectively attracted into or treated in other available therapeutic interventions.44,45 Granted the above, the primary emerging challenge for science—rather than conducting new and more HAT effectiveness studies—is to provide evidence-based guidelines on how to effectively match existing heroin addict profiles and needs with existing treatment options. This challenge has recently been complicated—in at least some jurisdictions—with the increasing diversification of heroin into poly-opioid (e.g., prescription) use profiles.46
    "Finally, after extensive HAT research efforts over the past decade, the principal onus of action has shifted from the scientific to the political arena in the jurisdictions under study.12,18 Despite the overall positive results of completed HAT trials undoubtedly justifying some role of HAT in the addiction treatment landscape, authorities in only two countries, Switzerland and the Netherlands, have decisively acted on this issue.34"

    Benedikt Fischer, Eugenia Oviedo-Joekes, Peter Blanken, Christian Haasen, Jurgen Rehm, Martin T. Schechter, John Strang, and Wim van den Brink, "Heroin-assisted Treatment (HAT) a Decade Later: A Brief Update on Science and Politics," Journal of Urban Health: Bulletin of the New York Academy of Medicine, (2007) Vol. 84, No. 4, pp. 559-560.