A 32-year-old female flight attendant is admitted to a surgical unit after an emergency appendectomy. She is pale and gaunt, exhibiting symptoms of malnutrition. Post-operatively, the patient complains of inadequate pain control and requires escalating dosages of narcotics. Her nurse notices that the patient is experiencing symptoms of nausea and vomiting, muscle cramps, sweating, chills, and restlessness. After further questioning, the patient admits to snorting heroin. She says she uses heroin because everyone does; in fact, it is the drug of choice among her friends. She admits that she didn’t offer this information during her admission history and physical because no one asked her.

The use of heroin is “in” among certain groups. A fashionable thing to do in the late 1990s, some called it “heroin chic.”¹ Heroin users move in and out of a variety of inpatient and outpatient settings where nurses care for patients from diverse social and economic situations. Nurses in practice settings ranging from the emergency department to physicians’ offices are in pivotal positions to identify the signs and symptoms associated with heroin abuse or dependence in their patients and to guide them to treatment.

Heroin, which is derived from the opium poppy, was first extracted from morphine in 1874. In 1898, Bayer Company first commercially marketed heroin as a potent analgesic. It was not until two years later that the addictive properties of this drug were known. More recently, the deaths of Janis Joplin and Jimi Hendrix highlighted the popularity of heroin within the rock music culture in the late 1960s and early 1970s. Finally, in 1970, the Drug Enforcement Administration classified heroin as a Schedule I drug – one that had no medical use and high potential for abuse.² Heroin use waxed and waned during the intervening decades, but by 2003, there were an estimated 3.7 million people in the US who had used heroin at least once during their lives.³ Between 1995 and 2001 there have been consistently greater than 100,000 new users every year.⁴

The rise in heroin use in recent years is due, in part, to its relatively low cost, widespread availability, and increased purity. Enhanced purity along with the fear of HIV/AIDS has shifted the usual route of administration from IV or subcutaneous injection to smoking or snorting, making it easier to use by young people.³ Although heroin use is most prevalent among persons 26 years or older, from 2003 to 2004 1.6% of eighth graders and 1.5 percent of 10th and 12th graders had used the drug at some time.³ In contrast to popular stereotypes, heroin users tend to be white men, older than 30, of low socioeconomic position, who live in central city areas.⁵ The demographic of the heroin epidemic makes it likely that nurses in all settings may come in contact with patients experiencing heroin intoxication/overdose, withdrawal, or other related complications. It is imperative that nurses become knowledgeable about the actions of heroin and clinical manifestations of heroin dependence and abuse.

Anatomy of a drug

Referred to on the streets as dope, horse, smack, junk, brown, harry, and boy, heroin — diacetylmorphine — is classified as an opioid drug with morphine-like actions. Heroin acts primarily on the central nervous system (CNS), particularly in areas related to pain perception, mood regulation, and autonomic body functions, such as respirations. The body naturally produces opioid substances, or endorphins, and opioid receptors are located throughout the body, most heavily concentrated in the brain.

One milligram of heroin is equivalent to two milligrams of morphine.⁶ However, on the street, heroin doses are not standardized and difficult to estimate. For example, although a bag of heroin may contain 100 mg of powder, the proportion of pure heroin could be variable, mixed with other substances, such as sugar, starch, powdered milk, or quinine. In the past, the purity of heroin ranged from 1% to 10%. However, purity is now estimated to be between 1% and 98%.

IV injection has the fastest onset of action, resulting in feelings of euphoria within seven to eight seconds; smoking or snorting produces effects in 10 to 15 minutes.⁷ The duration of action is approximately four to five hours.⁶ Heroin initially produces a pleasurable sensation described as a “rush,” which lasts only briefly. The rush is accompanied by feelings of euphoria along with clouded mental functioning. Warm flushing of the skin, dry mouth, and a heavy feeling in the extremities often follow the initial rush. Users may experience a relaxed, contented state or drowsiness for up to several hours.

Heroin is absorbed directly into the bloodstream following injection or through mucous membranes (e.g., nasal, respiratory). Heroin itself is a biologically inactive substance, but it is rapidly converted into morphine in the brain. Because heroin crosses the blood-brain barrier more easily than morphine, it acts more quickly than morphine, which is why addicts report being able to differentiate the quick “rush” of heroin from morphine.⁸ The drug is primarily metabolized by the liver, and most is excreted into the urine. Ninety percent is eliminated from the body within 24 hours. For several days after the last dose, small amounts can be detected in both urine and feces.

Heroin is being sold on the streets along with cocaine in what is termed double-breasted dealing.⁹ Users snort alternate lines of cocaine and heroin; cocaine is used as the primary drug, with heroin added to ease agitation.⁹ Speedballing refers to injecting a mixture of heroin with cocaine powder or with crack. It is estimated that the practice of combining cocaine and heroin was responsible for 46% of all heroin-related deaths in 1995.¹⁰ Heroin potentiates the effects of other drugs, such as CNS depressants. For example, the use of heroin with alcohol may produce severe sedation and respiratory depression. Other drugs that are dangerous when combined with heroin include barbiturates; benzodiazepines, such as diazepam (Valium); MAO inhibitors, such as phenelzine sulfate (Nardil), and tranylcypromine sulfate (Parnate); antihypertensives; antihistamines; and general anesthetics.⁶

Heroin use equals complications

Heroin is highly addictive. Physical dependence develops with regular use, and tolerance occurs as larger and larger doses must be taken to achieve the same effects. Physical dependence produces molecular and neurochemical changes in the CNS as the body adapts to the drug’s presence. Withdrawal symptoms occur if the dosage is reduced, use is stopped, or an opioid antagonist, such as naloxone (Narcan), is administered. Psychological dependence occurs as the heroin user becomes preoccupied with obtaining and using the drug. Heroin use becomes more important than other personal, social, occupational, or recreational responsibilities and activities.

Heroin users continue to crave and use this drug despite serious physical effects. Those who snort the drug are susceptible to chronic sinusitis and perforated nasal septum. Long-term users who inject heroin typically develop localized dermatological (e.g., cellulitis, ulcerations, abscesses) and vascular (e.g., collapsed veins, phlebitis, sclerosis) complications at injection sites throughout the body. Users who inject can develop emboli from talc and other substances mixed with heroin; emboli, in turn, may lead to pulmonary hypertension. If heroin is cut with quinine, toxic amblyopia may occur in one or both eyes. Additives in street heroin that do not completely dissolve may clog blood vessels in major organs, leading to liver, kidney, or lung disease.⁷ Most other long-term problems related to heroin use represent systemic infections, including HIV/AIDS, hepatitis B and C, tetanus, bacterial endocarditis, septic arthritis, and cotton fever, which results from injection of cotton particles and other impurities after heroin is purified by filtering it through cotton.^7,11 Most of these problems do not result from heroin itself but from repeated injection with contaminated needles. Other problems, such as malnutrition, tuberculosis, and pneumonia, may develop because of the poor health status and living conditions of the users.

Heroin overdose

Although heroin was glorified during the early part of this century through the music of the Jazz Age and later in the lyrics of popular musicians, the glamour associated with heroin usually faded with the deaths of celebrities who used the drug. Between 1992 and 1995, annual heroin-related deaths rose from 2,782 to 3,809, and heroin became the most frequently reported drug among deaths reported by medical examiners in 1995 and 1996. The drug continues to kill. The Drug Abuse Warning Network survey found that heroin was among the four most frequently reported substances in drug-related deaths in 2002, and emergency visits for heroin problems increased by 35% from 1995 to 2002.¹² Heroin overdose is physiologically the same as morphine overdose.⁶ However, the variability of heroin dose and interactions between heroin and other substances, such as alcohol and barbiturates, complicate heroin overdose.¹³ Signs and symptoms of overdose include hypotension, pinpoint pupils, respiratory depression, and marked sedation. Heroin lowers blood pressure by dilating peripheral arteries and veins and the person suffering from an overdose may exhibit symptoms of shock. Hypotension becomes more severe in the face of prolonged hypoxia and CNS depression. As hypoxia progresses, the pupils become dilated.⁶

Respiratory depression is another serious consequence, and deaths due to heroin overdose are almost always from respiratory arrest.¹⁴ Respiratory depression begins about seven minutes after an IV injection and may last up to four or five hours. The respiratory rate may be as low as two to four breaths a minute. As tolerance to heroin rises with prolonged use, so does tolerance to respiratory depression.⁶ However, when doses of the drug are unknown, individuals with a high tolerance may unknowingly take doses up to 10 times their usual amount.⁷

Excessive CNS sedation can lead to coma, which is generally deep. Since CNS and respiratory depression may occur in a matter of minutes, a trip to the emergency department for a heroin overdose does not always result in a successful outcome.

Treatment of heroin overdose includes IV fluids to support the blood pressure and to manage shock. Respiratory assistance, including intubation, is often required until the individual is able to breathe independently. Naloxone is administered IV, IM, or into the endotracheal tube when heroin overdose is suspected. Naloxone reverses the analgesia, sedation, and respiratory depression of heroin by blocking opioid receptors.⁶ When given IV, naloxone begins to reverse the actions of heroin almost immediately and continues to act for about one hour. The dose of naloxone is titrated to treat the individual patient, since the amount of drug required depends on the dose of heroin injected. A dose of 0.4 mg to 2 mg is usually administered and repeated, if necessary.¹⁵ Caution needs to be taken after naloxone treatment, since blocking heroin action may result in symptoms of withdrawal in the individual addicted to heroin. In cases of suspected heroin overdose, or if it is not known whether the patient took a large dose of heroin along with another drug, naloxone may not improve the condition, but it will not make it worse.⁶ If there is no response to the administration of naloxone, other causes of CNS depression should be investigated.

Heroin withdrawal

Symptoms of heroin withdrawal are usually the reasons users seek medical care.¹¹ The DSM IV classification for opioid withdrawal (292.0) includes criteria used to diagnose this disorder.¹⁶ Heroin withdrawal usually begins eight to 24 hours after the last dose or may be experienced if there is a decrease in the usual dosage of heroin after prolonged and heavy use.¹⁶ Symptoms will also be experienced if an opioid antagonist such as naloxone is administered to persons with recurrent heroin use. Since heroin inhibits norepinephrine secretion, withdrawal symptoms reflect a sympathomimetic state caused by a rapid catecholamine release.¹¹ Symptoms may peak between 24 and 48 hours and subside within a week. However, some individuals have persistent withdrawal symptoms for several months.⁷

Early signs and symptoms of withdrawal begin with feelings of anxiety, restlessness, sweating and chills, and an achy “flu-like” feeling. The user also may engage in drug-seeking behaviors. Other symptoms associated with heroin withdrawal include dysphoric mood, pupillary dilation, rhinorrhea, insomnia, diarrhea, and nausea and vomiting.¹⁶ Elevations in blood pressure, pulse, respirations, and temperature also occur.¹⁷ Heroin withdrawal is very distressful to the person and causes disruptions in social and occupational functions.¹⁶ However, heroin withdrawal is rarely fatal to an otherwise healthy adult, although death may result from complications of prior use.¹⁷

The severity of heroin withdrawal depends on the amount of heroin used, duration of use, and intervals between dosages.⁶ Medical detoxification is initiated with the use of long-acting opiates, such as methadone, prescribed in decreasing dosages.¹⁸ After medical detoxification, a methadone maintenance program can be used for a year or more to eliminate the craving for heroin. The Food and Drug Administration (FDA) has also approved levo-alpha-acetyl-methadol (LAAM), a long-acting opioid, as a maintenance medication.¹⁹ Patients who may benefit from LAAM therapy include those entering treatment, individuals in their first two years of a methadone maintenance program, chronic relapsers, or those required to report for methadone six times a week because of state or local policies for maintenance programs.¹⁹ Although clonidine (Catapres) has not been approved by the FDA for opiate withdrawal, it may be used by addictions specialists to treat withdrawal symptoms. Clonidine diminishes some of the symptoms of opiate withdrawal; however, it does not have an effect on the insomnia, muscle aches, or drug cravings.⁶

Nurses’ encounters with users

Given the changing demographic patterns of this new epidemic, nurses need to discard old stereotypes regarding heroin users. Heroin abuse now spans all segments of the population; users and addicts come from all walks of life. But heroin abuse is just one aspect of a total person. Nurses should avoid judgmental attitudes and should not overlook nonheroin-related acute and chronic health problems. As part of their assessment, nurses should obtain a substance abuse history on all patients, since there is no profile of a typical heroin user.

Nurses, who encounter patients in many different healthcare settings, are in positions where they can identify signs and symptoms of abuse and dependence.²⁰ Subtle indicators of heroin use may include the presence of “tracks” or needle marks, long sleeves in warm weather, recurrent sinus infections, drug-seeking behaviors, and changes in personal hygiene. Once a heroin abuser is identified, the nurse can explore treatment options with the person and make appropriate referrals. Treatment options include inpatient versus outpatient treatment; pharmacological agents, such as methadone or LAAM; individual counseling; and behavioral, group, and/or family therapies. Factors that influence treatment decisions include personal preference, agency criteria or protocol, insurance, and interpersonal and environmental resources. It is important to emphasize that multidisciplinary, individualized assessment and treatment are most effective.

Nurses have a key role in educating their clients and the general public about heroin abuse and its consequences. Prevention efforts should be started in elementary schools and targeted toward all segments of the population, including the workforce. “Heroin chic” is not glamorous, and American society needs to get the message that heroin is “nothing to horse around with.”