View source for Chemistry:Heroin

{{Short description|Opioid used as an analgesic and a recreational drug for its euphoric effects}}
{{Pp-semi-indef}}
{{drugbox
| Watchedfields = changed
| verifiedrevid = 443854562
| drug_name = Heroin
| BAN = Diamorphine<ref name="Martindale36">{{Cite book| veditors = Sweetman SC |title=Martindale: the complete drug reference |edition=36th |publisher=Pharmaceutical Press |location=London |year=2009 |isbn=978-0-85369-840-1 |page=42}}</ref>
| IUPAC_name = (5α,6α)-7,8-didehydro-4,5-epoxy-17-methylmorphinan-3,6-diol diacetate
| image = Heroin - Heroine.svg
| image2 = Heroin-from-xtal-horizontal-3D-balls.png

<!--Clinical data-->
| pronounce = Heroin: {{IPAc-en|ˈ|h|ɛr|oʊ|ᵻ|n}}
| Drugs.com = {{drugs.com|parent|heroin}}
| pregnancy_AU = <!-- A / B1 / B2 / B3 / C / D / X -->
| pregnancy_AU_comment =     
| pregnancy_US = <!-- A / B            / C / D / X / N -->
| pregnancy_US_comment =
| pregnancy_category =
| legal_AU = S9
| legal_BR = F1
| legal_CA = Schedule I
| legal_DE = Anlage I, II and III
| legal_NZ = Class A
| legal_UK = Class A
| legal_US = Schedule I
| legal_UN = Narcotic Schedules I and IV
| dependency_liability = Very high<ref>{{cite book | vauthors = Bonewit-West K, Hunt SA, Applegate E |title=Today's Medical Assistant: Clinical and Administrative Procedures |date=2012 |publisher=Elsevier Health Sciences |isbn=9781455701506 |page=571 |url=https://books.google.com/books?id=YalYPI1KqTQC&pg=PA571 |language=en}}</ref>
| addiction_liability = Very high<ref name=Drugs2014/>
| routes_of_administration = Intravenous, inhalation, transmucosal, by mouth, intranasal, rectal, intramuscular, subcutaneous, intrathecal
| class = [[Chemistry:Opioid|Opioid]]

<!--Pharmacokinetic data-->
| bioavailability = <35% (by mouth), 44–61% (inhaled)<ref name="pmid16433897">{{cite journal | vauthors = Rook EJ, van Ree JM, van den Brink W, Hillebrand MJ, Huitema AD, Hendriks VM, Beijnen JH | title = Pharmacokinetics and pharmacodynamics of high doses of pharmaceutically prepared heroin, by intravenous or by inhalation route in opioid-dependent patients | journal = Basic & Clinical Pharmacology & Toxicology | volume = 98 | issue = 1 | pages = 86–96 | date = January 2006 | pmid = 16433897 | doi = 10.1111/j.1742-7843.2006.pto_233.x | doi-access = free }}</ref>
| protein_bound = 0% ([[Biology:Morphine|morphine]] metabolite 35%)
| metabolism = [[Biology:Liver|Liver]]
| onset = Within minutes<ref>{{cite book| vauthors = Riviello RJ |title=Manual of forensic emergency medicine: a guide for clinicians|date=2010|publisher=Jones and Bartlett Publishers|location=Sudbury, Mass.|isbn=978-0-7637-4462-5|page=41|url=https://books.google.com/books?id=keng9ELAE2IC&pg=PA41|url-status=live|access-date=29 August 2017|archive-url=https://web.archive.org/web/20170318224346/https://books.google.com/books?id=keng9ELAE2IC&pg=PA41|archive-date=18 March 2017}}</ref>
| elimination_half-life = 2–3 minutes<ref name=EMC>{{cite web|title=Diamorphine Hydrochloride Injection 30 mg – Summary of Product Characteristics|website=electronic Medicines Compendium|publisher=ViroPharma Limited|date=24 September 2013|access-date=30 March 2014|url=http://www.medicines.org.uk/emc/medicine/28258/SPC/Diamorphine+Hydrochloride+Injection+30+mg/|url-status=dead|archive-url=https://web.archive.org/web/20140330154716/http://www.medicines.org.uk/emc/medicine/28258/SPC/Diamorphine+Hydrochloride+Injection+30+mg/|archive-date=30 March 2014}}</ref>
| duration_of_action= 4 to 5 hours<ref>{{cite book| vauthors = Field J |title=The Textbook of Emergency Cardiovascular Care and CPR|date=2012|publisher=Lippincott Williams & Wilkins|isbn=978-1-4698-0162-9|page=447|url=https://books.google.com/books?id=o3m4oNRB4D4C&pg=PA447|url-status=live|archive-url=https://web.archive.org/web/20170910234542/https://books.google.com/books?id=o3m4oNRB4D4C&pg=PA447|archive-date=10 September 2017}}</ref>
| excretion = 90% kidney as [[Chemistry:Glucuronide|glucuronide]]s, rest biliary

<!--Identifiers-->
| CAS_number_Ref = {{cascite|correct|??}}
| CAS_number = 561-27-3
| ATC_prefix = N07
| ATC_suffix = BC06
| ChEBI_Ref = {{ebicite|correct|EBI}}
| ChEBI = 27808
| PubChem = 5462328
| DrugBank_Ref = {{drugbankcite|correct|drugbank}}
| DrugBank = DB01452
| KEGG_Ref = {{keggcite|correct|kegg}}
| KEGG = D07286
| ChemSpiderID_Ref = {{chemspidercite|correct|chemspider}}
| ChemSpiderID = 4575379
| UNII_Ref = {{fdacite|correct|FDA}}
| UNII = 70D95007SX

| index2_label = HCl
| CAS_number2_Ref = {{cascite|correct|CAS}}
| CAS_number2 =	1502-95-0
| UNII2_Ref = {{fdacite|correct|FDA}}
| UNII2 = 8H672SHT8E

| ChEMBL_Ref = {{ebicite|correct|EBI}}
| ChEMBL = 459324| C=21 | H=23 | N=1 | O=5
| smiles = CC(OC1=C(O[C@@H]2[C@]34CCN(C)[C@@H]([C@@H]4C=C[C@@H]2OC(C)=O)C5)C3=C5C=C1)=O
| StdInChI_Ref = {{stdinchicite|correct|chemspider}}
| StdInChI = 1S/C21H23NO5/c1-11(23)25-16-6-4-13-10-15-14-5-7-17(26-12(2)24)20-21(14,8-9-22(15)3)18(13)19(16)27-20/h4-7,14-15,17,20H,8-10H2,1-3H3/t14-,15+,17-,20-,21-/m0/s1
| StdInChIKey_Ref = {{stdinchicite|correct|chemspider}}
| StdInChIKey = GVGLGOZIDCSQPN-PVHGPHFFSA-N
| synonyms = Diacetylmorphine, acetomorphine, (dual) acetylated morphine, morphine diacetate
|alt=|caption=|type=|MedlinePlus=|legal_status=|licence_EU=|licence_US=
}}
<!--Definition and medical uses-->

'''Heroin''', also known as '''diacetylmorphine''' and '''diamorphine''' among other names,<ref name="Martindale36"/> is a [[Chemistry:Morphinan|morphinan]] [[Chemistry:Opioid|opioid]] substance synthesized from the [[Biology:Opium|dried latex]] of the ''[[Biology:Papaver somniferum|Papaver somniferum]]'' plant and is mainly used as a recreational drug for its euphoric effects. Medical-grade diamorphine is used as a pure [[Chemistry:Hydrochloride|hydrochloride salt]]. Various white and brown powders sold illegally around the world as heroin are routinely diluted with [[Chemistry:Cutting agent|cutting agents]]. [[Chemistry:Black tar heroin|Black tar heroin]] is a variable admixture of [[Biology:Morphine|morphine]] derivatives—predominantly 6-MAM (6-monoacetylmorphine), which is the result of crude [[Biology:Acetylation|acetylation]] during clandestine production of street heroin.<ref name="Drugs2014">{{cite web|title=Heroin|url=https://www.drugs.com/illicit/heroin.html|website=Drugs.com|access-date=19 October 2016|date=18 May 2014|url-status=live|archive-url=https://web.archive.org/web/20161019154754/https://www.drugs.com/illicit/heroin.html|archive-date=19 October 2016}}</ref> Heroin is used medically in several countries to relieve pain, such as during childbirth or a heart attack, as well as in opioid replacement therapy.<ref>{{cite journal | vauthors = Friedrichsdorf SJ, Postier A | title = Management of breakthrough pain in children with cancer | journal = Journal of Pain Research | volume = 7 | pages = 117–23 | date = 2014 | pmid = 24639603 | pmc = 3953108 | doi = 10.2147/JPR.S58862 | doi-access = free }}</ref><ref>{{cite book | location = Cardiff (UK) | publisher = National Collaborating Centre for Cancer (UK) | title = Opioids in Palliative Care: Safe and Effective Prescribing of Strong Opioids for Pain in Palliative Care of Adults | date = May 2012 | pmid = 23285502 | author1 = National Collaborating Centre for Cancer (UK) }}</ref><ref>{{cite journal | vauthors = Uchtenhagen AA | title = Heroin maintenance treatment: from idea to research to practice | journal = Drug and Alcohol Review | volume = 30 | issue = 2 | pages = 130–7 | date = March 2011 | pmid = 21375613 | doi = 10.1111/j.1465-3362.2010.00266.x | url = http://www.zora.uzh.ch/47764/1/Heroinmaintenance_Uchtenhagen-V.pdf | access-date = 20 April 2018 | archive-date = 28 August 2021 | archive-url = https://web.archive.org/web/20210828105215/http://www.zora.uzh.ch/id/eprint/47764/1/Heroinmaintenance_Uchtenhagen-V.pdf | url-status = dead }}</ref>

It is typically injected, usually into a [[Medicine:Vein|vein]], but it can also be snorted, smoked, or inhaled. In a clinical context, the route of administration is most commonly intravenous injection; it may also be given by intramuscular or subcutaneous injection, as well as orally in the form of tablets.<ref>{{cite web |title=Diamorphine |url=https://www.sps.nhs.uk/medicines/diamorphine/ |website=SPS – Specialist Pharmacy Service|date=15 February 2013 }}</ref><ref name=Drugs2014/><ref name=NIH2014/><ref>{{Cite book|url=https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/heroinrrs_11_14.pdf|title=Research Report Series: Heroin|last=National Institutes on Drug Abuse|publisher=National Institutes on Drug Abuse|year=2014|pages=1|quote=Highly pure heroin can be snorted or smoked and may be more appealing to new users because it eliminates the stigma associated with injection drug use…. Impure heroin is usually dissolved, diluted, and injected into veins, muscles, or under the skin.|url-status=live|archive-url=https://web.archive.org/web/20161230054652/https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/heroinrrs_11_14.pdf|archive-date=30 December 2016}}</ref> The onset of effects is usually rapid and lasts for a few hours.<ref name=Drugs2014/>

<!--Side effects and mechanism-->
Common side effects include respiratory depression (decreased breathing), dry mouth, drowsiness, impaired mental function, constipation, and [[Medicine:Addiction|addiction]].<ref name=NIH2014/> Use by injection can also result in abscesses, [[Medicine:Endocarditis|infected heart valves]], blood-borne infections, and [[Medicine:Pneumonia|pneumonia]].<ref name=NIH2014/> After a history of long-term use, [[Chemistry:Opioid withdrawal|opioid withdrawal]] symptoms can begin within hours of the last use.<ref name=NIH2014/> When given by injection into a vein, heroin has two to three times the effect of a similar dose of [[Biology:Morphine|morphine]].<ref name="Drugs2014"/> It typically appears in the form of a white or brown powder.<ref name="NIH2014">{{cite web|title=DrugFacts—Heroin|url=https://www.drugabuse.gov/publications/drugfacts/heroin|website=National Institute on Drug Abuse|access-date=19 October 2016|date=October 2014|url-status=dead|archive-url=https://web.archive.org/web/20161019150657/https://www.drugabuse.gov/publications/drugfacts/heroin|archive-date=19 October 2016}}</ref>

<!--Treatment and epidemiology -->
Treatment of heroin addiction often includes behavioral therapy and medications.<ref name=NIH2014/> Medications can include [[Chemistry:Buprenorphine|buprenorphine]], [[Chemistry:Methadone|methadone]], or [[Chemistry:Naltrexone|naltrexone]].<ref name=NIH2014/> A heroin overdose may be treated with [[Chemistry:Naloxone|naloxone]].<ref name=NIH2014/> An estimated 17&nbsp;million people {{as of|2015|lc=y}} use opiates, of which heroin is the most common,<ref name=WDR2016/><ref>{{cite web |title=Information sheet on opioid overdose |url=https://www.who.int/substance_abuse/information-sheet/en/ |website=WHO |access-date=10 December 2018 |date=August 2018 |archive-url=https://web.archive.org/web/20190421140401/https://www.who.int/substance_abuse/information-sheet/en/ |archive-date=21 April 2019 |url-status=live }}</ref> and opioid use resulted in 122,000 deaths.<ref>{{cite journal | vauthors = Wang H, Naghavi M, Allen C, Barber RM, Bhutta ZA, Carter A, etal| collaboration = GBD 2015 Mortality and Causes of Death Collaborators | title = Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015 | journal = Lancet | volume = 388 | issue = 10053 | pages = 1459–1544 | date = October 2016 | pmid = 27733281 | pmc = 5388903 | doi = 10.1016/s0140-6736(16)31012-1 }}</ref> The total number of heroin users worldwide as of 2015 is believed to have increased in Africa, the Americas, and Asia since 2000.<ref name=WDR2017Part3/> In the United States, approximately 1.6 percent of people have used heroin at some point.<ref name=NIH2014/><ref>{{cite web |title=What is the scope of heroin use in the United States? |url=https://www.drugabuse.gov/publications/research-reports/heroin/scope-heroin-use-in-united-states |website=National Institute on Drug Abuse |access-date=10 December 2018 |language=en |archive-url=https://web.archive.org/web/20181210110910/https://www.drugabuse.gov/publications/research-reports/heroin/scope-heroin-use-in-united-states |archive-date=10 December 2018 |url-status=live }}</ref> When people die from overdosing on a drug, the drug is usually an opioid and often heroin.<ref name="WDR2016">{{cite book|title=World Drug Report 2016|chapter-url=http://www.unodc.org/doc/wdr2016/WORLD_DRUG_REPORT_2016_web.pdf|access-date=1 August 2016|chapter=Statistical tables|isbn=978-92-1-057862-2|location=Vienna, Austria|date=May 2016|page=xii, 18, 32|url-status=live|archive-url=https://web.archive.org/web/20160809143704/http://www.unodc.org/doc/wdr2016/WORLD_DRUG_REPORT_2016_web.pdf|archive-date=9 August 2016| author = United Nations Office on Drugs and Crime }}</ref><ref>{{cite web | vauthors = Valencia M |title=Record 29 million people drug-dependent worldwide; heroin use up sharply – UN report |url=https://www.un.org/sustainabledevelopment/blog/2016/06/record-29-million-people-drug-dependent-worldwide-heroin-use-up-sharply-un-report/ |website=United Nations Sustainable Development |access-date=10 December 2018 |date=23 June 2016 |archive-url=https://web.archive.org/web/20190414091050/https://www.un.org/sustainabledevelopment/blog/2016/06/record-29-million-people-drug-dependent-worldwide-heroin-use-up-sharply-un-report/ |archive-date=14 April 2019 |url-status=live }}</ref>

<!-- History and culture -->
Heroin was first made by C. R. Alder Wright in 1874 from morphine, a natural product of the [[Biology:Papaver somniferum|opium poppy]].<ref>{{cite book|title=A Century of International Drug Control|date=2010|publisher=United Nations Publications|isbn=9789211482454|page=49|url=https://books.google.com/books?id=uRQiAVTTiYwC&pg=PT50|language=en|url-status=live|archive-url=https://web.archive.org/web/20170910234542/https://books.google.com/books?id=uRQiAVTTiYwC&pg=PT50|archive-date=10 September 2017}}</ref> Internationally, heroin is controlled under Schedules I and IV of the [[Medicine:Single Convention on Narcotic Drugs|Single Convention on Narcotic Drugs]],<ref>{{cite web|date=December 2004 |url=http://www.incb.org/pdf/e/list/46thedition.pdf |title=Yellow List: List of Narcotic Drugs Under International Control |publisher=International Narcotics Control Board |access-date=5 May 2006 |archive-url=https://web.archive.org/web/20120510002957/http://www.incb.org/pdf/e/list/46thedition.pdf |archive-date=10 May 2012 }} Referring URL = {{cite web|url=http://www.incb.org/incb/yellow_list.html |title=Yellow List |access-date=21 June 2006 |url-status=dead |archive-url=https://web.archive.org/web/20060621035248/http://www.incb.org/incb/yellow_list.html |archive-date=21 June 2006}}</ref> and it is generally illegal to make, possess, or sell without a license.<ref>{{cite book| vauthors = Lyman MD |title=Drugs in Society: Causes, Concepts, and Control|date=2013|publisher=Routledge|isbn=9780124071674|page=45|url=https://books.google.com/books?id=bRU4AAAAQBAJ&pg=PA45|language=en|url-status=live|archive-url=https://web.archive.org/web/20170910234542/https://books.google.com/books?id=bRU4AAAAQBAJ&pg=PA45|archive-date=10 September 2017}}</ref> About 448 tons of heroin were made in 2016.<ref name="WDR2017Part3">{{cite book |title=World Drug Report 2017 Part 3 |date=May 2017 |publisher=United Nations |isbn=978-92-1-148294-2 |pages=14, 24 |url=http://www.unodc.org/wdr2017/field/Booklet_3_Plantbased_drugs.pdf |access-date=10 December 2018 |archive-url=https://web.archive.org/web/20180727180346/https://www.unodc.org/wdr2017/field/Booklet_3_Plantbased_drugs.pdf |archive-date=27 July 2018 |url-status=live }}</ref> In 2015, Afghanistan produced about 66% of the world's opium.<ref name="WDR2016"/> Illegal heroin is often mixed with other substances such as sugar, [[Chemistry:Starch|starch]], [[Biology:Caffeine|caffeine]], [[Chemistry:Quinine|quinine]], or other opioids like [[Chemistry:Fentanyl|fentanyl]].<ref name=Drugs2014/><ref>{{Cite book|title=CUT: a guide to adulterants, bulking agents and other contaminants found in illicit drugs|date=2010 | vauthors = Cole C | location = Liverpool | publisher = Centre for Public Health. Faculty of Health and Applied Social Sciences, John Moores University. |isbn=978-1-907441-47-9 |oclc=650080999}}</ref>

==Uses==
===Recreational===
[[Company:Bayer|Bayer]]'s original trade name of heroin is typically used in non-medical settings. It is used as a recreational drug for the euphoria it induces. [[Social:Anthropology|Anthropologist]] Michael Agar once described heroin as "the perfect whatever drug."<ref name="agar">{{cite web | vauthors = Agar M | title = Dope Double Agent: The Naked Emperor on Drugs | url = http://www.americanethnography.com/article_sql.php?id=95 | access-date = 22 October 2009 | quote = What a great New York drug heroin was, I thought. As any city, but more than most, New York is an information overload, a constant perceptual tornado that surrounds you most places you walk on the streets. Heroin is the audio-visual technology that helps manage that overload by dampening it in general and allowing a focus on some part of it that the human perceptual equipment was, in fact, designed to handle. | url-status = live | archive-url = https://web.archive.org/web/20091117152041/http://www.americanethnography.com/article_sql.php?id=95 | archive-date = 17 November 2009}}</ref> Tolerance develops quickly, and increased doses are needed in order to achieve the same effects. Its popularity with recreational drug users, compared to [[Biology:Morphine|morphine]], reportedly stems from its perceived different effects.<ref>{{cite journal| vauthors = Tschacher W, Haemmig R, Jacobshagen N | title = Time series modeling of heroin and morphine drug action | journal = Psychopharmacology | volume = 165 | issue = 2 | pages = 188–93 | date = January 2003 | pmid = 12404073 | doi = 10.1007/s00213-002-1271-3 | s2cid = 33612363 | url = https://boris.unibe.ch/21515/ }}</ref>

Short-term addiction studies by the same researchers demonstrated that tolerance developed at a similar rate to both heroin and morphine. When compared to the opioids [[Chemistry:Hydromorphone|hydromorphone]], [[Chemistry:Fentanyl|fentanyl]], [[Chemistry:Oxycodone|oxycodone]], and [[Chemistry:Pethidine|pethidine]] (meperidine), former addicts showed a strong preference for heroin and morphine, suggesting that heroin and morphine are particularly susceptible to misuse and causing dependence. Morphine and heroin were also much more likely to produce euphoria and other positive subjective effects when compared to these other opioids.<ref name="martin and fraser">{{cite journal | vauthors = Martin WR, Fraser HF | title = A comparative study of physiological and subjective effects of heroin and morphine administered intravenously in postaddicts | journal = The Journal of Pharmacology and Experimental Therapeutics | volume = 133 | pages = 388–99 | date = September 1961 | pmid = 13767429 | url = http://jpet.aspetjournals.org/cgi/pmidlookup?view=long&pmid=13767429 }}</ref>

===Medical uses===
In the {{wipe|United States}}, heroin is not accepted as medically useful.<ref name=Drugs2014/>
[[File:Drug store sign for products Heroin and Aspirin before US Heroin ban 1924.jpg|thumb|upright|Advertising sign from Bayer for use in US drug stores, dating from before the federal prohibition of heroin in 1924]]
Under the generic name diamorphine, heroin is prescribed as a strong [[Biology:Analgesic|pain medication]] in the {{wipe|United Kingdom}}, where it is administered via [[Medicine:Tablet (pharmacy)|oral]], [[Medicine:Subcutaneous injection|subcutaneous]], intramuscular, intrathecal, intranasal or intravenous routes. It may be prescribed for the treatment of acute pain, such as in severe physical trauma, [[Medicine:Myocardial infarction|myocardial infarction]], post-[[Medicine:Surgery|surgical]] pain and [[Medicine:Chronic pain|chronic pain]], including end-stage [[Medicine:Terminal illness|terminal illness]]es. In other countries it is more common to use morphine or other strong opioids in these situations. In 2004, the National Institute for Health and Clinical Excellence produced guidance on the management of [[Medicine:Caesarean section|caesarean section]], which recommended the use of intrathecal or epidural diamorphine for post-operative pain relief. For women who have had intrathecal opioids, there should be a minimum hourly observation of respiratory rate, sedation and pain scores for at least 12 hours for diamorphine and 24 hours for morphine. Women should be offered diamorphine (0.3–0.4&nbsp;mg intrathecally) for intra- and postoperative analgesia because it reduces the need for supplemental analgesia after a caesarean section. Epidural diamorphine (2.5–5&nbsp;mg) is a suitable alternative.<ref>{{cite web |url=http://www.nice.org.uk/guidance/cg132/chapter/1-recommendations#procedural-aspects-of-cs |title=National Institute for Health and Clinical Excellence (2011) Caesarean section.NICE Guideline (CG132) |date=23 November 2011 |access-date=28 October 2015 |url-status=live |archive-url=https://web.archive.org/web/20151025180200/http://www.nice.org.uk/guidance/cg132/chapter/1-recommendations#procedural-aspects-of-cs |archive-date=25 October 2015}}</ref>

Diamorphine continues to be widely used in palliative care in the UK, where it is commonly given by the [[Medicine:Subcutaneous injection|subcutaneous]] route, often via a [[Engineering:Syringe driver|syringe driver]] if patients cannot easily swallow [[Biology:Morphine|morphine solution]]. The advantage of diamorphine over morphine is that diamorphine is more [[Chemistry:Lipophilicity|fat soluble]] and therefore more potent by injection, so smaller doses of it are needed for the same effect on pain. Both of these factors are advantageous if giving high doses of opioids via the subcutaneous route, which is often necessary for palliative care.

It is also used in the palliative management of bone fractures and other trauma, especially in children. In the trauma context, it is primarily given by nose in hospital; although a prepared nasal spray is available.<ref>{{cite web |title=Ayendi 720microgram/actuation Nasal Spray – Summary of Product Characteristics (SmPC) – (emc) |url=https://www.medicines.org.uk/emc/product/5139/smpc |website=www.medicines.org.uk |access-date=29 December 2019 |archive-url=https://web.archive.org/web/20191229031102/https://www.medicines.org.uk/emc/product/5139/smpc |archive-date=29 December 2019 |url-status=live }}</ref> It has traditionally been made by the attending physician, generally from the same "dry" ampoules as used for injection. In children, Ayendi nasal spray is available at 720 micrograms and 1600 micrograms per 50 microlitres actuation of the spray, which may be preferable as a non-invasive alternative in pediatric care, avoiding the fear of injection in children.<ref name="DIAMORPHINE HYDROCHLORIDE (medicinal forms)">{{cite web |title=BNFc is only available in the UK |url=https://bnfc.nice.org.uk/medicinal-forms/diamorphine-hydrochloride.html |website=NICE |publisher=NICE – national institute for health and care excellence |access-date=3 July 2020}}</ref>

====Maintenance therapy====
{{Main|Unsolved:Heroin-assisted treatment}}
A number of European countries prescribe heroin for treatment of heroin addiction.<ref>{{cite journal | vauthors = Lintzeris N | title = Prescription of heroin for the management of heroin dependence: current status | journal = CNS Drugs | volume = 23 | issue = 6 | pages = 463–76 | date = 2009 | pmid = 19480466 | doi = 10.2165/00023210-200923060-00002 | s2cid = 11018732 }}</ref> The initial Swiss HAT ([[Unsolved:Heroin-assisted treatment|heroin-assisted treatment]]) trial ("PROVE" study) was conducted as a prospective cohort study with some 1,000 participants in 18 treatment centers between 1994 and 1996, at the end of 2004, 1,200 patients were enrolled in HAT in 23 treatment centers across Switzerland.<ref>{{cite book |doi=10.1159/000062984 |chapter=Preliminary Pages |title=Prescriptions of Narcotics for Heroin Addicts |series=Medical Prescription of Narcotics |year=1999 |volume=1 |isbn=3-8055-6791-X }}</ref><ref>{{cite journal | vauthors = Fischer B, Oviedo-Joekes E, Blanken P, Haasen C, Rehm J, Schechter MT, Strang J, van den Brink W | display-authors = 6 | title = Heroin-assisted treatment (HAT) a decade later: a brief update on science and politics | journal = Journal of Urban Health | volume = 84 | issue = 4 | pages = 552–62 | date = July 2007 | pmid = 17562183 | pmc = 2219559 | doi = 10.1007/s11524-007-9198-y }}</ref> Diamorphine may be used as a maintenance drug to assist the treatment of opiate addiction, normally in long-term chronic intravenous (IV) heroin users. It is only prescribed following exhaustive efforts at treatment via other means. It is sometimes thought that heroin users can walk into a clinic and walk out with a prescription, but the process takes many weeks before a prescription for diamorphine is issued. Though this is somewhat controversial among proponents of a zero-tolerance [[Medicine:Drug policy|drug policy]], it has proven superior to [[Chemistry:Methadone|methadone]] in improving the social and health situations of addicts.<ref name="haasen">{{cite journal | vauthors = Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D | title = Heroin-assisted treatment for opioid dependence: randomised controlled trial | journal = The British Journal of Psychiatry | volume = 191 | pages = 55–62 | date = July 2007 | pmid = 17602126 | doi = 10.1192/bjp.bp.106.026112 | doi-access = free }}</ref>

The UK Department of Health's Rolleston Committee Report<ref>{{cite web|title=Rolleston Report|url=http://www.drugtext.org/Table/Rolleston-Report/|publisher=Departmental Commission on Morphine and Heroin Addiction, United Kingdom|access-date=28 January 2011|year=1926|url-status=live|archive-url=https://web.archive.org/web/20110417125310/http://www.drugtext.org/Table/Rolleston-Report/|archive-date=17 April 2011}}</ref> in 1926 established the British approach to diamorphine prescription to users, which was maintained for the next 40 years: dealers were prosecuted, but doctors could prescribe diamorphine to users when withdrawing. In 1964, the Brain Committee recommended that only selected approved doctors working at approved specialized centres be allowed to prescribe diamorphine and [[Biology:Cocaine|cocaine]] to users. The law was made more restrictive in 1968. Beginning in the 1970s, the emphasis shifted to abstinence and the use of methadone; currently, only a small number of users in the UK are prescribed diamorphine.<ref>{{cite web| vauthors = Goldacre B | year =1998| url =http://www.badscience.net/?p=327| title =Methadone and Heroin: An Exercise in Medical Scepticism| access-date =18 December 2006| url-status=live| archive-url =https://web.archive.org/web/20070304065723/http://www.badscience.net/?p=327| archive-date =4 March 2007}}</ref>

In 1994, Switzerland began a trial [[Unsolved:Heroin-assisted treatment|diamorphine maintenance]] program for users that had failed multiple withdrawal programs. The aim of this program was to maintain the health of the user by avoiding medical problems stemming from the illicit use of diamorphine. The first trial in 1994 involved 340 users, although enrollment was later expanded to 1000, based on the apparent success of the program. The trials proved diamorphine maintenance to be superior to other forms of treatment in improving the social and health situation for this group of patients.<ref name="haasen"/> It has also been shown to save money, despite high treatment expenses, as it significantly reduces costs incurred by trials, incarceration, health interventions and delinquency.<ref>{{cite web|url=https://sencanada.ca/content/sen/committee/371/ille/presentation/ucht-e.htm |title=Heroin Assisted Treatment for Opiate Addicts – The Swiss Experience |publisher=Parl.gc.ca |date=31 March 1995 |access-date=12 October 2013 |archive-url=https://web.archive.org/web/20100120061027/https://sencanada.ca/content/sen/committee/371/ille/presentation/ucht-e.htm |archive-date=20 January 2010}}</ref> Patients appear twice daily at a treatment center, where they inject their dose of diamorphine under the supervision of medical staff. They are required to contribute about 450 Swiss francs per month to the treatment costs.<ref>{{cite web| vauthors = Nadelmann E | date =10 July 1995| url =http://www.drugpolicy.org/library/tlcnr.cfm| title =Switzerland's Heroin Experiment| publisher =Drug Policy Alliance| access-date =22 October 2006| archive-url=https://web.archive.org/web/20041129115253/http://www.drugpolicy.org/library/tlcnr.cfm| archive-date=29 November 2004}}</ref> A national referendum in November 2008 showed 68% of voters supported the plan,<ref>{{cite news |title=Swiss approve prescription heroin |url=http://news.bbc.co.uk/2/hi/europe/7757050.stm |work=BBC News Online |date=30 November 2008 |access-date=30 November 2008 |url-status=live |archive-url=https://web.archive.org/web/20081130052931/http://news.bbc.co.uk/2/hi/europe/7757050.stm |archive-date=30 November 2008}}</ref> introducing diamorphine prescription into federal law. The previous trials were based on time-limited executive ordinances. The success of the Swiss trials led German, Dutch,<ref>{{cite news| url =http://news.bbc.co.uk/2/hi/health/4607233.stm| title =Heroin prescription 'cuts costs'| work =BBC News| access-date =22 October 2006| date =5 June 2005| url-status=live| archive-url =https://web.archive.org/web/20060628053230/http://news.bbc.co.uk/2/hi/health/4607233.stm| archive-date =28 June 2006}}</ref> and Canadian<ref>{{cite web| url =http://www.naomistudy.ca/| title =About the study| publisher =North American Opiate Medication Initiative| access-date =22 October 2006| url-status=dead| archive-url =https://web.archive.org/web/20061104035153/http://www.naomistudy.ca/| archive-date =4 November 2006}}</ref> cities to try out their own diamorphine prescription programs.<ref>{{cite journal | vauthors = Nordt C, Stohler R | title = Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis | journal = Lancet | volume = 367 | issue = 9525 | pages = 1830–4 | date = June 2006 | pmid = 16753485 | doi = 10.1016/S0140-6736(06)68804-1 | url = http://www.cesda.net/downloads/lancet1.pdf | url-status = dead | s2cid = 46366844 | citeseerx = 10.1.1.190.1876 | archive-url = https://web.archive.org/web/20100203001705/http://www.cesda.net/downloads/lancet1.pdf | archive-date = 3 February 2010 }}</ref> Some Australian cities (such as Sydney) have instituted legal diamorphine supervised injecting centers, in line with other wider harm minimization programs.

Since January 2009, Denmark has prescribed diamorphine to a few addicts who have tried methadone and [[Chemistry:Buprenorphine|buprenorphine]] without success.<ref>
{{cite web |date=November 2008 | url=http://www.dn.se/DNet/jsp/polopoly.jsp?d=3561&a=857991 | title=Danmark redo för skattebetalt heroin | trans-title = Denmark ready for tax-paid heroin | language=sv | access-date=30 November 2008 |archive-url=https://web.archive.org/web/20081203104630/http://www.dn.se/DNet/jsp/polopoly.jsp?d=3561&a=857991 |archive-date=3 December 2008}}</ref> Beginning in February 2010, addicts in [[Place:Copenhagen|Copenhagen]] and Odense became eligible to receive free diamorphine. Later in 2010, other cities including Århus and Esbjerg joined the scheme. It was estimated that around 230 addicts would be able to receive free diamorphine.<ref>{{cite web | date=January 2010 | url=http://www.information.dk/221689 | title=Gratis heroin klar til danske narkomaner | trans-title = Free heroin ready for Danish drug addicts | publisher=Information | language=da | access-date=14 February 2010 | url-status=live | archive-url=https://web.archive.org/web/20110430110231/http://www.information.dk/221689 | archive-date=30 April 2011}}</ref>

However, Danish addicts would only be able to inject heroin according to the policy set by Danish National Board of Health.<ref>{{cite web | vauthors = Dahlin U | date=February 2009 | url=http://www.information.dk/182783 | title=Heroin-behandling bliver kun i kanyler | trans-title = Heroin treatment stays only in needles | publisher=Information | language=da | access-date=14 February 2010 | url-status=live | archive-url=https://web.archive.org/web/20090220152740/http://www.information.dk/182783 | archive-date=20 February 2009}}</ref> Of the estimated 1500 drug users who did not benefit from the then-current oral substitution treatment, approximately 900 would not be in the target group for treatment with injectable diamorphine, either because of "massive multiple drug abuse of non-opioids" or "not wanting treatment with injectable diamorphine".<ref>{{cite report | date=October 2007 | url=http://sundhedsstyrelsen.dk/Udgivelser/2008/Prescription%20of%20injectable%20heroin%20for%20drug%20users.aspx | title=Prescription of injectable heroin for drug users | publisher=Danish National Boad of Health | access-date=14 February 2010 | archive-url=https://web.archive.org/web/20110429192839/http://sundhedsstyrelsen.dk/Udgivelser/2008/Prescription%20of%20injectable%20heroin%20for%20drug%20users.aspx | archive-date=29 April 2011 | url-status=live }}</ref>{{Update inline|date=January 2015}}

In July 2009, the German Bundestag passed a law allowing diamorphine prescription as a standard treatment for addicts; a large-scale trial of diamorphine prescription had been authorized in the country in 2002.<ref>{{cite web| date = 28 May 2009| url = http://www.bmg.bund.de/ministerium/presse/pressemitteilungen/2009-02/durchbruch-fuer-die-behandlung-von-schwerstopiatabhaengigen.html| title = Durchbruch für die Behandlung von Schwerstopiatabhängigen|trans-title=Breakthrough for the treatment of heavily addicted opiate users| language = de| publisher = Bundesministerium für Gesundheit (German ministry of health)| access-date = 28 April 2014| url-status=live| archive-url = https://web.archive.org/web/20140429045558/http://www.bmg.bund.de/ministerium/presse/pressemitteilungen/2009-02/durchbruch-fuer-die-behandlung-von-schwerstopiatabhaengigen.html| archive-date = 29 April 2014}}</ref>

On 26 August 2016, [[Organization:Health Canada|Health Canada]] issued regulations amending prior regulations it had issued under the Controlled Drugs and Substances Act; the "New Classes of Practitioners Regulations", the "Narcotic Control Regulations", and the "Food and Drug Regulations", to allow doctors to prescribe diamorphine to people who have a severe opioid addiction who have not responded to other treatments.<ref name="gazette2016">{{cite web| date=7 September 2016| url=http://www.gazette.gc.ca/rp-pr/p2/2016/2016-09-07/html/sor-dors239-eng.php| title=Regulations Amending Certain Regulations Made Under the Controlled Drugs and Substances Act (Access to Diacetylmorphine for Emergency Treatment)| publisher=Canada Gazette Directorate| access-date=19 September 2016| url-status=live| archive-url=https://web.archive.org/web/20160918215019/http://www.gazette.gc.ca/rp-pr/p2/2016/2016-09-07/html/sor-dors239-eng.php| archive-date=18 September 2016}}</ref><ref>{{cite web| date =14 September 2016| url =http://www.cnn.com/2016/09/14/health/prescription-heroin-canada/index.html| title =Prescription heroin gets green light in Canada| publisher =CNN| access-date =19 September 2016| url-status=live| archive-url =https://web.archive.org/web/20160918230920/http://www.cnn.com/2016/09/14/health/prescription-heroin-canada/index.html| archive-date =18 September 2016}}</ref> The prescription heroin can be accessed by doctors through [[Organization:Health Canada|Health Canada]]'s Special Access Programme (SAP) for "emergency access to drugs for patients with serious or life-threatening conditions when conventional treatments have failed, are unsuitable, or are unavailable."<ref name="gazette2016" />

==Routes of administration==
{| class="wikitable floatright" style="width: 15em"
|-
|'''Recreational uses:'''
* Euphoria
'''Medicinal uses:'''
* [[Biology:Analgesic|Pain medication]]
* Cough suppressant
* Anti-[[Medicine:Diarrhea|diarrhea]]l
|-
|'''[[Medicine:Contraindication|Contraindication]]s:'''
* [[Chemistry:Ethanol|Ethanol]] (alcoholic beverages), isopropanol, 2M2B
* [[Chemistry:Barbiturate|Barbiturate]]s and benzodiazepines
* [[Chemistry:Stimulant|Stimulant]]s
* Other [[Chemistry:Opioid|opioid]]s
|-
|'''''Central nervous system:'''''
* Drowsiness
* Disorientation
* [[Medicine:Delirium|Delirium]]

'''''Neurological:'''''
* Analgesia
* [[Chemistry:Drug tolerance|Tolerance]]
* Addiction
* Dependence

'''''Psychological:'''''
* Anxiolysis
* [[Medicine:Confusion|Confusion]]
* Euphoria
* [[Medicine:Somnolence|Somnolence]]

'''''Cardiovascular & Respiratory:'''''
* [[Medicine:Bradycardia|Bradycardia]]
* [[Medicine:Hypotension|Hypotension]]
* Hypoventilation
* [[Medicine:Shallow breathing|Shallow breathing]]
* Respiratory depression

'''''Gastrointestinal:'''''
* Nausea
* Protracted vomiting
* [[Medicine:Constipation|Constipation]]
* Dyspepsia (heartburn)

'''''Musculoskeletal:'''''
* Analgesia
* [[Medicine:Ataxia|Ataxia]]
* Muscle spasticity

'''''Skin:'''''
* Itching
* Flushing/Rash

'''''Miscellaneous:'''''
* Dry mouth (xerostomia)
* [[Medicine:Miosis|Miosis]] (pupil constriction)
* [[Medicine:Urinary retention|Urinary retention]]
|}
The onset of heroin's effects depends upon the [[Medicine:Route of administration|route of administration]]. Smoking is the fastest route of drug administration, although intravenous injection results in a quicker rise in blood concentration.<ref>{{cite journal | vauthors = Budman SH, Grimes Serrano JM, Butler SF | title = Can abuse deterrent formulations make a difference? Expectation and speculation | journal = Harm Reduction Journal | volume = 6 | issue = 8 | pages = 8 | date = May 2009 | pmid = 19480676 | pmc = 2694768 | doi = 10.1186/1477-7517-6-8 | doi-access = free }}</ref> These are followed by [[Chemistry:Suppository|suppository]] (anal or vaginal insertion), [[Medicine:Insufflation|insufflation]] (snorting), and [[Biology:Ingestion|ingestion]] (swallowing).

A 2002 study suggests that a fast onset of action increases the reinforcing effects of addictive drugs. Ingestion does not produce a [[Medicine:Rush (psychology)|rush]] as a forerunner to the high experienced with the use of heroin, which is most pronounced with intravenous use. While the onset of the rush induced by injection can occur in as little as a few seconds, the oral route of administration requires approximately half an hour before the high sets in. Thus, with both higher the dosage of heroin used and faster the route of administration used, the higher the potential risk for [[Medicine:Psychological dependence|psychological dependence]]/[[Medicine:Addiction|addiction]].<ref>{{cite journal | vauthors = Winger G, Hursh SR, Casey KL, Woods JH | title = Relative reinforcing strength of three N-methyl-D-aspartate antagonists with different onsets of action | journal = The Journal of Pharmacology and Experimental Therapeutics | volume = 301 | issue = 2 | pages = 690–7 | date = May 2002 | pmid = 11961074 | doi = 10.1124/jpet.301.2.690 | s2cid = 17860947 }}</ref>

Large doses of heroin can cause fatal respiratory depression, and the drug has been used for suicide or as a murder weapon. The serial killer Harold Shipman used diamorphine on his victims, and the subsequent Shipman Inquiry led to a tightening of the regulations surrounding the storage, prescribing and destruction of controlled drugs in the UK.

Because significant tolerance to respiratory depression develops quickly with continued use and is lost just as quickly during withdrawal, it is often difficult to determine whether a heroin lethal overdose was accidental, suicide or homicide. Examples include the overdose deaths of Sid Vicious, Janis Joplin, Tim Buckley, Hillel Slovak, [[Biography:Layne Staley|Layne Staley]], Bradley Nowell, Ted Binion, and River Phoenix.<ref>{{cite news|url=http://www.timesonline.co.uk/article/0,,11069-2329203,00.html |title=First murder charge over heroin mix that killed 400|newspaper=Times Online |date=13 March 2012 |access-date=20 July 2012 | vauthors = Eason K, Naughton P |location=London}}</ref><!-- more information needed! -->

===By mouth===
Use of heroin by mouth is less common than other methods of administration, mainly because there is little to no "rush", and the effects are less potent.<ref>{{cite web |author=sepulfreak |url=http://www.erowid.org/experiences/exp.php?ID=41495 |title=Erowid Experience Vaults: Heroin – Catching the Waves – 41495 |publisher=Erowid.org |date=8 July 2005 |access-date=20 July 2012 |url-status=live |archive-url=https://web.archive.org/web/20121011062609/http://www.erowid.org/experiences/exp.php?ID=41495 |archive-date=11 October 2012}}</ref> Heroin is entirely converted to [[Biology:Morphine|morphine]] by means of first-pass metabolism, resulting in [[Chemistry:Deacetylation|deacetylation]] when ingested. Heroin's oral [[Chemistry:Bioavailability|bioavailability]] is both dose-dependent (as is morphine's) and significantly higher than oral use of morphine itself, reaching up to 64.2% for high doses and 45.6% for low doses; opiate-naive users showed far less absorption of the drug at low doses, having bioavailabilities of only up to 22.9%. The maximum plasma concentration of morphine following oral administration of heroin was around twice as much as that of oral morphine.<ref>{{cite journal | vauthors = Halbsguth U, Rentsch KM, Eich-Höchli D, Diterich I, Fattinger K | title = Oral diacetylmorphine (heroin) yields greater morphine bioavailability than oral morphine: bioavailability related to dosage and prior opioid exposure | journal = British Journal of Clinical Pharmacology | volume = 66 | issue = 6 | pages = 781–91 | date = December 2008 | pmid = 18945270 | pmc = 2675771 | doi = 10.1111/j.1365-2125.2008.03286.x }}</ref>

===Injection===

Injection, also known as "slamming", "banging", "shooting up", "digging" or "mainlining", is a popular method which carries relatively greater risks than other methods of administration. Heroin base (commonly found in Europe), when prepared for injection, will only dissolve in water when mixed with an acid (most commonly citric acid powder or lemon juice) and heated. Heroin in the east-coast United States is most commonly found in the hydrochloride salt form, requiring just water (and no heat) to dissolve.{{Citation needed|date=March 2023}} Users tend to initially inject in the easily accessible arm veins, but as these veins collapse over time, users resort to more dangerous areas of the body, such as the femoral vein in the groin. Some medical professionals have expressed concern over this route of administration, as they suspect that it can lead to [[Medicine:Deep vein thrombosis|deep vein thrombosis]].<ref>{{cite book | vauthors = Strang J, Gossop M |title=Heroin Addiction and the British System: Treatment and policy responses |date=2005 |publisher=Psychology Press |isbn=978-0-415-29817-9 |page=121 |url=https://books.google.com/books?id=gdwgn83NEJgC&pg=PA121 |language=en}}</ref>

Intravenous users can use a variable single dose range using a [[Medicine:Hypodermic needle|hypodermic needle]]. The dose of heroin used for recreational purposes is dependent on the frequency and level of use.

As with the injection of any drug, if a group of users share a common needle without sterilization procedures, blood-borne diseases, such as HIV/AIDS or [[Medicine:Hepatitis|hepatitis]], can be transmitted.
The use of a common dispenser for water for the use in the preparation of the injection, as well as the sharing of spoons and filters can also cause the spread of blood-borne diseases. Many countries now supply small sterile spoons and filters for single use in order to prevent the spread of disease.<ref name="Thakarar_2020">{{cite journal | vauthors = Thakarar K, Nenninger K, Agmas W | title = Harm Reduction Services to Prevent and Treat Infectious Diseases in People Who Use Drugs | journal = Infectious Disease Clinics of North America | volume = 34 | issue = 3 | pages = 605–620 | date = September 2020 | pmid = 32782104 | pmc = 7596878 | doi = 10.1016/j.idc.2020.06.013 }}</ref>

===Smoking===
Smoking heroin refers to vaporizing it to inhale the resulting fumes, rather than burning and inhaling the smoke. It is commonly smoked in glass pipes made from [[Engineering:Glassblowing|glassblown]] [[Chemistry:Pyrex|Pyrex]] tubes and light bulbs. Heroin may be smoked from aluminium foil that is heated by a flame underneath it, with the resulting smoke inhaled through a tube of rolled up foil, a method also known as "chasing the dragon".<ref>{{cite journal | vauthors = Strang J, Griffiths P, Gossop M | title = Heroin smoking by 'chasing the dragon': origins and history | journal = Addiction | volume = 92 | issue = 6 | pages = 673–83; discussion 685–95 | date = June 1997 | pmid = 9246796 | doi = 10.1111/j.1360-0443.1997.tb02927.x }}</ref>

===Insufflation===
Another popular route to intake heroin is [[Social:Insufflation|insufflation]] (snorting), where a user crushes the heroin into a fine powder and then gently inhales it (sometimes with a straw or a rolled-up [[Engineering:Banknote|banknote]], as with cocaine) into the nose, where heroin is absorbed through the soft tissue in the [[Biology:Mucous membrane|mucous membrane]] of the sinus cavity and straight into the bloodstream. This method of administration redirects [[Chemistry:First pass effect|first-pass metabolism]], with a quicker onset and higher bioavailability than oral administration, though the duration of action is shortened. This method is sometimes preferred by users who do not want to prepare and administer heroin for injection or smoking but still want to experience a fast onset. Snorting heroin becomes an often unwanted route, once a user begins to inject the drug. The user may still get high on the drug from snorting, and experience a nod, but will not get a rush. A "rush" is caused by a large amount of heroin entering the body at once. When the drug is taken in through the nose, the user does not get the rush because the drug is absorbed slowly rather than instantly.

Heroin for pain has been mixed with sterile water on site by the attending physician, and administered using a syringe with a nebulizer tip.<ref name="Surrey">{{cite web |title=Clinical Policy for the Use of Intranasal Diamorphine for Analgesia in Children Attending the Paediatric Emergency Department, SASH |url=https://www.surreyandsussex.nhs.uk/wp-content/uploads/2013/04/1-SASH_Intra_Nasal_Diamorphine.pdf |access-date=9 January 2020 |archive-url=https://web.archive.org/web/20200111133557/https://www.surreyandsussex.nhs.uk/wp-content/uploads/2013/04/1-SASH_Intra_Nasal_Diamorphine.pdf |archive-date=11 January 2020 |url-status=live }}</ref> Heroin may be used for fractures, burns, finger-tip injuries, suturing, and wound re-dressing, but is inappropriate in head injuries.<ref name=Surrey/>

===Suppository===
Little research has been focused on the [[Chemistry:Suppository|suppository]] (anal insertion) or [[Medicine:Pessary|pessary]] (vaginal insertion) methods of administration, also known as "plugging". These methods of administration are commonly carried out using an oral syringe. Heroin can be dissolved and withdrawn into an oral syringe which may then be lubricated and inserted into the anus or vagina before the plunger is pushed. The rectum or the vaginal canal is where the majority of the drug would likely be taken up, through the membranes lining their walls.

==Adverse effects==
[[File:HarmCausedByDrugsTable.svg|thumb|left|upright=1.4|A 2010 study ranking various illegal and legal drugs based on statements by drug-harm experts. Heroin was found to be the second overall most dangerous drug.<ref>{{cite journal | vauthors = Nutt DJ, King LA, Phillips LD | title = Drug harms in the UK: a multicriteria decision analysis | journal = Lancet | volume = 376 | issue = 9752 | pages = 1558–65 | date = November 2010 | pmid = 21036393 | doi = 10.1016/S0140-6736(10)61462-6 | s2cid = 5667719 | citeseerx = 10.1.1.690.1283 }}</ref>]]

Heroin is classified as a hard drug in terms of [[Medicine:Drug harmfulness|drug harmfulness]]. Like most opioids, unadulterated heroin may lead to adverse effects. The purity of street heroin varies greatly, leading to overdoses when the purity is higher than expected.<ref>{{cite news | vauthors = Seelye KQ |title=Heroin Epidemic Is Yielding to a Deadlier Cousin: Fentanyl |url=https://www.nytimes.com/2016/03/26/us/heroin-fentanyl.html |archive-url=https://ghostarchive.org/archive/20220103/https://www.nytimes.com/2016/03/26/us/heroin-fentanyl.html |archive-date=3 January 2022 |url-access=subscription |url-status=live |work={{wipe|The New York Times}} |date=25 March 2016 }}{{cbignore}}</ref>

===Short-term effects===
[[File:Short-term effects of heroin.png|thumb|Short-term effects of usage<ref name="ONDCP">{{cite web |url=http://www.whitehousedrugpolicy.gov/drugfact/heroin/heroin_ff.html#healtheffects |title=Office of National Drug Control Policy (ONDCP): Heroin Facts & Figures |publisher=Whitehousedrugpolicy.gov |access-date=20 July 2012 |url-status=live |archive-url=https://web.archive.org/web/20110806022931/http://www.whitehousedrugpolicy.gov/drugfact/heroin/heroin_ff.html#healtheffects |archive-date=6 August 2011}}</ref>]]
Users report an intense [[Medicine:Rush (psychology)|rush]], an acute transcendent state of [[Chemistry:Euphoria|euphoria]], which occurs while diamorphine is being metabolized into 6-monoacetylmorphine (6-MAM) and morphine in the brain. Some believe that heroin produces more euphoria than other opioids; one possible explanation is the presence of 6-monoacetylmorphine, a metabolite unique to heroin – although a more likely explanation is the rapidity of onset. While other opioids of recreational use produce only morphine, heroin also leaves 6-MAM, also a psycho-[[Biology:Active metabolite|active metabolite]].

However, this perception is not supported by the results of clinical studies comparing the physiological and subjective effects of injected heroin and morphine in individuals formerly addicted to opioids; these subjects showed no preference for one drug over the other. Equipotent injected doses had comparable action courses, with no difference in subjects' self-rated feelings of euphoria, ambition, nervousness, relaxation, drowsiness, or sleepiness.<ref name="martin and fraser" />

The rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities. Nausea, [[Medicine:Vomiting|vomiting]], and severe itching may also occur. After the initial effects, users usually will be drowsy for several hours; mental function is clouded; heart function slows, and breathing is also severely slowed, sometimes enough to be life-threatening. Slowed breathing can also lead to coma and permanent [[Medicine:Brain damage|brain damage]].<ref name="National Institute on Drug Abuse">{{Cite web|url=https://www.drugabuse.gov/publications/research-reports/heroin/what-are-immediate-short-term-effects-heroin-use|title=What are the immediate (short-term) effects of heroin use? | author = National Institute on Drug Abuse |language=en|access-date=7 September 2018|archive-url=https://web.archive.org/web/20180908054251/https://www.drugabuse.gov/publications/research-reports/heroin/what-are-immediate-short-term-effects-heroin-use|archive-date=8 September 2018|url-status=dead}}</ref> Heroin use has also been associated with [[Medicine:Myocardial infarction|myocardial infarction]].<ref>{{cite journal | vauthors = Karoli R, Fatima J, Singh P, Kazmi KI | title = Acute myocardial involvement after heroin inhalation | journal = Journal of Pharmacology & Pharmacotherapeutics | volume = 3 | issue = 3 | pages = 282–4 | date = July 2012 | pmid = 23129970 | pmc = 3487283 | doi = 10.4103/0976-500X.99448 | doi-access = free }}</ref>

===Long-term effects===
[[File:Long-term effects of heroin.png|thumb|Long-term effects of intravenous usage, including – and indeed primarily because of – the effects of the contaminants common in illegal heroin and contaminated needles<ref name="ONDCP" />]]
Repeated heroin use changes the physical structure and physiology of the brain, creating long-term imbalances in neuronal and hormonal systems that are not easily reversed. Studies have shown some deterioration of the brain's white matter due to heroin use,<ref name=Hamp2019>{{cite journal | vauthors = Hampton WH, Hanik I, Olson IR | title = [Substance Abuse and White Matter: Findings, Limitations, and Future of Diffusion Tensor Imaging Research] | language = en | journal = Drug and Alcohol Dependence | volume = 197 | issue = 4 | pages = 288–298 | year = 2019 | pmid = 30875650 | pmc = 6440853 | doi = 10.1016/j.drugalcdep.2019.02.005}}</ref> which may affect decision-making abilities, the ability to regulate behavior, and responses to stressful situations. Heroin also produces profound degrees of tolerance and physical dependence. Tolerance occurs when more and more of the drug is required to achieve the same effects. With [[Medicine:Substance dependence|physical dependence]], the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced abruptly.<ref name="National Institute on Drug Abuse" />

===Injection ===
Intravenous use of heroin (and any other substance) with needles and syringes or other related equipment may lead to:

* Contracting blood-borne pathogens such as HIV and [[Medicine:Hepatitis|hepatitis]] via the sharing of needles
* Contracting bacterial or fungal [[Medicine:Endocarditis|endocarditis]] and possibly venous sclerosis
* Abscesses
* Poisoning from contaminants added to "[[Chemistry:Cutting agent|cut]]" or dilute heroin
* [[Medicine:Kidney disease|Decreased kidney function (nephropathy)]], although it is not currently known if this is because of adulterants or infectious diseases<ref>{{cite journal | vauthors = Dettmeyer RB, Preuss J, Wollersen H, Madea B | title = Heroin-associated nephropathy | journal = Expert Opinion on Drug Safety | volume = 4 | issue = 1 | pages = 19–28 | date = January 2005 | pmid = 15709895 | doi = 10.1517/14740338.4.1.19 | s2cid = 11646280 }}</ref>

===Withdrawal===
{{Main|Chemistry:Opioid withdrawal}}
The [[Medicine:Drug withdrawal|withdrawal]] syndrome from heroin may begin within as little as two hours of discontinuation of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose, and more typically begins within 6–24 hours after cessation. Symptoms may include sweating, malaise, anxiety, depression, [[Medicine:Akathisia|akathisia]], [[Medicine:Priapism|priapism]], extra sensitivity of the genitals in females, general feeling of heaviness, excessive yawning or sneezing, rhinorrhea, [[Medicine:Insomnia|insomnia]], cold sweats, chills, severe muscle and bone aches, nausea, vomiting, diarrhea, cramps, watery eyes,<ref>{{cite web|author=Myaddiction|title=Heroin Withdrawal Symptoms|publisher=MyAddiction|date=16 May 2012|url=http://www.myaddiction.com/heroin.html|access-date=16 May 2012|url-status=live|archive-url=https://web.archive.org/web/20120511193410/http://www.myaddiction.com/heroin.html|archive-date=11 May 2012}}</ref> fever, cramp-like pains, and involuntary spasms in the limbs (thought to be an origin of the term "kicking the habit"<ref>{{cite book | title=The Street Addict Role: A Theory of Heroin Addiction | publisher=SUNY Press | vauthors = Stephens R | year=1991 | page=7 | isbn=978-0-7914-0619-9}}</ref>).<ref>{{cite web | url=http://www.discoveryplace.info/narcotic-drug-withdrawal | title=Narcotic Drug Withdrawal | publisher=Discovery Place | access-date=18 April 2014 | url-status=dead | archive-url=https://web.archive.org/web/20140419025851/http://www.discoveryplace.info/narcotic-drug-withdrawal | archive-date=19 April 2014}}</ref><ref>{{Cite web|url=https://medlineplus.gov/ency/article/000949.htm|title=Opiate and opioid withdrawal: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=20 November 2019|archive-url=https://web.archive.org/web/20191208070501/https://medlineplus.gov/ency/article/000949.htm|archive-date=8 December 2019|url-status=live}}</ref>

==Overdose==
{{more|US drug overdose death rates and totals over time}}
Heroin overdose is usually treated with the opioid antagonist [[Chemistry:Naloxone|naloxone]]. This reverses the effects of heroin and causes an immediate return of consciousness but may result in [[Medicine:Drug withdrawal|withdrawal]] symptoms. The [[Physics:Half-life|half-life]] of naloxone is shorter than some opioids, such that it may need to be given multiple times until the opioid has been metabolized by the body.

Between 2012 and 2015, heroin was the leading cause of drug-related deaths in the United States.<ref name="CDC2018Death">{{cite web |title=Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011–2016 |url=https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf |website=CDC |access-date=21 December 2018 |date=12 December 2018 |archive-url=https://web.archive.org/web/20181213221854/https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf |archive-date=13 December 2018 |url-status=live }}</ref> Since then, [[Chemistry:Fentanyl|fentanyl]] has been a more common cause of drug-related deaths.<ref name=CDC2018Death/>

Depending on drug interactions and numerous other factors, death from overdose can take anywhere from several minutes to several hours. Death usually occurs due to [[Medicine:Hypoxia (medical)|lack of oxygen]] resulting from the lack of breathing caused by the opioid. Heroin overdoses can occur because of an unexpected increase in the dose or purity or because of diminished opioid tolerance. However, many fatalities reported as overdoses are probably caused by interactions with other depressant drugs such as alcohol or [[Chemistry:Benzodiazepine|benzodiazepine]]s.<ref>{{cite journal | vauthors = Darke S, Zador D | title = Fatal heroin 'overdose': a review | journal = Addiction | volume = 91 | issue = 12 | pages = 1765–72 | date = December 1996 | pmid = 8997759 | doi = 10.1046/j.1360-0443.1996.911217652.x }}</ref> Since heroin can cause nausea and vomiting, a significant number of deaths attributed to heroin overdose are caused by aspiration of vomit by an unconscious person. Some sources quote the [[Chemistry:Median lethal dose|median lethal dose]] (for an average 75&nbsp;kg opiate-naive individual) as being between 75 and 600&nbsp;mg.<ref>{{cite web |url=http://lincoln.pps.k12.or.us/lscheffler/ToxicSubstances%20in%20water.htm |title=Toxic Substances in water |publisher=Lincoln.pps.k12.or.us |access-date=20 October 2010 |url-status=dead |archive-url=https://web.archive.org/web/20110430180739/http://lincoln.pps.k12.or.us/lscheffler/ToxicSubstances%20in%20water.htm |archive-date=30 April 2011}}</ref><ref>{{cite web| vauthors = Breecher E |title=The Consumers Union Report on Licit and Illicit Drugs|url=http://www.druglibrary.org/schaffer/Library/studies/cu/cu12.htm|url-status=live|archive-url=https://web.archive.org/web/20070208092708/http://www.druglibrary.org/Schaffer/Library/studies/cu/cu12.htm|archive-date=8 February 2007}}</ref> Illicit heroin is of widely varying and unpredictable purity. This means that the user may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, tolerance typically decreases after a period of abstinence. If this occurs and the user takes a dose comparable to their previous use, the user may experience drug effects that are much greater than expected, potentially resulting in an overdose. It has been speculated that an unknown portion of heroin-related deaths are the result of an overdose or allergic reaction to [[Chemistry:Quinine|quinine]], which may sometimes be used as a cutting agent.<ref>{{cite book | vauthors = Brecher EM | collaboration = Editors of Consumer Reports Magazine | date = 1972 | chapter-url = http://www.druglibrary.org/schaffer/Library/studies/cu/cu12.htm | chapter = Chapter 12. The "heroin overdose" mystery and other occupational hazards of addiction | title = The Consumers Union Report on Licit and Illicit Drugs | archive-url = https://web.archive.org/web/20070208092708/http://www.druglibrary.org/Schaffer/Library/studies/cu/cu12.htm | archive-date=8 February 2007 | publisher = Schaffer Library of Drug Policy }}</ref>

==Pharmacology==
[[File:Heroin black tar.jpg|thumb|Black tar heroin ]]
When taken orally, heroin undergoes extensive first-pass metabolism via [[Biology:Acetylation|deacetylation]], making it a [[Chemistry:Prodrug|prodrug]] for the systemic delivery of morphine.<ref name="Sawynok 1986">{{cite journal | vauthors = Sawynok J | title = The therapeutic use of heroin: a review of the pharmacological literature | journal = Canadian Journal of Physiology and Pharmacology | volume = 64 | issue = 1 | pages = 1–6 | date = January 1986 | pmid = 2420426 | doi = 10.1139/y86-001 }}</ref> When the drug is injected, however, it avoids this first-pass effect, very rapidly crossing the [[Biology:Blood–brain barrier|blood–brain barrier]] because of the presence of the acetyl groups, which render it much more [[Chemistry:Lipophilicity|fat soluble]] than morphine itself.<ref name="Klous 2005">{{cite journal | vauthors = Klous MG, Van den Brink W, Van Ree JM, Beijnen JH | title = Development of pharmaceutical heroin preparations for medical co-prescription to opioid dependent patients | journal = Drug and Alcohol Dependence | volume = 80 | issue = 3 | pages = 283–95 | date = December 2005 | pmid = 15916865 | doi = 10.1016/j.drugalcdep.2005.04.008 }}</ref> Once in the brain, it then is deacetylated variously into the inactive 3-monoacetylmorphine and the active 6-monoacetylmorphine (6-MAM), and then to morphine, which bind to [[Biology:Μ-opioid receptor|μ-opioid receptor]]s, resulting in the drug's euphoric, analgesic (pain relief), and [[Chemistry:Anxiolytic|anxiolytic]] (anti-anxiety) effects; heroin itself exhibits relatively low affinity for the μ receptor.<ref>{{cite journal | vauthors = Inturrisi CE, Schultz M, Shin S, Umans JG, Angel L, Simon EJ | title = Evidence from opiate binding studies that heroin acts through its metabolites | journal = Life Sciences | volume = 33 | issue = Suppl 1 | pages = 773–6 | year = 1983 | pmid = 6319928 | doi = 10.1016/0024-3205(83)90616-1 }}</ref> Analgesia follows from the activation of the μ receptor G-protein coupled receptor, which indirectly hyperpolarizes the neuron, reducing the release of [[Biology:Nociception|nociceptive]] neurotransmitters, and hence, causes analgesia and increased pain tolerance.<ref>{{cite book | vauthors = Hitchings A, Lonsdale D, Burrage D, Baker E |title=Top 100 drugs: clinical pharmacology and practical prescribing |date=2014 |publisher=Churchill Livingstone |isbn=9780702055164}}</ref>

Unlike [[Chemistry:Hydromorphone|hydromorphone]] and [[Chemistry:Oxymorphone|oxymorphone]], however, administered intravenously, heroin creates a larger histamine release, similar to morphine, resulting in the feeling of a greater subjective "body high" to some, but also instances of pruritus (itching) when they first start using.<ref>{{cite web|url=http://grande.nal.usda.gov/ibids/index.php?mode2=detail&origin=ibids_references&therow=35525|title=Histamine release by morphine and diamorphine in man | archive-url=https://web.archive.org/web/20100812062454/http://grande.nal.usda.gov/ibids/index.php?mode2=detail&origin=ibids_references&therow=35525 | archive-date=12 August 2010 }}</ref><ref name="pmid14746612">{{cite journal | vauthors = Del Giudice P | title = Cutaneous complications of intravenous drug abuse | journal = The British Journal of Dermatology | volume = 150 | issue = 1 | pages = 1–10 | date = January 2004 | pmid = 14746612 | doi = 10.1111/j.1365-2133.2004.05607.x | s2cid = 32380001 | url = http://bcbsma.medscape.com/viewarticle/468419_4 |archive-url=https://archive.today/20121123175249/http://bcbsma.medscape.com/viewarticle/468419_4|archive-date=23 November 2012|url-status=live }}</ref>

Normally, GABA, which is released from inhibitory neurones, inhibits the release of dopamine. Opiates, like heroin and morphine, decrease the inhibitory activity of such neurones. This causes increased release of dopamine in the brain which is the reason for euphoric and rewarding effects of heroin.<ref>{{cite book | vauthors = Papich MG |title=Saunders Handbook of Veterinary Drugs |date=2016 |publisher=W.B. Saunders |isbn=9780323244855 |pages=183–184 |doi=10.1016/B978-0-323-24485-5.00175-3|chapter=Codeine|edition=Fourth }}</ref>

Both morphine and 6-MAM are [[Biology:Μ-opioid receptor|μ-opioid]] [[Biology:Agonist|agonist]]s that bind to receptors present throughout the brain, [[Biology:Spinal cord|spinal cord]], and gut of all [[Biology:Mammal|mammal]]s. The μ-opioid receptor also binds endogenous [[Biology:Opioid peptide|opioid peptide]]s such as β-endorphin, [[Chemistry:Leu-enkephalin|leu-enkephalin]], and [[Chemistry:Met-enkephalin|met-enkephalin]]. Repeated use of heroin results in a number of physiological changes, including an increase in the production of μ-opioid receptors (upregulation).<ref>{{cite journal | vauthors = Hammers A, Asselin MC, Hinz R, Kitchen I, Brooks DJ, Duncan JS, Koepp MJ | title = Upregulation of opioid receptor binding following spontaneous epileptic seizures | journal = Brain | volume = 130 | issue = Pt 4 | pages = 1009–16 | date = April 2007 | pmid = 17301080 | doi = 10.1093/brain/awm012 | doi-access = free }}</ref> These physiological alterations lead to tolerance and dependence, so that stopping heroin use results in uncomfortable symptoms including pain, anxiety, muscle spasms, and insomnia called the opioid [[Medicine:Drug withdrawal|withdrawal]] syndrome. Depending on usage it has an onset 4–24&nbsp;hours after the last dose of heroin. Morphine also binds to [[Biology:Δ-opioid receptor|δ]]- and [[Biology:Κ-opioid receptor|κ-opioid receptor]]s.

There is also evidence that 6-MAM binds to a subtype of μ-opioid receptors that are also activated by the morphine metabolite morphine-6β-glucuronide but not morphine itself.<ref>{{cite journal | vauthors = Brown GP, Yang K, King MA, Rossi GC, Leventhal L, Chang A, Pasternak GW | title = 3-Methoxynaltrexone, a selective heroin/morphine-6beta-glucuronide antagonist | journal = FEBS Letters | volume = 412 | issue = 1 | pages = 35–8 | date = July 1997 | pmid = 9257684 | doi = 10.1016/S0014-5793(97)00710-2 | s2cid = 45475657 | doi-access = free }}</ref> The third subtype of third opioid type is the mu-3 receptor, which may be a commonality to other six-position monoesters of morphine. The contribution of these receptors to the overall pharmacology of heroin remains unknown.

A subclass of morphine derivatives, namely the 3,6 esters of morphine, with similar effects and uses, includes the clinically used strong analgesics [[Chemistry:Nicomorphine|nicomorphine]] (Vilan), and [[Chemistry:Dipropanoylmorphine|dipropanoylmorphine]]; there is also the latter's [[Chemistry:Dihydromorphine|dihydromorphine]] analogue, [[Chemistry:Diacetyldihydromorphine|diacetyldihydromorphine]] (Paralaudin). Two other 3,6 diesters of morphine invented in 1874–75 along with diamorphine, [[Chemistry:Dibenzoylmorphine|dibenzoylmorphine]] and [[Chemistry:Acetylpropionylmorphine|acetylpropionylmorphine]], were made as substitutes after it was outlawed in 1925 and, therefore, sold as the first "designer drugs" until they were outlawed by the League of Nations in 1930.

==Chemistry==
Diamorphine is produced from [[Biology:Acetylation|acetylation]] of [[Biology:Morphine|morphine]] derived from natural opium sources, generally using [[Chemistry:Acetic anhydride|acetic anhydride]].<ref name="auto">{{cite web|url=http://www.unodc.org/pdf/research/Bulletin07/bulletin_on_narcotics_2007_Zerell.pdf|title=Documentation of a heroin manufacturing process in Afghanistan. BULLETIN ON NARCOTICS, Volume LVII, Nos. 1 and 2, 2005|publisher=United Nations Office on Drugs and Crime|access-date=20 October 2010|url-status=live|archive-url=https://web.archive.org/web/20100705045725/http://www.unodc.org/pdf/research/Bulletin07/bulletin_on_narcotics_2007_Zerell.pdf|archive-date=5 July 2010}}</ref>

The major metabolites of diamorphine, [[Chemistry:6-Monoacetylmorphine|6-MAM]], morphine, [[Chemistry:Morphine-3-glucuronide|morphine-3-glucuronide]], and [[Chemistry:Morphine-6-glucuronide|morphine-6-glucuronide]], may be quantitated in blood, plasma or urine to monitor for use, confirm a diagnosis of poisoning, or assist in a medicolegal death investigation. Most commercial opiate screening tests cross-react appreciably with these metabolites, as well as with other biotransformation products likely to be present following usage of street-grade diamorphine such as [[Chemistry:6-Monoacetylcodeine|6-Monoacetylcodeine]] and [[Chemistry:Codeine|codeine]].<ref>{{Cite web |title=Opiates - Mayo Clinic Laboratories |url=https://www.mayocliniclabs.com/test-catalog/drug-book/specific-drug-groups/opiates |access-date=2022-08-06 |website=www.mayocliniclabs.com}}</ref> However, [[Physics:Chromatography|chromatographic]] techniques can easily distinguish and measure each of these substances. When interpreting the results of a test, it is important to consider the diamorphine usage history of the individual, since a chronic user can develop [[Chemistry:Drug tolerance|tolerance]] to doses that would incapacitate an opiate-naive individual, and the chronic user often has high baseline values of these metabolites in his system. Furthermore, some testing procedures employ a [[Chemistry:Hydrolysis|hydrolysis]] step before quantitation that converts many of the metabolic products to morphine, yielding a result that may be 2&nbsp;times larger than with a method that examines each product individually.<ref>{{cite book | vauthors = Baselt R |title=Disposition of Toxic Drugs and Chemicals in Man |edition=9th |publisher=Biomedical Publications |location=Seal Beach, CA |year=2011 |pages=793–7 |isbn=978-0-9626523-8-7}}</ref>

==History==
[[File:BayerHeroin.png|thumb|upright|Advertisement for Bayer Heroin]]


The opium poppy was cultivated in lower [[Place:Mesopotamia|Mesopotamia]] as long ago as 3400 BC.<ref>{{cite web|url=https://www.pbs.org/wgbh/pages/frontline/shows/heroin/etc/history.html|title=Opium Throughout History|publisher=PBS Frontline|access-date=22 October 2006|url-status=live|archive-url=https://web.archive.org/web/20060923053042/http://www.pbs.org/wgbh/pages/frontline/shows/heroin/etc/history.html|archive-date=23 September 2006}}</ref> The chemical analysis of [[Biology:Opium|opium]] in the 19th century revealed that most of its activity could be ascribed to the alkaloids [[Chemistry:Codeine|codeine]] and [[Biology:Morphine|morphine]].

Diamorphine was first synthesized in 1874 by C. R. Alder Wright, an English chemist working at St. Mary's Hospital Medical School in London who had been experimenting combining morphine with various acids. He boiled anhydrous morphine alkaloid with [[Chemistry:Acetic anhydride|acetic anhydride]] for several hours and produced a more potent, acetylated form of morphine which is now called ''diacetylmorphine'' or ''morphine diacetate''. He sent the compound to F. M. Pierce of Owens College in Manchester for analysis. Pierce told Wright:

{{blockquote|Doses… were subcutaneously injected into young dogs and rabbit… with the following general results… great prostration, fear, and sleepiness speedily following the administration, the eyes being sensitive, and pupils constrict, considerable salivation being produced in dogs, and a slight tendency to vomiting in some cases, but no actual emesis. Respiration was at first quickened, but subsequently reduced, and the heart's action was diminished and rendered irregular. Marked want of coordinating power over the muscular movements, and loss of power in the pelvis and hind limbs, together with a diminution of temperature in the rectum of about 4°.<ref>{{cite web|url=http://adhpage.dilaudid.net/heroin.html|title=On the action of organic acids and their anhydrides on the natural alkaloids| vauthors = Wright CR |date=12 August 2003|archive-url=https://web.archive.org/web/20040606103721/http://adhpage.dilaudid.net/heroin.html|archive-date=6 June 2004}} Note: this is an annotated excerpt of {{cite journal| vauthors = Wright CR | year = 1874| title = On the action of organic acids and their anhydrides on the natural alkaloids| journal = [[Organization:Journal of the Chemical Society|Journal of the Chemical Society]]| volume = 27| pages = 1031–1043 |url=https://babel.hathitrust.org/cgi/pt?id=mdp.39015077817453&view=1up&seq=1039 | doi = 10.1039/js8742701031}}</ref>}}

[[File:Bayer Heroin bottle.jpg|thumb|left|upright|Bayer Heroin bottle]]
Wright's invention did not lead to any further developments, and diamorphine became popular only after it was independently re-synthesized 23 years later by chemist Felix Hoffmann.<ref name="Bio">{{cite web|title=Felix Hoffmann|url=https://www.sciencehistory.org/historical-profile/felix-hoffmann|website=Science History Institute|access-date=18 March 2018|date=June 2016|archive-url=https://web.archive.org/web/20180321130305/https://www.sciencehistory.org/historical-profile/felix-hoffmann|archive-date=21 March 2018|url-status=live}}</ref> Hoffmann was working at [[Company:Bayer|Bayer]] pharmaceutical company in Elberfeld, Germany, and his supervisor Heinrich Dreser instructed him to acetylate morphine with the objective of producing codeine, a constituent of the opium poppy that is pharmacologically similar to morphine but less potent and less addictive. Instead, the experiment produced an acetylated form of morphine one and a half to two times more potent than morphine itself. Hoffmann synthesized heroin on August 21, 1897, just eleven days after he had synthesized [[Chemistry:Aspirin|aspirin]].<ref>{{cite book |last1=Schaefer |first1=Bernd |title=Natural Products in the Chemical Industry |date=2015 |publisher=[[Company:Springer Science+Business Media|Springer]] |isbn=9783642544613 |page=316 |url=https://books.google.com/books?id=DbO4CQAAQBAJ&pg=PA316 |access-date=19 December 2022}}</ref>

The head of Bayer's research department reputedly coined the drug's new name of "heroin", based on the German ''heroisch'' which means "heroic, strong" (from the ancient Greek word "heros, ήρως"). Bayer scientists were not the first to make heroin, but their scientists discovered ways to make it, and Bayer led the commercialization of heroin.<ref>{{cite web | vauthors = Edwards J | work = Business Insider | date = 17 November 2011 | url = http://www.businessinsider.com/yes-bayer-promoted-heroin-for-children-here-are-the-ads-that-prove-it-2011-11 | title = Yes, Bayer Promoted Heroin for Children – Here Are The Ads That Prove It | archive-url = https://web.archive.org/web/20150501031210/http://www.businessinsider.com/yes-bayer-promoted-heroin-for-children-here-are-the-ads-that-prove-it-2011-11 | archive-date = 1 May 2015 }}</ref>

Bayer marketed diacetylmorphine as an [[Medicine:Over-the-counter drug|over-the-counter drug]] under the trademark name Heroin.<ref name="etymonline.com">{{cite web|url=http://www.etymonline.com/index.php?term=heroin|title=Online Etymology Dictionary|publisher=Etymonline.com|access-date=20 October 2010|url-status=live|archive-url=https://web.archive.org/web/20110515083725/http://www.etymonline.com/index.php?term=heroin|archive-date=15 May 2011}}</ref> It was developed chiefly as a [[Biology:Morphine|morphine]] substitute for [[Medicine:Cough medicine|cough suppressants]] that did not have morphine's addictive side-effects. Morphine at the time was a popular recreational drug, and Bayer wished to find a similar but non-addictive substitute to market. However, contrary to Bayer's advertising as a "non-addictive morphine substitute", heroin would soon have one of the highest rates of [[Medicine:Addiction|addiction]] among its users.<ref>{{cite web|url=http://www.drugrehabtreatment.com/most-addictive-drugs.html|title=The Most Addictive Drugs|archive-url=https://web.archive.org/web/20100213101818/http://www.drugrehabtreatment.com/most-addictive-drugs.html|archive-date=13 February 2010}}</ref>

From 1898 through to 1910, diamorphine was marketed under the trademark name Heroin as a non-addictive morphine substitute and cough suppressant.<ref name="TimesUnion">{{cite web | vauthors = Moore D | work = Times Union | date = 24 August 2014 | url = http://www.timesunion.com/518life/article/Heroin-A-brief-history-of-unintended-consequences-5705610.php | title = Heroin: A brief history of unintended consequences | archive-url = https://web.archive.org/web/20150419071311/http://www.timesunion.com/518life/article/Heroin-A-brief-history-of-unintended-consequences-5705610.php | archive-date=19 April 2015 }}</ref> In the 11th edition of ''[[Encyclopædia Britannica]]'' (1910), the article on morphine states: "In the cough of [[Medicine:Tuberculosis|phthisis]] minute doses [of morphine] are of service, but in this particular disease morphine is frequently better replaced by codeine or by heroin, which checks irritable coughs without the narcotism following upon the administration of morphine."

In the US, the Harrison Narcotics Tax Act was passed in 1914 to control the sale and distribution of diacetylmorphine and other opioids, which allowed the drug to be prescribed and sold for medical purposes. In 1924, the United States Congress banned its sale, importation, or manufacture. It is now a Schedule I substance, which makes it illegal for non-medical use in signatory nations of the [[Medicine:Single Convention on Narcotic Drugs|Single Convention on Narcotic Drugs]] treaty, including the United States.

The Health Committee of the League of Nations banned diacetylmorphine in 1925, although it took more than three years for this to be implemented. In the meantime, the first designer drugs, viz. 3,6 diesters and 6 monoesters of morphine and acetylated analogues of closely related drugs like [[Chemistry:Hydromorphone|hydromorphone]] and [[Chemistry:Dihydromorphine|dihydromorphine]], were produced in massive quantities to fill the worldwide demand for diacetylmorphine—this continued until 1930 when the Committee banned diacetylmorphine analogues with no therapeutic advantage over drugs already in use, the first major legislation of this type.{{citation needed|date=April 2015}}

Bayer lost some of its trademark rights to heroin (as well as [[Chemistry:Aspirin|aspirin]]) under the 1919 Treaty of Versailles following the German defeat in [[Social:World War I|World War I]].<ref>{{Cite book|title=Science and Its Times: Understanding the Social Significance of Scientific Discovery| vauthors = Schlager N, Lauer J |date=2001|publisher=Gale Group |isbn=078763932X|location=Detroit|pages=[https://archive.org/details/scienceitstimesu0000unse/page/360 360]|oclc=43836551|url-access=registration|url=https://archive.org/details/scienceitstimesu0000unse/page/360}}</ref><ref>{{cite news |title=Happy birthday to the wonder drug that changed our lives |url=https://www.theguardian.com/uk/1999/mar/06/1 |work=The Guardian|date=6 March 1999 }}</ref>

Use of heroin by jazz musicians in particular was prevalent in the mid-twentieth century, including Billie Holiday, saxophonists Charlie Parker and Art Pepper, trumpeter and vocalist Chet Baker, guitarist Joe Pass and piano player/singer Ray Charles; a "staggering number of jazz musicians were addicts".<ref name="MartinWaters2008">{{cite book|url=https://books.google.com/books?id=e64R7pJ3zJsC&pg=PA168|title=Essential Jazz: The First 100 Years| vauthors = Martin H, Waters K |date=25 January 2008|publisher=Cengage Learning|isbn=978-0-495-50525-9|page=168|access-date=26 August 2012|url-status=live|archive-url=https://web.archive.org/web/20131203231043/http://books.google.com/books?id=e64R7pJ3zJsC&pg=PA168|archive-date=3 December 2013}}</ref> It was also a problem with many rock musicians, particularly from the late 1960s through the 1990s. Pete Doherty is also a self-confessed user of heroin.<ref>{{cite web | vauthors = Michaels S | date = 28 June 2012 | work = The Guardian | title = Pete Doherty skips T in the Park to enter rehab | url = https://www.theguardian.com/music/2012/jun/28/pete-doherty-t-park-rehab }}</ref> Nirvana lead singer Kurt Cobain's heroin addiction was well documented.<ref>{{cite book | vauthors = Azerrad M |title=Come as You Are: The Story of Nirvana. |date=1993 |publisher=Doubleday |location=New York |isbn=978-0-385-47199-2 |edition=1st | page = 241 }}</ref> Pantera frontman Phil Anselmo turned to heroin while touring during the 1990s to cope with his back pain.<ref>{{cite news|url=http://www.blabbermouth.net/news.aspx?mode=Article&newsitemID=125509|title=Philip Anselmo Opens Up About His Heroin Addiction, Pantera's Breakup|date=19 August 2009|work=Blabbermouth.net|access-date=12 October 2013|archive-url=https://web.archive.org/web/20200111133613/https://www.blabbermouth.net/news.aspx%3Fmode%3DArticle%26newsitemID%3D125509|archive-date=11 January 2020|url-status=live}}</ref> James Taylor, Jimmy Page, [[Biography:John Lennon|John Lennon]], Eric Clapton, Johnny Winter, Keith Richards and Janis Joplin also used heroin. Many musicians have made songs referencing their heroin usage.<ref>{{cite news|url=https://www.theguardian.com/music/2004/jul/09/velvetrevolver.gunsnroses|title=I died. I do remember that| vauthors = Sweeting A |date=9 July 2004|work=The Guardian|location=London|url-status=live|archive-url=https://web.archive.org/web/20161230054611/https://www.theguardian.com/music/2004/jul/09/velvetrevolver.gunsnroses|archive-date=30 December 2016}}</ref><ref>{{cite book | vauthors = Brown P | title=The Love You Make: An Insider's Story of The Beatles | orig-date=1983 | date = 2002 | page = 331 |location=New York  | publisher = McGraw-Hill / New American Library |isbn=978-0-07-008159-8 }}</ref><ref name="nuaa">{{cite web|url=http://www.nuaa.org.au/nuaa/News/media/UN52/UN52-loaded_great_heroin_songs.pdf|title=Loaded – Great heroin songs of the rock era| vauthors = Bates M |date=December 2008|pages=26–27|archive-url=https://web.archive.org/web/20080409082048/http://www.nuaa.org.au/nuaa/News/media/UN52/UN52-loaded_great_heroin_songs.pdf <!-- Bot retrieved archive -->|archive-date=9 April 2008|access-date=17 January 2008}}</ref><ref>Liner notes, Music Bank box set. 1999.</ref><ref>{{cite web | vauthors = Howard G | date = 18 September 2009 |url=http://www.slate.com/articles/news_and_politics/obit/2009/09/death_of_a_poet.html|title=Death of a Poet: Saying goodbye to Jim Carroll. | work = Slate |access-date=2 January 2014|url-status=live|archive-url=https://web.archive.org/web/20140102224352/http://www.slate.com/articles/news_and_politics/obit/2009/09/death_of_a_poet.html|archive-date=2 January 2014 }}</ref>

==Society and culture==

===Names===
"Diamorphine" is the Recommended International Nonproprietary Name and [[Chemistry:British Approved Name|British Approved Name]].<ref name="Heroin's rINN">{{cite book | vauthors = Rang HP, Ritter JM, Flower RJ, Henderson G |title=Rang & Dale's Pharmacology|date=2014|publisher=Elsevier Health Sciences|isbn=9780702054976|page=515|edition=8th|url=https://books.google.com/books?id=iOLTBQAAQBAJ&pg=PA515|access-date=12 April 2016|quote=While 'diamorphine' is the recommended International Nonproprietary Name (rINN), this drug is widely known as heroin.|url-status=live|archive-url=https://web.archive.org/web/20170307152341/https://books.google.com/books?id=iOLTBQAAQBAJ&pg=PA515|archive-date=7 March 2017}}</ref><ref>{{cite book | vauthors = Rang HP, Ritter JM, Flower RJ, Henderson G |title=Rang & Dale's pharmacology|date=2011|publisher=Churchill Livingstone|edition=7th|location=Edinburgh, UK|isbn=978-0-7020-3471-8}}</ref> Other synonyms for heroin include: diacetylmorphine, and morphine diacetate. Heroin is also known by many street names including dope, H, smack, junk, horse, scag, and brown, among others.<ref>{{cite web|url=http://thecyn.com/heroin-rehab/street-names/|title=Nicknames and Street Names for Heroin|publisher=Thecyn.com|access-date=12 October 2013|url-status=dead|archive-url=https://web.archive.org/web/20131014153652/http://thecyn.com/heroin-rehab/street-names/|archive-date=14 October 2013}}</ref>

===Legal status===

====Asia====
In Hong Kong, diamorphine is regulated under Schedule 1 of [[Place:Hong Kong|Hong Kong]]'s Chapter 134 ''Dangerous Drugs Ordinance''. It is available by prescription. Anyone supplying diamorphine without a valid prescription can be fined $5,000,000 ([[Finance:Hong Kong dollar|HKD]]) and imprisoned for life. The penalty for trafficking or manufacturing diamorphine is a $5,000,000 (HKD) fine and life imprisonment. Possession of diamorphine without a license from the Department of Health is illegal with a $1,000,000 (HKD) fine and 7 years of jail time.<ref>{{cite web|title=Heroin, the Poppy|url=http://www.addiction-recovery-expose.com/heroin.html|website=Addiction Recovery Expose|publisher=Randolph Online Solutions Inc|access-date=27 May 2012|url-status=dead|archive-url=https://web.archive.org/web/20120822084042/http://www.addiction-recovery-expose.com/heroin.html|archive-date=22 August 2012}}</ref><ref>{{cite web|title=Hong Kong Police – The Dangerous Drug Ordinance – Chapter 134|url=https://www.police.gov.hk/ppp_en/04_crime_matters/drug/law_pen.html|website=The Hong Kong Police website|publisher=The Hong Kong Police|access-date=5 January 2020|url-status=live|archive-url=https://web.archive.org/web/20191005070448/https://www.police.gov.hk/ppp_en/04_crime_matters/drug/law_pen.html|archive-date=5 October 2019}}</ref>

====Europe====
In the Netherlands, diamorphine is a List I drug of the [[Medicine:Opium Law|Opium Law]]. It is available for prescription under tight regulation exclusively to long-term addicts for whom [[Chemistry:Methadone maintenance|methadone maintenance]] treatment has failed. It cannot be used to treat severe [[Medicine:Pain|pain]] or other illnesses.<ref>{{cite web|title=Canada now allows prescription heroin in severe opioid addiction|url=https://www.cbc.ca/news/canada/british-columbia/canada-now-allows-prescription-heroin-in-severe-opioid-addiction-1.3753312|website=cbc.ca|publisher=CBC News|access-date=11 November 2018|archive-url=https://web.archive.org/web/20190115200403/https://www.cbc.ca/news/canada/british-columbia/canada-now-allows-prescription-heroin-in-severe-opioid-addiction-1.3753312|archive-date=15 January 2019|url-status=live}}</ref>

In the United Kingdom, diamorphine is available by prescription, though it is a restricted Class A drug. According to the 50th edition of the British National Formulary (BNF), diamorphine [[Chemistry:Hydrochloride|hydrochloride]] may be used in the treatment of acute pain, [[Medicine:Myocardial infarction|myocardial infarction]], acute pulmonary oedema, and [[Medicine:Chronic pain|chronic pain]]. The treatment of chronic non-malignant pain must be supervised by a specialist. The BNF notes that all opioid analgesics cause dependence and tolerance but that this is "no deterrent in the control of pain in terminal illness". When used in the palliative care of cancer patients, diamorphine is often injected using a [[Engineering:Syringe driver|syringe driver]].<ref>{{cite web|title=Heroin|url=http://www.nacada.go.ke/drugs/heroin/|publisher=NACADA|access-date=27 May 2012 |archive-url=https://web.archive.org/web/20121203073833/http://www.nacada.go.ke/drugs/heroin/ |archive-date=3 December 2012}}</ref>

In Switzerland, heroin is produced in injectable or tablet form under the name Diaphin by a private company under contract to the Swiss government.<ref>{{Cite web|url=https://www.swissinfo.ch/eng/good-crop--bad-crop_-federal-dealer--on-20-years-of-heroin-scheme/37953750|title='Federal dealer' on 20 years of heroin scheme| vauthors = Ochsenbein G |website=SWI swissinfo.ch|date=14 February 2014 |language=en|access-date=13 December 2018|archive-url=https://web.archive.org/web/20181215221901/https://www.swissinfo.ch/eng/good-crop--bad-crop_-federal-dealer--on-20-years-of-heroin-scheme/37953750|archive-date=15 December 2018|url-status=live}}</ref> Swiss-produced heroin has been imported into Canada with government approval.<ref>{{Cite web|url=https://www.canada.ca/en/health-canada/services/drugs-health-products/access-drugs-exceptional-circumstances/list-drugs-urgent-public-health-need.html|title=List of Drugs for an Urgent Public Health Need|publisher=Health Canada|date=28 June 2017|access-date=13 December 2018|archive-url=https://web.archive.org/web/20181206220049/https://www.canada.ca/en/health-canada/services/drugs-health-products/access-drugs-exceptional-circumstances/list-drugs-urgent-public-health-need.html|archive-date=6 December 2018|url-status=live}}</ref>

====Australia====
In Australia, diamorphine is listed as a schedule 9 prohibited substance under the Poisons Standard (October 2015).<ref name="Poisons Standard">Poisons Standard October 2015 {{cite web |url=https://www.comlaw.gov.au/Details/F2015L01534 |title=Poisons Standard October 2015 |date=30 September 2015 | publisher = Commonwealth of Australia |access-date=6 January 2016 |url-status=live |archive-url=https://web.archive.org/web/20160119074606/https://www.comlaw.gov.au/Details/F2015L01534/ |archive-date=19 January 2016}}</ref> The state of Western Australia, in its ''Poisons Act 1964'' (Reprint 6: amendments as at 10 Sep 2004), described a schedule 9 drug as: "Poisons that are drugs of abuse, the manufacture, possession, sale or use of which should be prohibited by law except for amounts which may be necessary for educational, experimental or research purposes conducted with the approval of the Governor."<ref>{{cite act |title=The Poisons Act 1964 |article=20 (2) (i) |page=16 |date=10 September 2004 |legislature=Parliament of Western Australia |url=https://www.legislation.wa.gov.au/legislation/former/Swans.nsf/(DownloadFiles)/Poisons+Act+1964.pdf/$file/Poisons+Act+1964.pdf |access-date=2023-11-15 |archive-url=https://web.archive.org/web/20231116050739/https://www.legislation.wa.gov.au/legislation/former/Swans.nsf/%28DownloadFiles%29/Poisons+Act+1964.pdf/$file/Poisons+Act+1964.pdf |archive-date=2023-11-16 |url-status=live}}</ref>

====North America====
In Canada, diamorphine is a controlled substance<ref>{{cite news|title=Medically prescribed heroin more cost-effective than methadone, study suggests|url=https://www.thestar.com/news/canada/article/1144818--medically-prescribed-heroin-more-cost-effective-than-methadone-study-suggests|work=The Toronto Star|access-date=27 May 2012| vauthors = Ubelacker S |date=12 March 2012|url-status=live|archive-url= https://web.archive.org/web/20120416015457/http://www.thestar.com/news/canada/article/1144818--medically-prescribed-heroin-more-cost-effective-than-methadone-study-suggests|archive-date=16 April 2012}}</ref> under Schedule I of the Controlled Drugs and Substances Act (CDSA).<ref>{{cite web|title=Heroin Legal Status|url=http://www.erowid.org/chemicals/heroin/heroin_law.shtml|website=Vaults of Erowid|publisher=[[Organization:Erowid|Erowid]] |access-date=27 May 2012|url-status=live|archive-url=https://web.archive.org/web/20120514101729/http://www.erowid.org/chemicals/heroin/heroin_law.shtml|archive-date=14 May 2012}}</ref> Any person seeking or obtaining diamorphine without disclosing authorization 30&nbsp;days before obtaining another prescription from a practitioner is guilty of an indictable offense and subject to imprisonment for a term not exceeding seven years. Possession of diamorphine for the purpose of trafficking is an indictable offense and subject to imprisonment for life.

In the United States, diamorphine is a Schedule I drug according to the Controlled Substances Act of 1970, making it illegal to possess without a DEA license.<ref name="DOJ 1308.11">{{cite web | title = Title 21 of the Code of Federal Regulations (21 CFR) 1308.11 | url = http://www.deadiversion.usdoj.gov/21cfr/cfr/1308/1308_11.htm | archive-url = https://web.archive.org/web/20090827043725/http://www.deadiversion.usdoj.gov/21cfr/cfr/1308/1308_11.htm | archive-date=27 August 2009 | quote= (CSA Sched I) with changes through {{USFR|77|64032}} | date = 18 October 2012 }}</ref> Possession of more than 100&nbsp;grams of diamorphine or a mixture containing diamorphine is punishable with a minimum mandatory sentence of 5 years of imprisonment in a federal prison.

In 2021, the US state of Oregon became the first state to decriminalize the use of heroin after voters passed Ballot Measure 110 in 2020.<ref>{{cite news |url=https://www.washingtonpost.com/nation/2020/11/04/election-drugs-oregon-new-jersey/ |title=Oregon decriminalizes possession of hard drugs, as four other states legalize recreational marijuana |newspaper=The Washington Post |date=5 November 2020 }}</ref> This measure will allow people with small amounts to avoid arrest.<ref>{{Cite web|url=http://www.theguardian.com/us-news/2020/nov/03/oregon-drugs-decriminalize-arizona-new-jersey-marijuana|title=Oregon becomes first US state to decriminalize possession of hard drugs|date=4 November 2020|website=The Guardian}}</ref>

====Turkey====
[[Place:Turkey|Turkey]] maintains strict laws against the use, possession or [[Finance:Illegal drug trade|trafficking of illegal drugs]]. If convicted under these offences, one could receive a heavy fine or a prison sentence of 4 to 24 years.<ref>{{cite web|url=https://www.gov.uk/foreign-travel-advice/turkey/local-laws-and-customs|title=Turkey Travel Advice|access-date=20 March 2013|publisher=GOV.UK |archive-url=https://web.archive.org/web/20130607023012/https://www.gov.uk/foreign-travel-advice/turkey/local-laws-and-customs|archive-date=7 June 2013|url-status=live}}</ref>

====Misuse of prescription medication====
Misused prescription medicine, such as opioids, can lead to heroin use and dependence.<ref name="Abuse">{{Cite news|url=https://www.drugabuse.gov/publications/research-reports/heroin/how-heroin-linked-to-prescription-drug-abuse|title=How is heroin linked to prescription drug abuse? |author = National Institute on Drug Abuse |access-date=28 November 2017|language=en-US|archive-url=https://web.archive.org/web/20171201035612/https://www.drugabuse.gov/publications/research-reports/heroin/how-heroin-linked-to-prescription-drug-abuse|archive-date=1 December 2017|url-status=dead}}</ref> The number of death from illegal opioid overdose follows the increasing number of death caused by prescription opioid overdoses.<ref>{{Cite web|url=https://www.cdc.gov/drugoverdose/data/analysis.html|title=Opioid Data Analysis {{!}} Drug Overdose {{!}} CDC Injury Center|website=www.cdc.gov|language=en-us|access-date=28 November 2017|archive-url=https://web.archive.org/web/20180130110545/https://www.cdc.gov/drugoverdose/data/analysis.html|archive-date=30 January 2018|url-status=live}}</ref> Prescription opioids are relatively easy to obtain.<ref>{{Cite news|url=https://www.cbsnews.com/news/whats-a-pill-mill/|title=What's A Pill Mill?|access-date=28 November 2017|language=en|archive-url=https://web.archive.org/web/20171201041552/https://www.cbsnews.com/news/whats-a-pill-mill/|archive-date=1 December 2017|url-status=live}}</ref> This may ultimately lead to heroin injection because heroin is cheaper than prescribed pills.<ref name="Abuse"/>

===Economics===

====Production====
Diamorphine is produced from [[Biology:Acetylation|acetylation]] of morphine derived from natural opium sources. One such method of heroin production involves isolation of the water-soluble components of raw opium, including morphine, in a strongly basic aqueous solution, followed by [[Chemistry:Recrystallization|recrystallization]] of the morphine base by addition of [[Chemistry:Ammonium chloride|ammonium chloride]]. The solid morphine base is then filtered out. The morphine base is then reacted with [[Chemistry:Acetic anhydride|acetic anhydride]], which forms heroin. This highly impure brown heroin base may then undergo further purification steps, which produces a white-colored product; the final products have a different appearance depending on purity and have different names.<ref name="auto"/> Heroin purity has been classified into four grades. No.4 is the purest form – white powder (salt) to be easily dissolved and injected. No.3 is "brown sugar" for smoking (base). No.1 and No.2 are unprocessed raw heroin (salt or base).<ref>{{cite web |title=Heroin—Illicit Drug Report |publisher=Government of Australia |access-date=31 March 2014 |year=2004 |url=http://www.crimecommission.gov.au/sites/default/files/iddr_0304_heroin.pdf |url-status=dead |archive-url=https://web.archive.org/web/20140212170007/https://www.crimecommission.gov.au/sites/default/files/iddr_0304_heroin.pdf |archive-date=12 February 2014}}</ref>

====Trafficking====
[[File:CIA Map of International illegal drug connections.gif|thumb|400px|International drug routes]]

Traffic is heavy worldwide, with the biggest producer being Afghanistan. According to a U.N. sponsored survey,<ref name="UNODCSurvey">{{cite web|url=http://www.unodc.org/pdf/afg/afghanistan_opium_survey_2004.pdf|title=Afghanistan opium survey – 2004|publisher=United Nations Office on Drugs and Crime|access-date=22 October 2006|url-status=live|archive-url=https://web.archive.org/web/20061024170057/http://www.unodc.org/pdf/afg/afghanistan_opium_survey_2004.pdf|archive-date=24 October 2006}}</ref> in 2004, Afghanistan accounted for production of 87 percent of the world's diamorphine.<ref>{{cite news| vauthors = McGirk T | date =2 August 2004| url =http://www.time.com/time/asia/magazine/printout/0,13675,501040809-674806,00.html| title =Terrorism's Harvest: How al-Qaeda is tapping into the opium trade to finance its operations and destabilize Afghanistan| magazine =Time Asia| access-date =22 October 2006| url-status=dead| archive-url =https://web.archive.org/web/20070123133151/http://www.time.com/time/asia/magazine/printout/0,13675,501040809-674806,00.html| archive-date =23 January 2007}}</ref> Afghan opium kills around 100,000 people annually.<ref>{{cite news |url=http://www.cnn.com/2009/WORLD/asiapcf/10/21/un.heroin.trade/index.html |title=World failing to dent heroin trade, U.N. warns |publisher=CNN |date=21 October 2009 |access-date=20 July 2012 |url-status=live |archive-url=https://web.archive.org/web/20121106182829/http://www.cnn.com/2009/WORLD/asiapcf/10/21/un.heroin.trade/index.html |archive-date=6 November 2012}}</ref>

In 2003 ''The Independent'' reported:<ref>Andy McSmith and Phil Reeves. "Afghanistan regains its Title as World's biggest Heroin Dealer" in ''The Independent'', 22 June 2003</ref><ref>{{cite news | vauthors = North A |url=http://news.bbc.co.uk/2/hi/south_asia/3476377.stm |title=The drugs threat to Afghanistan |work=BBC |date=10 February 2004 |access-date=28 July 2013 |url-status=live |archive-url=https://web.archive.org/web/20131015080956/http://news.bbc.co.uk/2/hi/south_asia/3476377.stm |archive-date=15 October 2013}}</ref>
{{blockquote|The cultivation of opium [in Afghanistan] reached its peak in 1999, when {{convert|350|sqmi|km2}} of poppies were sown&nbsp;... The following year the Taliban banned poppy cultivation,&nbsp;... a move which cut production by 94 percent&nbsp;... By 2001 only {{convert|30|sqmi|km2}} of land were in use for growing opium poppies. A year later, after American and British troops had removed the Taliban and installed the interim government, the land under cultivation leapt back to {{convert|285|sqmi|km2}}, with Afghanistan supplanting Burma to become the world's largest opium producer once more.}}

Opium production in that country has increased rapidly since, reaching an all-time high in 2006. War in Afghanistan once again appeared as a facilitator of the trade.<ref>{{cite news| vauthors = Gall C | date =3 September 2006| url =https://www.nytimes.com/2006/09/03/world/asia/03afghan.html| title =Opium Harvest at Record Level in Afghanistan| work =The New York Times| access-date =22 October 2006| url-status=live| archive-url =https://web.archive.org/web/20071228015047/http://www.nytimes.com/2006/09/03/world/asia/03afghan.html| archive-date =28 December 2007}}</ref> Some 3.3&nbsp;million Afghans are involved in producing opium.<ref>{{cite news | vauthors = Walsh D |url=https://www.theguardian.com/afghanistan/story/0,,2157313,00.html |title=UN horrified by surge in opium trade in Helmand |newspaper=Guardian |date= 30 August 2007|access-date=20 July 2012 |location=London}}</ref>
[[File:Afghanistan opium poppy cultivation 1994-2007b.PNG|thumb|right|300px|Afghanistan opium poppy cultivation, 1994–2016 (hectares)]]
At present, opium poppies are mostly grown in Afghanistan ({{convert|224000|hectare}}), and in Southeast Asia, especially in the region known as the [[Place:Golden Triangle (Southeast Asia)|Golden Triangle]] straddling Burma ({{convert|57600|hectare}}), Thailand, Vietnam, Laos ({{convert|6200|hectare}}) and Yunnan province in China. There is also cultivation of opium poppies in Pakistan ({{convert|493|hectare}}), Mexico ({{convert|12000|hectare}}) and in Colombia ({{convert|378|hectare}}).<ref name="UNODC2014">{{cite web | url=https://www.unodc.org/documents/crop-monitoring/Colombia/censo_INGLES_2014_WEB.pdf | title=Coca cultivation survey | publisher=United Nations Office on Drugs and Crime (UNODC) | website=Report | date=July 2015 | access-date=28 May 2016 | author=Government of Colombia | pages=67 | url-status=live | archive-url=https://web.archive.org/web/20160413083056/https://www.unodc.org/documents/crop-monitoring/Colombia/censo_INGLES_2014_WEB.pdf | archive-date=13 April 2016}}</ref> According to the [[Organization:Drug Enforcement Administration|DEA]], the majority of the heroin consumed in the United States comes from Mexico (50%) and Colombia (43–45%) via Mexican criminal cartels such as Sinaloa Cartel.<ref>{{cite web | url = http://www.theyucatantimes.com/2014/11/50-of-the-heroin-consumed-in-the-united-states-is-produced-in-mexico/ | title = 50% of the Heroin consumed in the United States is produced in Mexico | archive-url = https://web.archive.org/web/20151102193328/http://www.theyucatantimes.com/2014/11/50-of-the-heroin-consumed-in-the-united-states-is-produced-in-mexico/ | archive-date=2 November 2015 | work = The Yucatan Times | date = 26 November 2014 }}</ref> However, these statistics may be significantly unreliable, the DEA's 50/50 split between Colombia and Mexico is contradicted by the amount of hectares cultivated in each country and in 2014, the DEA claimed most of the heroin in the US came from Colombia.<ref name="InSight">{{cite web | url=http://www.insightcrime.org/news-analysis/mexico-cartel-takeover-of-us-heroin-market-questionable | title=Sinaloa Cartel's Takeover of US Heroin Market Questionable | publisher=InSight Crime | website=Website | date=26 May 2016 | access-date=28 May 2016 | vauthors = Yagoub M | url-status=live | archive-url=https://web.archive.org/web/20160527122359/http://www.insightcrime.org/news-analysis/mexico-cartel-takeover-of-us-heroin-market-questionable | archive-date=27 May 2016}}</ref>
{{As of|2015}}, the Sinaloa Cartel is the most active drug cartel involved in smuggling illicit drugs such as heroin into the United States and trafficking them throughout the United States.<ref name="DEA 2015 assessment">{{cite web|title=2015 National Drug Threat Assessment Summary|url=http://www.dea.gov/docs/2015%20NDTA%20Report.pdf|website=Drug Enforcement Administration|publisher=United States Department of Justice: Drug Enforcement Administration|access-date=10 April 2016|pages=1–2|date=October 2015|quote=Mexican TCOs pose the greatest criminal drug threat to the United States; no other group is currently positioned to challenge them. These Mexican poly-drug organizations traffic heroin, methamphetamine, cocaine, and marijuana throughout the United States, using established transportation routes and distribution networks.&nbsp;... While all of these Mexican TCOs transport wholesale quantities of illicit drugs into the United States, the Sinaloa Cartel appears to be the most active supplier. The Sinaloa Cartel leverages its expansive resources and dominance in Mexico to facilitate the smuggling and transportation of drugs throughout the United States.|url-status=dead|archive-url=https://web.archive.org/web/20160410100038/http://www.dea.gov/docs/2015%20NDTA%20Report.pdf|archive-date=10 April 2016}}</ref> According to the Royal Canadian Mounted Police, 90% of the heroin seized in Canada (where the origin was known) came from Afghanistan.<ref name="RMCP">{{cite web | url=https://ottawacitizen.com/news/politics/u-s-raises-alarm-over-afghan-heroin-flowing-through-canada | title=U.S. raises alarm over Afghan heroin flowing through Canada | newspaper=Ottawa Citizen | date=20 November 2014 | access-date=28 May 2016 | vauthors = Berthiaume L | url-status=live | archive-url=https://web.archive.org/web/20160615054458/http://ottawacitizen.com/news/politics/u-s-raises-alarm-over-afghan-heroin-flowing-through-canada | archive-date=15 June 2016}}</ref> Pakistan is the destination and transit point for 40 percent of the opiates produced in Afghanistan, other destinations of Afghan opiates are Russia, Europe and Iran.<ref name="NYT2014">{{cite web | url=https://www.nytimes.com/2014/10/27/opinion/afghanistans-unending-addiction.html | title=Afghanistan's Unending Addiction | work=The New York Times | date=26 October 2014 | access-date=28 May 2016 | author=Editorial Board | url-status=live | archive-url=https://web.archive.org/web/20160814143949/http://www.nytimes.com/2014/10/27/opinion/afghanistans-unending-addiction.html | archive-date=14 August 2016}}</ref><ref>{{cite web|url=https://www.unodc.org/pakistan/en/country-profile.html|title=Country Profile: Pakistan|publisher=[[Organization:United Nations Office on Drugs and Crime|United Nations Office on Drugs and Crime]]|access-date=5 January 2015|url-status=live|archive-url=https://web.archive.org/web/20150405032932/http://www.unodc.org/pakistan/en/country-profile.html|archive-date=5 April 2015}}</ref>

A conviction for trafficking heroin carries the death penalty in most Southeast Asian, some East Asian and Middle Eastern countries (see Use of death penalty worldwide for details), among which Malaysia, Singapore and Thailand are the strictest. The penalty applies even to citizens of countries where the penalty is not in place, sometimes causing controversy when foreign visitors are arrested for trafficking, for example, the arrest of nine Australians in Bali, the death sentence given to Nola Blake in Thailand in 1987, or the hanging of an Australian citizen Van Tuong Nguyen in Singapore.

====Trafficking history====
[[File:HeroinWorld-en.svg|thumb|400px|Primary worldwide producers of heroin]]

The origins of the present international illegal heroin trade can be traced back to laws passed in many countries in the early 1900s that closely regulated the production and sale of opium and its derivatives including heroin. At first, heroin flowed from countries where it was still legal into countries where it was no longer legal. By the mid-1920s, heroin production had been made illegal in many parts of the world. An illegal trade developed at that time between heroin labs in China (mostly in Shanghai and Tianjin) and other nations. The weakness of the government in China and conditions of civil war enabled heroin production to take root there. Chinese triad gangs eventually came to play a major role in the illicit heroin trade. The French Connection route started in the 1930s.

Heroin trafficking was virtually eliminated in the US during [[Social:World War II|World War II]] because of temporary trade disruptions caused by the war. Japan's war with China had cut the normal distribution routes for heroin and the war had generally disrupted the movement of opium. After World War II, the Mafia took advantage of the weakness of the postwar Italian government and set up heroin labs in Sicily which was located along the historic route opium took westward into Europe and the United States.<ref>Eric C. Schneider, ''Smack:  Heroin and the American City'', University of Pennsylvania Press, 2008, chapter one</ref> Large-scale international heroin production effectively ended in China with the victory of the communists in the civil war in the late 1940s.{{Citation needed|date=December 2008}} The elimination of Chinese production happened at the same time that Sicily's role in the trade developed.

Although it remained legal in some countries until after World War II, health risks, addiction, and widespread recreational use led most western countries to declare heroin a controlled substance by the latter half of the 20th century. In the late 1960s and early 1970s, the CIA supported anti-Communist Chinese Nationalists settled near the {{wipe|China}}-Burmese border and Hmong tribesmen in Laos. This helped the development of the [[Place:Golden Triangle (Southeast Asia)|Golden Triangle]] opium production region, which supplied about one-third of heroin consumed in the US after the 1973 American withdrawal from Vietnam. In 1999, Burma, the heartland of the Golden Triangle, was the second-largest producer of heroin, after Afghanistan.<ref name="Afghan_Burmese_heroin">{{cite news|url=http://news.bbc.co.uk/1/hi/uk/1590827.stm|title=War Views: Afghan heroin trade will live on.|date=October 2001|work=Richard Davenport-Hines|publisher=BBC|access-date=30 October 2008|url-status=live|archive-url=https://web.archive.org/web/20090115095732/http://news.bbc.co.uk/1/hi/uk/1590827.stm|archive-date=15 January 2009}}</ref>

The Soviet-Afghan war led to increased production in the Pakistani-Afghan border regions, as US-backed mujaheddin militants raised money for arms from selling opium, contributing heavily to the modern [[Place:Golden Crescent|Golden Crescent]] creation. By 1980, 60 percent of the heroin sold in the US originated in Afghanistan.<ref name="Afghan_Burmese_heroin"/> It increased international production of heroin at lower prices in the 1980s. The trade shifted away from Sicily in the late 1970s as various criminal organizations violently fought with each other over the trade. The fighting also led to a stepped-up government law enforcement presence in Sicily.

Following the discovery at a Jordanian airport of a [[Engineering:Toner cartridge|toner cartridge]] that had been modified into an improvised explosive device, the resultant increased level of airfreight scrutiny led to a major shortage (drought) of heroin from October 2010 until April 2011. This was reported in most of mainland Europe and the UK which led to a price increase of approximately 30 percent in the cost of street heroin and increased demand for diverted [[Chemistry:Methadone|methadone]]. The number of addicts seeking treatment also increased significantly during this period. Other heroin droughts (shortages) have been attributed to cartels restricting supply in order to force a price increase and also to a fungus that attacked the opium crop of 2009. Many people{{weasel inline|date=April 2014}} thought that the American government had introduced pathogens into the Afghanistan atmosphere in order to destroy the opium crop and thus starve insurgents of income.{{citation needed|date=April 2014}}

On 13 March 2012, Haji Bagcho, with ties to the [[Religion:Taliban|Taliban]], was convicted by a US District Court of conspiracy, distribution of heroin for importation into the United States and narco-terrorism.<ref>{{cite web|title=Haji Bagcho Sentenced To Life in Prison on Narco-Terrorism, Drug Trafficking Charges – Funded Taliban, Responsible for Almost 20 Percent of World's Heroin Production, More Than a Quarter-Billion in Drug Proceeds, Property Forfeited|url=http://aikenleader.villagesoup.com/news/story/haji-bagcho-sentenced-to-life-in-prison-on-narco-terrorism-drug-trafficking-charges/838118|website=The Aiken Leader|access-date=7 June 2012|url-status=dead|archive-url=https://web.archive.org/web/20120615215354/http://aikenleader.villagesoup.com/news/story/haji-bagcho-sentenced-to-life-in-prison-on-narco-terrorism-drug-trafficking-charges/838118|archive-date=15 June 2012}}</ref><ref name="justice2006">{{cite web|title=Haji Bagcho Convicted by Federal Jury in Washington, D.C., on Drug Trafficking and Narco-terrorism Charges – Afghan National Trafficked More Than 123,000 Kilograms of Heroin in 2006|date=13 March 2012 |url=https://www.justice.gov/opa/pr/2012/March/12-crm-320.html|publisher=US Department of Justice|access-date=7 June 2012|url-status=live|archive-url=https://web.archive.org/web/20120713015227/http://www.justice.gov/opa/pr/2012/March/12-crm-320.html|archive-date=13 July 2012}}</ref><ref name="surfky1">{{cite web|title=Haji Bagcho Sentenced to Life in Prison on Trafficking/Narco-Terrorism Charges|url=http://surfky.com/index.php/news/national/15973-haji-bagcho-sentenced-to-life-in-prison-on-traffickingnarco-terrorism-charges|publisher=Surfky News|access-date=7 June 2012 |archive-url=https://web.archive.org/web/20140116103054/http://surfky.com/index.php/news/national/15973-haji-bagcho-sentenced-to-life-in-prison-on-traffickingnarco-terrorism-charges |archive-date=16 January 2014}}</ref><ref name="foster1">{{cite web| vauthors = Foster Z |title=Haji Bagcho, One of World's Largest Heroin Traffickers, Convicted on Drug Trafficking, Narco-Terrorism Charges|date=23 March 2012 |url=http://terrorism-online.blogspot.com/2012/03/haji-bagcho-one-of-worlds-largest.html|publisher=War on Terrorism Online|access-date=7 June 2012|url-status=live|archive-url=https://web.archive.org/web/20140116143405/http://terrorism-online.blogspot.com/2012/03/haji-bagcho-one-of-worlds-largest.html|archive-date=16 January 2014}}</ref><ref name="tucker1">{{cite news| vauthors = Tucker E |title=Afghan heroin trafficker gets life in US prison |url=http://www.katu.com/news/national/158797915.html |access-date=7 June 2012 |newspaper=Associated Press |date=12 June 2012 |url-status=dead |archive-url=https://web.archive.org/web/20130514223906/http://www.katu.com/news/national/158797915.html |archive-date=14 May 2013}}</ref> Based on heroin production statistics<ref>{{cite web|title=2007 WORLD DRUG REPORT|url=http://www.unodc.org/pdf/research/wdr07/WDR_2007.pdf|publisher=United Nations Office on Drugs and Crime|access-date=26 July 2012|url-status=live|archive-url=https://web.archive.org/web/20120912022032/http://www.unodc.org/pdf/research/wdr07/WDR_2007.pdf|archive-date=12 September 2012}}</ref> compiled by the [[Organization:United Nations Office on Drugs and Crime|United Nations Office on Drugs and Crime]], in 2006, Bagcho's activities accounted for approximately 20 percent of the world's total production for that year.<ref name="justice2006"/><ref name="surfky1"/><ref name="foster1"/><ref name="tucker1"/>

====Street price====
The European Monitoring Centre for Drugs and Drug Addiction reports that the retail price of brown heroin varies from €14.5 per gram in Turkey to €110 per gram in Sweden, with most European countries reporting typical prices of €35–40 per gram. The price of white heroin is reported only by a few European countries and ranged between €27 and €110 per gram.<ref>{{cite book |author=European Monitoring Centre for Drugs and Drug Addiction |title=Annual report: the state of the drugs problem in Europe |year=2008 |publisher=Office for Official Publications of the European Communities |location=Luxembourg |isbn=978-92-9168-324-6 |page=70 |url=http://www.emcdda.europa.eu/attachements.cfm/att_64227_EN_EMCDDA_AR08_en.pdf |url-status=live |archive-url=https://web.archive.org/web/20130425191815/http://www.emcdda.europa.eu/attachements.cfm/att_64227_EN_EMCDDA_AR08_en.pdf |archive-date=25 April 2013}}</ref>

The [[Organization:United Nations Office on Drugs and Crime|United Nations Office on Drugs and Crime]] claims in its 2008 World Drug Report that typical US retail prices are US$172 per gram.<ref>{{cite book |author=United Nations Office on Drugs and Crime |title=World drug report |year=2008 |publisher=United Nations Publications |isbn=978-92-1-148229-4 |page=49 |url=http://www.unodc.org/documents/wdr/WDR_2008/WDR_2008_eng_web.pdf |url-status=live |archive-url=https://web.archive.org/web/20081215184124/http://www.unodc.org/documents/wdr/WDR_2008/WDR_2008_eng_web.pdf |archive-date=15 December 2008}}</ref>

==Research==
Researchers are attempting to reproduce the biosynthetic pathway that produces [[Biology:Morphine|morphine]] in genetically engineered [[Biology:Yeast|yeast]].<ref>{{cite magazine|url=https://www.newscientist.com/article/dn27546-home-brew-heroin-soon-anyone-will-be-able-to-make-illegal-drugs/|title=Home-brew heroin: soon anyone will be able to make illegal drugs|magazine=New Scientist| vauthors = Le Page M |date=18 May 2015|url-status=live|archive-url=https://web.archive.org/web/20160413033207/https://www.newscientist.com/article/dn27546-home-brew-heroin-soon-anyone-will-be-able-to-make-illegal-drugs/|archive-date=13 April 2016}}</ref> In June 2015 the ''S''-reticuline could be produced from sugar and ''R''-reticuline could be converted to morphine, but the intermediate reaction could not be performed.<ref>{{cite journal|url=https://www.science.org/content/article/final-step-sugar-morphine-conversion-deciphered|title=Final step in sugar-to-morphine conversion deciphered|journal=Science| vauthors = Service RF |date=25 June 2015|url-status=live|archive-url=https://web.archive.org/web/20150821122148/http://news.sciencemag.org/biology/2015/06/final-step-sugar-morphine-conversion-deciphered|archive-date=21 August 2015}}</ref>

==See also==
<!-- alphabetical order please WP:SEEALSO -->
<!-- please add a short description WP:SEEALSO, via {{subst:AnnotatedListOfLinks}} or {{Annotated link}} -->
{{div col|colwidth=20em|small=yes}}
* {{Annotated link |Allegations of CIA drug trafficking}}
* {{Annotated link |Cheese (recreational drug)}}
* {{Annotated link |The Politics of Heroin in Southeast Asia|''The Politics of Heroin in Southeast Asia''}}
{{div col end}}
<!-- alphabetical order please WP:SEEALSO -->

==References==
{{Reflist}}

==External links==
{{Commons|Heroin}}
*{{Curlie|Health/Addictions/Substance_Abuse/Drugs/Opiates/}}
* [https://web.archive.org/web/20110806073908/http://www.nida.nih.gov/Infofacts/heroin.html NIDA InfoFacts on Heroin]
* [http://www.whitehousedrugpolicy.gov/drugfact/heroin/ ONDCP Drug Facts]
* [http://druginfo.nlm.nih.gov/drugportal/dpdirect.jsp?name=Heroin U.S. National Library of Medicine: Drug Information Portal – Heroin]
* [http://news.bbc.co.uk/1/hi/magazine/4647018.stm BBC Article entitled 'When Heroin Was Legal'. References to the United Kingdom and the United States]
* [https://purl.fdlp.gov/GPO/gpo57130 Drug-poisoning Deaths Involving Heroin: United States, 2000–2013] U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.
* [https://fas.org/sgp/crs/misc/R44599.pdf Heroin Trafficking in the United States] (2016) by Kristin Finklea, [[Social:Congressional Research Service|Congressional Research Service]].

{{Analgesics}}
{{Euphoriants}}
{{Opioid receptor modulators}}
{{Drug use}}

[[Category:Acetate esters]]
[[Category:4,5-Epoxymorphinans]]
[[Category:Euphoriants]]
[[Category:Mu-opioid receptor agonists]]
[[Category:Nephrotoxins]]
[[Category:Opioids]]
[[Category:Phenol ethers]]
[[Category:Prodrugs]]
[[Category:Semisynthetic opioids]]
[[Category:Wikipedia medicine articles ready to translate]]

{{Sourceattribution|Heroin}}