Heroin is a white or brown powder or a black, sticky goo. It's an opioid drug made from morphine, a natural substance in the seedpod of the Asian poppy plant. It can be mixed with water and injected with a needle. Heroin can also be smoked or snorted up the nose. All of these ways of taking heroin send it to the brain very quickly. This makes it very addictive.

Major health problems from heroin include miscarriages, heart infections, and death from overdose. People who inject the drug also risk getting infectious diseases, including HIV/AIDS and hepatitis.

Regular use of heroin can lead to tolerance. This means users need more and more drug to have the same effect. At higher doses over time, the body becomes dependent on heroin. If dependent users stop heroin, they have withdrawal symptoms. These symptoms include restlessness, muscle and bone pain, diarrhea and vomiting, and cold flashes with goose bumps.

Over 19% of all opioid overdose deaths in 2020 involved heroin. Not only are people using heroin, but they are also using multiple other substances, including cocaine and prescription opioids. Nearly all people who use heroin also use at least one other drug.

However, from 2019 to 2020, the heroin-involved overdose death rate decreased by nearly 7%. Factors that may contribute to the decrease in heroin-involved deaths include fewer people initiating heroin use, shifts from a heroin-based market to a fentanyl-based market, increased treatment provision for people using heroin, and expansion of naloxone access.

How is heroin harmful?

• Heroin is an illegal, highly addictive opioid drug.
• A heroin overdose can cause slow and shallow breathing, coma, and death.
• People often use heroin along with other drugs or alcohol. This practice is especially dangerous because it increases the risk of overdose.
• Heroin is typically injected but is also smoked and snorted. When people inject heroin, they are at risk of serious, long-term viral infections such as HIV, Hepatitis C, and Hepatitis B, as well as bacterial infections of the skin, bloodstream, and heart.

What is it?

An opiate (narcotic) drug processed from morphine and extracted from certain poppy plants. Heroin comes in a white or brownish powder, or a black sticky substance known as “black tar heroin.” Often “cut” with other drugs or substances such as sugar or powdered milk. User is unaware how much actual heroin is being used, creating likelihood of overdose.

Street Names

Big H, Black Tar, Chiva, Hell Dust, Horse, Negra, Smack, Thunder


How is it used?

Injected, smoked, or sniffed/snorted. High purity heroin is usually snorted or smoked.

Paraphernalia

How does it affect the body?

• Highly addictive.
• Initial surge of euphoria or “rush,” followed by a twilight state of sleep and wakefulness
• Physical symptoms of use include: drowsiness, respiratory depression, constricted pupils, nausea, a warm flushing of the skin, dry mouth, and heavy extremities.
• Overdose symptoms: slow and shallow breathing, blue lips and fingernails, clammy skin, convulsions, coma, and possible death.

Heroin is an illegal, highly addictive drug processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. It is typically sold as a white or brownish powder that is "cut" with sugars, starch, powdered milk, or quinine. Pure heroin is a white powder with a bitter taste that predominantly originates in South America and, to a lesser extent, from Southeast Asia, and dominates U.S. markets east of the Mississippi River. 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. "Black tar" heroin is sticky like roofing tar or hard like coal and is predominantly produced in Mexico and sold in U.S. areas west of the Mississippi River. The dark color associated with black tar heroin results from crude processing methods that leave behind impurities. Impure heroin is usually dissolved, diluted, and injected into veins, muscles, or under the skin.

All data refer to the United States population.

How many people use heroin?

• Among people aged 12 or older in 2020, 0.3% (or about 902,000 people) reported using heroin in the past 12 months.
  Source: 2020 National Survey on Drug Use and Health

How many young students use heroin?

• In 2021, an estimated 0.2% of 8 graders, 0.1% of 10 graders, and 0.1% of 12 graders reported using heroin in the past 12 months.
  Source: 2021 Monitoring the Future Survey

How many people have a heroin use disorder?

• Among people aged 12 or older in 2020, an estimated 0.2% (or about 691,000 people) had a heroin use disorder in the past 12 months.
  Source: 2020 National Survey on Drug Use and Health

How many people die from heroin overdose?

• In 2020, approximately 13,165 people died from an overdose involving heroin. Learn more about overdose death rates.
  Source: CDC WONDER Database

The greatest increase in heroin use is seen in young adults aged 18-25.

Heroin binds to and activates specific receptors in the brain called mu-opioid receptors (MORs). Our bodies contain naturally occurring chemicals called neurotransmitters that bind to these receptors throughout the brain and body to regulate pain, hormone release, and feelings of well-being. When MORs are activated in the reward center of the brain, they stimulate the release of the neurotransmitter dopamine, causing a reinforcement of drug taking behavior. The consequences of activating opioid receptors with externally administered opioids such as heroin (versus naturally occurring chemicals within our bodies) depend on a variety of factors: how much is used, where in the brain or body it binds, how strongly it binds and for how long, how quickly it gets there, and what happens afterward.

Once heroin enters the brain, it is converted to morphine and binds rapidly to opioid receptors. People who use heroin typically report feeling a surge of pleasurable sensation—a "rush." The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the opioid receptors. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities. Nausea, 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 brain damage.

Opioids Act on Many Places in the Brain and Nervous System

• Opioids can depress breathing by changing neurochemical activity in the brain stem, where automatic body functions such as breathing and heart rate are controlled.
• Opioids can reinforce drug taking behavior by altering activity in the limbic system, which controls emotions.
• Opioids can block pain messages transmitted through the spinal cord from the body.

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, 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 physical dependence, the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced abruptly.

Withdrawal may occur within a few hours after the last time the drug is taken. Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps ("cold turkey"), and leg movements. Major withdrawal symptoms peak between 24–48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Finally, repeated heroin use often results in heroin use disorder—a chronic relapsing disease that goes beyond physical dependence and is characterized by uncontrollable drug-seeking, no matter the consequences. Heroin is extremely addictive no matter how it is administered, although routes of administration that allow it to reach the brain the fastest (i.e., injection and smoking) increase the risk of developing heroin use disorder. Once a person has heroin use disorder, seeking and using the drug becomes their primary purpose in life.

Harmful health consequences resulting from the misuse of opioid medications that are prescribed for the treatment of pain have dramatically increased in recent years. For example, almost half of all opioid deaths in the U.S. now involve a prescription opioid. People often assume prescription pain relievers are safer than illicit drugs because they are medically prescribed; however, when these drugs are taken for reasons or in ways or amounts not intended by a doctor, or taken by someone other than the person for whom they are prescribed, they can result in severe adverse health effects including substance use disorder, overdose, and death, especially when combined with other drugs or alcohol. Research now suggests that misuse of these medications may actually open the door to heroin use. Some also report switching to heroin because it is cheaper and easier to obtain than prescription opioids.

No matter how they ingest the drug, chronic heroin users experience a variety of medical complications, including insomnia and constipation. Lung complications (including various types of pneumonia and tuberculosis) may result from the poor health of the user as well as from heroin’s effect of depressing respiration. Many experience mental disorders, such as depression and antisocial personality disorder. Men often experience sexual dysfunction and women’s menstrual cycles often become irregular. There are also specific consequences associated with different routes of administration. For example, people who repeatedly snort heroin can damage the mucosal tissues in their noses as well as perforate the nasal septum (the tissue that separates the nasal passages).

Medical consequences of chronic injection use include scarred and/or collapsed veins, bacterial infections of the blood vessels and heart valves, abscesses (boils), and other soft-tissue infections. Many of the additives in street heroin may include substances that do not readily dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in vital organs. Immune reactions to these or other contaminants can cause arthritis or other rheumatologic problems.

Sharing of injection equipment or fluids can lead to some of the most severe consequences of heroin use—infections with hepatitis B and C, HIV, and a host of other blood-borne viruses, which drug users can then pass on to their sexual partners and children.

Heroin use increases the risk of being exposed to HIV, viral hepatitis, and other infectious agents through contact with infected blood or body fluids (e.g., semen, saliva) that results from the sharing of syringes and injection paraphernalia that have been used by infected individuals or through unprotected sexual contact with an infected person. Snorting or smoking does not eliminate the risk of infectious disease like hepatitis and HIV/AIDS because people under the influence of drugs still engage in risky sexual and other behaviors that can expose them to these diseases.

People who inject drugs (PWIDs) are the highest-risk group for acquiring hepatitis C (HCV) infection and continue to drive the escalating HCV epidemic: Each PWID infected with HCV is likely to infect 20 other people. Of the 30,500 new HCV infections occurring in the United States in 2014, most cases occurred among PWID.

Hepatitis B (HBV) infection in PWIDs was reported to be as high as 25 percent in the United States in 2014, which is particularly disheartening since an effective vaccine that protects against HBV infection is available. There is currently no vaccine available to protect against HCV infection.

Drug use, viral hepatitis and other infectious diseases, mental illnesses, social dysfunctions, and stigma are often co-occurring conditions that affect one another, creating more complex health challenges that require comprehensive treatment plans tailored to meet all of a patient’s needs. For example, NIDA-funded research has found that substance use disorder treatment, along with HIV prevention and community-based outreach programs, can help people who use drugs change the behaviors that put them at risk for contracting HIV and other infectious diseases. They can reduce drug use and drug-related risk behaviors such as needle sharing and unsafe sexual practices and, in turn, reduce the risk of exposure to HIV/AIDS and other infectious diseases.

Heroin use during pregnancy can result in neonatal abstinence syndrome (NAS). NAS occurs when heroin passes through the placenta to the fetus during pregnancy, causing the baby to become dependent, along with the mother. Symptoms include excessive crying, fever, irritability, seizures, slow weight gain, tremors, diarrhea, vomiting, and possibly death. NAS requires hospitalization and treatment with medication (often morphine) to relieve symptoms; the medication is gradually tapered off until the baby adjusts to being opioid-free. Methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the outcomes associated with untreated heroin use for both the infant and mother, although infants exposed to methadone during pregnancy typically require treatment for NAS as well.

A NIDA-supported clinical trial demonstrated that buprenorphine treatment of opioid-dependent mothers is safe for both the unborn child and the mother. Once born, these infants require less morphine and shorter hospital stays compared to infants born of mothers on methadone maintenance treatment. Research also indicates that buprenorphine combined with naloxone (compared to a morphine taper) is equally safe for treating babies born with NAS, further reducing side effects experienced by infants born to opioid-dependent mothers. A NIDA-funded study found that treating NAS babies with sublingual buprenorphine resulted in a shorter duration of treatment than oral morphine, and also resulted in a shorter length of hospital stay, with similar rates of adverse events.

Mothers' Buprenorphine Treatment During Pregnancy Benefits Infants

Overdose is a dangerous and deadly consequence of heroin use. A large dose of heroin depresses heart rate and breathing to such an extent that a user cannot survive without medical help. Naloxone (e.g., Narcan, Kloxxado) is an opioid receptor antagonist medication that can eliminate all signs of opioid intoxication to reverse an opioid overdose. It works by rapidly binding to opioid receptors, preventing heroin from activating them. Because of the huge increase in overdose deaths from prescription opioid misuse, there has been greater demand for opioid overdose prevention services. Naloxone that can be used by nonmedical personnel has been shown to be cost-effective and save lives. In April 2015, the U.S. Food and Drug Administration (FDA) approved a Narcan nasal spray that is sprayed directly into one nostril. In 2021, the FDA approved a higher dose naloxone nasal spray—KLOXXADO. Since Narcan and Kloxxado can be used by family members or caregivers, it greatly expands access to naloxone.

In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) continually updates its Opioid Overdose Prevention Toolkit that provides helpful information necessary to develop policies and practices to prevent opioid-related overdoses and deaths. The kit provides material tailored for first responders, treatment providers, and individuals recovering from an opioid overdose.

A variety of effective treatments are available for heroin use disorder, including both behavioral and pharmacological (medications). Both approaches help to restore a degree of normalcy to brain function and behavior, resulting in increased employment rates and lower risk of HIV and other diseases and criminal behavior. Although behavioral and pharmacologic treatments can be extremely useful when utilized alone, research shows that for many people, integrating both types of treatments is the most effective approach.

Pharmacological Treatment (Medications)

Scientific research has established that pharmacological treatment of opioid use disorder increases retention in treatment programs and decreases drug use, infectious disease transmission, and criminal activity.

When people addicted to opioids like heroin first quit, they undergo withdrawal symptoms (pain, diarrhea, nausea, and vomiting), which may be severe. Medications can be helpful in this detoxification stage to ease craving and other physical symptoms that can often prompt a person to relapse. The FDA approved lofexidine, a non-opioid medicine designed to reduce opioid withdrawal symptoms. While not a treatment for addiction itself, detoxification is a useful first step when it is followed by some form of evidence-based treatment.

Medications developed to treat opioid use disorders work through the same opioid receptors as the addictive drug, but are safer and less likely to produce the harmful behaviors that characterize a substance use disorder. Three types of medications include: (1) agonists, which activate opioid receptors; (2) partial agonists, which also activate opioid receptors but produce a smaller response; and (3) antagonists, which block the receptor and interfere with the rewarding effects of opioids. A particular medication is used based on a patient’s specific medical needs and other factors. Effective medications include:

• Methadone (Dolophine or Methadose) is a slow-acting opioid agonist. Methadone is taken orally so that it reaches the brain slowly, dampening the "high" that occurs with other routes of administration while preventing withdrawal symptoms. Methadone has been used since the 1960s to treat heroin use disorder and is still an excellent treatment option, particularly for patients who do not respond well to other medications. Methadone is only available through approved outpatient treatment programs, where it is dispensed to patients on a daily basis.
• Buprenorphine (Subutex) is a partial opioid agonist. Buprenorphine relieves drug cravings without producing the "high" or dangerous side effects of other opioids. Suboxone is a novel formulation of buprenorphine that is taken orally or sublingually and contains naloxone (an opioid antagonist) to prevent attempts to get high by injecting the medication. If a person with a heroin use disorder were to inject Suboxone, the naloxone would induce withdrawal symptoms, which are averted when taken orally as prescribed. FDA approved buprenorphine in 2002, making it the first medication eligible to be prescribed by certified physicians through the Drug Addiction Treatment Act. This approval eliminates the need to visit specialized treatment clinics, thereby expanding access to treatment for many who need it. Additionally, the Comprehensive Addiction and Recovery Act (CARA), which was signed into law in July 2016, temporarily expands prescribing eligibility to prescribe buprenorphine-based drugs for medication-assisted treatment to qualifying nurse practitioners and physician assistant through October 1, 2021. In February 2013, FDA approved two generic forms of Suboxone, making this treatment option more affordable. The FDA approved a 6-month subdermal buprenorphine implant in May 2016 and a once-monthly buprenorphine injection in November 2017, which eliminates the treatment barrier of daily dosing.
• Naltrexone (Vivitrol)is an opioid antagonist. Naltrexone blocks the action of opioids, is not addictive or sedating, and does not result in physical dependence; however, patients often have trouble complying with the treatment, and this has limited its effectiveness. In 2010, the injectable long-acting formulation of naltrexone (Vivitrol) received FDA approval for a new indication for the prevention of relapse to opioid dependence following opioid detoxification. Administered once a month, Vivitrol may improve compliance by eliminating the need for daily dosing.

Behavioral Therapies

The many effective behavioral treatments available for opioid use disorder can be delivered in outpatient and residential settings. Approaches such as contingency management and cognitive-behavioral therapy have been shown to effectively treat heroin use disorder, especially when applied in concert with medications. Contingency management uses a voucher-based system in which patients earn "points" based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitive-behavioral therapy is designed to help modify the patient’s expectations and behaviors related to drug use and to increase skills in coping with various life stressors. An important task is to match the best treatment approach to meet the particular needs of the patient.

What is heroin?

Heroin is an opioid drug made from morphine, a natural substance taken from the seed pod of the various opium poppy plants grown in Southeast and Southwest Asia, Mexico, and Colombia. Heroin can be a white or brown powder, or a black sticky substance known as black tar heroin.

How do people use heroin?

People inject, sniff, snort, or smoke heroin. Some people mix heroin with crack cocaine, a practice called speedballing.

What are the effects of heroin?

Heroin enters the brain rapidly and binds to opioid receptors on cells located in many areas, especially those involved in feelings of pain and pleasure and in controlling heart rate, sleeping, and breathing.

Prescription Opioids and Heroin

Prescription opioid pain medicines such as OxyContin and Vicodin have effects similar to heroin. Research suggests that misuse of these drugs may open the door to heroin use. Data from 2011 showed that an estimated 4 to 6 percent who misuse prescription opioids switch to heroin and about 80 percent of people who used heroin first misused prescription opioids. More recent data suggest that heroin is frequently the first opioid people use. In a study of those entering treatment for opioid use disorder, approximately one-third reported heroin as the first opioid they used regularly to get high.

This suggests that prescription opioid misuse is just one factor leading to heroin use. Read more about this intertwined problem in our Prescription Opioids and Heroin Research Report.

Short-Term Effects

People who use heroin report feeling a "rush" (a surge of pleasure, or euphoria). However, there are other common effects, including:

• dry mouth
• warm flushing of the skin
• heavy feeling in the arms and legs
• nausea and vomiting
• severe itching
• clouded mental functioning
• going "on the nod," a back-and-forth state of being conscious and semiconscious

Long-Term Effects

Injection Drug Use, HIV, and Hepatitis

People who inject drugs such as heroin are at high risk of contracting the HIV and hepatitis C (HCV) virus. These diseases are transmitted through contact with blood or other bodily fluids, which can occur when sharing needles or other injection drug use equipment. HCV is the most common bloodborne infection in the Unites States. HIV (and less often HCV) can also be contracted during unprotected sex, which drug use makes more likely.

Read more about the connection between heroin and these diseases in our Heroin Research Report.

People who use heroin over the long term may develop:

• insomnia
• collapsed veins for people who inject the drug
• damaged tissue inside the nose for people who sniff or snort it
• infection of the heart lining and valves
• abscesses (swollen tissue filled with pus)
• constipation and stomach cramping
• liver and kidney disease
• lung complications, including pneumonia
• mental disorders such as depression and antisocial personality disorder
• sexual dysfunction for men
• irregular menstrual cycles for women

Other Potential Effects

Heroin often contains additives, such as sugar, starch, or powdered milk, that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage. Also, sharing drug injection equipment and having impaired judgment from drug use can increase the risk of contracting infectious diseases such as HIV and hepatitis (see "Injection Drug Use, HIV, and Hepatitis").

Can a person overdose on heroin?

Yes, a person can overdose on heroin. A heroin overdose occurs when a person uses enough of the drug to produce a life-threatening reaction or death. Heroin overdoses have increased in recent years.

When people overdose on heroin, their breathing often slows or stops. This can decrease the amount of oxygen that reaches the brain, a condition called hypoxia. Hypoxia can have short- and long-term mental effects and effects on the nervous system, including coma and permanent brain damage.

How can a heroin overdose be treated?

Naloxone is a medicine that can treat an opioid overdose when given right away. It works by rapidly binding to opioid receptors and blocking the effects of heroin and other opioid drugs. Sometimes more than one dose may be needed to help a person start breathing again, which is why it’s important to get the person to an emergency department or a doctor to receive additional support if needed. Read more in the Substance Abuse and Mental Health Services Administration’s Opioid Overdose Prevention Toolkit.

Naloxone is available as an injectable (needle) solution and nasal sprays (NARCAN Nasal Spray and KLOXXADO). Friends, family, and others in the community can use the nasal spray versions of naloxone to save someone who is overdosing.

The rising number of opioid overdose deaths has led to an increase in public health efforts to make naloxone available to at-risk persons and their families, as well as first responders and others in the community. Some states have passed laws that allow pharmacists to dispense naloxone without a prescription from a person’s personal doctor.

Is heroin addictive?

Heroin is highly addictive. People who regularly use heroin often develop a tolerance, which means that they need higher and/or more frequent doses of the drug to get the desired effects. A substance use disorder (SUD) is when continued use of the drug causes issues, such as health problems and failure to meet responsibilities at work, school, or home. An SUD can range from mild to severe, the most severe form being addiction.

Those who are addicted to heroin and stop using the drug abruptly may have severe withdrawal. Withdrawal symptoms—which can begin as early as a few hours after the drug was last taken—include:

• restlessness
• severe muscle and bone pain
• sleep problems
• diarrhea and vomiting
• cold flashes with goose bumps ("cold turkey")
• uncontrollable leg movements ("kicking the habit")
• severe heroin cravings

Researchers are studying the long-term effects of opioid addiction on the brain. Studies have shown some loss of the brain’s white matter associated with heroin use, which may affect decision-making, behavior control, and responses to stressful situations.

How is heroin addiction treated?

A range of treatments including medicines and behavioral therapies are effective in helping people stop heroin use. It’s important to match the best treatment approach to meet the particular needs of each individual patient.

There are medicines being developed to help with the withdrawal process. The FDA approved lofexidine, a non-opioid medicine designed to reduce opioid withdrawal symptoms.

Medicines to help people stop using heroin include buprenorphine and methadone. They work by binding to the same opioid receptors in the brain as heroin, but more weakly, reducing cravings and withdrawal symptoms. Another treatment is naltrexone, which blocks opioid receptors and prevents opioid drugs from having an effect. A NIDA study found that once treatment is initiated, both a buprenorphine/naloxone combination and an extended release naltrexone formulation are similarly effective in addiction. Because full detoxification is necessary for treatment with naloxone, initiating treatment among active users was difficult, but once detoxification was complete, both medications had similar effectiveness.

Behavioral therapies for heroin addiction include methods called cognitive-behavioral therapy and contingency management. Cognitive-behavioral therapy helps modify the patient’s drug-use expectations and behaviors, and helps effectively manage triggers and stress. Contingency management provides motivational incentives, such as vouchers or small cash rewards for positive behaviors such as staying drug-free. These behavioral treatment approaches are especially effective when used along with medicines. Read more about drug addiction treatment in our Treatment Approaches for Drug Addiction DrugFacts.

Points to Remember

• Heroin is an opioid drug made from morphine, a natural substance taken from the seed pod of various opium poppy plants.
• Heroin can be a white or brown powder, or a black sticky substance known as black tar heroin.
• People inject, sniff, snort, or smoke heroin. Some people mix heroin with crack cocaine, called speedballing.
• Heroin enters the brain rapidly and binds to opioid receptors on cells located in many areas, especially those involved in feelings of pain and pleasure and in controlling heart rate, sleeping, and breathing.
• People who use heroin report feeling a "rush" (or euphoria). Other common effects include dry mouth, heavy feelings in the arms and legs, and clouded mental functioning.
• Long-term effects may include collapsed veins, infection of the heart lining and valves, abscesses, and lung complications.
• Research suggests that misuse of prescription opioid pain medicine is a risk factor for starting heroin use.
• A person can overdose on heroin. Naloxone is a medicine that can treat a heroin overdose when given right away, though more than one dose may be needed.
• Heroin can lead to addiction, a form of substance use disorder. Withdrawal symptoms include severe muscle and bone pain, sleep problems, diarrhea and vomiting, and severe heroin cravings.
• A range of treatments including medicines and behavioral therapies are effective in helping people stop heroin use. However, treatment plans should be individualized to meet the needs of the patient.