The most feared, the most dreaded, the "hardest" drug (Kaplan, 1983)—for decades, heroin has virtually defined the drug problem. In spite of being somewhat overshadowed, since the mid-1980s, by cocaine, heroin is still the substance the American public is most likely to point to as an example of a dangerous drug; disapproval of any level of use is higher for heroin than it is for any other drug; opposition to legalization is higher for heroin than it is for any other drug; and heroin addicts are the most stigmatized of all drug users. Heroin is the epitome of the illicit street drug. Its association in the public mind with street crime, even today, in spite of strong competition from crack, is stronger than for any other drug. The stereotype of the "junkie" is that he or she is by nature a lowlife, an outcast, a dweller in the underworld, an unsavory, untrustworthy character to be avoided at almost any cost. This fact alone makes heroin an immensely fascinating drug to study.

Heroin is chemically derived from morphine; in volume, five units of morphine produce one of heroin. Morphine is in turn extracted from opium. which is roughly 10 percent morphine by weight. Opium is grown in and imported mainly from Southeast Asia, Afghanistan, Pakistan, Iran, the Middle East, and Mexico. All the various alkaloid products of opium are called opiates, and they include, aside from opium itself, morphine, heroin, codeine, Dilaudid (a semisynthetic derivative of opium), laudanum (a 10 percent tincture of opium), and paregoric (a 4 percent tincture of opium). There are also a number of synthetic narcotics with many of the same effects as heroin, usually called opioids, which include Demerol (meperidine), Dolophine (methadone), Percodan, and Darvon. In addition, there are the newer "designer" narcotics, including fentanyl, whose potency in some cases, is far greater than heroin's.

The term "narcotic" is often used loosely and incorrectly to refer to any illegal drug. A newspaper headline, for instance, might read, "Police Nab Suspect, Confiscate Narcotics Stash" to refer to cocaine, marijuana, or illegal prescription drugs. Properly speaking, however, narcotics are painkillers or analgesics. (It could be that one feels pain under the influence, but is unconcerned about it.) These drugs tend, in fact, to reduce sensory feeling and sensitivity of all kinds—to pleasure as well as pain. A second characteristic of narcotics is that they tend to be soporific—that is, in sufficiently large doses, they induce drowsiness, mental clouding, lethargy, even sleep. (Morphine is named after Morpheus, the Greek god of dreams, and the scientific name for the opium poppy is Papaver somniferum, named for its quality of inducing somnolence.) As analgesics, narcotics are without peer, and are therefore of immense therapeutic value.

But they are also, without exception, physically addicting—a third characteristic of the narcotics. In the terms we introduced in Chapter 2, they generate a physical dependence. They are also highly reinforcing—that is, they generate a very strong psychic or psychological dependence, possibly second only to that of the stimulants. And they are capable of generating an overwhelming behavioral dependence. (However, the belief "One shot and you're hooked for life" is completely false; of the total universe of all people who have tried heroin, most are or were experimenters, and there are far more sporadic or infrequent heroin users than addicts.)

And fourth, narcotics generate euphoria—after the IV injection of a narcotic, the user feels a "flash," a "rush," an intense voluptuous, orgasmlike sensation. Following this is the feeling of well-being, tranquility, ease, and calm, the sensation that everything in the user's life is just fine. Tensions, worries, problems, the rough edges of life, seem simply to melt away. Few drugs or drug types generate this feeling of well-being as effectively as narcotics, and of the more commonly used narcotics, heroin seems to do the job best of all.

There are a number of painkillers that are not classified as narcotics— aspirin is the best-known; they do not produce mental clouding or dependence, and are far safer in terms of overdosing. Still, as we saw in Chapter 4, thousands of Americans overdose on aspirin each year; in 1986, there were 5,500 nonlethal emergency-room episodes in the United States associated with aspirin. At the same time, on a user-for-user, dose-for-dose basis, the non-narcotic analgesics are relatively safe; the narcotics, clearly dangerous.

One thing that makes heroin and the other narcotics dangerous is that ihe range between their effective dose (ED) and lethal dose (LD) is fairly narrow; the quantity that can kill a user is only ten to fifteen times the amount that can get him or her high. Thus it is extremely easy to die of an erdose of any of the narcotics, especially heroin. Although the mechanism tf death by narcotics overdose is not completely understood —the adulterants mixed with heroin and/or the other drugs used in conjunction with it, possibly alcohol, may contribute—still, taking huge doses of a narcotic is an almost certain way to kill oneself. As with alcohol and barbiturates, an overdose of heroin causes respiratory paralysis, resulting in oxygen starvation of the brain.

It is remarkable that heroin is such a well-known and almost universally dreaded drug, since it attracts far fewer users than almost any other illegal drug or drug type. The small number of heavy heroin users that we do have inflict a great deal of damage on the rest of society—and, in turn, the rest of society inflicts a great deal of damage on them.

In the high-school survey I've so often cited, heroin ranks dead last in popularity among all drugs asked about, with the next least-used drug PCP) used by four times as many individuals as heroin. In this survey, marijuana was used by almost fifty times as many high-school seniors as heroin was. In 1986, only 1.1 percent of these high-school seniors had even tried heroin; 0.5 percent had used it at least once in the past year; and 0.2 percent used it within the past month. These numbers represent a decline from 1975, when the comparable figures were 2.2, 1.0, and 0.4 percent respectively. The figures for college students were significantly below those for the high-school seniors.

In the national household survey, about 1 percent of all Americans had tried heroin at least once in their lives—less than 0.5 percent for youths age 12 to 17; 1.2 percent for young adults age 18 to 25; and 1.1 percent for adults age 26 and over. Less than 0.5 of youth and older adults had used it in the past year; 0.6 percent of 18- to 25-year-olds had done so. Of all individuals who had used at least one illegal drug once or more in their lives, fewer than 3 percent had tried or used heroin (NIDA, 1986). A fraction of 1 percent of all episodes of illegal drug use involved heroin. Clearly, then, heroin is one of the least widely used of all the well-known drugs or drug types.

At the same time, heroin shows up with remarkable frequency in the available abuse statistics. According to the Drug Awareness Warning Network (DAWN) statistics, in 1986, nearly 18 percent of all emergency-room episodes entailed the use of heroin, and, in a whopping 30 percent of all lethal drug overdoses, heroin was involved . As we saw, not every time a drug is mentioned or reported in DAWN's figures is it the causal mechanism in the overdose. Nonetheless, when a given drug shows up frequently in overdose episodes, it can be presumed to play a significant role in lethal or life-threatening reactions. Given how infrequently heroin is used in comparison with all other drugs, its contribution to nonlethal and especially lethal overdoses is nothing short of spectacular.

Heroin is not the only narcotic that is used for recreational or nonmedical purposes. In the survey of high-school seniors cited above, all the other narcotics, added together, were used by ten times as many respondents as heroin was. In its national survey, the National Institute on Drug Abuse (NIDA) estimated that, while 1.9 million Americans had used heroin at least once during their life, 12.6 million had used one or more of the "analgesics" for nonmedical purposes. Thus the narcotics aside from heroin—Darvon. Percodan, methadone, Dilaudid, codeine, and Demerol—make up a major type of illicit drug, used outside a medical context by roughly as mam Americans as are stimulants (not counting cocaine), tranquilizers, sedatives. hallucinogens, or inhalants. (Opium, a major narcotic, is not widely used in the United States; and DAWN counts another narcotic, morphine, as belonging to the same category as heroin, since heroin breaks down to morphine once it enters the body.) At the same time, among users of narcotics. heroin is the drug of choice. Street addicts will ingest any narcotic that is available at a particular time; while heroin is preferred, at some times, in some of the nation's smaller cities, or in certain neighborhoods, or in some social circles, it may not be as readily available as some of the other narcotics, such as codeine, Dilaudid, Percodan, or Darvon. Consequently, these drugs will be used until heroin becomes available.

In 1986, there were about 25,000 mentions of narcotics in nonlethal emergency-room overdoses; more than 15,000 of these involved heroin or morphine. There were roughly 2,500 lethal drug overdoses with one or more narcotics implicated reported by medical examiners; more than 1,500 of these entailed heroin or morphine. Thus, while all the narcotics other than heroin attract 90 percent of the users of narcotics, and heroin only 10 percent, heroin contributes to more than 60 percent of the lethal and nonlethal narcotics overdoses. Once again, we must be impressed with heroin's massive contribution to harmful drug effects, even among the narcotics.

Heroin's role in the number of both nonlethal and lethal overdoses is growing over time. In fact, from 1979-1980 to 1986, the number of emergency-room episodes involving heroin doubled (from 7,784 to 15,832) and the number of medical examiner's reports more than tripled (474 to 1,549). As we know from our discussion of DAWN data in Chapter 4, an increase in overdoses over time could involve a number of factors—an increase in the purity of the drug, an increase in the frequency of use among the same number of users, a greater tendency for users to take that drug in combination with other drugs, and its use by means of more potentially lethal routes of administration (injecting, for instance, instead of snorting). It is entirely possible that, as both lethal and nonlethal heroin overdoses increase, the number of heroin users is actually declining. There are three indications that this might in fact be the case.

To begin with, none of the indicators in the available national surveys has demonstrated an increase in heroin use in the past few years; if anything, most of these indicators are down. Second, as we noted in the discussion on cocaine (in Chapter 8), recruitment of young heroin addicts seems to be slowing down, at least in New York City, possibly as a result of their use of crack instead of heroin.

And third, the potency of street heroin has been increasing dramatically. For decades, the heroin available at the retail or user level has been 3 to 5 percent pure, with the rest made up of adulterants and fillers, such as mannitol, lactose, and quinine. In 1986, though, the New York City police were confiscating heroin with a purity of 30 to 70 percent. Much of this is "China White" heroin—derived from opium grown in Southeast Asia, and imported from Hong Kong by ethnic Chinese.

Chinese gangs have been getting into heroin importation in a big way, at least on the East coast, only in the last few years. (In fact, heroin is now being smuggled into the United States by gangs with a wide variety of national and ethnic backgrounds; they include—aside from Chinese—Thais, Pakistanis, Indians, Iranians, Afghans, Nigerians, Lebanese, and Israelis; see Kessler, 1985; Kerr, 1987b.) Inciardi says that a substance found on the streets of Miami in 1980 called China White was not in fact this "mythical strain of heroin." However, the New York City police claim that what they are seeing invading the streets of New York in the late 1980s is, in fact, remarkably pure heroin from Hong Kong. In 1983, only 3 percent of the heroin confiscated on the streets of New York was "China White"; in 1986, 40 percent of it was; and in 1987, police estimate, this had reached 70 percent. In addition, between 1983 and 1986, a new strain of Mexican heroin, called "black tar," with a purity of 60 to 70 percent, showed up with great frequency across the country (Brinkley, 1986). And third, a synthetic "designer drug," a narcotic called fentanyl, with a potency of twenty to forty times that of heroin, began to appear on the street all over the country, especially California; it is especially frequently used by physicians (Gallagher, 1986a).1 Many observers believe that the purity of today's street heroin is as high as it is in pan to attract a dwindling clientele who are moving away from heroin to other drugs, especially cocaine.