Heroin dependence

Heroin is a highly addictive drug, made from morphine and other chemicals. Morphine comes from a flower called the opium poppy. Drugs that come from opium act on nerve receptors in the body called opioid receptors.

Drugs that come from opium are called opiates, and include heroin, morphine and codeine.

Synthetic drugs called opioids can have similar affects to opiates. These include pethidine, methadone, fentanyl, oxycodone and hydrocodone.

All of these drugs can cause changes in mood, including:

• intense euphoria (happiness)
• sleepiness
• emotional numbing.

Opioids can also be used to treat pain.

Heroin is classified as a Class A drug under the Misuse of Drugs Act 1971. This means it is illegal to produce, sell or possess heroin.

Heroin can be taken in several different ways. It can be heated on foil and smoked, mixed with water and injected, or snorted.

Heroin dependence, also called heroin addiction, is a substance use disorder that can develop after repeatedly using heroin.

If you are heroin dependent, you will have a strong desire to take more of the drug, and difficulty controlling how much you use. You might:

• continue to use heroin, despite it having harmful consequences
• prioritise using heroin over doing other things
• become gradually more tolerant to higher doses of the drug
• experience withdrawal symptoms when you stop taking it

In a recent survey of a sample of people in England and Wales, 0.1% of adults aged 16 to 59 took heroin in 2018. Another survey showed there were over 260,000 people who have been using heroin for a long time in England in 2018/19.

The overall number of heroin users in the UK has remained relatively stable over the last 10 years. However, the number of people using heroin for the first time has fallen, particularly among people under 30.

In the UK, there are a lot of middle-aged or older people who are heroin dependent. Many of these people started using heroin in the 1980s and 1990s, and still use it today. As someone who uses heroin gets older, their risk of physical health problems increases.

Heroin dependence can affect anyone, but many of the people who use heroin live in more deprived areas. People with poorer general health, and people who have had family members with substance dependence issues are more likely to become dependent on heroin.

There are many risks associated with heroin use. These include:

• Physical health problems – For example, infections at the places where heroin is being injected into the body, and abscesses.
• Blood-borne viruses – For example, HIV or hepatitis. These viruses can be caused by sharing needles or other equipment.
• Overdose – There is always a risk of overdose when someone uses heroin, especially if they also use other drugs at the same time. Overdose can lead to death.
• Longer-term health problems – For example, undiagnosed health problems, poor nutrition and dental problems. These could be caused by a lack of self-care, a reluctance to use health services due to stigma and a fear of legal repercussions, or other things that stop people from getting care when they need it.
• Mental health problems – There are higher rates of mental health problems in people who use heroin. This could be because heroin causes people to develop mental health problems or because it makes existing mental health problems worse. Or it could be that people use heroin to ‘self-medicate’ mental health problems they already have.
• Social problems – Unemployment, homelessness, financial difficulties or getting into trouble with the law are also more common in people who use heroin.

People who have complex needs are less likely to complete treatment for heroin dependence. Because of this, addressing these needs is crucial to recovery. Complex needs can include things like:

• housing and homelessness
• financial difficulties
• difficulties with reading and writing
• other physical or mental health conditions

People who are dependent on heroin are ten times more likely to die earlier than the general population. Heroin-related deaths in the UK have more than doubled since 2012.

If you don’t get treatment for heroin dependence, as well as the above risks, your chances of stopping and no longer using heroin can be very low. People who are given treatment can go in and out of it for some time before becoming drug-free. Heroin dependence is often a long-term challenge.

There are several treatments and therapies used to treat heroin dependence.

Opioid Substitution Therapy (OST)

Opioid Substitution Therapy (OST), also known as Opioid Assisted Treatment (OAT), involves replacing heroin with a safer, prescribed opioid drug. If these drugs are taken at the right doses alongside social and psychological treatments, they can reduce heroin use and the risks associated with it.

If you are starting OST, you will usually need to have an assessment and discussion with a specialist addictions service. It is unusual for OST to be started by your GP.

You will work with the addictions service and agree on when you will attend regular reviews. These reviews will be an opportunity for you to be monitored while you are taking OST. You will be able to talk to your addictions team about which OST is right for you.

Methadone

Methadone is a liquid or tablet that affects the same opioid receptors as heroin and reduces your cravings for heroin. If you are given methadone, you will be started on a low dose. This will be increased depending on how much you need to reduce your cravings. It will be given to you at a pharmacy, and you will be supervised while you take it. This will usually be daily until you are considered to be stable. When you are stable, you may be allowed to take some of your doses at home.

Buprenorphine

Buprenorphine works on the same receptors as methadone and heroin, but in a different way. Buprenorphine comes in a few different forms:

• Subutex and Suboxone – these are tablets that you put under your tongue until they dissolve
• Espranor – this is a tablet that dissolves on top of your tongue.

Buprenorphine tablets will be given to you at a pharmacy, usually by a community pharmacist, and you will be supervised while you take them.

Buprenorphine can also be given as an injection (called Buvidal), which has a much longer lasting effect. This means that instead of having to attend a pharmacy every day, you can be given it once a week or once a month.

Suboxone

Suboxone is a tablet that has been designed to reduce the risk of people intentionally misusing it. It contains a combination of buprenorphine and naloxone. Naloxone blocks the effects of opioids like heroin, and is designed to bring on withdrawal symptoms if the drug is misused.

Naltrexone

Naltrexone is another drug that can be used to treat heroin dependence. It blocks the effects of opioids, and can be used to help you to stay off heroin.

Treatment with medical heroin (diamorphine)                                    

Some areas of the UK have heroin-assisted treatment (HAT) programmes. In these programmes, doctors can prescribe medical heroin, called diamorphine.

If given in a strictly controlled setting, treatment with diamorphine has been shown to reduce heroin use. It has also been shown to help people who have not benefitted from other OSTs to stay in treatment.

If you are prescribed diamorphine, you will usually inject it more than once a day and be supervised while you take it. Staff are there to offer you support, and medical help is available in the event of an overdose.

Psychological and social treatments

A number of psychological and social treatments are usually offered alongside treatment with medication. Different treatments may be offered at different stages of your recovery.

An important part of treatment for heroin dependence is having a positive relationship with a keyworker. They can help you to develop a flexible, individual care plan that meets your needs. This might include:

• Motivational enhancement therapy – This is a counselling approach that can help you to improve your motivation to change.
• Contingency management therapy – This offers incentives and rewards to encourage positive behaviours.
• Relapse prevention therapy – This can help you to identify what might cause you to relapse, and develop strategies for preventing or managing situations that may lead to relapse.
• Harm reduction advice – This can help you reduce the harm to yourself if you are still taking drugs.
• Anxiety management
• Support to attend mutual aid meetings and recovery meetings, in person or online.
• Support to get suitable housing, benefits, employment or vocational training.

Self-help, mutual aid (including 12-step programmes such as Narcotics Anonymous (NA)) and SMART recovery groups (which use principles based on cognitive behavioural therapy) can help you in your recovery. Addiction services can help to signpost you to your local peer support organisations.

When you have just started OST there are risks. Both methadone and buprenorphine need to be started at a low dose and increased carefully to a dose that helps to reduce drug use. People often need support during this time to deal with withdrawal symptoms and drug cravings.

There is an increased risk of overdose during the first weeks of treatment if you continue to use heroin or other drugs at the same time as OST.

Once you have been on OST for a while and have stopped using other drugs, your risk of overdose will reduce. If you used to inject heroin, your risk of contracting a blood-borne virus will also reduce as you stop using or sharing drugs with others.

There is evidence that there is a higher risk of fatal overdose in the first weeks of taking methadone, compared to buprenorphine. However, there is also evidence that people who take methadone are more likely to stay in treatment. Currently, there isn’t enough evidence to recommend one OST over another.

This table lists some of the advantages and disadvantages of methadone and buprenorphine.

Note: table adapted from Choice and Medication

Detoxification, also known as detox or managed withdrawal, is where someone stops using heroin or OST. You can detox as an inpatient or an outpatient. This decision will depend on:

• your needs
• what is available in your area
• how quickly you want to stop
• your personal plan for staying in recovery

Detoxing from heroin

You might be encouraged to detox from heroin if you have been using heroin for a short time. If you are detoxing from heroin, there are some medications that you can take to help with symptoms of withdrawal. These include lofexidine, buscopan, loperamide and diazepam.

The symptoms of heroin withdrawal include:

• feeling hot and cold
• shivering and sweating
• feeling extremely tired
• feeling restless
• having a runny nose
• feelings anxious and depressed
• painful muscles and joints
• diarrhoea
• vomiting
• muscle spasms
• craving heroin

Detoxing from OST

You might choose to detox from OST after you have been taking the treatment for a while and are stable. Detox from OST usually happens by gradually reducing the dose of your medication.

All options for treating heroin dependence come with some risks. When someone detoxes, there is always a risk that they will start taking heroin again, and that this will lead to an overdose. This is because the body’s tolerance to heroin will be reduced. However, for those who stay in treatment programmes, risk of overdose or death from any cause is reduced.

If you aren’t ready, feel unable or don’t want to have treatment for heroin dependence, there are a number of ways you can still reduce the potential harm from injecting or smoking heroin.

Needle exchange

At needle exchanges it is possible to exchange used needles for clean needles. This reduces the risk of blood-borne viruses, injection-site abscesses and injury to others from discarded needles. Needle exchange programmes can also offer clean foil, which can reduce damage to the lungs from smoking heroin.

Needle exchange services are available across the UK. In some areas they are in community pharmacies, in others they are provided by drug outreach services. Search online for services in your area, or speak to your GP or local addictions service to find out more.

Naloxone for opiate overdose

Naloxone is an emergency antidote to opiate overdose. It blocks opioid receptors and can reverse the life-threatening effects of overdose such as slow breathing. It is injected directly into the body, and anyone who has been shown how can give this treatment to someone else. If you are likely to witness an overdose, you might choose to have access to a naloxone kit. For example, if you are a friend or family member of someone who is using heroin, this might be recommended to you.

Drug consumption rooms (also known as overdose prevention centres) aim to reduce the harm associated with drug use by allowing people to use their own heroin or other illicit drugs in a monitored space. They have been established in other countries and have been shown to be effective in reducing harm related to drug use. There is currently only one drug consumption room available in the UK, in Glasgow.

Studies from other countries have shown that drug consumption rooms are used by high-risk drug users, and can potentially reduce harm. This includes reducing the risk of death from accidental overdose. When someone visits a drug consumption room they will be encouraged to get treatment for drug dependence and to access other health and social services.

If you are worried that you are unable to stop using heroin, or are having health problems related to heroin use, speak to your GP or your local addictions service. They can help to refer you to the right services.

There is a lot of information available on the internet. However, some of it is wrong or out of date. Here are some good places to get high-quality information:

• Heroin addition: get help, NHS – find out more about your local drug treatment service and getting help from your GP if you are addicted to heroin.
• Support for recreational drug and alcohol problems, Mind – this information looks at where to find support if you have a drug or alcohol problem.
• UKNA – this website offers information about NA meetings and events in the UK, and information on other services
• SMART Recovery – this charity offers a national network of mutual-aid meetings and online training to help people abstain from addictive behaviours and support sustained recovery.
• Talk to Frank – this website offers honest, clear information about drugs, as well as help and advice on addiction.
• Drug Wise – this website offers information on different drugs

Regional support

Below are links to websites that can direct you to support in your area:

• England
• Northern Ireland
• Scotland
• Wales
  

Information for families

If you are worried about a partner, friend or family member using drugs, here are some places you can get help:

• NHS, advice for families of people who use drugs – This information from the NHS for families and friends of people who are using or trying to come off drugs.
• Adfam – an organisation that offers support to friends and family of people who use alcohol and drugs. Helpline: 0207 4984 680
• Scottish Families Affected by Alcohol and Drugs – a charity offering support to families in Scotland affected by alcohol and drugs.
• DrugFam - phone and email support to people affected by other people’s drug or alcohol misuse. Helpline: 0300 888 3853
• Release - the national centre of expertise on drugs and drugs law, offering free, confidential advice on drugs law for people who use drugs, and their families. Helpline: 020 7324 2989

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

Expert authors: Dr Zarah Fleming and Dr Donna Mullen

Full references available on request.