How Can You Tell If Someone Is Using Heroin?

heroin injection into arm

“How long does it take to get physically addicted to heroin?” reads the query on the Web forum Bluelight. “I’ve been smoking on and off every other day … the last 3 days I’ve smoked throughout the day.”

The answer from an enlightened member is blunt:

It’s been known that people get addicted to heroin after just a couple times … it will literally take your soul, steal your personality and leave you in the most brutal place known to man. Also, about the time you think you’re starting to get addicted, it will be way too late. Eventually, you will become a slave to heroin.”

Heroin is one of the most addictive drugs, and just one use can create dependence. The U.S. is mired in an opioid addiction epidemic, yet 80% of people who are dependent on opioids such as heroin or prescription painkillers don’t receive treatment. What’s more, the number of deaths caused by heroin overdose has tripled since 2010 to 10,574 in 2014, according to the Centers for Disease Control and Prevention.

The prescription opioid and heroin crises overlap, but it is heroin market forces — including the increased availability of pure and cheap heroin — that appear to be the major drivers of the recent surge in heroin use and overdose deaths, according to Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse and the lead author of a new review article published in the New England Journal of Medicine. Young adults often turn to the drug as a salve for childhood trauma. The CDC-Kaiser Permanente Adverse Childhood Experiences Study (ACE Study) — which has been replicated by 29 states — has found a strong connection between emotional, physical or sexual abuse suffered in childhood and all types of addiction.

Dr. Michael Wilkes, a professor of medicine at UC Davis who treats addicts on Saturdays at a free clinic, says only a very small percentage of young people try heroin without having experienced trauma.

“Sit with me for an afternoon and talk with these people and ask them about that first instant when they used heroin,” Wilkes said. “I can’t think of a single case ever where someone was having fun and decided to shoot heroin. Someone had just raped them, their parents had died — it was never someone who was choosing this because they were looking for a good time.”

A shot of heroin washes away all of those bad feelings in seconds. A sense of euphoria sets it. Users describe a feeling of warmth and safety. They feel heavy, calm. All is right with the world. But the high is short-lived and when addicts come down, their problems are still there waiting for them — until the next use. And when the pleasure of the initial rush doesn’t repeat itself, the never-ending chase ensues.

The good news is that opioid dependence can be effectively treated — but part of the problem is recognizing the symptoms of abuse. People on heroin may think slowly and might move slowly. They’ll feel sleepy, like they’re in a dream. Here are some additional side effects of heroin use to watch for if you fear a loved one or friend is using the drug:

Physical Signs of Heroin Addiction

  • Cravings
  • Feeling disoriented
  • Hyperactivity
  • Fatigue
  • Slow breathing
  • Weight loss
  • Track marks on arms or legs
  • Itching
  • Constant runny nose
  • Headache
  • Dry mouth

What Does Heroin Look Like?

Heroin can be injected, smoked or snorted. It may be a white or brown powder, black and sticky tarlike substance or hard black rock. Depending on the method of use, you could find remnants of the drug or the paraphernalia left behind. Here’s what to look for:

  • Needles
  • Burned spoons
  • Aluminum foil or aluminum gum wrappers with burn marks
  • Missing shoelaces, belts or rubbing tubing (used as tie-offs for injecting)
  • Cut up drinking straws with burn marks
  • Lighters
  • Cotton balls (used as filters for injecting)
  • Water pipe or other pipe

Symptoms of Heroin Withdrawal

People who are trying to quit taking heroin will experience physical withdrawal symptoms that typically start within eight to 12 hours of last use. Early withdrawal symptoms from heroin include anxiety and agitation, insomnia, increased tearing, sweating and yawning. Later symptoms of withdrawal can last up to a week and include abdominal cramps, diarrhea, dilated pupils, cold flashes with goosebumps, nausea and vomiting.

Heroin Overdose

Signs of a heroin overdose include slow and difficult breathing, extremely small pupils, sometimes as small as the head of a pin (“pinpoint pupils”), blue lips and fingernails, cold clammy skin, weak pulse and shaking. If a drug user does not respond when you talk to them, is snoring loudly or making gurgling noises, don’t assume that they are just “sleeping off” the drug’s effects. Call 911 immediately for help. Heroin overdoses can be reversed with the opioid antidote naloxone (Narcan), which can buy the addict time until paramedics arrive. The drug comes in the form of a nasal spray that can be administered by family and friends and is available without a prescription in pharmacies in many states.

Treatment Options for Heroin Addiction

Most people cannot quit using on their own. Research indicates that participation in treatment, whether inpatient or outpatient, can help even the most severely addicted individuals. Drug addiction treatment typically includes a combination of behavioral therapy and medications such as buprenorphine and naltrexone that weans patients off heroin and are far safer to use. Behavioral approaches such as contingency management, which uses a voucher-based system that rewards patients for negative drug tests, and cognitive behavioral therapy, which teaches patients to recognize and avoid destructive thoughts and behaviors, have proven effective in treating heroin addiction.

If you are seeing signs of heroin use in a friend or family member, don’t wait and hope things will get better. “Even near-death experiences aren’t enough to get them to quit a habit that is causing them, from their perspective, more benefit than risk,” UC Davis’ Wilkes said.

A substance abuse professional, mental health professional, physician, employee assistance professional or a member of the clergy can help arrange treatment. Don’t wait for an addict to hit bottom. People die before they hit a bottom. Do everything you can to get them help.

By Laura Nott


Driven by Prescription Drug Abuse, Heroin Use Increases Among Suburban and Rural Whites. JAMA. 2014;312(2):118-119. doi:10.1001/jama.2014.7404.

Buprenorphine Treatment for Hospitalized, Opioid-Dependent Patients: A Randomized Clinical Trial. JAMA. 2014;174(8):1369-1376. doi:10.1001/jamainternmed.2014.2556.

Relationship Between Nonmedical Prescription-Opioid Use and Heroin Use. Wilson M. Compton, M.D., M.P.E., Christopher M. Jones, Pharm.D., M.P.H., and Grant T. Baldwin, Ph.D., M.P.H. N Engl J Med 2016; 374:154-163 January 14, 2016DOI: 10.1056/NEJMra1508490

CVS Adds NY to List of States It Will Sell Anti-Opioid Overdose Drug Naloxone. National pain report, Jan. 20, 2016




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