Heroin is an illegal drug, categorized as a Schedule I controlled substance by the Drug Enforcement Administration (DEA). This means it has no recognized medical use in the United States and it is considered to be highly dangerous.

Heroin is extracted from the opium poppy plant, which is indigenous to South America, Mexico, and Southeast Asia. It is sold on the streets as a white powder, brown powder, or in “black tar” form.

Part of what makes the drug so dangerous is the fact that you never know exactly what is in the drug since it is not regulated in any way and is sold through the black market after being processed in illicit laboratories. During processing, heroin is often “cut” with other substances to stretch the product out and make it go further. By doing this, those who sell heroin can get more bang for their buck since individual buyers often can’t tell the difference.

The San Diego Union-Tribune publishes that heroin purity in the United States fluctuates between about 20 percent and 40 percent on average, meaning that the majority of the product being passed off as heroin actually isn’t. Combining it with other products and drugs raises the risk for dangerous and unpredictable side effects, including a potentially life-threatening overdose. The U.S. Department of Health and Human Services (HHS) reports that in 2016 over 15,000 Americans lost their lives to an overdose.

Common Heroin Cutting Agents

Heroin is commonly cut with the following substances:

  • Sugar
  • Starch
  • Baking soda
  • Talcum powder
  • Laundry detergent
  • Powdered milk
  • Quinine
  • Rat poison
  • Caffeine

Many of these additives are similar in color and texture to the white powder form of heroin, so they can be used to make the finished product appear larger in quantity. Some of these cutting agents can make the drug even more dangerous, however. For example, quinine mixed with heroin can cause blindness, and the stimulant caffeine can mask the depressant effects and increase the risk of overdose. Heroin is also being cut with other drugs, including prescription opioids, over-the-counter (OTC) pain relievers like acetaminophen, and OTC antihistamines containing diphenhydramine.

The Office of National Drug Control Policy (ONDCP) warns that the emergence of fentanyl, a synthetic opioid that can be manufactured in clandestine laboratories, is driving up the number of opioid overdose deaths in recent years. Fentanyl is 50 to 100 times more potent than morphine, the National Institute on Drug Abuse (NIDA) publishes, and it is regularly being added to heroin, often without the knowledge of the person taking the drug.

Carfentanil is another synthetic opioid that is showing up laced into heroin as well, and it is even 100 times more powerful than fentanyl. It is an elephant tranquilizer that can also be made inexpensively in underground labs and then used to cut and stretch heroin, TIME warns.

Prescription Opioids and Over-The-Counter Painkillers

Due to the tighter regulation of prescription opioid painkillers like OxyContin (oxycodone) and Vicodin (hydrocodone/acetaminophen), heroin is typically cheaper and easier to get on the street. That being said, it is still cut with prescription opioids. The reverse is also true; prescription pain relievers are being laced or cut with heroin and then pressed into counterfeit pills to be passed off as the real thing. The danger is that once again, a person may not realize that the drug they are taking actually contains heroin, which is a more powerful opiate than most prescription strength painkillers.

Opioid overdose deaths are at epidemic levels. The U.S. Centers for Disease Control and Prevention (CDC) reports that between 1999 and 2016 over 350,000 people died from an opioid overdose. The risk for overdose goes up when opioid drugs are mixed.

Opiates like heroin are central nervous system depressants, which means that they slow down breathing and heart rate while also lowering body temperature and blood pressure. An opioid overdose usually results in a person having trouble breathing or not being able to breathe at all. Other signs of an opioid overdose include:

  • Mental confusion
  • Sluggishness
  • Loss of balance and coordination skills
  • Cold, clammy skin
  • Pinpoint pupils
  • Trouble staying awake or loss of consciousness
  • Bluish color on the skin, lips, or nails

Heroin is also cut with OTC medications like Tylenol PM, which contains both acetaminophen and the antihistamine diphenhydramine. This “cheese” is made from black tar Mexican heroin, which is then cut with an OTC sleep aid like Tylenol PM; this is ground up to resemble grated, tan-colored cheese. Cheese heroin is cheap and often snorted through a straw or ballpoint pen. CNN warns that this mixture of drugs can be deadly as both heroin and diphenhydramine are depressant substances that can stop your heart and breathing.

What is Fentanyl?

Fentanyl is a synthetic opioid, meaning that it is manufactured in a lab and it is cheap and easy to make. This makes it an ideal agent for cutting drugs, such as heroin.

Fentanyl can be deadly in as little as 2 milligrams, the DEA, warns and it can be absorbed through the skin on contact. This means that all a person has to do is touch fentanyl to be affected by it.

National overdose death rates involving synthetic opioids like fentanyl have more than tripled between 2013 and 2015, the CDC reports, and the number of drug submissions that have tested positive for fentanyl has skyrocketed in many states. Overdose deaths involving synthetic opioids other than methadone jumped 100 percent from 2015 to 2016, as nearly 20,000 Americans died from a synthetic opioid overdose, the CDC publishes.

Fentanyl is the driving force behind these rising numbers. While it is a prescription opioid that has medical use as a pain reliever, it is also being manufactured covertly and illegally for distribution. Fentanyl-containing heroin is often called “China white.”

When fentanyl is added to heroin, it elevates the overdose risk exponentially. Opioid drugs bind to opiate receptors in the brain. This blocks pain receptors and depresses the central nervous system, which is responsible for autonomic functions, such as body temperature regulation, heart rate, respiration, and blood pressure. Opioids also cause a flood of dopamine in the brain. Dopamine is one of the brain’s chemical messengers that helps to regulate emotions, and high levels of this neurotransmitter are what produces the euphoric rush.

Heroin is a fast-acting and powerful opiate that crosses the blood-brain barrier pretty rapidly, causing a rapid and short-lasting high. Fentanyl is even more potent than heroin; thus, a smaller amount of the drug can have similar and more intense effects.

The Washington Post warns that synthetic opioids like fentanyl can also be resistant to the opioid antagonist drug Narcan (naloxone) that is generally used to reverse an opioid overdose. It may take several doses of Narcan to overturn a heroin/fentanyl overdose, and this can be even more challenging if the person is unaware that fentanyl is involved. Fentanyl is similar in appearance to heroin; therefore, it can be difficult to know if the product actually contains fentanyl or not.

Why is Carfentanil so Dangerous?

“Though carfentanil is an analog of fentanyl, it is even more dangerous and powerful than fentanyl, making it even more hazardous when it is mixed into heroin. Since it is used to sedate large animals, it can be deadly in as little as a few granules, similar in size to a couple grains of salt.  ”

Like fentanyl, it can be made illicitly in a lab and then added to heroin without a person’s knowledge, exponentially increasing the risk of a fatal overdose. It can also be difficult to differentiate carfentanil-laced drugs from pure heroin.

How to Spot Laced Heroin and What to do

Side effects like nausea, confusion, drowsiness, dizziness, vomiting, breathing difficulties, and sedation can be indicators of heroin that is laced with fentanyl or other powerful opioids. Oftentimes, when it is laced with these more powerful opioids will take effect sooner and have a greater impact.

There are some characteristics of purer powder heroin.

  • Shiny appearance
  • Bitter taste
  • Pure white color
  • Possible vinegar smell from being washed during processing

When it is more dull in color and sweeter in taste it’s likely less pure and cut with something other than heroin. Just eyeballing a heroin product may not be enough, however, as many of the agents used to cut the drug are so close in appearance. Since fentanyl can also give someone a “contact high” just by touching it, the drug can be dangerous to handle as well.

There are test strips on the market that can help individuals detect the presence of fentanyl. NPR reports that a needle exchange program in Boston is handing them out in an attempt to reduce unintentional overdose deaths.

It can be next to impossible to be sure that heroin is pure, however. There is always a risk associated with taking an unregulated and illegal street drug.

If someone suspects that they have taken or come into contact with a laced product, immediate medical attention is needed. Tell first responders that the heroin may have been laced, so they know that additional doses of Narcan may be necessary to reverse the overdose.

If you or a loved one has been abusing heroin or any other substance, remember that help is always available. Call The Palm Beach Institute immediately or contact us online to speak to an addiction specialist who can give you the care you deserve.

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