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Why Is Heroin So Deadly Today?

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For more than a century, heroin has been a dangerous drug of abuse. For years, people have been attracted to the substance’s ability to produce a relatively inexpensive, rapid-onset, and intensely euphoric high 1,2. While the drug’s high holds a strong appeal for its users, chronic heroin abuse is almost certain to have several physical or mental health repercussions in those who become addicted to it.

Aside from the damage incurred from repeated use, it’s important to know that any time you use heroin, you risk your life. This statement has never been more true, as the drug is becoming increasingly adulterated by other, powerful narcotics that make deadly overdose an all-too-common occurrence.

The New Face of Heroin

The dangers of heroin use are not new, but over the last few years, there has been a shift. Different people are using heroin, and the drug itself is changing. According to the Centers for Disease Control and Prevention (CDC), the number of people addicted to heroin doubled from 2002 to 2013. Most notably, use has increased significantly throughout many demographics, including women and those with higher incomes 3.

The increasing prevalence of heroin use has been accompanied by alarmingly high rates of severe or fatal overdose in recent years. In fact, the number of overdoses skyrocketed between 2010 and 2015 4. The comparison is shocking—fewer than 4,000 people died from a heroin overdose in 2010, but by 2015, the drug was responsible for killing nearly 13,000 people in the U.S. alone 1,4.

While the surge in heroin use across most demographics explains some of the increased number of overdose deaths, it doesn’t account for them all. In reality, the change in heroin itself (or rather, the drugs being sold as or combined with it) is a key reason for the alarming rise in deaths attributed to this substance.

Prior to being sold on the street, pure heroin has frequently been mixed with other substances with the goal of producing larger amounts of the product or producing a stronger high 1,2,5. Prior to being sold on the illicit market, it was frequently mixed other substances with the goal of increasing end-product amount and therefore profit. To achieve this, the drug was mixed with sugars, powdered milk, starches, quinine, or other bulking agents. Now, however, the emphasis has shifted to creating a more powerful product to more thoroughly ensnare repeat business from addicted individuals. To this end, heroin has, more recently, been ‘cut’ or ‘laced’ with dangerous substances that can introduce their own hazards that range from severe illness to irreversible overdose 1,2.

Why “Heroin” Isn’t As Simple As Before

Silhouette of sad woman heroin addict

With these other substances being combined with the drug, heroin really isn’t just the one drug anymore, and users cannot count on any one batch being the same as the last. So, a user who has developed an increased tolerance to the drug may think they’ll be fine getting a dose equal to or similar to their normal dose, but because of ever-changing ingredients and potencies, they could experience an immediate overdose and die.

A bag full of whitish powder can contain any number of harmful drugs and chemicals. At times, the mixture may contain no heroin at all.

Currently, many of the substances mixed with heroin fit into the category of synthetic opioids. These drugs work similarly in the body to produce the same kind of high, but they are often much more potent and can lead to a treacherous slowing of several physiological processes such as breathing. Some of these substances are used for medical reasons while others are not approved for human consumption at any time 5.

Drugs commonly mixed with it include:

  • Fentanyl.
  • Carfentanil.
  • Xylazine.
  • U-47700 (commonly called “Pink”).


Fentanyl is a manufactured opioid drug available with a prescription and used in the treatment of severe pain such as that which is related to cancer 6. Fentanyl is up to 100 times more potent than morphine and up to 50 times stronger than heroin 5,6. Due to the difference in strength, fentanyl can have a higher risk of fatality compared to heroin. Someone ingesting only 2 milligrams of fentanyl can experience a deadly overdose 5. Fentanyl is so potent that a normal, appropriate dose for someone with a medical need is a mere microgram (equivalent to a few granules of table salt) 5.

Fentanyl is sometimes sought after by people seeking an intense high and sometimes is sold in or as heroin to unsuspecting buyers. Either way, its presence on the street is unprecedented. From 2013 to 2014, the amount of fentanyl acquired by law enforcement increased by about 3.5 times 7. Most of this is illicitly manufactured fentanyl or non-pharmaceutical fentanyl 8, which is produced in clandestine labs and distributed illegally. In 2013, about 550 people died from fentanyl overdoses. Only one year later, that number rose above 2,000 6.

The presence of fentanyl-laced heroin appears to be concentrated in certain regions and is associated with a string of deaths in the Northeast, Midwest, and Southeast U.S 8. This may be due to fentanyl mixing easily into the powder form of heroin that is more commonly seen in these regions vs. the ‘black tar’ form often found on the West Coast.


Like fentanyl, carfentanil is a synthetic opioid substance. While chemically similar to fentanyl, carfentanil is much more potent—fentanyl is strong, but carfentanil is 100 times stronger. When compared to morphine, it is an astounding 10,000 times more potent 7. Carfentanil is so strong that it is used to tranquilize large animals (particularly elephants) 5.

The amount needed to cause a lethal overdose in humans is not known, but even insignificant amounts can be harmful based on the drug’s strength. The DEA encourages all people to be cautious of exposure to carfentanil 5. One exposure to even a tiny amount of carfentanil through the skin or by inhalation may be fatal 5.

Carfentanil led to several overdose deaths in Ohio during the second half of 2016 8.   The substance is expected to appear in more areas throughout the country in the future 8.   Since the drug is a white powder, it may be easily disguised in a batch of heroin or cocaine 5,8.


A particularly deadly combination of opioids has been seen in certain states such as Georgia and Ohio. This drug, called “gray death,” looks like concrete and combines powerful opioids to create a frighteningly potent mix.

The exact mixture varies with batches but it commonly includes heroin, fentanyl, carfentanil, and “pink”. It is inexpensive ($10-$20) and can cause a deadly overdose within seconds.

“Pink” is the name used to refer to the substance U-47700 9. The nickname for the substance comes from its slight pinkish color.

This product is illegal in the U.S., as it currently has no approved medical use 9. Though not intended for human consumption, the drug is purchased over the internet as a “research chemical” and is abused for its desirable opioid-like effects.

The substance is encountered on the streets as a powder in envelopes or plastic bags. It may be found alone or in combination with other drugs like heroin and fentanyl 9. In some cases, it is sold in bags with logos that make it look like heroin.

To date, a limited number of studies have revealed little about U-47700’s potency or toxic impact, apart from its powerful potential to produce overdose 9. Pink is associated with at least 15 overdose deaths across 5 states in 2015 and 2016 9. North Carolina felt the biggest impact, with 10 of the 15 deaths occurring in that state alone 9.


Unlike fentanyl, carfentanil, and “Pink,” xylazine is not a synthetic opioid. Instead, it is an adrenergic receptor antagonist similar to clonidine. It is used in veterinary medicine as an analgesic, sedative anesthetic, and muscle relaxant 10. Xylazine may be an effective horse tranquilizer, but it is not approved for use by humans. On the streets, xylazine is sometimes mixed directly in with it and sometimes sold to users with heroin separately (in a different package) as a modifier to enhance its effects 10.

To this point, xylazine abuse has been observed mainly in Puerto Rico; however, there have been reports of the substance in other locations including Pennsylvania 10 and it may continue to spread as dealers look for ways to increase profits and buyers search for new ways to enhance their highs.

Overdose: Easier to Do and Harder to Reverse

Overdose from heroin can happen to any user at any time during any use of the drug. Whether it is their first use or the person has a long history with the drug, the next hit could be the last. As an illicit substance, there is no way for a person to know with certainty what they are getting and how strong it is 11.

A person who has repeatedly abused heroin or other opioids will develop a tolerance, meaning they will come to need increasing amounts of the substance to feel the wanted effects 1. Should a person, even one with a high tolerance, unknowingly use from a batch laced with fentanyl or another potent adulterant, the combination of substances could easily overwhelm their body because it is so much stronger than normal heroin.

Using a large amount of heroin or using it combined with a stronger substance increases the high but also the potential to experience dangerous physical side effects. Opioids and other depressants severely impact breathing and in the case of overdose, breathing could become dangerously slowed or stopped completely 1.

How long does it take to die from a heroin overdose?

Based on reports from law enforcement and active users, an overdose can begin immediately after the drug enters the body 5,10,12.  In the past, an overdose could take more than 10 minutes to fully develop, with symptoms progressing along the way, but when other substances are involved, overdose can occur instantly 12.

Other signs and symptoms of overdose include 11:

  • Dry mouth.
  • Tiny pupils.
  • Disorientation.
  • Drowsiness.
  • Delirium.
  • Weak pulse and low blood pressure.
  • Blue lips and fingernails.
  • Loss of consciousness.
  • Coma.

Abuse of even more potent drugs like fentanyl and carfentanil increase the likelihood of opioid overdose.

Perhaps the best tool used in managing overdose is naloxone (Narcan). Administered via an injectable solution, a nasal spray, or an autoinjector pen, this substance is an opioid antagonist that displaces and blocks the heroin from the opioid receptors to reverse symptoms and prevent overdose death 1,8,11.

Unfortunately, synthetic opioids and other drugs mixed with heroin make it more difficult to reverse an overdose with this drug. An overdose involving adulterated heroin may require multiple doses of the antidote to be effective, but medical/law enforcement professionals, friends, and family members may not have the knowledge or the supply of the medication to properly treat an overdose of this type 5,8,9.

Think It’s Just Heroin? Pills are Deadlier Too

Addict looking down at deadly heroin pills in hands

People may view prescription painkillers as a safer alternative to heroin, but the risks associated with abusing these substances is also increasing due to the emergence of counterfeit pills on the streets 13. Illicit labs located overseas will produce high volumes of fentanyl and other synthetic opioids and sell the product to drug traffickers in North America 13. From there, the substance may be mixed into heroin or formed into pills that closely resemble legitimate prescription drugs 13.

In early 2016, officers in Ohio seized 500 synthetic pills that mimicked a 30 mg oxycodone prescription. Instead of oxycodone, though, the pills contained “Pink” 13. Any drug purchased on the street or through an unregulated online pharmacy could be counterfeit or laced with unknown substances. It is best to avoid these completely or risk overdose and death. The availability of synthetic opioids like fentanyl and “Pink” has resulted in higher opioid overdose deaths. The number of people killed from synthetic opioids increased by almost 80% from 2013 to 2014, according to the Drug Enforcement Administration 13.

Need Help for Addiction?

Heroin addiction is a serious problem that destroys the lives of those addicted to it. There is good news, though. Professional heroin addiction treatment is helpful in reducing cravings, improving well-being, and setting the stage for long-term recovery 14. Treatment can consist of various stages that promote recovery like 14:

  • Supervised detoxification—This is the initial segment of treatment in which the individual can safely process the substance from their body in a supervised, supportive environment while receiving medical attention, when needed.
  • Inpatient/residential treatment—For people with significant addictions and limited supports, inpatient and residential treatments allow the person to escape from their negative habits and routines by living in the treatment center. Treatment and supervision will be intense, with a focus on therapy and life skills training.
  • Outpatient assistance and care—Less intense than inpatient care, outpatient programs allow the individual to receive treatment while living at home and maintaining their responsibilities. During outpatient therapy, the addict can attend individual, group, or family therapy sessions to learn how to prevent relapse and extend recovery.
  • Prescribed medication—Various forms of medication-assisted treatments are available to reduce discomfort and encourage abstinence. Some medications will block the effects of opioids like heroin to deter continued abuse, and others will help to manage withdrawal and cravings by eliciting similar opioid effects in a safe, controlled way.

Using drugs from sources on the street or on the internet is not safe, and the danger is growing each day. Seek treatment before you fall victim to these insidious substances that are spreading across the country. If you are ready to commit to recovery before it is too late, call to speak to a treatment representative about available options today.

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Senior Medical Editor
Dr. Thomas received his medical degree from the University of California, San Diego School of Medicine. During his medical studies, Dr. Thomas saw firsthand the multitude of lives impacted by struggles with substance abuse and addiction, motivating him to seek a clinical psychiatry preceptorship at the San Diego VA Hospital’s Inpatient Alcohol and Drug Treatment Program. In his post-graduate clinical work, Dr. Thomas later applied the tenets he learned to help guide his therapeutic approach with many patients in need of substance treatment. In his current capacity as Senior Medical Editor for American Addiction Centers, Dr. Thomas, works to provide accurate, authoritative information to those seeking help for substance abuse and behavioral health issues.
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