There is nothing new about heroin: What has changed is the way that we consume, dispense and talk about it. Despite the rising rate of opioid abuse and overdose in this country, we continue to mischaracterize heroin, thereby neglecting to understand the indelible hold it has on users. Here’s an attempt to clear up some of the most common misconceptions.

Heroin Isn’t Always White Powder

Heroin generally comes in three different forms in the United States: powder heroin – which falls into two subcategories, brown and off-white – tar heroin and heroin pills. Historically, the Mississippi River has been the line of demarcation between the tar and powder markets. Off-white powder heroin, which originates in Southeast and Southwest Asia, is generally considered the most desirable kind. Powder, with its origins in Mexico, often carries a deeper, browner hue, and is usually less powerful. On the West Coast, heroin comes almost exclusively from Mexico and South America and is most often sold in tar form; little balls of goo that look like black earwax. The third, least common form of heroin is “pill” form. “Pills” refer to heroin often sold in gel capsules and mixed with other powders – be it cocaine, methamphetamine or the more common heroin adulterants like powdered lactose, quinine and baby laxative. Pills are usually the cheapest and lowest-quality form of the drug.

What Might Look Like an Opioid High Is Actually the Symptoms of Withdrawal
Outsiders often confuse withdrawal symptoms for the effects of the drug, because the effects of withdrawal are far more noticeable than the euphoria the drug produces. Dilated pupils, sweating, shaking, slurring and vomiting aren’t signs of being high; they’re signs of opioid withdrawal. Quitting heroin is often called “kicking” in reference to the tendency to kick out one’s legs in attempt to stretch away the discomfort.

The War on Drugs Expanded the Ways People Use Heroin – and Set the Stage for the Opioid Crisis
In the Sixties and Seventies, just about all heroin addicts were intravenous users, but as the purity of the drug increased, so did potential methods for use.

During the 1960s, heroin use rose, in part, due to soldiers returning from Vietnam who were exposed to the drug overseas, and drug dealers in urban centers seized on this opportunity. Then, in the summer of 1969, when Nixon declared his war on drugs, he cited New York City’s heroin trade as the core of the problem. The speech apparently roused the NYPD, who proceeded to arrest some of the city’s biggest dealers.

Meanwhile, suppliers in Asia became concerned that they would lose their distribution. In response, they began setting up their own networks in America’s cities to establish a more discrete trade. Heroin sold in the U.S. saw a bump in purity around this time as a result of this more direct supply line. However, purity levels would soon skyrocket as the heroin market was about to become competitive.

Though Nixon targeted heroin in his speech, in practice the drug war mainly targeted toward marijuana.

With cocaine, heroin and marijuana all categorized as Schedule I drugs, DEA agents opted to pursue the smelliest, bulkiest and most conspicuous of those three substances.

Colombian and Mexican drug cartels, who had previously trafficked mainly in marijuana, switched to a product that was less noticeable and carried more value by weight. Ironically, it was the drug war itself that pushed the cartels into the heroin business.

Additionally, in the Eighties, crack appeared almost overnight – and authorities suddenly deprioritized heroin. Meanwhile, as a result of the tenfold rise in heroin purity between 1970 and 1990, nasal administration became a viable option for users. Mexican and Colombian cartels introduced the drug to suppliers and users who previously had only dealt with cocaine. The new, more socially acceptable method of use endeared the drug to an entirely new demographic of trendy, wealthy and often white cocaine users.

The demographic that had previously been most afflicted by heroin addiction took a deliberate step away from the drug. In low-income urban centers, the fallout of the 1970s heroin explosion became a cautionary tale. A generation came up witnessing the long-term effects of the drug, which had hardly existed as a threat in rural and suburban America. “Young African Americans and young Latinos were not going into heroin because they saw the destruction that occurred in their families and in their neighborhoods and they didn’t want to go down that road,” says Philippe Bourgois, a cultural anthropologist and author of the book Righteous Dope Fiend. “It was seen as a loserly thing to do.”

Meanwhile, he says, working-class white people in rural areas – which in the past had not been as affected by drug epidemics – found themselves beset by poverty due to the shifting nature of the American economy. The groundwork was laid for a potential drug crisis. 

The Pharmaceutical Companies Made it Worse
For a true public health crisis to occur, there first had to be an influx of opioids into the country, the likes of which no drug cartel could muster. Enter the major American pharmaceutical companies. In the late 1990s, the pharmaceutical companies successfully lobbied the Joint Commission, an organization responsible for accrediting American health care programs thereby essentially setting the standard for American health care programs, to accept the concept of pain as a vital sign. Before that, pain was a secondary consideration. But now, physicians would be required to ask about and treat their patients’ pain. In the decade that followed, sales of prescription opioids in the U.S. quadrupled. Roughly during the same time period, the overdose rates quadrupled as well. 

And as they made public attempts to reform, it only took the crisis in new directions. Take “abuse-proof” OxyContin. In 2010, OxyContin producer Purdue Pharma introduced a new version of the pill that they claimed was “crush-proof,” turning into a jelly if you tried to crush it into a powder, therefore making it impossible to inject or snort. Almost immediately, though, Internet forums lit up with collective solutions for overcoming the newly implemented safeguards. Meanwhile, anecdotes of addicts visiting the emergency room as a result of injecting the binders contained within the abuse-proof pills began to spread. Other users opted for a better workaround: switching to heroin.

Naloxone Is No Party
The existence of more opioid-dependent citizens continues to benefit the pharmaceutical industry. Naloxone, often sold under the brand name Narcan, counteracts the effects of an opioid overdose. Since 2014, there’s been a near 500 percent increase in sales of the drug. Meanwhile, over the last three years, pharmaceutical companies have steadily raised the price by as much as 50 percent. Now, with first responders throughout the country needing a steady supply of naloxone on hand, Big Pharma doesn’t only see several billion dollars per year off opioids themselves, but they see a growing profit from the sale of anti-opioids.

Thus far, 46 U.S. states have opted to make naloxone available over the counter. Despite this progress, a vocal minority has expressed concern that increased access to naloxone might have dangerous repercussions. The hysteria generated by those who oppose naloxone access may be responsible for the creation of a relatively new heroin myth.

In August 2017, a report from Boston’s Fox News 25 claimed to have identified a new trend where partygoers were intentionally overdosing on opioids so they could take Naloxone, thereby “giving the drug user a rush.” Several similar reports described the practice, dubbed “Narcan Parties.” The supposed trend was touted by Pennsylvania State Senator Lisa Boscola and State Representative Dan McNeil as a reason not to expand access to naloxone in the state. However, there’s no evidence that these parties are actually happening. “I have not been able to verify a single case of this,” Bill Stauffer, Executive Director at the Pennsylvania Recovery Organization, told The Outline. “I suspect it to be an urban legend.” 

Replacement and Maintenance Therapies Gets Results
Maintenance therapies like methadone and subutex have shown better results than non-medication-assisted treatments, both in cases of addicts seeking abstinence from opioids, and for those seeking simply to carry on living relatively normal lives. Replacement therapy with drugs like methadone, subutex, kratom and even cannabis have also shown major promise in helping addicts get clean.

The success rate of addicts getting clean without the help of replacement therapies has been stated to be as low as 3 to 5 percent and as high as 20 to 30 percent. Success rates amongst those using drugs like methadone and buprenorphine to help them taper off opioids have been cited as high as 60 to 90 percent. According to the California Society of Addiction Medicine, addicts who go cold turkey are significantly more likely to relapse than those who taper off with drugs like methadone or Suboxone.

Though Attorney General Jeff Sessions recently shared his opinion that most heroin addiction starts with marijuana “and other drugs too,” the benefits of marijuana as a potential treatment for opioid addiction have become the cornerstone of several controversial treatment modalities. Researchers also believe that painkillers derived from chemicals found in marijuana such as CBD could provide an effective and far less dangerous alternative to prescription opioids.

Safe-injection Sites Reduce Risk, Too
A 2005 study in Switzerland found greater reductions in opioid use and greater rates of complete abstinence among subjects who were given injectable heroin while supervised, over those who were given methadone over the same 12-month period. With the number of supervised injection sites around the world nearing 100, and showing promise in major cities like Sydney, Vancouver and Amsterdam, activists in major cities like New York have begun the fight to bring supervised injection sites to the U.S.

The Cure Could be in Hallucinogens
If anything like a “cure” for opioid addiction ever emerges, it will likely come from outside the medical establishment. For example, many consider Ibogaine, a hallucinogenic plant, to be one of the most promising opioid-dependence treatments on the horizon. The anti-addictive potential of the drug was discovered in the 1960s by Howard Lotsoff, an opioid-addicted beatnik who would spend the rest of his life championing the drug as a treatment for addiction.

The mantle for Ibogaine advocacy has since been taken up by people like Dimitri Mugianis, who after getting clean with Ibogaine put his life and freedom on the line to help suffering addicts with guerilla-style treatments in hotels across New York City. After a DEA sting landed Mugianis in jail in 2011, he became an icon of the harm reduction movement, a movement many consider integral to improving the state of addiction in this country. (After a years-long court battle, he was eventually convicted of a misdemeanor drug charge and served 45 days house arrest.) 

While scientists see promise in drugs like 18MC, a new chemical compound that attempts to make use of the anti-addictive properties of Ibogaine without the hallucinogenic effects, Mugianis believes that too much emphasis is put on chemical solutions.

Mugiainis insists that the only way forward is to begin changing our outlook on those addicted to opioids. “We need to start treating drug users well, like human beings,” he tells Rolling Stone. “We must offer a menu of choices as varied and complex as humans are, and addiction is.”

Addicts Aren’t So Easily Pegged
Mugianis believes that the biggest misconception about heroin addicts is that they are non-functional. During his time treating addicts, Mugianis says he’s seen heroin users with careers and families living what many would consider successful, fulfilling lives. The harm for them mainly came when they didn’t have access to the drug. “To say that people are totally dysfunctional on opiates as Americans, we’d have to discount all that active users have given to this culture, from Billie Holliday to Edgar Allan Poe to Jimi Hendrix; people who not only functioned but excelled and enriched our culture,” he says. “The people who made our culture were high.”