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Heroin and Opioid Painkillers: What’s the Difference?

Most opioid drugs – such as heroin and opioid painkillers – are extremely similar in terms of their chemical structure, mechanism of action and range of effects.

Heroin is an illegal, opioid drug. It is most frequently used via injection, which rapidly result in a pleasant feeling of euphoria, warmth, drowsiness and decreased pain. Opioid painkillers are drugs that are prescribed to relieve mild to severe pain – but they can also elicit a reinforcing, euphoric effect similar to heroin due to their shared neural receptor interaction and subsequent activation of the brain’s reward circuitry.

heroin and opioid painkillers

Approximately 517,000 people in the United States suffer from a heroin addiction, while an estimated 1.9 million are addicted to opioid painkillers. Over 8,000 people die each year from heroin overdose, and an estimated 17,000 people die annually from opioid painkiller overdose.1 The numbers are staggering – less than 5% of the world’s population live in the United States, yet Americans take an estimated 80% of the world’s opioid painkiller supply.2

Some of the common opioid prescription medications are as follows:

  • Oxycodone (OxyContin, Percocet).
  • Hydrocodone (Vicodin).
  • Morphine.
  • Codeine. 3

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Heroin most frequently comes in the form of a white or brown powder. Among its various dangerous health effects, it can drastically slow breathing and can cause death. Since heroin is usually injected, the user is at high risk of contracting hepatitis, HIV and other infectious diseases that can spread by sharing needles. Additionally, heroin users who inject the drug can develop collapsed veins, abscesses and infections in the heart’s lining and valves. This illegal opioid is highly addictive, and an estimated 23% of people who use heroin develop a dependence.4

Heroin – unlike opioid painkillers – is not a regulated substance. It can be cut with a number of additives and impurities that can further damage multiple organ systems and make precise dosing an impossibility.

Conversely, when taken as prescribed, opioid painkillers are generally a safe, therapeutic pain management intervention for a number of patients. It is when people begin to abuse opioid painkillers for their euphoric effect – either by taking too many pills at once, by crushing and snorting pills or by injecting the powder – that the drug becomes dangerous and life-threatening.

Opioid prescription drugs are capable of producing profound respiratory depression, just as heroin does. Someone who abuses a painkiller is at higher risk of involuntarily stopping all breathing and subsequently dying. If prescription painkillers are taken for a short period of time and as directed by a doctor, addiction is rare. But if painkillers are taken long-term or abused, the risks of dependence and addiction are significantly increased.5

Opioid Painkillers: Gateway Drugs to Heroin?

Research reveals a connection between opioid painkiller abuse and the initiation of heroin use. A 2013 study showed that those who had previously used opioid prescription drugs were 19 times more likely to begin using heroin in the 12 months prior to the study.

And as many as 4 out of 5 new heroin users in the study had previously abused opioids.6 There is an undeniable correlation between the two drugs, and heroin is often chosen as an alternative to opioids for being less expensive and more readily accessible.7

President Obama has acknowledged the growing dangers of opioid abuse in the U.S. In October 2015, he committed to a series of strategies aimed at combatting this epidemic.

Where Do These Opioid Drugs Come From?

Both heroin and prescription opioids are derived from opium poppy plants in Asia. Heroin is made from morphine – which is extracted from opium poppy plants. Natural and semisynthetic prescription opioids are made from various opium poppy plant derivatives.

Origins and Structure of Heroin and Rx Opioids Copy

At a molecular level, heroin and many of the opioid painkillers are nearly indistinguishable from each other, with similar chemical structures. The characteristic chemical structure interacts with certain opioid receptors – targeting the brain’s reward centers, and inducing the euphoria and relaxation. Namely, heroin appears in white or brown powders unless it is in form of “black tar heroin” – which looks like a black, sticky tar substance that resembles coal or roofing tar. Opioid medications are most commonly encountered as pills or capsules.5,8-11

How Easy Is It to Get?

Opioid prescription drugs have become gateway drugs to heroin for many people due to the rising costs of opioid prescription drugs and the lower cost of heroin.

In 2013, the Food and Drug Administration announced that they would be tightening controls on access to opioid painkillers by limiting the amount of refills a patient could have before having to return to the doctor.12 

This change in painkiller access – combined with the relatively low price and high accessibility of heroin – has caused many opioid users to turn to heroin.

Rx Opioid Painkillers as Gateway Drugs to Heroin

A total of 15,000 individuals struggling with opioid prescription drug addiction were interviewed between the years of 2008 and 2014, and the results were staggering. Many of those addicted to painkillers were not exclusively using painkillers anymore. The rate of exclusive painkiller use had decreased from 70% to 50% throughout the study – while combined painkiller plus heroin abuse rose from 24% to 42%. The majority of the responding individuals who had been addicted to opioid medications reported lower cost and higher accessibility as two major reasons for trying heroin.13

While heroin is an illegal drug, it is still relatively easy for individuals to get ahold of the drug off the streets when they want to. This is evident by the Centers for Disease Control statistics that report that there were 517,000 people who used heroin in 2012 – a 150% increase from 5 years prior in 2007.14

What Is the Drug Experience Like?

Heroin and opioid prescription medications produce very similar “highs” – which makes it easy to see why opioid abusers make a natural transition into using heroin.

The Drug Experience

Heroin has a short onset of effects and is extremely addictive – while opioid medications become increasingly more addictive when abused compared to when they are taken as prescribed. The withdrawal symptoms for heroin and opioid medications are identical, and the withdrawal experience for both depends on the length and severity of the addiction.

The Drug High

Heroin is converted to morphine – one of the more commonly prescribed opioid drugs – in the brain. So while the drug high from both heroin and opioid prescription drugs should theoretically be very similar experiences, heroin is known to be about 3 times stronger than morphine. So much larger doses of opioid painkillers would be required to come close to matching the intensity of heroin’s drug high. When taken correctly as prescribed, however, the “high” produced by opioid painkillers would be a much milder version than that produced by heroin.

heroin high

Heroin elicits an intense “rush” of:

  • Euphoria.
  • Warmth.
  • Heavy extremities.
  • Foggy mental functioning.
  • Reduced pain.

Drowsiness can last for hours after immediate effects take place.15 Prescription opioids similarly produce feelings of euphoria, drowsiness, mental confusion and decreased pain.


Both heroin and opioid medications have potential for addiction. Heroin is extremely addictive, and tolerance and dependence can build rapidly.

An estimated 23% of people who try heroin become addicted.14

The main routes of administration include injecting, snorting and smoking heroin. Each of these methods deliver heroin quickly to the brain, which contributes to the highly addictive nature of the drug.

When taken appropriately and for short time periods, prescription opioids don’t have a high potential for addiction. However, certain individuals may be more likely than others to develop physical tolerance and dependence on the medications. When pills are crushed and snorted or injected, the risk for developing addiction increases greatly. It’s important to maintain good communication with your healthcare provider to ensure safe monitoring of your opioid prescription use so that it doesn’t develop into addiction.


The withdrawal symptoms as well as the onset of withdrawal symptoms for heroin and opioid medications are generally identical. Withdrawal symptoms of heroin can begin hours to days after one’s last heroin dose. Depending on the severity of the heroin addiction, withdrawal symptoms can persist for months and sometimes even years.

Below are some of the more common withdrawal symptoms of both heroin and opioid medications16,17:

  • Drug cravings.
  • Moodiness: depression, anxiety, fear of withdrawal.
  • Stomach cramps.
  • Upper body secretions: watery eyes, runny nose, sweating.
  • Restlessness, yawning, insomnia.
  • Diarrhea
  • Fever and chills.
  • Muscle spasms, joint pain, tremor.
  • Nausea and vomiting.
  • Cardiovascular problems: elevated heart rate and blood pressure.

The range of symptoms and timing of arrival of a characteristic opiate withdrawal syndrome will be nearly identical for both opioid medications and heroin. The severity of painkiller withdrawal symptoms depends on the half-life of the drug used. If your medication is short-acting, then withdrawal symptoms will appear 6-12 hours after the most recent dose. Conversely, if it is long-acting (or says “extended release”), then withdrawal symptoms may not appear for 2-4 days after the last dose.

How Dangerous Are the Health Effects?

The short-term and long-term effects of opioid pain medications and heroin are more or less the same. Both drugs are capable of producing life-threatening symptoms, including suppressed breathing and comas.

These dangerous effects arise as a result of the drug in question binding with the opioid receptors in certain regions of the brain stem – a part of the brain that controls autonomic processes such as breathing, heart rate and blood pressure.17 When taking prescription opioids, it’s important to maintain a sense of self-awareness in terms of drug use behavior and closely adhere to your doctor’s instructions to reduce risks of developing addiction.

Short-term Effects

Shared short-term effects of both heroin and opioid painkillers include the following18:

Short-term Effects of Heroin vs Rx Opioids

  • Anxiety.
  • Severe itching.
  • Sweating.
  • Miosis, or pupillary constriction.
  • Vision problems.
  • Slowed heart rate.
  • Depressed breathing, coma and death.
  • Nausea.
  • Vomiting, which can cause you to aspirate, or inhale non-sterile, acidic contents of your stomach into your lungs.
  • Lung injury and infection, as a result of vomiting.
  • Dehydration and electrolyte imbalance from prolonged vomiting.

Heroin users have also frequently reported clouded mental functioning and a feeling of heavy extremities after short-term heroin use. Short-term painkiller use may often be accompanied by decreased appetite and constipation.15,19,20

Long-term Effects

Shared long-term effects of both heroin and opioid prescriptions may include the following16:

Long-term Effects of Heroin vs Prescription Opioids

  • Insomnia
  • Depression
  • Tolerance: needing more of the drug to get high or reach the desired effect.
  • Increased risk of overdose as tolerance and doses increase.
  • Increased intranasal user risk of nasal septum perforation.
  • Increased intravenous user risk of contracting hepatitis viruses or HIV.
  • Increased injection user risks of: track marks, collapsed veins, cellulitis, and abscesses.

Long-term effects typically more common to either heroin or painkiller use are as follows:


  • Increased risk of deadly infections in the valves or on the surface of the heart.
  • Decay of white matter in the brain, which may hinder ability to regulate behavior and make decisions.
  • Sexual dysfunction (men and women).
  • Irregular menstrual cycles or spontaneous abortion (women).
  • Kidney diseases.
  • Constipation.
  • Increased risk of suicide.16,21,22

Prescription Opioids

  • Increased risk for heart attack and heart failure.
  • Concentration problems.
  • Decreased tolerance to pain.
  • Sleep-disordered breathing.20

How Does the Treatment Process for Heroin and Opioid Painkillers Differ?

When considering the treatment approaches for either a heroin or prescription opioid addiction, the similarities will outweigh the differences.  Both addictions will likely get worse the longer rehabilitation steps aren’t taken. So it’s in one’s best interest of to talk to a doctor sooner rather than later, and find a recovery center that meets your needs.

There are many treatment options for those suffering from an addiction to heroin or opioid painkillers. If your addiction is moderate to severe, it is recommended that you seek inpatient treatment, which allows you to live at the facility while receiving 24-hour care in addition to therapy and group counseling.

One benefit of inpatient treatment is that there is supervised, medically-assisted detoxification, which can alleviate withdrawal symptoms and minimize relapse risks. If your addiction is mild, you may benefit from outpatient treatment, in which you can still live at home and tend to your everyday responsibilities throughout recovery.

Comprehensive treatment may incorporate a combination of components from both inpatient and outpatient treatment types.

Inpatient Treatment

  • Length of treatment: Can be 30, 60 or 90 days, depending on your individual needs.
  • Individual therapy: A therapist works with you to explore the nature and cause of your addiction while building healthy coping skills.
  • Group counseling: A supportive and engaging environment is provided in which you can develop positive social skills under the supervision of a group leader.
  • Medically-assisted detox: If needed, medications will be administered to help ease your withdrawal symptoms and decrease cravings.

Outpatient Treatment

  • Intensive outpatient: Similar to inpatient treatment and a more serious option for those opting for outpatient treatment. Includes relapse prevention and meets more often than standard outpatient treatment.
  • Individual therapy: Patients attend sessions at a treatment center where the therapist uncovers the root cause of your addiction, helps to repair relationships and aids in the development of healthy coping skills.
  • Partial hospitalization: A good option for those who require medical supervision but don’t want to live at the facility. Patients usually meet 3-5 days a week for 2-4 hours at a time.
  • 12-step programs: These programs are fellowships of recovering addicts that follow a series of 12 steps in order to achieve and maintain sobriety, while providing support to one another. Examples include Heroin Anonymous, Pills Anonymous and Narcotics Anonymous.

Medical Treatment

Several different medications are commonly used in both inpatient and outpatient treatment for heroin and opioid painkiller addictions. Below are some of the more commonly used medications:

1. Naloxone.

The most commonly used opioid antagonist that stops opioids from causing further effects in opioid overdose or intoxication.23

2. Naltrexone.

An opioid antagonist that works similarly to naloxone and doesn’t have any addictive properties. A new injectable form of it has been approved and only needs to be administered once a month, which improves compliance with instructions.

3. Buprenorphine.

A partial opioid agonist, which means it binds to the opioid receptors in a weaker manner than opioid drugs and helps alleviate cravings by mimicking opioids without eliciting a powerful “high.” Buprenorphine is sometimes combined with naloxone (“Suboxone”) to further lower risk of overdose.

4. Methadone.

In some cases that don’t respond well to other pharmacologic interventions, or for others who have been first stabilized on the aforementioned medications, methadone can be another beneficial option. Methadone is an opioid agonist, but – compared with many abused opioids – its relatively longer-acting, less potent drug profile facilitates withdrawal management as well as longer-term maintenance and gradual tapering.24

Learn More and Find Help for Your Addiction

If you or a loved one is suffering from an addiction to heroin or prescription opioids, help is available for you when you’re ready. Call one of our treatment advisors to discuss what your options are and learn what next steps you can take that will be best for you and your particular circumstances.

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  1. Opioid Addiction Disease 2015 Facts and Figures. (n.d.). Retrieved November 11, 2015.
  2. A Nation in Pain: Focusing on U.S. Opioid Trends for Treatment of Short-term and Long-term Pain. (2014, December 1). Retrieved November 11, 2015.
  3. What are opioids? (2014, November 1). Retrieved November 11, 2015.
  4. Drug Facts: Heroin. (2014, October 1). Retrieved November 11, 2015.
  5. What are the possible consequences of opioid use and abuse? (2014, November 1). Retrieved November 11, 2015.
  6. Muhuri, P., Gfroerer, J., & Davies, M. (2013, August 1). Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. Retrieved November 11, 2015.
  7. Cicero, T., Ellis, M., Surratt, H., & Kurtz, S. (2014). The Changing Face of Heroin Use in the United States. JAMA Psychiatry, 71(7), 821-826. doi:10.1001/jamapsychiatry.2014.366.
  8. What is heroin and how is it used? (2014, November 1). Retrieved November 11, 2015.
  9. Diacetylmorphine. (2015, November 7). Retrieved November 11, 2015.
  10. DeRuiter, J. (2000). Narcotic Analgesis: Morphine and “Peripherally Modified” Morphine Analogs. Retrieved November 11, 2015.
  11. Absolute Contraindications to Opioid Prescribing. (2003). Retrieved November 11, 2015.
  12. Meier, B. (2013, October 24). D.A. Urging a Tighter Rein on Painkillers. The New York Times. Retrieved November 11, 2015.
  13. Why More Painkiller Addicts Are Using Heroin, Too. MedlinePlus. (2015, October 28). Retrieved November 11, 2015.
  14. Vital Signs: Demographic and substance use trends among heroin users – United States, 2002-2013. CDC MMWR, 10 July 2015, 64(26):719-725.
  15. What are the immediate (short-term) effects of heroin use? (2014, November 1). Retrieved November 11, 2015.
  16. Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
  17. Hosztafi, S. (2011). Heroin Addiction. Acta Pharm Hung, 81(4), 173-183.
  18. Opiate withdrawal. MedlinePlus Medical Encyclopedia. (2013, April 5). Retrieved November 11, 2015.
  19. Opioid Analgesis (Painkillers). (2011). Retrieved November 11, 2015.
  20. Baldini, A., Korff, M., & Lin, E. (2012). A Review of Potential Adverse Effects of Long-Term Opioid Therapy. The Primary Care Companion For CNS Disorders Prim. Care Companion CNS Disord., 14(3).
  21. What are the long-term effects of heroin use? (2014, November 1). Retrieved November 11, 2015.
  22. What are the medical complications of chronic heroin use? National Institute on Drug Abuse.
  23. Opioid Toxicity Medication. (n.d.). Retrieved November 11, 2015.
  24. What are the treatments for heroin addiction? (2014, November 1). Retrieved November 11, 2015.

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