1. Running Head: WOMEN AND HEROIN 1
Women and Heroin: A Literature Review
Shannon Farley
The Ohio State University

2. WOMEN AND HEROIN 2
Introduction
I chose to look into the literature regarding the prevalence and effects of heroin use on
women for hopes of finding answers as to why it is commonly the drug of choice amongst the
human trafficking victims I serve. I’ve also recently heard about the “Ohio Opiate Epidemic” in
my classes and on the news. Heroin use has many consequences due to the addictive nature of
the drug (one will do just about anything to get the next hit to prevent withdrawal.) Heroin use
comes with a wide array of consequences (physical, emotional, and mental health, STD’s), and
then we have to consider women getting pregnant and the growth in the number of “drug babies”
being born. The issue is becoming widespread and rather costly to society. After sifting through
the available research, I have found a few answers regarding the “Who, what, where, when, why
and how” surrounding the effects and prevalence of heroin use among women, but there is plenty
room for more research to be done in this arena. The better we can understand this specific
population, the more effective service providers can be with treatment and addressing the
epidemic appropriately. Guiterres, et al. suggested that the reason for lack of literature in her
1984 article was due to “tarnished angel syndrome” which was the culture of looking down on
women who abuse drugs more than men who abuse and it seems we are still dealing with those
ramifications to this day. There is not a ton of literature out there specifically on women who
struggle with heroin addiction, but this review attempts to snapshot what pieces we have and
what we are still missing.
Prevalence: Who? What? Where? When?
According to a retrospective analysis over the past 50 years of heroin use in the United
States, the percentage of heroin users that were women was 20% in the 1960’s, but has more

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recently surpassed 50% (Cicero, Ellis, Surratt, & Kurtz, 2014). The article argued that heroin has
moved from an inner city, minority problem involving mostly young men in the 60’s and 70’s,
into a predominately white and nonurban area epidemic in the 2000’s, with 90% of users being
white in the last decade.
It was interesting to find a literature review from 1984 which compared heroin abusing
women against prescription opioid abusing women. This article stereotyped women heroin
abusers as those who had low self-esteem, anxiety and depression issues, low socioeconomic
status, unstable childhood due to parental substance use, physical abuse, sexual abuse and/or
incest, and frequently battered by their husbands or mates, and suggested that women who were
abusing prescription opioids at the time were mostly middle class housewives (Guiterres, Patton,
Raymond, & Rhoads, 1984). Ironically enough, the most recent research suggests that the vast
majority of those who started their abuse after 1990, did so with prescription opioids and then
later had a primary drug of heroin (Cicero, et al., 2014). This implies that we cannot adequately
address the heroin issue without also looking at prescription opioids.
Prescription opioids are oftentimes prescribed for those dealing with chronic pain.
Similar to the factors listed in the above paragraph, predisposing factors such as personal and
family history, psychiatric disorders, childhood abuse, and lack of family support put chronic
pain patients at an increased risk for addiction and drug abuse or misuse. The good news is when
opioids are used for pain management by patients with no history of substance disorders, the
potential for developing one is significantly less than 1% (Rosenblatt & Mekhail, 2005).
According to the same article, addictive disorders occur in 3-26% of the general population, 19-
25% of hospitalized patients, and 40-60% in patients who sustained major trauma. Oftentimes in
social work, it is assumed that if a woman is abusing substances, there is some sort of trauma in

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the background. More research and understanding in this area of the issue would be helpful,
seeing as trauma is common amongst those who are prostituted.
Heroin abusing women were also described as “more self-critical, less self-confident,
hostile and angry due to frequently being involved in prostitution and suffering with feelings of
‘dirtiness and ‘worthlessness,’ and also were frequent offenders of petty theft” (Guiterres, et al.,
1984). Ironically enough, all of these “symptoms” of a 1984 woman abusing heroin closely
relates to the signs and symptoms we see in our female sex trafficking victims today. The federal
government did not define human or sex trafficking until the year 2000 with the Trafficking
Victim’s Protection Act (TVPA). Statistically now we know up to 92% of the prostituted women
we encounter in local service programs have been trafficked at some point, so my guess is many
of the women in this study were in a trafficking situation without it being realized at the time. It
would be interesting to know if the percentage we have today would have matched the data from
30 years ago in regards to those who were using and involved in prostitution and/ or a trafficking
situation. I would also like to recommend for research to look at which came first, heroin use or
prostitution? Currently we know the common age of entry into prostitution is 12-14 years old (a
minor in prostitution automatically deems a human sex trafficking situation per federal law), and
the average age of heroin users when they first used an opioid is between 20-25 years old, so my
hypothesis would be prostitution would come first prior to heroin use majority of the time
(Cicero, et al., 2014).
The Why and How: Effects of Heroin Use on Women
The big question of the day is why so many women are turning to heroin. Although there
isn’t exactly a straight answer from a qualitative study to answer that question, we do have the
fact that 98.1% of users referenced “the high” they get using heroin to be a determining factor of

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their use, especially over prescription opioids (Cicero, et al., 2014). Similarly, 94% from that
same study said they used heroin because prescription opioids were too expensive and heroin
was cheaper (Cicero, et al., 2014).
Also in the literature was a study that looked at the acute effects of heroin on emotions.
What they found was prior to injection, heroin dependents had an increased level of anxiety and
depression, but once heroin was administered, all those negative emotions declined, including
the cravings (which are related to feelings of sadness and anger) (Blum et al., 2013). Another
aspect of the study that may help answer why people, especially women use, is that after
administration of heroin, folks rated their emotional level of well-being much higher than those
who received the placebo. An implication for treatment we can take away from this article is that
47-97% of heroin dependents have comorbid psychiatric disorders, with affective disorders
especially common. Affective disorders indicate a vulnerability to treatment due to characteristic
decreased stress tolerance and ability to cope. The study referenced neurobiological concepts of
addiction and talked about how their findings aligned with previous studies. “It appears the
emotional imbalance of heroin addicts is even more severe than addicts to other substances
which dampen negative emotions…heroin addicts have an even greater need to suppress
negative emotions due to living in stressful environments (i.e. homelessness, prostitution,
delinquency, social isolation.) This presents an ongoing stressor due to constant exposure to
negative stimuli” (Blum et al., 2013). The limitation to all this is that this study was conducted
on mostly males (males made up 67.9% of experimental group and 70% of the control group.) It
may be helpful to replicate this study on women only to better understand the effects of heroin
on the emotions of women who are dependent on the drug. For my purposes, another research

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recommendation would be to look at the acute effects on women in prostitution who use heroin
versus those that use, but aren’t in a prostitution or sex trafficking situation.
In the literature review search, I was able to find two different studies that were
purposeful in comparing gender and the effects of heroin. The first was focused on the fact that
repeated exposure to heroin impairs the functions of the central nervous system (CNS). In order
to test this theory, they tested reaction times of men and women at 1-3 months of abstinence,
after 3 months of abstinence, and after 6 months of abstinence. The results they found were that
overall women had slower reaction times, but after 3 months of abstinence the men were able to
get their reaction times to that of the control, but the females still responded slower even after 6
months of abstinence (Liu, Zhou, Li, Ma, & Hu, 2006). This implies that similar to alcohol
consumption, heroin effects men and women differently and therefore should be treated
differently.
The other study looked at cognitive impairment of heroin abusers and compared the two
different genders. The women had better measures for cognitive ability, but the number of
subjects of men and women was not equal (almost twice as many men were studied than
women), but the article stated that this study had by far the largest sample size of heroin abusing
patients (Roberts & Horton, 2001).
What We Don’t Know: Recommendations for Future Research
We still have a lot to learn and research in terms of how heroin effects women differently
than it affects men (similar to how alcohol affects the two genders differently). I believe it would
be helpful to take a biopsychosocial approach to studying these effects. What are the
neurobiological effects of heroin on the brain of women and how does that relate to the effects of
heroin on emotions? It may be worthwhile to conduct a qualitative study with these women to

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get a better glimpse of the “Who, what, where, when, why, and how” questions relating to
women using heroin. I would personally also like to see more research on how prostitution and
sex trafficking affect this issue, as well as the role pregnancy plays in the life of a heroin using
woman.
In the “Women and Drugs” article from 1984, the authors discussed how the research on
women and drug abuse is mostly descriptive, and the need for more than psychological and
sociological components to drug abuse with proper control groups (Guiterres, et al., 1984). It
seems this still seems to be the case with the articles based on biological principles lacking
adequate pieces to compare gender differences and apply implications for treatment.
Conclusion
It doesn’t take a long look at the numbers to see that women are abusing heroin more
than they ever have in the last 50 years, and at a devastating, alarming rate. At this point, it
makes sense to invest the time and money to continue and further research this costly problem.
The end game would be to develop effective, evidence-based prevention programs, while in the
meantime, we have our hands full trying to treat those who are already addicted. From the
literature, we can definitely pick up on a link between abusing heroin and being involved in the
commercial sex industry, most commonly in the form of prostitution. It’s also noted that the
descriptive factors of a woman addicted to heroin in 1984 is closely related to vulnerability
factors of women today who are involved in human sex trafficking.
One also can’t ignore the link between heroin use and prescription opiates. In 1984, the
women who abused prescriptions were seen in a much different light than those who abused
heroin, but the research now suggests that line is blurring.

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There isn’t much argument at this point about the “benefits” users feel with the high and
in-the-moment emotional rewards. There is discrepancy about how heroin use effects the
functions of the central nervous system and cognitive ability (one would think a negative effect
on one would negatively impact the other, but that’s not how it played out.) There may be value
in researching long term effects of heroin use for treatment and prevention purposes.

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References
Blum, J., Gerber, H., Gerhard, U., Schmid, O., Petitjean, S., Riecher-Rössler, A., . . . Walter, M.
(2013). Acute effects of heroin on emotions in heroin-dependent patients. The American
Journal on Addictions Am J Addict, 22(6), 598-604. doi:10.1111/j.1521-
0391.2013.12025.x
Cicero, T. J., Ellis, M. S., Surratt, H. L., & Kurtz, S. P. (2014). The Changing Face of Heroin
Use in the United States. JAMA Psychiatry, 71(7), 821-826.
doi:10.1001/jamapsychiatry.2014.366
Gutierres, S. E., Patton, D. S., Raymond, J. S., & Rhoads, D. L. (1984). Women and Drugs: The
Heroin Abuser and the Prescription Drug Abuser. Psychol of Women Q Psychology of
Women Quarterly, 8(4), 354-369. doi:10.1111/j.1471-6402.1984.tb00643.x
Liu, N., Zhou, D., Li, B., Ma, Y., & Hu, X. (2006). Gender related effects of heroin abuse on the
simple reaction time task. Addictive Behaviors, 31(1), 187-190.
doi:10.1016/j.addbeh.2005.05.004
Roberts, C., & Horton, A. M. (January 01, 2001). Sex, Ethnicity, Age and Education Effects on
the Trail Making Test in a Sample of Heroin Abusers. International Journal of
Neuroscience, 110, 99-106.
Rosenblatt, A. B., & Mekhail, N. A. (2005). Management of Pain in Addicted/Illicit and Legal
Substance Abusing Patients. Pain Practice, 5(1), 2-10. doi:10.1111/j.1533-
2500.2005.05102.x