Heroin has regained the attention of the media, as its use is now reported to be of epidemic proportions. According to the CDC (Centers for Disease Control and Prevention) the amount of deaths related to opioids including heroin has quadrupled since 1999 to 2014. Today the incidence of heroin abuse is seen primarily in White males, in young people —both male and female, ages 18-25, and in states occupying the Midwest region of the United States. The reason for this recent epidemic has been associated with the use of prescription opioid painkillers. In fact, non-medical use of prescription opioids is a major risk factor for heroin use. In addition, the cost of heroin has decreased, its purity increased, and its availability is still readily attainable.
With so many people currently dying from heroin, government officials and policy makers are struggling with how to cope with an epidemic that is neither air-borne, vector-borne, or food-borne, but born out of the psychology of pain. Recently, media attention and public debate has surrounded the establishment of heroin clinics as a solution to the death crisis. Addicts may go to heroin clinics to receive injections of heroin, and in case of overdose, the antidote Naloxone (Narcan). Astonishing as it may seem, this is not the first time there has been a heroin epidemic, and neither is the idea of giving heroin to addicts at heroin clinics novel.
What is Heroin?
Heroin is a narcotic opiate. Opium is the prototypic opioid and had been used for centuries in the management of pain and the treatment of dysenteries (pathogenic intestinal disease and diarrhea), as a side effect of opioids is constipation —you may have reently seen the Movantik commercial for the treatment of opioid induced constipation.
Found in the Opus (greek word for juice) or sap of the Poppy plant (Papaver Somniferum) is Opium. Opium contains over 20 alkaloid compounds —Morphine is an opium alkaloid. Any drug derived from Opium is referred to as an Opiate, and all compounds related to opium are termed Opioids. The two words are often use interchangeably. Another word commonly interchanged with opiate/opioid is narcotic. A narcotic is any substance that induces sleep; having the potential to develop addiction.
Heroin is ultimatley biotransformed to morphine, with monoacetylmorphine as an intermediate metabolite. Morphine is excreted in the urine mainly in its conjugated form, with very little (less than 15%) excreted as free morphine.
According to an article written in 1972 for The Washington Post entitled, The Myths of Heroin by James Q. Wilson, Mark H. Moore, and I. David Wheat Jr., heroin was considered at that time to be a “phenomenon of alarming proportions” that affected middle-class Whites as well as lower-class Blacks.
There was also much debate over developing policies to deal with heroin addiction. These included detoxifying centers and methadone programs, as well as, legalizing the use and possession of heroin and, “the distribution of heroin to addicts at low-cost, or zero cost, through government-controlled clinics.”
Heroin was not just an American problem. So, officials in the U.S. looked to other countries for solutions. Heroin was once given free and legal to addicts in the United Kingdom of Great Britain. Addicts could obtain heroin from any physician or from a government controlled heroin clinic. In order to obtain heroin at sanctioned clinics, British heroin users had to be registered with the government and proven to be addicted to the drug. This prevented non-addicts from obtaining heroin, and allowed the government to monitor the number of heroin addicts. Initially, any British doctor was allowed to write a prescription of heroin to anyone who proved to be an addict. However, it is not possible to determine the amount of heroin that is needed to satiate heroin dependency. The amount of heroin required varies from person to person, and as such some doctors inadvertently supplied addicts with a surplus of heroin, which they then turned around and gave away to friends or sold for cash.
Heroin is primarily injected intravenoulsy, in liquid form, but can also be smoked or sniffed. Not all people who try heroin will become addicted to it, though a substantial amount will (nausea and vomiting are common with the initial use of Heroin). Heroin causes a “rush” as the drug enters the bloodstream, then a “high” feeling of euphoria, followed by a period of sedation, in which the user becomes drowsy. With continued habitual use, a tolerance develops where the user begins chasing the “high”, never again achieving the type of euphoria they first experienced in the early phase of addiction. At this stage of tolerance and dependence, habitual use revolves around anesthetizing oneself against the painful feelings of withdrawal. A preoccupation with obtaining and using heroin develops, along with a fixation on injecting oneself with a needle. This idiosyncrasy would prove to be a complication in the course of treatment. British doctors sometimes had to resort to intravenously administering methadone to addicts. This further lead to the illicit use of methadone. By 1968, the prescription of heroin by private practices was banned, and legal distribution was restricted to government clinics.
What happened when Heroin was no longer legally distributed?
When the availability of heroin by way of prescription became restricted, addicts turned to barbiturates. They crushed pills that were designed for oral ingestion, and mixed them with water. This concoction was then injected intravenously. The problem is barbiturates are very alkaline and if the vein was missed, the drug would form abscesses under the skin, eventually becoming golf-ball sized sores. When administered into the vein barbiturates were not readily carried away by the blood from the site of injection. As the vein collapsed; circulation was impaired. Untreatable sores that became infected and hypoxic tissue from collapsed veins lead to gangrene and the loss of limbs and digits.
In addition to street methadone, and barbiturate sleeping-pills, black-market heroin became available.
Addiction Treatment : Methadone Vs. Heroin
Methadone has been the hallmark treatment for heroin addiction since the 1960’s, and it is successful in reducing opiate drug use. However, oral Methadone treatment has its limitation. For one, methadone itself is a synthetic narcotic, though less potent than heroin, it carries its own risk of addiction. Secondly, the oral administration of methadone does not produce a feeling of euphoria; it is used to prevent the symptoms of withdrawal. Injecting methadone does produce a euphoric high similar to heroin, however this is not the standard form of treatment. Yet, injecting methadone was exactly what some British doctors had to resort to in order to manage some of their heroin addicted patients.
Methadone withdrawal takes longer to happen, but once it does, it last longer than heroin withdrawal. Heroin withdrawal although brief, is intense. For example, a person who takes one dose a day of methadone with remain stable with little fluctuation in mood. However, a person who injects heroin will have to do so several times a day in order to avoid oscillating between feeling high and being sick.
Currently, proponents of establishing heroin clinics in New York, suggest that heroin be administered at the clinic by trained medical professionals, instead of giving the heroin to the addict to administer by themselves. Nurses would monitor patients, allowing them to administer Naloxone (Narcan) — an opioid antagonist, used as an antidote for opioid overdose, if necessary. The purpose of this is to reduce the rate and number of deaths associated with heroin.
Heroin Mechanism of Action and Toxicity
Opiates inhibit the response to pain stimuli by mimicking endogenous (naturally occurring in the body) opioid peptides known as endorphins and enkephalins. They bind to opioid receptors in the CNS (central nervous system) and other tissues, resulting in alterations in mood, behavior, and movement.
Signs and Symptoms of Heroin Use and Toxicity.
Opioid use causes euphoria, analgesia (pain relief), sedation, and inhibits gastrointestinal motility (constipation). Opioid toxicity causes miosis , coma, and Respiratory depression —often the cause of death in cases of overdose. Anther complication of opiate overdose is Pulmonary edema, which may result from hypoxia due to Respiratory depression in which pulmonary capillaries become leaky and the lungs fill with fluid. Opiate induced Pulmonary edema appears most frequently in cases where heroin was used with other drugs such as barbiturates, benzodiazepines, and alcohol. CNS depressants have a synergistic effect when used with sedative-hypnotic drugs, that results in stupor and death. Other signs and symptoms include, hyperventilation, loss of consciousness, bradycardia (slow heart beat), hypotension, and diminished urine output.
Current Heroin Epidemic. The resurgence of heroin as an epidemic was inadvertently fueled by doctors indiscriminately over-prescribing opioids to patients in the treatment of pain, either acute or chronic. All opioids have the potential to be addictive, and as such, prescription pain-killers began to be abused. Almost half off all people prescribed a narcotic end-up abusing it in some form: seeking earlier refills, combining it with other medications, and not taking it as it was described. Opioids are often used in combination with other drugs, and heroin use is part of the progression of addiction for some opioid users.
Without a doctor’s prescription, opioids like Morphine (roxycontin), Oxycodone (oxycontin), Hydrocodone, and Fentanyl are available on the black-market. Illicit Fentanyl is sometimes combined with heroin, or sold on the streets as heroin, and cocaine is also combined with heroin (“Speedball”) for improved euphoria.
Rational for Heroin Clinics. The mortality rate for heroin users is very high. The dose, purity, sterility and identity of the drug when obtained on the street is uncertain, and infection with Hepatitis C and HIV are common consequences of sharing needles. Heroin administered at government clinics would help to eliminate these risk, but heroin users might still use outside of the clinic. Legalizing heroin use for addicts would, also dismantle the black-market system by reducing the incentive to deal heroin, as heroin would be available free or low-cost from government clinics. This would also prevent addicts from turning to thievery and prostitution; in order to finance their addiction.
Current Heroin Treatment. Narcotic addiction is a chronic disorder and requires long-term treatment. Methadone remains the most successful treatment for heroin addiction. Residential withdrawal programs and out-patient programs, also employ the use of oral Buprenorphine (a FDA approved opioid agonist for the treatment opioid addiction) to block the effect of heroin. In combination with the opioid antagonist Naloxone, intravenous Buprenorphine abuse is avoided, as naloxone will block any “high”that could be produced by Buprenorphine. As of now, there is no legal supply of heroin for clinical use in the United States.
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