Opium and Heroin

What is Opium?

Opium is a highly addictive narcotic drug acquired in the dried latex form from the opium poppy (Papaver somniferum) seed pod. Traditionally the unripened pod is slit open and the sap seeps out and dries on the outer surface of the pod. The resulting yellow-brown latex, which is scraped off of the pod, is bitter in taste and contains varying amounts of alkaloids such as morphine, codeine, thebaine and papaverine.

What is Heroin?

Heroin (diacetylmorphine) is derived from the morphine alkaloid found in opium and is roughly 2-3 times more potent. A highly addictive drug, heroin exhibits euphoric ("rush"), anxiolytic and analgesic central nervous system properties. Heroin is classified as a Schedule I drug under the Controlled Substances Act of 1970 and as such has no acceptable medical use in the United States. Pure heroin is a white powder with a bitter taste. Most illicit heroin is sold as a white or brownish powder and is usually "cut" with other drugs or with substances such as sugar, starch, powdered milk, or quinine. It can also be cut with strychnine or other poisons. Because heroin abusers do not know the actual strength of the drug or its true contents, they are at risk of overdose or death. Another form of heroin known as "black tar" may be sticky, like roofing tar, or hard, like coal. Its color may vary from dark brown to black. Heroin street names include smack, H, skag, junk, brown sugar, horse, and black tar.

Methods of Use

Heroin is most often injected, however, it may also be vaporized ("smoked"), sniffed ("snorted"), used as a suppository, or orally ingested. Smoking and sniffing heroin do not produce a "rush" as quickly or as intensely as intravenous injection. Oral ingestion does not usually lead to a "rush", but use of heroin in suppository form may have intense euphoric effects. Heroin can be addictive by any given route.

Effects of Heroin Use

Heroin is metabolized to morphine and other metabolites which bind to opioid receptors in the brain. The short-term effects of heroin abuse appear soon after a single dose and disappear in a few hours. After an injection of heroin, the user reports feeling a surge of euphoria (the "rush") accompanied by a warm flushing of the skin, a dry mouth, and heavy extremities. Following this initial euphoria, the user experiences an alternately wakeful and drowsy state. Mental functioning becomes clouded due to the depression of the central nervous system. Other effects that heroin may have on users include respiratory depression, constricted ("pinpoint") pupils and nausea. Effects of heroin overdose may also include slow and shallow breathing, hypotension, muscle spasms, convulsions, coma, and possible death.

Intravenous heroin use is complicated by other issues such as the sharing of contaminated needles, the spread of HIV/AIDS, hepatitis, and toxic reactions to heroin impurities. Other medical complications that may arise due to heroin use include collapsed veins, abscesses, spontaneous abortion, or endocarditis, an inflammation of the heart lining and valves. Heroin addiction can remove an otherwise healthy and contributing member from society.

Treatment Options for Heroin Addiction or Overdose

Several medical treatment options exist for heroin addiction. These treatments can be effective when combined with a medication compliance program and behavioral therapy. Methadone (Dolophine®, Methadose®), buprenorphine (Subutex®), buprenorphine combined with naloxone (Suboxone®) and naltrexone (Depade®, ReVia®) are approved in the US to treat opioid dependence. These treatments work by binding fully or partially to opiate receptors in the brain and work as agonists, antagonists or a combination of the two. Agonists mimic the action of the opiate, and antagonists block and reverse the action of the opiate. Oral administration of these drugs may allow for a more gradual withdrawal from opiates. A long-acting intramuscular depot formulation of naltrexone (Vivitrol®) is also available for use following opiate detoxification.

Methadone has been used for over a quarter century to treat heroin addiction. The use of methadone in opiate dependency is highly regulated in the US, and may differ between states. Oral methadone is approved for opiate detoxification and maintenance only in approved and certified treatment programs, although certain emergency or inpatient care exceptions exist. Patients usually need to visit a center daily for treatment and follow-up; however, special exceptions may be granted for Sundays, State and Federal holidays, and other times as determined by the Treatment Center Medical Director.[1]

Buprenorphine/naloxone, like methadone, has been shown in clinical trials to be effective in treating heroin dependence, and may have a lower risk for withdrawal effects upon discontinuation. Naloxone (a pure opiate antagonist at receptor sites) is present to help prevent the intravenous abuse of the buprenorphine component. Buprenorphine/naloxone treatment takes place in an authorized physicians' office, and this may be more acceptable to patients. Buprenorphine is also available as a single agent and is used primarily for induction at treatment onset. Patients are usually switched to the combined buprenorphine/naloxone agent for outpatient maintenance therapy.

Naltrexone, available orally and as an intramuscular depot injection is another treatment option, but patients must be opioid-free for at least 7 to 10 days prior to treatment. Naltrexone is a pure opioid antagonist and may result in withdrawal symptoms if the patient is not opioid-free.

Heroin overdose is a medical emergency that requires treatment with naloxone. Intravenous naloxone will result in reversal of the opioid-induced respiratory depression within 2 minutes. Retreatment with naloxone may be required as the duration of action of naloxone (30 to 120 minutes) may be shorter than the action of the opioid. Respiratory support, intravenous fluids, and other adjunctive medications may be required.

Heroin addiction is a treatable condition but a growing concern. According to the 2009 Survey on Drug Use and Health by the US Substance Abuse and Mental Health Administration, there were 180,000 persons who reported using heroin for the first time in the previous 12 months[2]. This number was significantly higher than the 91,000 to 118,000 average annual first-time users from 2002 to 2008. To put these numbers in perspective, in 2009 there were 2.4 million first-time users of marijuana. Patients with heroin addiction should seek advice from health care providers who can guide them with the most appropriate and safe treatment. Combined behavioral and medical therapies may allow the patient to integrate back into mainstream society and lead a positive and productive life.

References

[1] U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Division of Pharmacologic Therapies. Medication-Assisted Treatment for Substance Use Disorders. 42 CFR Part 8 Opioid Drugs in Maintenance and Detoxification. Treatment of Opiate Addiction; Final Rule. Published January 17, 2001. http://www.dpt.samhsa.gov/pdf/regs.pdf Accessed June 2011

[2] U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings. http://www.oas.samhsa.gov/NSDUH/2k9NSDUH/2k9ResultsP.pdf Accessed June 2011