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Heroin Abuse

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What is heroin?

He roin is an illegal, highly addictive drug. It is both the most abused and the most rapidly acting of the opiates. Heroin is processed fro m morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. It is typically sold as a white or brownish powder or as the black sticky substance known on the streets as “black tar heroin.” Although purer heroin is becoming more common, most street heroin is “cut” with other drugs or with substances such as sugar, starch, powdere d milk, or quinine. Street hero i n can also be cut with strychnine or other poisons. Because hero i n abusers do not know the actual s t rength of the drug or its true contents, they are at risk of overdose or death. Heroin also poses special problems because of the transmission of HIV and other diseases that can occur from sharing needles or other injection equipment.

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What is the scope of heroin use in the United States?

According to the 1998 National Household Survey on Drug Abuse, which may actually underestimate illicit opiate (heroin) use, an estimated2.4 million people had used h e roin at some time in their lives, and nearly 130,000 of them reported using it within the month p receding the survey. The survey report estimates that there w e re 81,000 new hero in users in 1997. A large pro p o r t i o n of these recent new users were smoking, snorting, or sniff i n g h e roin, and most (87 perc e n t ) w e re under age 26. In 1992, only 61 percent were younger than 26.

The 1998 Drug Abuse Wa rning Network (DAWN), which collects data on drugrelated hospital emerg e n c y department (ED) episodes fro m 21 metropolitan areas, estimates that 14 percent of all drug-re l a t e ED episodes involved hero i n . Even more alarming is the fact that between 1991 and 1996, h e ro i n - related ED episodes more than doubled (from 35,898 to 73,846). Among youths aged 12 to 17, hero i n - related episodes nearly quadrupled.

NIDA’s Community Epidemiology Work Gro u p (CEWG), which provides information about the nature and p a t t e rns of drug use in 21 cities, reported in its December 1999 publication that heroin was mentioned most often as the primary drug of abuse in drug abuse treatment admissions in B a l t i m o re, Boston, Los Angeles, Newark, New York, and San Francisco.

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How is heroin used?

He roin is usually injected, s n i ffed/snorted, or smoked. Typically, a heroin abuser may inject up to four times a day. Intravenous injection provides the g reatest intensity and most rapid onset of euphoria (7 to 8 seconds), while intramuscular injection produces a relatively slow onset of euphoria (5 to 8 minutes). When heroin is sniffed or smoked, peak effects are usually felt within 10 to 15 minutes. Although smoking and sniffing heroin do not produce a “rush” as quickly or as intensely as intravenous injection, NIDA researchers have confirmed that all three forms of heroin administration are addictive.

Injection continues to be the p redominant method of hero i n use among addicted users seeking treatment; however, researchers have observed a shift in heroin use patterns, from injection to sniffing and smoking. In fact, sniff i n g / s n o r t i n g h e roin is now the most widely reported means of taking hero i n among users admitted for drug t reatment in Newark, Chicago, and New York.

With the shift in heroin abuse patterns comes an even more diverse group of users. Older users (over 30) continue to be one of the largest user groups in most national data. However, the i n c rease continues in new, young users across the country who are being lured by inexpensive, highpurity heroin that can be sniffed or smoked instead of injected. Heroin has also been appearing in more affluent communities.

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What are the immediate (short-term) effects of heroin use?

Soon after injection (or inhalation), heroin crosses the blood-brain barrier. In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. Abusers typically re p o r t feeling a surge of pleasurable sensation, a “rush.” The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the natural opioid receptors. Heroin is particularly addictive because it enters the brain so rapidly. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities, which may be accompanied by nausea, vomiting, and severe itching.

After the initial effects, abusers usually will be dro w s y for several hours. Mental function is clouded by heroin’s effect on the central nervous system. Cardiac function slows. Breathing is also severely slowed, sometimes to the point of death. H e roin overdose is a particular risk on the street, where the amount and purity of the drug cannot be accurately known.

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What are the long-term effects of heroin use?

One of the most detrimental l o n g - t e rm effects of hero i n is addiction itself. Addiction is a chronic, re l a p s i n g disease, characterized by compulsive drug seeking and use, and by n e u rochemical and molecular changes in the brain. Heroin also p roduces profound degrees of tolerance and physical dependence, which are also powerful motivating factors for compulsive use and abuse. As with abusers of any addictive drug, heroin abusers gradually spend more and more time and energy obtaining and using the drug. Once they are addicted, the heroin abusers’ primary purpose in life becomes seeking and using drugs. The drugs literally change their brains.

Physical dependence develops with higher doses of the drug. With physical dependence, the body adapts to the presence of the drug and withdrawal symptoms occur if use is reduced abruptly. Withdrawal may occur within a few hours after the last time the drug is taken. Symptoms of withdrawal include restles sness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”), and leg movements. Major withdrawal symptoms peak between 24 and 48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Heroin withdrawal is never fatal to otherwise healthy adults, but it can cause death to the fetus of a pregnant addict.

At some point during continuous heroin use, a person can become addicted to the drug. Sometimes addicted individuals will endure many of the withdrawal symptoms to reduce their tolerance for the drug so that they can again experience the r u s h .

Physical dependence and the e m e rgence of withdrawal symptoms were once believed to be the key features of heroin addiction. We now know this may not be the case entirely, since craving and relapse can occur weeks and months after withdrawal symptoms are long gone. We also know that patients with chro n i c pain who need opiates to function (sometimes over extended periods) have few if any pro blems leaving opiates after their pain is resolved by other means. This may be because the patient in pain is simply seeking relief of pain and not the rush sought by the addict.

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What are the medical complications of chronic heroin use?

Medical consequences of c h ronic heroin abuse include scarred and/or collapsed veins, bacterial infections of the blood vessels and heart valves, abscesses (boils) and other soft-tissue infections, and liver or kidney disease. Lung complications (including various types of pneumonia and tuberculosis) may result from the poor health condition of the abuser as well as from heroin’s depressing effects on respiration. Many of the additives in street heroin may include substances that do not readily dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in vital organs. Immune reactions to these or other contaminants can cause arthritis or other rheumatologic problems.

Of course, sharing of injection equipment or fluids can lead to some of the most severe consequences of heroin abuse— infections with hepatitis B and C, HIV, and a host of other blood - borne viruses, which drug abusers can then pass on to their sexual partners and children.

Short- and Long-Term Effects of Heroin Abuse
Short - Term Effects:
  • "Rush"
  • Depressed respiration
  • Clouded mental functioning
  • Nausea and vomiting
  • Suppression of pain
  • Spontaneous abortion
Long - Term Effects:
  • Addiction
  • Infectious diseases, for example, HIV/AIDS and hepatitis B and C
  • Collapsed veins
  • Bacterial infections
  • Abscesses
  • Infection of heart lining and valves
  • Arthritis and other rheumatologic problems

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How does heroin abuse affect pregnant women?

Heroin abuse can cause serious complications during p regnancy, including miscarriage and pre m a t u re delivery. C h i l d ren born to addicted mothers are at greater risk of SIDS (sudden infant death syndro m e ) , as well. Pre g n a n t women should not be d e t o x i f i e d f rom opiates because of the incre a s e d risk of spontaneous abortion or pre m a t u re delivery; rather, tre a tment with methadone is strongly advised. Although infants born to mothers taking p re s c r i b e d methadone may show signs of physical dependence, they can be treated easily and safely in the nursery. R e s e a rch has demonstrated also that the effects of in utero exposure to methadone are relativelybenign .

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Why are heroin users at special risk for contracting HIV/AIDS and hepatitis C?

Heroin addicts are at risk for contracting HIV, hepatitis C, and other infectious diseases. Drug abusers may become infected with HIV, hepatitis C, and other bloodb o rne pathogens through sharing and reuse of syringes and injection paraphern a l i a that have been used by infected individuals. They may also become infected with HIV and, although less often, to hepatitis C thro u g h u n p rotected sexual contact with an infected person. Injection drug use has been a factor in an estimated one-third of all HIV and more than half of all hepatitis C cases in the N a t i o n . N I D A - f u n d e d re s e a rch has found that drug abusers can change the behaviors that put them at risk for contracting HIV, t h rough drug abuse tre a tment, prevention, and community-based outreach programs. They can eliminate drug use, drugrelated risk behaviors such as needle sharing, unsafe sexual practices, and, in turn, the risk of e x p o s u re to HIV/AIDS and other infectious diseases. Drug abuse p revention and treatment are highly effective in preventing the s p read of HIV.

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What are the treatments for heroin addiction?

A variety of effective tre a tments are available for h e roin addiction. Tre a t m e n t tends to be more effective when h e roin abuse is identified early. The treatments that follow vary depending on the individual, but methadone, a synthetic opiate that blocks the effects of hero i n and eliminates withdrawal symptoms, has a proven record of success for people addicted to h e roin. Other pharm a c e u t i c a l a p p roaches, like LAAM (levoalpha- acetyl-methadol) and b u p renorphine, and many behavioral therapies also are used for treating heroin addiction.

Detoxification

The primary objective of detoxification is to relieve withdrawal symptoms while patients adjust to a drug-free state. Not in itself a t reatment for addiction, detoxification is a useful step only when it leads into long-term tre a t m e n t that is either drug-free (re s i d e n t i a l or outpatient) or uses medications as part of the treatment. The best documented drug-free tre a tments are the therapeutic community residential pro g r a m s lasting at least 3 to 6 months.

Methadone programs

Methadone treatment has been used effectively and safely to t reat opioid addiction for more than 30 years. Properly prescribed methadone is not intoxicating or sedating, and its eff e c t s do not interf e re with ordinary activities such as driving a car. The medication is taken orally and it suppresses narcotic withdrawal for 24 to 36 hours. Patients are able to perceive pain and have emotional re a c t i o n s . Most important, methadone relieves the craving associated with heroin addiction; craving is a major reason for relapse . Among methadone patients, it has been found that normal stre e t doses of heroin are ineffective at producing euphoria, thus making the use of heroin more easily extinguishable .

Methadone’s effects last for about 24 hours—four to six times as long as those of hero i n — s o people in treatment need to take it only once a day. Also, methadone is medically safe even when used continuously for 10 years or m o re. Combined with behavioral therapies or counseling and other supportive services, methadone enables patients to stop using h e roin (and other opiates) and re t u rn to more stable and productive lives.

Methadone dosages must be carefully monitored in patients who are receiving antiviral therapy for HIV infection, to avoid potential medication interactions.

LAAM and other medications

LAAM, like methadone, is a synthetic opiate that can be used to treat heroin addiction. LAAM can block the e ffects of heroin for up to 72 hours with minimal side e ffects when taken orally. In 1993 the Food and Drug A d m i n i s t r a t i o n a p p roved the use of LAAM for t reating patients addicted to hero i n . Its long duration of action permits dosing just thre e times per week, t h e reby eliminating the need for daily dosing and take-home doses for weekends. LAAM will be i n c reasingly available in clinics that a l ready dispense methadone.

Naloxone and naltrexone are medications that also block the e ffects of morphine, hero i n , and other opiates. As antagonists, they are especially useful as antidotes. Naltre x o n e has long-lasting effects, ranging f rom 1 to 3 days, depending on the dose. Naltrexone blocks the pleasurable effects of heroin and is useful in treating some highly motivated individuals. Naltre x o n e has also been found to be successful in preventing relapse by former opiate addicts released f rom prison on probation .

Another medication to treat heroin addiction, buprenorphine , may already be available by the time this Research Report appears. Buprenorphine is a particularly attractive treatment because, compared to other medications, such as methadone, it causes weaker opiate effects and is less likely to cause overdose problems . Buprenorphine also produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than do those who stop taking methadone. Because of these advantages, buprenorphine may be appropriate for use in a wider variety of treatment settings than the currently available medications. Several other medications with potential for treating hero i n overdose or addiction are c u r rently under investigation by NIDA.

Behavioral therapies

Although behavioral and pharmacologic treatments can be extremely useful when employed alone, science has taught us that integrating both types of treatments will ultimately be the most effective appro a c h . T h e re are many effective behavioral treatments available for h e roin addiction. These can include residential and outpatient a p p roaches. An important task is to match the best tre a t m e n t a p p roach to meet the particular needs of the patient. More o v e r, several new behavioral therapies, such as contingency management therapy and cognitive-behavioral interventions, show particular p romise as treatments for hero i n addiction. Contingency management therapy uses a voucherbased system, where patients e a rn “points” based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitivebehavioral interventions are designed to help modify the patient’s thinking, expectancies, and behaviors and to incre a s e skills in coping with various life s t ressors. Both behavioral and p h a rmacological treatments help to restore a degree of normalcy to brain function and behavior, with increased employment rates and lower risk of HIV and other diseases and criminal behavior.

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What are the opioid analogs and their dangers?

Drug analogs are chemical compounds that are similar to other drugs in their e ffects but differ slightly in their chemical structure. Some analogs a re produced by pharm a c e u t i c a l companies for legitimate medical reasons. Other analogs, sometimes re f e r red to as “designer” drugs, can be produced in illegal laboratories and are often more d a n g e rous and potent than the original drug. Two of the most commonly known opioid analogs a re fentanyl and meperidine (marketed under the brand name Demerol, for example).

Fentanyl was introduced in 1968 by a Belgian pharmaceutical company as a synthetic narcotic to be used as an analgesic in s u rgical procedures because of its minimal effects on the heart. Fentanyl is particularly dangero u s because it is 50 times more potent than heroin and can rapidly stop respiration. This is not a problem during surgical procedures because machines a re used to help patients breathe . On the street, however, users have been found dead with the needle used to inject the drug still in their arms.

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Where can I get further scientific information about heroin abuse and addiction?

http://www.drugabuse.gov

http://www.steroidabuse.org

http://www.clubdrugs.org

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Heroin Abuse