Causes of Death
HIV-AIDS & Injection Drug Use
Methadone and Opioid Substitution Therapy
Pain Management & Prescription Drugs
Safe Injection Facilities
(Description of Heroin) "Heroin is an opiate drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant. Heroin usually appears as a white or brown powder or as a black sticky substance, known as 'black tar heroin.'"Source:National Institute on Drug Abuse, DrugFacts: Heroin (Rockville, MD: US Department of Health and Human Services, Revised March 2010), last accessed Jan. 12, 2013.
(Prevalence of Heroin Use in the US, 2012) "The number and percentage of persons aged 12 or older who were current heroin users in 2012 (335,000 or 0.1 percent) were similar to those in 2011 (281,000 or 0.1 percent), but they were higher than those in 2002 through 2005 (166,000 or 0.1 percent in 2002; 119,000 or 0.1 percent in 2003; 166,000 or 0.1 percent in 2004; and 136,000 or 0.1 percent in 2005), 2007 (161,000 or 0.1 percent), and 2009 (193,000 or 0.1 percent) (Figure 2.4). Recent increases in the use of heroin were also evident in the estimate of past year heroin use."Source:Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013, p. 16.
(Law Enforcement and Treatment Indicators of Heroin Use in the US, 2011)
" Increasing heroin trends were reported by area representatives for Boston, Cincinnati, Denver/Colorado, Detroit, Honolulu/Hawaii, Minneapolis/St. Paul, San Diego, Seattle, and Texas. The area representatives from Atlanta, Chicago, Los Angeles, St. Louis, and Washington, DC, reported mostly stable indicators. Mixed indicators (some stable, some declining, and some increasing) were reported by area representatives from Baltimore/Maryland, Maine, New York City, Philadelphia, Phoenix, and the South Florida/Miami-Dade and Broward Counties area. Decreasing indicators were reported by the representative for the San Francisco area.
" Among all substance abuse treatment admissions, including those for whom alcohol was the primary drug in 2011, heroin ranked first in 3 of the 23 CEWG reporting areas: Baltimore City, Boston, and St. Louis. Heroin ranked second in three areas (Detroit, Maryland, and San Diego) among all treatment admissions. Heroin ranked third in five areas: Los Angeles, Minneapolis/St. Paul, New York City, San Francisco, and Seattle (table 2).
" In more than one-half (13) of the 24 CEWG areas, heroin items accounted for less than 10.0 percent of the drug reports from drug items seized and analyzed in forensic laboratories in 2011. As a proportion of total drug reports, heroin reports were highest in Baltimore City and lowest in Honolulu (figure 5). Heroin did not rank first or second among drug reports in the 24 reporting CEWG areas in 2011, with the exception of St. Louis, where heroin ranked second among total drug reports. Heroin placed third in the rankings of drug reports in 11 CEWG reporting areas. In the West, heroin ranked third in two of the nine reporting areas (Phoenix and Seattle). It ranked third in four of six areas in the Midwest (Chicago, Cincinnati, Detroit, and Michigan); in three of four northeastern areas (Boston, New York City, and Philadelphia); and in two of five southern CEWG areas (Baltimore City and Maryland) (table 1)."Source:"Epidemiologic Trends in Drug Abuse: Highlights and Executive Summary -- Proceedings of the Community Epidemiology Work Group, Vol. 1, June 2012" (Bethesda, MD: National Institute on Drug Abuse, June 2012), pp. 10-11.
(Law Enforcement and Treatment Indicators of Increasing Heroin Use in the US, 2011)
"Evidence of Increasing Heroin Use by Youth:
" Area representatives from Denver/Colorado, Los Angeles, San Diego, San Francisco, Seattle, and Texas reported on young heroin users in current indicator data, suggesting increases in proportions of young heroin treatment admissions. For example, in the Denver/Colorado area, the proportion of clients younger than age 25 increased from 13 percent of all heroin admissions in 2007 to 28 percent of all admissions in 2011. The proportion of clients in their twenties similarly increased in the Seattle area and the State of Texas, and the proportion of clients younger than age 35 increased in Los Angeles and San Diego. The New York City representative reported that although no quantitative indicator data were available at the time of reporting, field reports suggest an increase in youth heroin use in the city.
"Emergence of Heroin Indicators Outside Major Metropolitan Areas:
" Several area representatives reported on the emergence of heroin in indicators outside of major metropolitan areas where it has been traditionally reported. For instance, in Seattle, the area representative reported an increasing heroin presence in mid-size towns outside the Seattle/King County area. Increasing heroin use in the suburbs outside Chicago and New York City was reported by the area representatives from those urban centers. In Missouri, heroin was appearing in indicator data in rural areas outside of St. Louis, according to that area representative. Some area representatives also reported on a continuing relationship between heroin use and the use of prescription opioids."Source:"Epidemiologic Trends in Drug Abuse: Highlights and Executive Summary -- Proceedings of the Community Epidemiology Work Group, Vol. 1, June 2012" (Bethesda, MD: National Institute on Drug Abuse, June 2012), p. 11.
(Global Opiate Consumption) "The world consumes some 3,700 tons of illicit opium per year (1/3 raw and 2/3 processed into heroin) and seizes 1,000 tons."Source:United Nations Office on Drugs and Crime, "Addiction, Crime and Insurgency: The transnational threat of Afghan opium" (Vienna, Austria: October 2009), p. 7.
(Global Heroin Seizures, 2011) "The fluctuation in Afghan opium production affected the European market, which has seen decreased supply, owing in part to successful law enforcement activity, as well as to changes in trafficking flows. Heroin seizures have also decreased in Europe since 2009. In Western and Central Europe, greater access to treatment and alternatives to heroin, along with relatively smaller numbers of new heroin users, have contributed to a change in the structure of the European heroin market. While the decreased heroin supply also affected Eastern and South-Eastern Europe, structural changes on the demand side to the extent observed in Western and Central Europe were not reported in those subregions.
"Increased law enforcement activity, as reflected in the figures for global heroin seizures, also affected the supply to Europe, where heroin seizures declined by 28 per cent in 2011 to 16 tons, only half the amount seized in 2008 (29 tons). A decline was also noticed in heroin seizures in the Islamic Republic of Iran (by 15 per cent to 23 tons) and Turkey (by 43 per cent to 7 tons) in 2011, two countries on the Balkan route through which Afghan opiates reach Europe.
"Interestingly, heroin seizures had already started to decline in 2010 in Turkey and South-East Europe, despite the fact that they are further along the trafficking route than the Islamic Republic of Iran.
"EMCDDA argues that the decline in seizures reported in Turkey and the European Union in 2010 and 2011 could be a result of changes in both trafficking flows and law enforcement activity.65"
(Heroin Trafficking and Seizures in the Americas, 2011) "All countries in the Americas, except Canada, are supplied by heroin produced in the region. According to Government reports, the Canadian heroin market is supplied by heroin originating in Asia, mainly Afghanistan. Middle Eastern and Asian organized criminal groups both within Canada and abroad continued to be involved in the smuggling of heroin intended for Canada.78
"The available information on heroin production in Colombia and Mexico, two important supply countries for the United States market, is inconsistent and does not fully explain the heroin supply situation in the region, given that the potential cultivation is greater in Mexico, while the United States reports Colombia as its main supplier.79 There is insufficient information about the role played by heroin originating in Afghanistan for the United States market.
"In Colombia, between 2007 and 2011, 4 tons of heroin of unknown purity was seized, while potential production amounted to 6 tons of pure heroin. In 2010, the amount of heroin (of unknown quality) seized was even larger than the amount of potential production in the country. Allowing for lower purity of the seized heroin, this would indicate a very high seizure rate, which would leave only a small amount of heroin for local consumption and export. Though, with an annual prevalence of only 0.02 per cent among those aged 15-64 years, opiates are not widely used in the country, and the number of estimated opiate users is around 6,000.
"Official data show a strong decline in opium and heroin production in Colombia over the period 1998-2007 and further declines to 2011. However, heroin prices did not increase. Nominal prices for heroin at the wholesale level were lower in 2011 in both dollars and Colombian pesos, than they were five years before, suggesting that the supply of heroin did not drastically diminish.
"In comparison, in Mexico, potential heroin production is estimated to be 30 times higher than in Colombia, and heroin seizures reached the Colombian level in 2011. Despite this, and while acknowledging the growing importance of Mexico as a supply country for heroin reaching its market, the United States – on the basis of information from its Heroin Signature Program – continues to consider Colombia the primary source of heroin in the country,80 although heroin from South-West Asia continues to be available. The United States estimates poppy cultivation in Mexico at 12,000 hectares,81 with a correspondingly higher potential production of heroin.82
"It is unclear how Colombia, given its much lower potential production, could supply larger amounts to the United States market than Mexico. This points to heroin production in Colombia having a greater degree of importance than that reflected in the available potential production estimates, and/or different interpretations could be drawn from the United States Heroin Signature Program, since 'investigative reporting suggests that heroin producers in Mexico maybe using Colombian processing techniques'.83
(Health Risks from Heroin Use) "Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, and liver or kidney disease. Pulmonary complications, including various types of pneumonia, may result from the poor health of the abuser as well as from heroin’s depressing effects on respiration. In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs."Source:National Institute on Drug Abuse, DrugFacts: Heroin (Rockville, MD: US Department of Health and Human Services, Last Revised March 2010), last accessed Jan. 12, 2013.
(Mortality from Heroin Use) "The majority of drug deaths in an Australian study, conducted by the National Alcohol and Drug Research Centre, involved heroin in combination with either alcohol (40 percent) or tranquilizers (30 percent)."Source:Peele, Stanton, MD (1998), "The persistent, dangerous myth of heroin overdose," published in DPFT News (Drug Policy Forum of Texas), August, 1999, p. 5, from The Stanton Peele Addiction Website, last accessed June 8, 2013.
(Opioid Overdose Deaths in the US, 1999-2005) "There can be no doubt, however, that fatal opioid overdose, long a chronic health problem in the United States, is now a rapidly growing one.71 National surveillance data suggest that almost 83,000 Americans died from this form of overdose between 1999 to 2005, with over 16,000 fatalities in 2005 alone.72 Opioid overdose death has seen a sharp increase over the last decade, especially in the category of overdose from prescription medications.73 Because of gaps in the surveillance system, the actual figure is likely to be substantially higher."Source:Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 284.
(Opioid Withdrawal Syndrome) "The withdrawal syndrome usually includes symptoms and signs of CNS hyperactivity. Onset and duration of the syndrome depend on the specific drug and its half-life. Symptoms may appear as early as 4 h after the last dose of heroin, peak within 48 to 72 h, and subside after about a week. Anxiety and a craving for the drug are followed by increased resting respiratory rate (> 16 breaths/min), usually with diaphoresis, yawning, lacrimation, rhinorrhea, mydriasis, and stomach cramps. Later, piloerection (gooseflesh), tremors, muscle twitching, tachycardia, hypertension, fever and chills, anorexia, nausea, vomiting, and diarrhea may develop. Opioid withdrawal does not cause fever, seizures, or altered mental status. Although it may be distressingly symptomatic, opioid withdrawal is not fatal.
"The withdrawal syndrome in people who were taking methadone (which has a long half-life) develops more slowly and may be less acutely severe than heroin withdrawal, although users may describe it as worse. Even after the withdrawal syndrome remits, lethargy, malaise, anxiety, and disturbed sleep may persist up to several months. Drug craving may persist for years."Source:"Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Jan. 12, 2013.
(HIV and IDUs in Russia and Central Asia) "In terms of absolute numbers, the Russian Federation is particularly affected with its 1.5 million addict population. The hugely damaging threat of HIV/AIDS is directly related to heroin injection. To date, there are over a quarter of a million registered HIV cases (although the number of unregistered cases is estimated to be much higher than this) in the Russian Federation. Of these, over 80% are intravenous drug users. In the CARs [Central Asian Republics], nearly 15 years of continuous heroin transit has created a local market of 282,000 heroin users, consuming approximately 11 mt of heroin annually. Local opium consumption is estimated at approximately 34 mt (although demand in Turkmenistan may be underestimated). This puts some Central Asian states on par with countries with the highest global opiate abuse prevalence."
(Heroin Toxicity or Overdose) "The main toxic effect is decreased respiratory rate and depth, which can progress to apnea. Other complications (eg, pulmonary edema, which usually develops within minutes to a few hours after opioid overdose) and death result primarily from hypoxia. Pupils are miotic. Delirium, hypotension, bradycardia, decreased body temperature, and urinary retention may also occur.
"Normeperidine, a metabolite of meperidine, accumulates with repeated use (including therapeutic); it stimulates the CNS and may cause seizure activity."Source:"Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Feb. 16, 2013.
"A striking finding from the toxicological data was the relatively small number of subjects in whom morphine only was detected. Most died with more drugs than heroin alone 'on board', with alcohol detected in 45% of subjects and benzodiazepines in just over a quarter. Both of these drugs act as central nervous system depressants and can enhance and prolong the depressant effects of heroin."Source:Zador, Deborah, Sunjic, Sandra, and Darke, Shane, "Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances," The Medical Journal of Australia, 1996; 164 (4): 204-207.
"The disadvantage of continuing to describe heroin-related fatalities as 'overdoses' is that it attributes the cause of death solely to heroin and detracts attention from the contribution of other drugs to the cause of death. Heroin users need to be educated about the potentially dangerous practice of concurrent polydrug and heroin use."Source:Zador, Deborah, Sunjic, Sandra, and Darke, Shane, "Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances," The Medical Journal of Australia, 1996; 164 (4): 204-207.
(Adulterants) "If it is not pure drugs that kill, but impure drugs and the mixture of drugs, then the myth of the heroin overdose can be dangerous. If users had a guaranteed pure supply of heroin which they relied on, there would be little more likelihood of toxic doses than occur with narcotics administered in a hospital.
"But when people take whatever they can off the street, they have no way of knowing how the drug is adulterated. And when they decide to augment heroin's effects, possibly because they do not want to take too much heroin, they may place themselves in the greatest danger."
(Effectiveness of Heroin-Assisted Treatment Compared With Methadone Maintenance) "Diacetylmorphine was found to be a dominant strategy over methadone maintenance treatment in each time horizon studied (Table 2). Over a lifetime horizon, people in the methadone cohort lived 14.54 years on average following entry into the model, spending 8.79 years (60% of their remaining life) in treatment and 5.52 years in relapse. They accumulated 7.46 discounted QALYs and generated a societal cost of $1.14 million. People in the diacetylmorphine cohort lived 15.45 years on average, spending 10.41 years (67% of their remaining life) in treatment (2.34 years of which was in post-diacetylmorphine methadone treatment) and 4.05 years in relapse. They accumulated 7.92 discounted QALYs and generated a societal cost of $1.10 million. Based on these findings in the baseline model, over a lifetime horizon the provision of diacetylmorphine in the hypothetical cohort provided greater incremental health benefits and reduced the total costs to society compared with methadone maintenance treatment."Source:Bohdan Nosyk PhD., et al., "Cost-effectiveness of diacetylmorphine versus methadone for chronic opioid dependence refractory to treatment," Canadian Medical Association Journal, April 3, 2012, 184(6):E317-E328.
(Global Heroin Treatment Need and OD Deaths) "More than 60 per cent of drug treatment demand in Asia and Europe relate to opiates that are, especially heroin, the most deadly drugs. Deaths due to overdose are, in any single year, as high as 5,000-8,000 in Europe, and several times this amount in the Russian Federation alone."Source:United Nations Office on Drugs and Crime, "Addiction, Crime and Insurgency: The transnational threat of Afghan opium" (Vienna, Austria: October 2009, p. 7.
(Estimated Global Opium Production, 2012) "Production-wise, Afghanistan retained its position as the lead producer and cultivator of opium globally (74 per cent of global illicit opium production in 2012). While the global area under poppy cultivation rose by 15 per cent in 2012, driven largely by increases in Afghanistan and Myanmar, global opium production fell by almost 30 per cent, to less than 5,000 tons in 2012, mainly as a result of poor yields in Afghanistan. Mexico remained the largest
producer of opium in the Americas.
"It appears that opium production in the Lao People’s Democratic Republic and Myanmar may not be able to meet the demand posed by the increasing number of heroin users in some parts of Asia."
(Estimated Global Opium Production, 2012) "Afghanistan maintained its position as the lead producer and cultivator of opium globally. With a global total of over 236,000 hectares under cultivation, illicit cultivation of opium poppy reached peak levels in 2012, surpassing the 10-year high recorded in 2007. This was mainly the result of increases in Afghanistan and Myanmar (the two main producers). A preliminary assessment of opium poppy cultivation trends in Afghanistan in 2013 revealed that such cultivation is likely to increase in the main opium growing regions, which would be the third consecutive increase since 2010.62 Mexico remained the largest grower of opium poppy in the Americas. An overview of global potential production of opium and manufacture of heroin, as well as country data on opium poppy cultivation and eradication and opium production can be found in Annex II.
"The fluctuations which characterized opium production in Afghanistan in recent years, also affected Europe, the main market for opiates. Heroin use decreased in Western and Central Europe, which can be ascribed to a change in the structure of the market, which has seen decreased supply, increased law enforcement activity and an ageing user population, combined with an increase in the availability of treatment. However, the same does not apply to the non-medical use of prescription opioids."
Opiate Overdose Prevention and Treatment: Naloxone
(Naloxone As Overdose Prevention) "The heart of the challenge is the possibility that things could be different: overdose is a public health problem that can be solved. Unlike many of the other leading causes of death, death from opioid overdose is almost entirely preventable,21 and preventable at a low cost.22 Opioids kill by depressing respiration, a slow mode of death that leaves plenty of time for effective medical intervention.23 Overdose is rapidly reversed by the administration of a safe and inexpensive drug called naloxone. Naloxone strips clean the brain’s opioid receptors and reverses the respiratory depression causing almost immediate withdrawal.24 A growing number of harm reduction organizations in the United States are offering overdose prevention programs that provide injection drug users with resuscitation training and take-home doses of naloxone.25"Source:Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 277.
(Feasibility of Naloxone Distribution to Injection Drug Users (IDUs)) "This pilot trial is the first in North America to prospectively evaluate a program of naloxone distribution to IDUs to prevent heroin overdose death. After an 8-hour training, our study participants' knowledge of heroin overdose prevention and management increased, and they reported successful resuscitations during 20 heroin overdose events. All victims were reported to have been unresponsive, cyanotic, or not breathing, but all survived. These findings suggest that IDUs can be trained to respond to heroin overdose by using CPR and naloxone, as others have reported. Moreover, we found no evidence of increases in drug use or heroin overdose in study participants. These data corroborate the findings of several feasibility studies recommending the prescription and distribution of naloxone to drug users to prevent fatal heroin overdose."Source:Seal, Karen H., Robert Thawley, Lauren Gee, Joshua Bamberger, Alex H. Kral, Dan Ciccarone, Moher Downing, and Brian R. Edlin, "Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study," Journal of Urban Medicine (New York, NY: New York Academy of Medicine, 2005), Vol. 82, No. 2, p. 308.
(Benefits from Naloxone Distribution) "Naloxone distribution to heroin users would be expected to reduce mortality and be cost-effective even under markedly conservative assumptions of use, effectiveness, and cost. Although the absence of randomized trial data on naloxone distribution and reliance on epidemiologic data increase the uncertainty of results, there are few or no scenarios in which naloxone would not be expected to increase QALYs [Quality-Adjusted Life-Years] at a cost much less than the standard threshold for cost-effective health care interventions. Ecological data, in fact, suggest that naloxone distribution may have far greater benefits than those forecast in this model: Reductions in community-level overdose mortality from 37% to 90% have been seen concordant with expanded naloxone distribution in Massachusetts (7), New York City (11), Chicago (10), San Francisco (9, 67, 68), and Scotland (69). Such a result is approached in this model only by maximizing the likelihood of naloxone use or by assuming that naloxone distribution reduces the risk for any overdose. Preliminary data showing that naloxone distribution is associated with empowerment and reduced HIV risk behaviors (70, 71) suggest that future research is needed to test these hypotheses."Source:Coffin, Phillip O., MD, and Sullivan, Sean D. PhD, "Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal," Annals of Internal Medicine 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.
(Rapid Effect)"Heroin is particularly toxic because of high lipid solubility, which allows it to cross the blood–brain barrier within seconds and achieve high brain levels.10
"Naloxone is also lipid soluble and enters the brain rapidly. Reversal of respiratory depression is evident 3–4 minutes after IV and 5–6 minutes after subcutaneous administration.11"Source:Etherington, Jeremy; Christenson, James; Innes, Grant; Grafstein, Eric; Pennington, Sarah; Spinelli, John J.; Gao, Min; Lahiffe, Brian; Wanger, Karen; Fernandes, Christopher, "Is early discharge safe after naloxone reversal of presumed opioid overdose?" Canadian Journal of Emergency Medicine (Ottawa, ON: Canadian Association of Emergency Physicians, July 2000), p. 160.
(Barriers to Naloxone Access) "A more prosaic, but no less important, legal barrier to widespread naloxone access is the Food and Drug Administration’s (FDA) classification of naloxone as a prescription drug. This means that public health and harm reduction agencies cannot distribute naloxone like condoms or sterile syringes. Instead, naloxone must be prescribed by a properly licensed health care provider after an individualized evaluation of the patient. Because health care providers have to be involved, naloxone programs must deal with concerns about liability, which among doctors can be powerful even when they are not wellfounded in fact.31 The prescription status raises the cost of naloxone distribution and makes it illegal to give naloxone to lay people willing to administer the drug to others suffering an overdose."Source:Burris, Scott; Beletsky, Leo; Castagna, Carolyn; Coyle, Casey; Crowe, Colin; and McLaughlin, Jennie Maura, "Stopping an Invisible Epidemic: Legal Issues in the Provision of Naloxone to Prevent Opioid Overdose," Drexel Law Review (Philadelphia, PA: Earle Mack School of Law, Spring 2009), Vol. 1, Number 2, p. 278.
(Effectiveness of Naloxone Against Overdoses) "Treatment with naloxone can reverse respiratory failure within a few minutes (Darke and Hall, 1997; Physician’s Desk Reference, 2000). Naloxone is an opiate antagonist, and is thought to displace heroin at the Mu2 receptors. Physicians and emergency personnel treat patients suspected of heroin overdose by administering an initial dose of naloxone parenterally. While 2 mg are almost always sufficient to revive a patient, additional doses can be administered if the desired improvement does not occur, and smaller doses are often used to minimize the discomfort of sudden heroin withdrawal (Physician’s Desk Reference, 2000). In adults, naloxone has a half-life of between 30 and 81 minutes (Physician’s Desk Reference, 2000). Therefore, repeated administration could be necessary to reverse the effect of particularly large or long-lasting doses of heroin. (Sporer, 1999; Physician’s Desk Reference, 2000). In practice, however, a single 2 mg does is almost always sufficient. If a patient has not taken opioids, naloxone has no pharmacological effect (Darke and Hall, 1997).
"While administration of naloxone may produce acute withdrawal symptoms in patients with heroin dependence (Physician’s Desk Reference, 2000), the drug does not have long-term or life threatening adverse effects when it is administered at therapeutic doses (Strang, et al, 1996). Naloxone has been associated with complications such as seizures and arrhythmia, (Physician’s Desk Reference, 2000) but more recent research suggests that complications are exceedingly rare, that past reports of complications may have been erroneous (Goldfrank and Hoffman, 1995), or that complications occur, if at all, in patients with pre-existing heart disease (Goldfrank and Hoffman, 1995). Naloxone is not addictive, and has no psycho-pharmacological effects."Source:Burris, Scott; Norland, Joanna; and Edlin, Brian, "Legal Aspects of Providing Naloxone to Heroin Users in the United States," International Journal of Drug Policy, 2001, Vol. 12, pp. 237-48.
(Cost-Effectiveness of Naloxone Distribution) "Naloxone distribution was cost-effective in our base-case and all sensitivity analyses, with incremental costs per QALY [Quality-Adjusted Life-Year] gained much less than $50 000 (Table 2 and Appendix Figure 3, available at www.annals.org; see Appendix Table 3, available at www.annals.org, for detailed results of selected analyses). Cost-effectiveness was similar at starting ages of 21, 31, and 41 years; the greater QALY gains of younger persons were roughly matched by higher costs. In scenarios where naloxone administration reduced reliance on EMS, naloxone distribution was cost-saving and dominated (that is, less costly and more effective than) the no-distribution comparison. Cost-effectiveness was somewhat sensitive to the efficacy of lay-administered naloxone and the cost of naloxone but was relatively insensitive to the breadth of naloxone distribution, rates of overdose and other drug-related death, rates of abstinence and relapse, utilities, or the absolute cost of medical services. Naloxone was no longer cost-effective if the relative increase in survival was less than 0.05%, if 1 distributed kit cost more than $4480, or if average emergency care costs (as a proxy for downstream health costs) exceeded $1.1 million. A worst-case scenario, in which the likelihood of an overdose being witnessed, the effectiveness of naloxone, and the likelihood of naloxone being used were minimized and the cost of naloxone was maximized, resulted in an incremental cost of $14,000 per QALY gained. A best-case scenario, in which naloxone distribution reduced the risk for overdose, was dominant."Source:Coffin, Phillip O., MD, and Sullivan, Sean D. PhD, "Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal," Annals of Internal Medicine 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.
(Effectiveness of Enforcement) "Similar evidence of the drug war’s failure is provided by US drug surveillance data. For example, from 1981 to 2011, the budget of the US Office of National Drug Control Policy increased by more than 600 percent (inflation-adjusted). However, despite increasing annual multibillion dollar investments in drug control, US government data suggest an approximate inflation- and purity-adjusted decrease in heroin price of 80 percent, and a greater than 900 percent increase in heroin purity between 1981 and 2002, clearly indicating that expenditures on interventions to reduce the supply of heroin into the United States were unsuccessful."Source:"The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic," Global Commission on Drug Policy (Rio de Janeiro, Brazil: June 2012), p. 11.
(Non-Injection Means of Ingestion a Reason for Growth in Use) "We do think that the expansion in the world supply of heroin, particularly in the 1990s, had the effect of dramatically raising the purity of heroin available on the streets, thus allowing for new means of ingestion. The advent of new forms of heroin, rather than any change in respondents’ beliefs about the dangers associated with injecting heroin, very likely contributed to the fairly sharp increase in heroin use in the 1990s. Evidence from this study, showing that a significant portion of the self-reported heroin users in recent years are using by means other than injection, lends credibility to this interpretation."Source:Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E., Monitoring the Future national survey results on drug use, 1975–2011: Volume I, Secondary school students," Institute for Social Research (Ann Arbor, Michigan: The University of Michigan, 2012), 433.
(Acute Effects) "Acute intoxication is characterized by euphoria and drowsiness. Mast cell effects (eg, flushing, itching) are common, particularly with morphine. GI [gastro-intestinal] effects include nausea, vomiting, decreased bowel sounds, and constipation."Source:"Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Jan. 12, 2013.
(Chronic Effects) "Tolerance develops quickly, with escalating dose requirements. Tolerance to the various effects of opioids frequently develops unevenly. Heroin users, for example, may become relatively tolerant to the drug's euphoric and respiratory depression effects but continue to have constricted pupils and constipation.
"A minor withdrawal syndrome may occur after only several days' use. Severity of the syndrome increases with the size of the opioid dose and the duration of dependence.
"Long-term effects of the opioids themselves are minimal; even decades of methadone use appear to be well tolerated physiologically, although some long-term opioid users experience chronic constipation, excessive sweating, peripheral edema, drowsiness, and decreased libido. However, many long-term users who inject opioids have adverse effects from contaminants (eg, talc) and adulterants (eg, nonprescription stimulant drugs) and cardiac, pulmonary, and hepatic damage due to infections such as HIV infection and hepatitis B or C, which are spread by needle sharing and nonsterile injection techniques (see Drug Use and Dependence: Injection Drug Use)."Source:"Opioids," The Merck Manual for Health Care Professionals, Special Subjects: Drug Use and Dependence, Opioids (Merck & Co. Inc., last revised July 2008), last accessed Jan. 12, 2013.
(Health Risks) "Unlike alcohol or tobacco, heroin causes no ongoing toxicity to the tissues or organs of the body. Apart from causing some constipation, it appears to have no side effects in most who take it. When administered safely, its use may be consistent with a long and productive life. The principal harm comes from the risk of overdose, problems with injecting, drug impurities and adverse legal or financial consequences."
(Price of Heroin) In 2010, a kilogram of heroin typically sold for an average wholesale price of $2,527.60 in Pakistan. The 2010 wholesale price for a kilogram of heroin in Afghanistan ranged around $2,266. In Colombia, a kilogram of heroin typically sold for $10,772.3 wholesale in 2010. In the United States in 2010, a kilogram of heroin ranged in price between $33,000-$100,000.Source:UN Office on Drugs and Crime, World Drug Report 2012 (United Nations publication, Sales No. E.12.XI.1), Opioids: Retail and wholesale prices by drug type and country (2010 or latest available year)
(The Emergence of 'Krokodil') "In the last three to five years an increasing number of reports suggest that people who inject drugs (PWID) in Russia, Ukraine and other countries are no longer using poppies or raw opium as their starting material, but turning to over-the-counter medications that contain codeine (e.g. Solpadeine, Codterpin or Codelac). Codeine is reportedly converted into desomorphine (UNODC, 2012; Gahr et al., 2012a, 2012b, 2012c; Skowronek, Celinski, & Chowaniec, 2012). The drug is called Russian Magic, referring to its potential for short lasting opioid intoxication or, more common, to its street name, krokodil. Krokodil refers both to chlorocodide, a codeine derivate, and to the excessive harms reported, such as the scale-like and discolored (green, black) skin of its users, resulting from large area skin infections and ulcers. At this point, Russia and Ukraine seem to be the countries most affected by the use of krokodil, but Georgia (Piralishvili, Gamkrelidze, Nikolaishvili, & Chavchanidze, 2013) and Kazakhstan (Ibragimov & Latypov, 2012; Yusopov et al., 2012) have reported krokodil use and related injuries as well."Source:Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.04.007
(Krokodil Production) "In considering the drug krokodil, two aspects are of importance, its pharmacology and its chemistry. The short half-life, limited high after the impact effect and, in particular the need for frequent administration may narrow the attention of users on the (circular) process of acquiring, preparing and administering the drug, leaving little time for matters other than avoiding withdrawal and chasing high, as reported in several popular magazines (e.g. Shuster, 2011; Walker, 2011). However, when the layers of bootleg chemistry and attribution are peeled off, what’s left is an opioid analogue (or several ones) that, besides the variations in half-life, behaves pharmacologically not very different than heroin or Hanka (Haemmig, 2011). There are various paths to synthesize desomorphine from codeine, but the chemical process most commonly reported to be used by PWID in Russia and Ukraine is very similar to that of home-produced methamphetamine or Vint (Grund, Zábransky, Irwin, & Heimer, 2009; Zábransky, 2007) – a rudimentary version of a simple chemical reduction. The illicit production of krokodil reportedly involves the processing of codeine into the opiate analogue desomorphine (UNODC, 2012; Gahr et al., 2012a, 2012b, 2012c; Skowronek et al., 2012). Desomorphine (Dihydrodesoxymorphine-D or PermonidTM ) is an opiate analogue first synthesized by Small in 1932 (Small, Yuen, & Eilers, 1933). The analgesic effect of desomorphine is about ten times greater than that of morphine (and thus stronger than heroin), whereas its toxicity exceeds that of morphine by about three times (Weill & Weiss, 1951). The drug’s onset is described as very rapid but its action is of short duration, which may lead to rapid physical dependence and frequent administration."Source:Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.04.007
(Harms Associated with Krokodil Use) "In recent years, harm reduction and drug treatment services from Russia, Ukraine, Georgia and Kazakhstan began reporting severe health consequences associated with krokodil injecting. Although serious localized and systemic harms have previously been associated with injecting homemade opiates and stimulants in the region (Grund, 2002; Volik, 2008), the harms associated with krokodil injecting are extreme and unprecedented. The most common complications of krokodil appear to be serious venous damage and skin and soft tissue infections, rapidly followed by necrosis and gangrene (Gahr et al., 2012a, 2012b, 2012c; Skowronek et al., 2012). Our research further identified an impressive, undoubtedly incomplete, list of injuries and symptoms (Table 1), reported in the media (e.g. Shuster, 2011; Walker, 2011) and identified in YouTube clips and photographs on the internet. Importantly, this list includes several parts of the body that are not typically used as sites for injecting drugs. This suggests that the ill effects of krokodil are not limited to localized injuries, but spread throughout the body (Shuster, 2011; UNODC, 2012), with neurological, endocrine and organ damage associated with chemicals and heavy metals common to krokodil production (Lisitsyn, 2010).
"It is important to note that the described harms seem to become manifest relatively shortly after krokodil injecting is initiated. Present accounts of krokodil related harms often concern young people presenting in emergency rooms and surgeries with extreme and advanced complications. According to NGOs that work with people who inject krokodil, these young people have relatively short histories of using the drug. Mortality rates among young krokodil users are reportedly high (Akhmedova, 2012; Shuster, 2011; Walker, 2011), with official reports associating krokodil use with half of all drug-related deaths in at least two Oblasts (Walker, 2011)."Source:Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.04.007
(Prevalence of Krokodile Use) "The estimated number of PWID in Russia was close to 2 million in 2008 (Mathers et al., 2008). 2.3% of the Russian population uses opioids annually and 1.4% heroin, compared to an annual prevalence of 0.4% opioid use in Western and Central Europe (UNODC, 2012). While actual epidemiological data is not available, a number of academic and media reports suggest that 5% or more of Russian drug users (approximately 100,000 PWID) may be injecting krokodil (Walker, 2011), while 'various official estimates' place the numbers of Russian PWID using krokodil as high as one million (Shuster, 2011). Epidemiological data is critical to evaluating claims that the use of krokodil is reaching epidemic proportions in Russia (Walker, 2011), and potentially, the Ukraine. There are an estimated 290,000 to 375,000 PWID in Ukraine (Mathers et al., 2008). A recent national survey found that 7% of PWID have used krokodil in 2011 (Balakireva, 2012), suggesting that around 20,000 PWID in Ukraine may have used krokodil that year. Balakireva and colleagues furthermore found statistically significant differences in krokodil use between the cities in the study, with most krokodil use reported in Uzhhorod (35.6%), Simferopol (26.9%), Kyiv (21.7%), Chernivtsi (15.5%) and Donetsk (12.6%). Estimates from other countries are not available. Outside of the former Soviet region, krokodil has been reported in Germany (Der Spiegel, 2011) and in Tromsø in northern Norway (Lindblad, 2012)."Source:Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.04.007
(Krokodil - Reasons and Risks) "In sum, these observations suggest that the relatively limited availability of black market opiates and stimulants and the relative ease of harvesting legal precursors to powerful analogues from the countryside and pharmacies inspired and sustained a Soviet-style homemade drug culture in the Eastern European region that remains radically different from those observed in countries where narco-traffickers dominate the production and distribution of drugs (Booth, Kennedy, Brewster, & Semerik, 2003; Grund et al., 2009; Grund, 2005; Subata & Tsukanov, 1999; Zábransky, 2007).
"The physical and logistical exigencies of home production; its locus in networks of drug injecting friends and the high degree of cooperative action involved (in foraging for, producing and using the drugs); the multiple roles and ambiguous status of injecting paraphernalia; the routine occurrence of well-known risk behaviours (e.g. syringe sharing, frontloading) and those currently less well understood, such as the slapdash nature of the bootleg drug synthesis and its unpredictable outcomes in terms of actual drug product, purity and pollution— indeed all of these factors contribute to and interact within the vastly complex high risk environment of home drug production in the region."Source:Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.04.007
(Stigmatization and Inhumane Treatment of Krokodil Users) "In Russia and many other post-Soviet countries, the old ideology lingers on in narcological institutes, out of sync with modern public and mental health concepts (Grund et al., 2009). Many narcologists continue to view addiction as criminal or moral deviance and not as a disease. Narcological dispensaries continue to share information with law enforcement (Mendelevich, 2011). The threat of removal of child custody rights may impede women’s access to health care in particular (Shields, 2009). Stigma and discrimination, hostile treatment and lack of confidentiality are persistent in the treatment of PWID and must be viewed as important barriers to timely seeking medical care (Beardsley & Latypov, 2012; Mendelevich, 2011; Wolfe et al., 2010). PWID have therefore strong incentives to avoid narcological facilities and, by association, other state health services. In their personal 'hierarchy of risk,' seeking help for significant health problems is subordinated by the need to stay under the radar of the authorities (Connors, 1992). Several of the YouTube clips on the internet furthermore document not only the gravity of harms among krokodil users, but also poor and inhumane treatment of those hospitalized with krokodil related injuries. In one video a man’s leg is sawn off under the knee with a lint saw in what seems not to be a surgical unit, but perhaps a common hospital ward. The man sits wide-awake in an ordinary wheelchair and holds his leg himself above a bucket, which was lined with a garbage bag just before. These videos and case reports (Asaeva et al., 2011; Daria Ocheret, personal communication, 2012; Sarah Evans, personal communication, 2012) suggest that the care provided to those with krokodil related injuries may be (grossly) substandard, sometimes exacerbated by improper diagnosis and faulty clinical decisions."Source:Grund, J. -P. C., et al. "Breaking worse: The emergence of krokodil and excessive injuries among people who inject drugs in Eurasia." International Journal of Drug Policy (2013), http://dx.doi.org/10.1016/j.drugpo.2013.04.007
Laws and Policies
(Sentences) Possible federal sentences for heroin possession include:
Amount: 1 kilogram or more of a mixture or substance containing a detectable amount of heroin.
Sentence: Not less than 10 years or more than life. No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment.
Amount: 100 grams or more of a mixture or substance containing a detectable amount of heroin.
Sentence: Not less than 5 years and not more than 40 years. No person sentenced under this subparagraph shall be eligible for parole during the term of imprisonment.Source:"Title 21 United States Code (USC) Controlled Substances Act, From the U.S. Code Online via GPO Access [www.gpoaccess.gov] [Laws in effect as of January 3, 2007]" (21USC841), last accessed June 4, 2013.
In November 1997, the National Institutes of Health (NIH) convened a Consensus Panel on Effective Medical Treatment of Heroin Addiction. The panel of national experts concluded:
" Vigorous and effective leadership is needed within the Office of National Drug Control Policy (ONDCP) (and related Federal and State agencies) to inform the public that dependence is a medical disorder that can be effectively treated with significant benefits for the patient and society.
" Society must make a commitment to offering effective treatment for opiate dependence to all who need it.
" The panel calls attention to the need for opiate-dependent persons under legal supervision to have access to MMT [methadone maintenance treatment]. The ONDCP and the U.S. Department of Justice should implement this recommendation.
" The panel recommends improved training of physicians and other health care professionals in diagnosis and treatment of opiate dependence. For example, we encourage the National Institute on Drug Abuse and other agencies to provide funds to improve training for diagnosis and treatment of opiate dependence in medical schools.
" The panel recommends that unnecessary regulation of MMT and all long-acting agonist treatment programs be reduced.
" Funding for MMT should be increased.
" We advocate MMT as a benefit in public and private insurance programs, with parity of coverage for all medical and mental disorders.
" We recommend targeting opiate-dependent pregnant women for MMT.
" MMT must be culturally sensitive to enhance a favorable outcome for participating African American and Hispanic persons.
" Patients, underrepresented minorities, and consumers should be included in bodies charged with policy development guiding opiate dependence treatment.
" We recommend expanding the availability of opiate agonist treatment in those States and programs where this treatment option is currently unavailable."Source:"Effective Medical Treatment of Opiate Addiction," NIH Consensus Statement 1997, Nov 17-19 (Washington, DC: National Institutes of Health), 15(6), p. 24.
(Naloxone Programs) "Naloxone distribution programs in the US are ongoing in Chicago, Baltimore, San Francisco, New Mexico and New York City. Additional community-based organizations interested in minimizing the adverse consequences of drug use in several cities in the US, including Los Angeles, Providence, Pittsburgh and Boston, are in the process of planning and developing naloxone administration programs for drug users."Source:Tinka Markham Piper, Sasha Rudenstine, Sharon Stancliff, Susan Sherman, Vijay Nandi1 Allan Clear and Sandro Galea. "Overdose prevention for injection drug users: Lessons learned from naloxone training and distribution programs in New York City," Harm Reduction Journal (January 25, 2007).
(Heroin Assisted Treatment vs Methadone Maintenance) "The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."Source:Naber, Dieter, and Haasen, Christian, Centre for Interdisciplinary Addiction Research of Hamburg University, "The German Model Project for Heroin Assisted Treatment of Opioid Dependent Patients -- A Multi-Centre, Randomised, Controlled Treatment Study: Clinical Study Report of the First Study Phase," January 2006, p. 122.
(Effectiveness of Heroin-Assisted Treatment [HAT] and Overview of Research) "A few key conclusions and discussion points regarding the state and future of HAT (heroin-assisted treatment) can be offered based on the above review of completed or ongoing studies.
"First, although the basic goal of the different HAT studies is similar, each of the studies is distinct in key aspects, thus limiting direct comparisons and meta-analyses.40 Although this might be a desirable goal for science, it should be noted that heroin addiction and its consequences occur in distinct real-life environments (including unique cultural and system factors), and interventions need to be devised, measured, and evaluated within these to have authentic relevance for policy and practice.33,41
"Second, the discussed studies above have demonstrated in several different contexts that the implementation of HAT is feasible, effective, and safe as a therapeutic intervention.21,24,26,30 This should not be seen as a conclusion that could be taken for granted because many observers expected disastrous consequences from the provision of medical heroin prescription.
"Third, even within the contexts of relevant methodological constraints, e.g., the Swiss study relying purely on prospective observational data, and most of the other RCTs comparing HAT outcomes against a control intervention (MMT), which participants have previously either rejected by choice or proven to be ineffective, 32,42 the reviewed HAT studies have demonstrated rather robust and consistently positive therapeutic outcomes on the various indicators chosen for a population of high-risk heroin addicts for whom currently no effective alternative therapies are available. Clearly, this demonstrated effectiveness is at this point limited to short-term outcomes, and long-term examinations ought to follow (albeit Swiss follow-up data present initial positive evidence in this regard).43 It may very well emerge that HAT's main long-term benefit does not materialize through life-long maintenance, but by stabilizing and readying many of its patients for other simpler therapeutic interventions or even abstinence.
"Fourth, also given the current expansion and diversification of alternative oral opioid maintenance therapies (e.g., buprenorphine and morphine) and considering the complex logistics (on both providers and patients_ ends), high costs, and sociopolitical controversy around (especially injection) HAT, the most sensible role of HAT is likely that of an exceptional 'last resort' option for heroin addicts who cannot be effectively attracted into or treated in other available therapeutic interventions.44,45 Granted the above, the primary emerging challenge for science—rather than conducting new and more HAT effectiveness studies—is to provide evidence-based guidelines on how to effectively match existing heroin addict profiles and needs with existing treatment options. This challenge has recently been complicated—in at least some jurisdictions—with the increasing diversification of heroin into poly-opioid (e.g., prescription) use profiles.46
"Finally, after extensive HAT research efforts over the past decade, the principal onus of action has shifted from the scientific to the political arena in the jurisdictions under study.12,18 Despite the overall positive results of completed HAT trials undoubtedly justifying some role of HAT in the addiction treatment landscape, authorities in only two countries, Switzerland and the Netherlands, have decisively acted on this issue.34"Source:Benedikt Fischer, Eugenia Oviedo-Joekes, Peter Blanken, Christian Haasen, Jurgen Rehm, Martin T. Schechter, John Strang, and Wim van den Brink, "Heroin-assisted Treatment (HAT) a Decade Later: A Brief Update on Science and Politics," Journal of Urban Health: Bulletin of the New York Academy of Medicine, (2007) Vol. 84, No. 4, pp. 559-560.