Heroin

1. "Heroin is processed from morphine, a naturally occurring substance extracted from the seedpod of the Asian poppy plant. Heroin usually \ appears as a white or brown powder. Street names for heroin include 'smack,' 'H,' 'skag,' and 'junk.' Other names may refer to types of heroin produced in a specific geographical area, such as 'Mexican black tar.'"

   Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

2. "Acute intoxication (overdose) is characterized by euphoria, flushing, itching (particularly with morphine), miosis, drowsiness, decreased respiratory rate and depth, hypotension, bradycardia, and decreased body temperature."

   Source: "Opioids," The Merck Manual, Section 15: Psychiatric Disorders, Chapter 198: Drug Use and Dependence, Merck & Co. Inc., from the web at http://www.merck.com/mmpe/sec15/ch198/ch198l.html last accessed May 24, 2007.

3. "Complications of heroin addiction may be related to the unsanitary administration of the drug or to the drug's inherent properties, overdose, or intoxicated behavior accompanying drug use. Common complications are pulmonary, bone, and neurologic disorders; hepatitis; and immunologic changes."

   Source: "Opioids," The Merck Manual, Section 15: Psychiatric Disorders, Chapter 198: Drug Use and Dependence, Merck & Co. Inc., from the web at http://www.merck.com/mmpe/sec15/ch198/ch198l.html last accessed May 24, 2007.

4. "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 ('rush') accompanied by a warm flushing of the skin, a dry mouth, and heavy extremities. Following this initial euphoria, the user goes 'on the nod,' an alternately wakeful and drowsy state. Mental functioning becomes clouded due to the depression of the central nervous system. Long-term effects of heroin appear after repeated use for some period of time. Chronic users may develop collapsed veins, infection of the heart lining and valves, abscesses, cellulitis, and liver disease. Pulmonary complications, including various types of pneumonia, may result from the poor health condition of the abuser, as well as from heroin’s depressing effects on respiration.
   "Heroin abuse during pregnancy and its many associated environmental factors (e.g., lack of prenatal care) have been associated with adverse consequences including low birth weight, an important risk factor for later developmental delay."

   Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

5. "In addition to the effects of the drug itself, street heroin may have additives 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."

   Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

6. "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, published on the web at http://www.mja.com.au/public/issues/feb19/zador/zador.html last accessed on May 24, 2007.

7. "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.

8. "Our findings that an ambulance was called while the subject was still alive in only 10% of cases, and that a substantial minority of heroin users died alone, strongly suggest that education campaigns should also emphasise that it is safer to inject heroin in the company of others, and important to call for an ambulance early in the event of an overdose. Consideration should also be given to trialling the distribution of the opioid antagonist naloxone to users to reduce mortality from 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, published on the web at http://www.mja.com.au/public/issues/feb19/zador/zador.html last accessed on May 24, 2007.

9. "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, published on the web at http://www.mja.com.au/public/issues/feb19/zador/zador.html last accessed on May 24, 2007.

10. "A first priority for prevention must be to reduce the frequency of drug overdoses. We should inform heroin users about the risks of combining heroin with alcohol and other depressant drugs. Not all users will act on such information, but if there are similar behavioral changes to those that occurred with needle-sharing overdose deaths could be substantially reduced. Heroin users should also be discouraged from injecting alone and thereby denying themselves assistance in the event of an overdose."

    Source: Dr. W.D. Hall, "How can we reduce heroin 'overdose' deaths?" The Medical Journal of Australia (MJA 1996; 164:197), from the web at http://www.mja.com.au/public/issues/feb19/hall/hall.html last accessed on May 24, 2007.

11. "Physical dependence necessitates continued use of the same opioid or a related one to prevent withdrawal. Withdrawal of the drug or administration of an antagonist precipitates a characteristic, self-limited withdrawal syndrome. "Therapeutic doses taken regularly over 2 to 3 days can lead to some tolerance and dependence, and when the drug is stopped, the user may have mild withdrawal symptoms which are scarcely noticed or are flu-like."

    Source: "Opioids," The Merck Manual, Section 15: Psychiatric Disorders, Chapter 198: Drug Use and Dependence, Merck & Co. Inc., from the web at http://www.merck.com/mmpe/sec15/ch198/ch198l.html last accessed May 24, 2007.

12. "Withdrawal, which in regular abusers may occur as early as a few hours after the last administration, produces drug craving, restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps ('cold turkey'), kicking movements ('kicking the habit'), and other symptoms. Major withdrawal symptoms peak between 48 and 72 hours after the last dose and subside after about a week. Sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal, although heroin withdrawal is considered less dangerous than alcohol or barbiturate withdrawal."

    Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

13. "There is a broad range of treatment options for heroin addiction, including medications as well as behavioral therapies. Science has taught us that when medication treatment is integrated with other supportive services, patients are often able to stop heroin (or other opiate) use and return to more stable and productive lives."

    Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

14. "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 that opiate drug addictions are diseases of the brain and medical disorders that indeed can be treated effectively. The panel strongly recommended (1) broader access to methadone maintenance treatment programs for people who are addicted to heroin or other opiate drugs; and (2) the Federal and State regulations and other barriers impeding this access be eliminated. This panel also stressed the importance of providing substance abuse counseling, psychosocial therapies, and other supportive services to enhance retention and successful outcomes in methadone maintenance treatment programs. The panel's full consensus statement is available by calling 1-888-NIH-CONSENSUS (1-888-644-2667) or by visiting the NIH Consensus Development Program Web site at consensus.nih.gov."

    Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

15. "Methadone, a synthetic opiate medication that blocks the effects of heroin for about 24 hours, has a proven record of success when prescribed at a high enough dosage level for people addicted to heroin. Other approved medications are naloxone, which is used to treat cases of overdose, and naltrexone, both of which block the effects of morphine, heroin, and other opiates."

    Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

16. "These pilot study findings showed that opiate-dependent injecting drug users with long injecting careers (most started between 1970 and 1982) and for whom opiate treatment had failed multiple times previously were attracted into and retained by therapy with injectable opiates."

    Source: Metrebian, Nicky, Shanahan, William, Wells, Brian, and Stimson, Gerry, "Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users; associated health gains and harm reductions," The Medical Journal of Australia (MJA 1998; 168: 596-600), from the web at http://www.mja.com.au/public/issues/jun15/mtrebn/mtrebn.html last accessed on May 24, 2007.

17. "Prescribing injectable opiates is one of many options in a range of treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health and social status, our findings endorse the view that it is a feasible option."

    Source: Metrebian, Nicky, Shanahan, William, Wells, Brian, and Stimson, Gerry, "Feasibility of prescribing injectable heroin and methadone to opiate-dependent drug users; associated health gains and harm reductions," The Medical Journal of Australia (MJA 1998; 168: 596-600), from the web at http://www.mja.com.au/public/issues/jun15/mtrebn/mtrebn.html last accessed on May 24, 2007.

18. "The 2003 NSDUH reports stability at low levels for heroin use among young people. In 2002, 13,000 youth between the ages of 12 and 17 had used heroin at least once in the past year ("annual" use), compared with 12,000 in 2003. Among the general population age 12 and older, 404,000 had used annually in 2002, compared with 314,000 in 2003."

    Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

19. "In December 2003, CEWG [Community Epidemiology Work Group] members reported that heroin indicators were mixed but relatively stable, continuing at higher levels in Northeastern, north-central, and mid- Atlantic areas where high-purity powder is available, and also in the Northwest where black tar heroin predominates. Heroin injection and the health risks associated with it, such as the spread of HIV/AIDS and hepatitis C, are of growing concern at several CEWG sites. In 2002, rates of heroin emergency department mentions exceeded 200 per 100,000 in Chicago, Newark, and Baltimore and exceeded 100 per 100,000 in Seattle, New York City, San Francisco, Boston, and Philadelphia. The reporting of heroin/opiate-related deaths was highest in Detroit (464) and Philadelphia (111)."

    Source: National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services), from the web at http://www.nida.nih.gov/infofacts/heroin.html last accessed January 9, 2006.

Perspectives from Experts in the Field of Narcotics Treatment