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1 Opiates Heroin/Prescription Steve Hanson

2 Opiates Dates to 4,000 BC Mimics endorphin activity Natural - Opium, morphine, codeine Semi-synthetic- Heroin, Dilaudid Synthetics - Darvon, Demerol, Fentanyl

3 Modern History Off and on use through until the 60 s Man with the Golden Arm Vietnam war soldiers using heroin 1970 s increased prevalence urban areas Treatment programs Methadone Maintenance / Therapeutic Communities 1980 s Hard to find substitutes 1990 s resurgence

4

5 Heroin Chic

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7 Take the best orgasm you ve ever had Multiply it by a thousand. And you re still nowhere near it.

8 Opiates Heroin more potent % - <10% in 70 s Younger age group - High School Users start with snorting - IV within 12 months Withdrawal painful - not deadly

9 NATURAL OPIATES OPIUM Morphine Codeine Thebaine

10 Semi-synthetics ti Morphine Heroin Dilaudid

11

12 Synthetics Demerol Fentanyl Methadone Darvon

13 Opiates Fat solubility Heroin high rush Morphine lower longer onset Heroin metabolized into morphine Morphine metabolized by the liver Metabolite is 10-20X more powerful Detectable in urine for 2-4 days

14 The Action of Heroin (Morphine)

15 Tolerance Rapid tolerance with continued use Initial dose of 50mg/day can go to 500mg/day in as little as 10 days Cell sensitivity thought to be the tolerance mechanism.

16 Addiction/Dependency Opioids trigger reward system euphoria leads to continued use addiction Withdrawal symptoms are significant regular use to avoid withdrawal - dependence

17 Opiates & Reward Pathway

18 Opiates Increase DA Release

19 Opiate Effects Analgesia - change in pain perception p Euphoria - whole body orgasm Sedation - on the nod Respiratory Depression - OD Cough Suppression Nausea/vomiting Constipation

20 Withdrawal Pain Depression Alert Rapid Breathing Coughing Nausea/Vomiting Diarrhea 3-5 days

21 Addiction vs. Dependency

22 Potency Factors by Weight Morphine 1 Heroin 3 Codeine Dilaudid 8 Demerol 0.05 Fentanyl

23 Heroin usage patterns Highly addictive and dependence producing Significant tolerance up to 35X Increased cost Tolerance management (Tx, jail, etc.) Mixing with other opiates and other drugs (speedballing/cocaine)

24 Treatment Traditional Recovery Based/NA Naltrexone - Antagonist/Blocker Opiate Maintenance Tx withdrawal management Methadone- daily Buprenorphine/Suboxone Methadone to abstinence models

25

26 Commonly Abused Rx Drugs Opiates/pain killers Depressant/anti-anxietiesanxieties Stimulants t

27 Why Prescription Drugs They work They are fairly easily available The culture of Prescription Drugs Advertising Patient Expectations Pharmaceutical Company Promotion The Internet The Mail

28 Prescription Opiates

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30

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35

36 Among persons aged 12 or older in who used pain relievers nonmedically in the past 12 months, 55.3 percent got the pain relievers they most recently used from a friend or relative for free. Another 9.9 percent bought them from a friend or relative, and 5.0 percent took them from a friend or relative without asking.

37 Oxycontin

38 Oxycontin Oxycodone synthesized from thebaine (part of opium) Oxycontin 1995 Crush the tablet for quicker high Oral, snort, inject Percocet oxycodone & acetominophen Percodan oxycodone & aspirin

39 Vicodin

40 Vicodin Hydrocodone and acetominophen Lorcet, Lortab Schedule III high h psychological/medium physical Pain and post-surgical surgical use (pain)

41 Issues with Rx Opiate Dependence Presence of real pain I m addicted to vicodin, not alcohol, why do I have to quit that too? Drug Testing make sure you test for drug of choice as well as alternatives.

42 Anti-anxietals/Anxiolytics Panic Disorder Phobias / social phobia Obsessive Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Generalized Anxiety Disorder The neuroses treated by Freud

43 Benzodiazepines Share a chemical structure Librium 1960 Valium - #1 Rx drug , 78, 3x #2 Xanax Ativan Very profitable

44 Benzodiazepines Very Long Acting Halazepam (Paxipam ) Prazepam (Centrax ) Flurazepam p (Dalmane ) Short Acting Alprazolam (Xanax ) Temazepam (Restoril ) Oxazepam p (Serax ) Lorazepam (Ativan ) Intermediate Actingg Veryy Short Actingg Clonazepam (Klonipin ) Triazolam (Halcion ) Chlordiazepoxide (Librium ) Diazepam (Valium )

45 Effects of Benzodiazepines Anxiety control (e.g., panic attack) Rl Relaxation Drowsiness & sleep Control seizures Reduced muscular coordination Dulled physical sensations Tl Tolerance to effects develops

46 Benzodiazepines (cont.) Action most increase GABA Safe Ld very high Anticipation/placebo i effect Problems work so well, people don t want to stop. Side effects dose related cognitive impairment, amnesia, slurred speech Long Withdrawal

47 Two Types of Rx Drug Abusers (cocaine, alcohol, heroin, other non- Rx drugs) The Drug Abuser The Patient who who likes Rx drugs. Frequently use becomes dependent on their other drugs medication Fits the model of a drug abuser. addicted to high Infrequent use of other substances unless can t get Rx. Don t fit model of drug user age, other behaviors. dependent d on the drug

48 Why Prescription Drug Users May Believe That They Are Different I had/have real pain, I wasn t using these to get high like those drug addicts My doctor prescribed these for me. It wasn t my idea I never robbed anyone or did those things that t addicts do. I have to take something for this pain!

49 What the Rx Drug User Might Have Trouble Relating To Hitting Bottom Changing People, Places & Things Change your Lifestyle You must be completely abstinent from everything else alcohol included Going to meetings all of the time.

50 Drug Court/Treatment Issues Urine testing ensuring that the panel used includes the drugs that the participants take Medication needs people suffering from a medical/psychiatric condition that needs to be medicated which medications are okay Withdrawal risks

51 What s in the Medicine Cabinet?

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