1 GP Drug & Alcohol Supplement No.8 December 1997 Heroin Addiction Dr Tony Gill Introduction Heroin use is associated with tragic health and psychosocial problems which are experienced across all sections of the community. There has been an increase in heroin-related harm over the past 15 years. The mortality rate due to opiate drugs increased 170% during the 1980s. This increase is in contrast to alcohol-related deaths which decreased by 17% and tobacco-related deaths which decreased by 6% over the same period 1. Studies have shown that 2-3% of heroin users die each year 2. Heroin users are approximately 13 times more likely to die than their peers of the same age and gender 3. There are many other well recognised health and social problems associated with heroin use. Increased rates of infections including HIV, Hepatitis C and B, septicaemia, tetanus and abscesses occur in heroin users. Poorer health generally, higher complication rates in pregnancies, an elevated incidence of psychiatric problems, including depression, high rates of criminality, and financial and accommodation problems are all common associations with heroin use. Prevalence of Heroin Use Heroin use is typically under-reported because it is illegal and negatively perceived within the community. The most recent estimates of prevalence are that there are around (and perhaps up to ) dependent heroin users in Australia, of which well over one half are in NSW. Overseas studies suggest that only about one quarter to one half of people who ever use heroin become dependent 4, indicating that the number of people who use heroin recreationally will increase estimates of the prevalence of heroin use by up to four times the number of dependent users. Heroin has become the subject of escalating community concern in Australia in recent years due to the rise in heroin-related deaths, the apparent higher prevalence of use, and the rise in other related problems such as needle-born infections and crime. The community s perception is that conventional treatment is not working. Consequently, there has been a push for alternative treatment approaches to be explored. The Drug Heroin (diacetylmorphine) is a short-acting, semisynthetic opiate (slang names include: smack, hammer, h, horse ). Heroin usually comes in powder form; it can be different colours, depending on how refined it is. White powder is generally more refined than brown or pink rocks which look like lumpy powder. Heroin is sold in gram portions or fractions of grams. One gram of street heroin at present costs $250-$300 with a purity range from 50% to 75%. Heroin is usually injected intravenously. However, smoking heroin ( chasing the dragon ) is becoming increasingly more common, particularly among local Indochinese groups. The procedure for intravenously injecting heroin is often performed in a ritualised manner with a common group of fellow users. The powder (typically adulterated with compounds such as lactose, mannitol and quinine) is dissolved in water in a spoon or bottle cap. The combination is heated to speed its dissolution. The solution is drawn up, often through a small ball of cotton which serves to filter out the larger contaminants.
2 The process of injecting is important because one of the ways diseases such as HIV/AIDS and viral hepatitis are spread is by the exchange of blood occurring through the use of shared injecting equipment. This risk of infection goes beyond needle sharing. It seems that vectors for transmission of infection may also include other equipment and materials used for injecting and cleaning up after injecting, which have been contaminated with blood. Pharmacology of Heroin The length of action of heroin is 3-6 hours. The main effects include a sedated or relaxed euphoria, drowsiness, decreased concentration and mentation, lethargy and decreased physical activity, decreased visual acuity and meiosis, respiratory depression, orthostatic hypotension (due to peripheral vasodilation), nausea and vomiting, constipation, urinary retention, and release of histamine which may cause sweating and pruritis. Tolerance develops to most of the effects of the drug, except for meiosis and constipation which are relatively persistent. Heroin (diacetylmorphine) is rapidly hydrolysed to monoacetylmorphine (MAM), which in turn is hydrolysed to morphine. In adults, the bloodbrain barrier tends to impede the entry of morphine to the brain. The barrier is considerably less effective against heroin and MAM because both are more lipid soluble than morphine. Heroin is mainly excreted in urine, primarily as free and conjugated morphine. Heroin metabolites are present in urine for approximately 48 hours after use of the drug. Opioid Overdose Opioid overdose is a medical emergency which can result in central nervous system and respiratory depression, gastric hypomotility with ileus, and non-cardiogenic pulmonary oedema. The approach to opioid overdose includes airway support and naloxone hydrochloride (Narcan) to reverse cardiorespiratory depression. Naloxone infusion should follow for those who respond to initial naloxone boluses because most opioids have a longer half life than naloxone. Patients with pulmonary oedema are at high risk and require intubation, positive pressure ventilation and intensive care. Interestingly, a recent study 5 indicates that people who die from opioid overdose are not typically naive, first-time, nontolerant, heroin users, but are more likely to be older, have used for a long time and mostly die from an overdose of a combination of opioids, alcohol and benzodiazepines. The Natural History of Heroin Use Heroin dependence is a chronic, relapsing condition. It has been found that in the long term, approximately one third of heroin-dependent people will achieve enduring abstinence, one third will continue to use on and off, and one third will have a poor outcome (death, incarceration, ongoing severe dependence) 6. The proportion of heroin-dependent people who achieve enduring abstinence increases with age. Heroin dependence is predominantly a condition of people between the ages of 20 and 40, with maturing out apparent in many cases. Who Uses Heroin? Heroin users emanate from all social strata. However, heroin users usually move towards the more disadvantaged socio-economic groupings over time due to the impact heroin dependence has on finances, social functioning and health. Research on heroin users indicates that the prevalence of psychiatric disorders among opioid users is higher than that found in the general population 7. Depressive disorders, anxiety disorders, personality disorders and alcohol abuse/dependence are particularly common in this group. Identification of Heroin Use Heroin use can be identified by: history from the patient findings during an examination of the patient information from others (usually family of the patient) urine drug screening A surprisingly large proportion of patients who use heroin will admit to use when asked in an empathic and non-judgmental way in the context of the confidential doctor-patient relationship. Examination findings which may suggest heroin use are: signs of intoxication (Table 1)
3 signs of withdrawal (Table 2) track marks or needle puncture sites (usually found in the cubital fossae, on the forearms, or the dorsum of the hands) deterioration of general health which often manifests in loss of weight and poor skin condition A urine drug screen will identify heroin use if the patient has used the drug in the last 48 hours. Heroin will show up in the urine as its metabolite morphine. It is not uncommon for others to be concerned that a person who they care about may be using heroin. This creates a situation in which the GP is aware that the person may be using heroin, but direct confrontation with the patient may cause conflict between the source of the information and the patient. Raising the issue of heroin use with these patients will require a less direct approach, for example, I d like to ask you some general questions about your health. Is that OK with you? Ask about exercise, diet, smoking, alcohol use and then other drug use. Then specifically say, Heroin use is very common these days. Do you use heroin? Assessment of Heroin Use The assessment of heroin use includes the following: drug use history drug related problems past treatments related medical or psychiatric problems what the patient wants. The assessment should involve: development of a therapeutic relationship with the patient an understanding of the patient s stage of change gathering of sufficient information about the patient to match them to the most appropriate treatment intervention. It may be more productive to continue the assessment over more than one consultation, given the time constraints in general practice. Matching Patients to Treatment The considerations when matching a patient who uses heroin to treatment options are: 1. What does the patient want? Patients vary in their motivation to change their drug using behaviour. Those not wanting any assistance (pre-contemplation stage) are provided with information about the harms associated with heroin use and how to access help in the future. These patients are offered a further appointment to explore any issues from the information provided. The door is left open for assistance and ongoing medical care in the future, if required. A motivational approach is taken with patients who are ambivalent about changing their drug use behaviour (contemplation stage). This approach includes exploration of the pros and cons of their ongoing drug use, provision of personalised information about the harms related to use, and the opportunity to consider what has been discussed and then be seen again. It is clear from clinical experience that simply taking a directive, authoritarian approach of you should stop heroin use does not work with patients who are unsure if they really want to stop. Motivational interviewing approaches have been shown to be effective for these patients 8. Patients who are clear about wishing to change (action stage) will be matched to treatment which is dependent upon the following two considerations. 2. What are the medical/safety issues which direct treatment type? Withdrawal from heroin is not life threatening or medically serious except for pregnant women who are dependent on heroin. Acute heroin withdrawal in pregnant women should not be undertaken, unless in a highly specialised setting such as King George V Hospital Drugs in Pregnancy Unit, because the risk to the viability of the foetus is high. Acute withdrawal results in increased risks of complications in pregnancy including miscarriage, preterm labour, foetal
4 Table 1. Signs of Heroin Intoxication. *Itching *Pinpoint Pupils *Sedation *Low Blood Pressure *Respiratory Depression Table 2. Heroin Withdrawal Syndrome. Time from Last Use: Signs & Symptoms: 8-12 hours lacrimation rhinorrhoea yawning sweating hours dilated pupils onset of agitation irritability anorexia hot and cold flushes 24+ hours onset of nausea, vomiting abdominal cramps diarrhoea gooseflesh musculoskeletal symptoms, e.g., backpain, leg cramps insomnia hypoxia and foetal distress. The treatment of choice for heroin-using, pregnant women is a methadone program. 3. What are the duration and severity of the patient s problems?
5 Matching heroin-using patients to treatment always requires consideration of the severity of their problems. Many patients have experienced major losses in their life as a result of heroin use such as loss of jobs, relationship breakdown, family estrangement, financial problems and gaol. These patients will be more appropriately matched to intensive treatments such as residential rehabilitation programs and methadone maintenance. Those people who have only been using heroin for a short time and/or have not experienced many problems as a result of their use would be more appropriately matched to a less intensive form of treatment such as outpatient counselling. Heroin Withdrawal The initial step, prior to entry into treatment for heroin dependence, is assisting the patient through withdrawal. Heroin withdrawal is an uncomfortable flu-like syndrome that lasts three to five days. Withdrawal does not have medically serious risks associated with it (except in the case of pregnancy). Heroin withdrawal can be treated in the home or in a residential detoxification unit. The heroin withdrawal syndrome is described in Table 2. Management Approach to Heroin Withdrawal In the General Practice setting, the approach to management of heroin withdrawal involves two key components: 1) Reduction of Discomfort from Withdrawal Symptoms The pharmacological management of opiate withdrawal in general practice can be undertaken in two ways: a) Symptomatic treatment A commonly employed regime for heroin withdrawal involves the use of various medications targeting specific symptoms. An example of such a medication regime is: *Diazepam 5-10 mg tabs qid (for agitation, restlessness) *Buscopan (Hyoscine) 20 mg tabs tds (for abdominal cramps) *Quinate 300 mg tabs bd (for leg aches/cramps) *Maxalon 10 mg tabs 6-8 hrly prn (for nausea/vomiting) *Lomotil 1-2 tabs tds (for diarrhoea) Patients should be made aware that this regime reduces the severity of withdrawal symptoms; it does not leave the patient without symptoms or discomfort. Medication should be supplied daily or second daily to reduce the risk of patients misusing it or taking it all at once. Overdose can occur when patients take increasing doses of medication in an attempt to completely alleviate their symptoms. Quinate, in particular, is dangerous in overdose. b) Clonidine Clonidine is an α-2-adrenergic agonist that has a central action on opiate withdrawal symptoms. Clonidine is commonly used to treat opiate withdrawal symptoms in hospital; it is also effective in general practice, although its hypotensive actions necessitate that it be prescribed with care. The following is the usual Clonidine regime for the treatment of heroin withdrawal: Day 0 The patient s last use of heroin. There needs to be at least six hours between last heroin use and commencement of Clonidine. There is a recognised interaction between Clonidine and opiate drugs and in combination, excessive sedation can be produced 9. Day 1 A test dose of 75 mcg is given. The patient must have their lying and standing blood pressure checked 30 minutes later for an idiosyncratic, pronounced drop in blood pressure. If no problems with blood pressure are evident: Day 1: 150 mcg tds Day 2: mcg tds Day 3: mcg tds Day 4: 150 mcg tds Day 5: 150 mcg bd Day 6: 150 mcg nocte N.B. Patients should be seen daily for the first three days and blood pressure (lying and standing) should be checked prior to providing a script. If blood pressure drops
6 below 90/50 mm Hg (standing), Clonidine should be withheld. 2) Support and Coordination of Ongoing Rehabilitation The severity of withdrawal symptoms experienced by the patient can be reduced by the provision of appropriate information about the withdrawal syndrome 10. In particular, reassurance about the time limited course of withdrawal discomfort (three to four days) also assists the patient to cope. Difficulties for patients which arise commonly during heroin withdrawal are sleep disturbance and coping with cravings. Practical advice about sleep, reassurance that the sleep pattern will return to normal in about one to two weeks, and a maximum of three doses of night sedation, if necessary, can assist patients to negotiate heroin withdrawal. Patients can be assisted to cope with cravings by providing information about the time limited nature of cravings, and collaboratively developing strategies so that the patient will not use heroin during the periods of craving. Strategies to distract the patient from urges or thoughts to use heroin; delay the possibility of using until craving subsides; avoid situations in which it is possible to use heroin; or escape from situations in which it is difficult for the patient not to use heroin are all effective in assisting patients to negotiate the withdrawal phase. After withdrawal from heroin, ongoing rehabilitation should be encouraged. Treatment approaches which are most helpful in reducing the likelihood of relapse are: outpatient counselling focusing on providing the patient with skills to avoid relapse residential rehabilitation programs (such as The Buttery, The Bridge Program, Odyssey House, WHOS Program) for those with longstanding, severe problems related to their drug use Narcotics Anonymous. Pharmacotherapies as Treatment for Heroin Dependence Methadone is a treatment for heroin-dependent people who have substantial and protracted problems related to heroin use, and for whom detoxification and drug-free treatment is not preferred. Methadone has been shown to be an effective treatment for heroin dependence in reducing harm from heroin use as experienced by the user and by the community. Methadone treatment has been clearly shown to reduce the mortality risk of heroin users by at least four-fold. Methadone treatment also results in improved health, reduced heroin use, reduced criminality, and lower risk of contracting and spreading HIV. There is often an improvement in social functioning by those in treatment. Methadone treatment is focused on the reduction of problems and extension of life for those in treatment. However, methadone is a treatment which provides a long term cure for heroin dependence in only a minority of people. Nevertheless, it substantially reduces harm while people are in treatment. Other pharmacotherapies are now being proposed as additions to our armoury and may become available as treatments for heroin dependence over the next few years. Buprenorphine is a mixed agonist/antagonist that shows some promise for a proportion of patients with heroin dependence. Naltrexone, an opioid antagonist that blocks the effects of heroin, is also being considered as a treatment option in Australia. Naltrexone appears to be effective in reducing relapse to heroin use in some specific groups of patients (for example, professionals). General Practitioners who require further information or assistance regarding patients who are using or wish to withdraw from heroin can contact the GP Drug and Alcohol Local Consultancy Service on This service is for General Practitioners only. Patients can contact the Central Coast Alcohol and Other Drug Service on References: 1. Commonwealth Department of Health, Housing and Community Services (1990). Drug caused deaths in Australia Drugs of dependence branch statistical update, Number 18.
7 2 Mattick, R.P. (1993). A treatment outline for approaches to opioid dependence. Quality assurance in the treatment of drug dependence project, Monograph Series No. 21. Australian Government Publishing Service, Canberra. 3. English, D., Holman, C.D.J., Milne, E., Winter, M.G., Hulse, G.K., Codde, J.P., Corti, B., Dawes, V., de Klerk, N., Knuiman, M.W., Kurinczuk, J.J., Lewin, G.F. & Ryan, G.A. (1995). The quantification of drug caused morbidity and mortality in Australia. Commonwealth Department of Human Services and Health, Canberra. 4. Hall, W. (1996). Methadone maintenance treatment as a crime control measure. Crime and Justice Bulletin No. 29. New South Wales Bureau of Crime Statistics and Research, Sydney. 5. Darke, S., Ross, J., Cohen, J. & Hall, W. (1994). Context and correlates of non-fatal overdose among heroin users in Sydney, Monograph No. 20. National Drug and Alcohol Research Centre, Sydney. 6. Vaillant, G. (1973). A 20-year follow-up of New York narcotic addicts. Archives of General Psychiatry 29: Darke, S. & Ross, J. (1997). Polydrug dependence and psychiatric comorbidity among heroin injectors. Drug and Alcohol Dependence 48: DiClemente, C.C. (1991). Motivational interviewing and the stages of change. In Motivational interviewing. Preparing people to change addictive behavior. Eds W.R. Miller & S. Rollnick. The Guilford Press, New York. pp Saunders, J.B., Ward, H. & Novak, H. (1996). Guide to home detoxification. National Drug Strategy, Sydney. 10. Green, L. & Gossop, M. (1988). The effects of information on the Opiate Withdrawal Syndrome. British Journal of Addiction 83:
8 Filename: GPSUP8.DOC Directory: C:\Program Files\Adobe\Acrobat 4.0\Acrobat\plug_ins\OpenAll\Transform\temp Template: C:\WINDOWS\Application Data\Microsoft\Templates\Normal.dot Title: Heroin Addiction Subject: Author: Dr Tony Gill Keywords: Comments: This is number eight in the series of GP Supplements Creation Date: 2/12/97 3:21 PM Change Number: 14 Last Saved On: 6/10/99 4:40 PM Last Saved By: Gosford Hospital Total Editing Time: 83 Minutes Last Printed On: 14/01/00 4:58 PM As of Last Complete Printing Number of Pages: 7 Number of Words: 3,167 Number of Characters: 17,327