Heroin Addiction and Abuse

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1 Most users can control PDF display size by using Zoom or +\- on the reader interface. Heroin Addiction and Abuse The following materials are utilized in a continuing education course at Note: This material is drawn in part from sources freely available in the public domain. CEU-Hours.com is not affiliated with nor necessarily endorsed by the authors or issuing agency. See the article for additional source information. Heroin Addiction and Abuse - CEU-Hours.com - p 1

2 TIP Everyone likes FREE CEU s help spread the word by saving this document which contains the full course and test and ing it to a co-worker or colleague! What Is Heroin? Heroin is an illegal, highly addictive drug. It is both the most abused and the most rapidly acting of the non-prescription opiates. Heroin is processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. It is typically sold as a white or brownish powder or as the black sticky substance known on the streets as "black tar heroin." Although purer heroin is becoming more common, most street heroin is "cut" with other drugs or with substances such as sugar, starch, powdered milk, or quinine. Street heroin also can be cut with strychnine or other poisons. Because heroin abusers do not know the actual strength of the drug or its true contents, they are at risk of overdose or death. Heroin also poses special problems because of the transmission of HIV and other diseases that can occur from sharing needles or other injection equipment. How is heroin used? Heroin can be injected, snorted/sniffed, or smoked routes of administration that rapidly deliver the drug to the brain. Typically, a heroin abuser may inject up to four times a day. Intravenous injection provides the greatest intensity and most rapid onset of euphoria (7 to 8 seconds), while intramuscular injection produces a relatively slow onset of euphoria (5 to 8 minutes). When heroin is sniffed or smoked, where it is absorbed into the bloodstream through the nasal tissues, peak effects are usually felt within 10 to 15 minutes. All forms of heroin administration are addictive. Route of Administration Among Heroin Treatment Admissions in Selected Areas Heroin Addiction and Abuse - CEU-Hours.com - p 2

3 Source: Community Epidemiology Work Group, NIDA, December 2003, Vol. II. *Includes first half 2003 data from treatment facilities. Injection continues to be the predominant method of heroin use among addicted users seeking treatment; in many CEWG areas, heroin injection is reportedly on the rise, while heroin inhalation is declining. However, certain groups, such as White suburbanites in the Denver area, report smoking or inhaling heroin because they believe that these routes of administration are less likely to lead to addiction. With the shift in heroin abuse patterns comes an even more diverse group of users. In recent years, the availability of higher purity heroin (which is more suitable for inhalation) and the decreases in prices reported in many areas have increased the appeal of heroin for new users who are reluctant to inject. Heroin has also been appearing in more affluent communities. What are the immediate (short-term) effects of heroin use? Soon after injection (or inhalation), heroin crosses the blood-brain barrier. In the brain, heroin is converted to morphine and binds rapidly to opioid receptors. Abusers typically report feeling a surge of pleasurable sensation - a "rush." The intensity of the rush is a function of how much drug is taken and how rapidly the drug enters the brain and binds to the natural opioid receptors. Heroin is particularly addictive because it enters the brain so rapidly. With heroin, the rush is usually accompanied by a warm flushing of the skin, dry mouth, and a heavy feeling in the extremities, which may be accompanied by nausea, vomiting, and severe itching. Opiates Act on Many Places in the Brain and Nervous System Heroin Addiction and Abuse - CEU-Hours.com - p 3

4 After the initial effects, abusers usually will be drowsy for several hours. Mental function is clouded by heroin's effect on the central nervous system. Cardiac function slows. Breathing is also severely slowed, sometimes to the point of death. Heroin overdose is a particular risk on the street, where the amount and purity of the drug cannot be accurately known. What are the long-term effects of heroin use? One of the most detrimental long-term effects of heroin use is addiction itself. Addiction is a chronic, relapsing disease, characterized by compulsive drug seeking and use, and by neurochemical and molecular changes in the brain. Heroin also produces profound degrees of tolerance and physical dependence, which are also powerful motivating factors for compulsive use and abuse. As with abusers of any addictive drug, heroin abusers gradually spend more and more time and energy obtaining and using the drug. Once they are addicted, the heroin abusers' primary purpose in life becomes seeking and using drugs. The drugs literally change their brains and their behavior. Physical dependence develops with higher doses of the drug. With physical dependence, the body adapts to the presence of the drug and withdrawal symptoms occur if use is reduced abruptly. Withdrawal may occur within a few hours after the last time the drug is taken. Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps ("cold turkey"), and leg movements. Major withdrawal symptoms peak between 24 and 48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Heroin withdrawal is never fatal to otherwise healthy adults, but it can cause death to the fetus of a pregnant addict. At some point during continuous heroin use, a person can become addicted to the drug. Sometimes addicted individuals will endure many of the withdrawal symptoms to reduce their tolerance for the drug so that they can again experience the rush. Physical dependence and the emergence of withdrawal symptoms were once believed to be the key features of heroin addiction. We now know this may not be the case entirely, since craving and relapse can occur weeks and months after withdrawal symptoms are long gone. We also know that patients with chronic pain who need opiates to function (sometimes over extended periods) have few if any problems leaving opiates after their pain is resolved by other means. This may be because the patient in pain is simply seeking relief of pain and not the rush sought by the addict. An additional concern is that Persons addicted to alcohol or drugs are at 5-10 times higher risk for suicide compared to the general population (Voss, Kaufman, O Conner, Comtios, Conner, Ries, 2013). Heroin Addiction and Abuse - CEU-Hours.com - p 4

5 Short- and Long-Term Effects of Heroin Use Short-Term Effects "Rush" Depressed respiration Clouded mental functioning Nausea and vomiting Suppression of pain Spontaneous abortion Long-Term Effects Addiction Infectious diseases, for example, HIV/AIDS and hepatitis B and C Collapsed veins Bacterial infections Abscesses Infection of heart lining and valves Arthritis and other rheumatologic What Other Adverse Effects Does Heroin Have on Health? Heroin abuse is associated with serious health conditions, including fatal overdose, spontaneous abortion, and particularly in users who inject the drug infectious diseases, including HIV/AIDS and hepatitis. 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 Heroin Addiction and Abuse - CEU-Hours.com - p 5

6 contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs. Chronic use of heroin leads to physical dependence, a state in which the body has adapted to the presence of the drug. If a dependent user reduces or stops use of the drug abruptly, he or she may experience severe symptoms of withdrawal. These symptoms which can begin as early as a few hours after the last drug administration can include restlessness, muscle and bone pain, insomnia, diarrhea and vomiting, cold flashes with goose bumps ( cold turkey ), and kicking movements ( kicking the habit ). Users also experience severe craving for the drug during withdrawal, which can precipitate continued abuse and/or relapse. Major withdrawal symptoms peak between 48 and 72 hours after the last dose of the drug and typically subside after about 1 week. Some individuals, however, may show persistent withdrawal symptoms for months. Although heroin withdrawal is considered less dangerous than alcohol or barbiturate withdrawal, sudden withdrawal by heavily dependent users who are in poor health is occasionally fatal. In addition, heroin craving can persist years after drug cessation, particularly upon exposure to triggers such as stress or people, places, and things associated with drug use. How does heroin abuse affect pregnant women? 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. Methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental maternal and neonatal outcomes associated with untreated heroin abuse, although infants exposed to methadone during pregnancy typically require treatment for withdrawal symptoms. In the United States, several studies have found buprenorphine to be equally effective and as safe as methadone in the adult outpatient treatment of opioid dependence. Given this efficacy among adults, current studies are attempting to establish the safety and effectiveness of buprenorphine in opioid-dependent pregnant women. For women who do not want or are not able to receive pharmacotherapy for their heroin addiction, detoxification from opiates during pregnancy can be accomplished with relative safety, although the likelihood of relapse to heroin use should be considered. Why are heroin users at special risk for contracting HIV/AIDS and hepatitis B and C? Heroin users are at risk for contracting HIV, hepatitis C (HCV), and other infectious diseases, through sharing and reuse of syringes and injection paraphernalia that have been used by infected individuals, or through unprotected sexual contact with an infected person. Injection drug users (IDUs) represent the highest risk group for acquiring HCV infection; an estimated 70 to 80 Heroin Addiction and Abuse - CEU-Hours.com - p 6

7 percent of the 35,000 new HCV infections occurring in the United States each year are among IDUs. NIDA-funded research has found that drug abusers can change the behaviors that put them at risk for contracting HIV through drug abuse treatment, prevention, and community-based outreach programs. They can eliminate drug use, drug-related risk behaviors such as needle sharing, unsafe sexual practices, and, in turn, the risk of exposure to HIV/AIDS and other infectious diseases. Drug abuse prevention and treatment are highly effective in preventing the spread of HIV. What Treatment Options Exist? A range of treatments exist for heroin addiction, including medications and behavioral therapies. Science has taught us that when medication treatment is combined with other supportive services, patients are often able to stop using heroin (or other opiates) and return to stable and productive lives. Treatment usually begins with medically assisted detoxification to help patients withdraw from the drug safely. Medications such as clonidine and buprenorphine can be used to help minimize symptoms of withdrawal. However, detoxification alone is not treatment and has not been shown to be effective in preventing relapse it is merely the first step. Medications to help prevent relapse include the following: Methadone has been used for more than 30 years to treat heroin addiction. It is a synthetic opiate medication that binds to the same receptors as heroin; but when taken orally, it has a gradual onset of action and sustained effects, reducing the desire for other opioid drugs while preventing withdrawal symptoms. Properly administered, methadone is not intoxicating or sedating, and its effects do not interfere with ordinary daily activities. Methadone maintenance treatment is usually conducted in specialized opiate treatment programs. The most effective methadone maintenance programs include individual and/or group counseling, as well as provision of or referral to other needed medical, psychological, and social services. Buprenorphine is a more recently approved treatment for heroin addiction (and other opiates). Compared with methadone, buprenorphine produces less risk for overdose and withdrawal effects and produces a lower level of physical dependence, so patients who discontinue the medication generally have fewer withdrawal symptoms than those who stop taking methadone. The development of buprenorphine and its authorized use in physicians offices give opiate-addicted patients more medical options and extend the reach of addiction medication. Its accessibility may even prompt attempts to obtain Heroin Addiction and Abuse - CEU-Hours.com - p 7

8 treatment earlier. However, not all patients respond to buprenorphine some continue to require treatment with methadone. Naltrexone is approved for treating heroin addiction but has not been widely utilized due to poor patient compliance. This medication blocks opioids from binding to their receptors and thus prevents an addicted individual from feeling the effects of the drug. Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although initiation of the treatment often begins after medical detoxification in a residential setting. To prevent withdrawal symptoms, individuals must be medically detoxified and opioid-free for several days before taking naltrexone. Naloxone is a shorter-acting opioid receptor blocker, used to treat cases of overdose. For pregnant heroin abusers, methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental maternal and neonatal outcomes associated with untreated heroin abuse. Preliminary evidence suggests that buprenorphine may also be a safe and effective treatment during pregnancy, although infants exposed to either methadone or buprenorphine prenatally may still require treatment for withdrawal symptoms. For women who do not want or are not able to receive pharmacotherapy for their heroin addiction, detoxification from opiates during pregnancy can be accomplished with medical supervision, although potential risks to the fetus and the likelihood of relapse to heroin use should be considered. Behavioral therapies Although behavioral and pharmacologic treatments can be extremely useful when employed alone, science has taught us that integrating both types of treatments will ultimately be the most effective approach. There are many effective behavioral treatments available for heroin addiction. These can include residential and outpatient approaches. An important task is to match the best treatment approach to meet the particular needs of the patient. Moreover, several new behavioral therapies, such as contingency management therapy and cognitive-behavioral interventions, show particular promise as treatments for heroin addiction, especially when applied in concert with pharmacotherapies. Contingency management therapy uses a voucherbased system, where patients earn "points" based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitive-behavioral interventions are designed to help modify the patient's expectations and behaviors related to drug use, and to increase skills in coping with various life stressors. Both behavioral and pharmacological treatments help to restore a degree of normalcy to brain function and behavior, with increased employment rates and lower risk of HIV and other diseases and criminal behavior. Heroin Addiction and Abuse - CEU-Hours.com - p 8

9 How Widespread Is Heroin Abuse? Monitoring the Future Survey* According to the Monitoring the Future survey, there was little change between 2008 and 2009 in the proportion of 8th- and 12th-grade students reporting lifetime, past-year, and past-month use of heroin. There was, however a drop in both Lifetime and Past year use at all levels between 2009 and Past month figures were no longer available for heroin use in this population for These figures indicate a reduction in reported use among this population over the 3 year span. Heroin Use by Students, 2009: Monitoring the Future Survey 8th Grade 10th Grade 12th Grade Lifetime 1.3% 1.5% 1.2% Past Year Past Month Heroin Use by Students, 2012: Monitoring the Future Survey 8th Grade 10th Grade 12th Grade Lifetime 0.8% 1.1% 1.1% Past Year Past Month According to the 2003 National Survey on Drug Use and Health, which may actually underestimate illicit opiate (heroin) use, an estimated 3.7 million people had used heroin at some time in their lives, and over 119,000 of them reported using it within the month preceding the survey. An estimated 314,000 Americans used heroin in the past year, and the group that represented the highest number of those users were 26 or older. The survey reported that, from 1995 through 2002, the annual number of new heroin users ranged from 121,000 to 164,000. During this period, most new users were age 18 or older (on average, 75 percent) and most were male. In 2003, 57.4 percent of past year heroin users were classified with dependence on or abuse of heroin, and an estimated 281,000 persons received treatment for heroin abuse. In the 2012 National Survey on Drug Use and Health, the rate of use of heroin within the preceding 1 year was 0.9% among those with any mental illness, compared with 0.1% among those with no mental illness. Heroin Addiction and Abuse - CEU-Hours.com - p 9

10 Other Information Sources For additional information on heroin, please refer to the following sources on NIDA s Web site: Research Report Series - Heroin Abuse and Addiction NIDA Notes - Heroin NIDA Notes - Opioids Other Data Sources * These data are from the 2009 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan s Institute for Social Research. The survey has tracked 12th-graders illicit drug use and related attitudes since 1975; in 1991, 8th- and 10thgraders were added to the study. For the latest data visit: High School and Youth Trends. ** Lifetime refers to use at least once during a respondent s lifetime. Past year refers to use at least once during the year preceding an individual s response to the survey. Past month refers to use at least once during the 30 days preceding an individual s response to the survey. What are the opioid analogs and their dangers? Drug analogs are chemical compounds that are similar to other drugs in their effects but differ slightly in their chemical structure. Some analogs are produced by pharmaceutical companies for legitimate medical reasons. Other analogs, sometimes referred to as "designer" drugs, can be produced in illegal laboratories and are often more dangerous and potent than the original drug. Two of the most commonly known opioid analogs are fentanyl and meperidine (marketed under the brand name Demerol, for example). Fentanyl was introduced in 1968 by a Belgian pharmaceutical company as a synthetic narcotic to be used as an analgesic in surgical procedures because of its minimal effects on the heart. Fentanyl is particularly dangerous because it is 50 times more potent than heroin and can rapidly stop respiration. This is not a problem during surgical procedures because machines are used to help patients breathe. On the street, however, users have been found dead with the needle used to inject the drug still in his or her arm. Heroin Addiction and Abuse - CEU-Hours.com - p 10

11 A major source of information on substance use, abuse, and dependence among Americans aged 12 and older is the annual National Survey on Drug Use and Health (NSDUH) conducted by the Substance Abuse and Mental Health Services Administration. Following are facts and statistics on substance use in America from 2011, the most recent year for which NSDUH survey data have been analyzed. Illicit Drug Use Illicit drug use in America has been increasing. In 2011, an estimated 22.5 million Americans aged 12 or older or 8.7 percent of the population had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month. This is up from 8.3 percent in The increase mostly reflects a recent rise in the use of marijuana, the most commonly used illicit drug. A study conducted by Noruma, Hurd and Pilowsky (2012) examined overall risk, age of initiation, and functional impairments in adults with substance use problems (N = 1748) by child abuse status. They found that a history of child abuse was associated with earlier onset of marijuana, cocaine, and heroin use, and had there were increased risks of use for all drugs studied. Furthermore, child abuse was associated with increased medical and functional impairments, including ER visits, health problems, drug dealing, drug dependence, and drug cravings. Marijuana use has increased since In 2011, there were 18.1 million current (past-month) users about 7.0 percent of people aged 12 or older up from 14.4 million (5.8 percent) in Heroin Addiction and Abuse - CEU-Hours.com - p 11

12 Use of most drugs other than marijuana has not changed appreciably over the past decade or has declined. In 2011, 6.1 million Americans aged 12 or older (or 2.4 percent) had used psycho-therapeutic prescription drugs nonmedically (without a prescription or in a manner or for a purpose not prescribed) in the past month a decrease from And 972,000 Americans (0.4 percent) had used hallucinogens (a category that includes Ecstasy and LSD) in the past month a decline from Cocaine use has gone down in the last few years; from 2006 to 2011, the number of current users aged 12 or older dropped from 2.4 million to 1.4 million. Methamphetamine use has also dropped, from 731,000 current users in 2006 to 439,000 in Most people use drugs for the first time when they are teenagers. There were just over 3.0 million new users (initiates) of illicit drugs in 2011, or about 8,400 new users per day. Half (51 percent) were under 18. More than half of new illicit drug users begin with marijuana. Next most common are prescription pain relievers, followed by inhalants (which is most common among younger teens). Heroin Addiction and Abuse - CEU-Hours.com - p 12

13 Drug use is highest among people in their late teens and twenties. In 2011, 23.8 percent of 18- to 20-year-olds reported using an illicit drug in the past month. For more information on drug use among adolescents, see Drug Facts: High School and Youth Trends. Drug use is increasing among people in their fifties. This is, at least in part, due to the aging of the baby boomers, whose rates of illicit drug use have historically been higher than those of previous cohorts. Heroin Addiction and Abuse - CEU-Hours.com - p 13

14 Substance Dependence/Abuse and Treatment Rates of alcohol dependence/abuse declined from 2002 to 2011In 2011, 16.7 million Americans (6.5 percent of the population) were dependent on alcohol or had problems related to their use of alcohol (abuse). This is a decline from 18.1 million (or 7.7 percent) in 2002 After alcohol, marijuana has the highest rate of dependence or abuse among all drugs. In 2011, 4.2 million Americans met clinical criteria for dependence or abuse of marijuana in the past year more than twice the number for dependence/abuse of prescription pain relievers (1.8 million) and four times the number for dependence/abuse of cocaine (821,000). Heroin Addiction and Abuse - CEU-Hours.com - p 14

15 There continues to be a large treatment gap in this country. In 2011, an estimated 21.6 million Americans (8.4 percent) needed treatment for a problem related to drugs or alcohol, but only about 2.3 million people (less than 1 percent) received treatment at a specialty facility. Heroin Addiction and Abuse - CEU-Hours.com - p 15

16 Glossary Addiction: A chronic, relapsing disease, characterized by compulsive drug seeking and use and by neurochemical and molecular changes in the brain. Agonist: A chemical compound that mimics the action of a natural neurotransmitter to produce a biological response. Analog: A chemical compound that is similar to another drug in its effects but differs slightly in its chemical structure. Antagonist: A drug that counteracts or blocks the effects of another drug. Buprenorphine: A mixed opiate agonist/antagonist medication for the treatment of heroin addiction. Craving: A powerful, often uncontrollable desire for drugs. Detoxification: A process of allowing the body to rid itself of a drug while managing the symptoms of withdrawal; often the first step in a drug treatment program. Fentanyl: A medically useful opioid analog that is 50 times more potent than heroin. Meperidine: A medically approved opioid available under various brand names (e.g., Demerol). Methadone: A long-acting synthetic medication shown to be effective in treating heroin addiction. Physical dependence: An adaptive physiological state that occurs with regular drug use and results in a withdrawal syndrome when drug use is stopped; usually occurs with tolerance. Rush: A surge of euphoric pleasure that rapidly follows administration of a drug. Tolerance: A condition in which higher doses of a drug are required to produce the same effect as during initial use; often leads to physical dependence. Withdrawal: A variety of symptoms that occur after use of an addictive drug is reduced or stopped. Heroin Addiction and Abuse - CEU-Hours.com - p 16

17 References: Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (December 19, 2012). "The rise in teen marijuana use stalls, synthetic marijuana use levels, and use of 'bath salts' is very low." University of Michigan News Service: Ann Arbor, MI. Retrieved 03/10/2013 from National Institute on Drug Abuse, NIH Publication Number Heroin Abuse and Addiction. Printed October 1997; Reprinted September 2000, Revised May National Institute on Drug Abuse. Drug Facts: Heroin. Retrieved 03/10/2013 from Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-45, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Voss WD, Kaufman E, O'Connor SS, Comtois KA, Conner KR, Ries RK. Preventing addiction related suicide: A pilot study. Journal of Substance Abuse Treatment. January, 2013 [In print at time of publication]. Yoko Nomura, Yasmin L. Hurd and Daniel J. Pilowsky. Life-Time Risk for Substance Use Among Offspring of Abusive Family Environment From the Community. Substance Use and Misuse, October 2012, Vol. 47, No. 12, Pages Heroin Addiction and Abuse - CEU-Hours.com - p 17

18 Heroin Addiction and Abuse Post Test This course may be completed online at 1) Street heroin is commonly cut with which of the following substances? o Sugar o Powdered Milk o Starch o All of the above 2) The effects of IV injected heroin is usually onset in about how long? o 1 second o 7-8 seconds o 1 minute o 3-5 minutes 3) According to the text, addicted individuals are about more likely to commit suicide than non-addicted individuals. o 2-3 times o 3-5 times o 5-10 times o 20 times 4) Not listed as a common medical complication of heroin use. o Infection of the hear lining o Abscesses o Lung Complications o Tachycardia (Increased heart rate) 5) One advantage of Burenorphine over Methadone is: o Blood levels remain lower throughout treatment o It's completely safe in all populations o It develops lower levels of physical dependence o None of the above 6) Reported use of heroin in 8th, 10th and 12th graders in the period between 2009 and o Increased o Decreased o Remained Steady o Inverted 7) Pregnant women should never be detoxed from heroin. o True o False Heroin Addiction and Abuse - CEU-Hours.com - p 18

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