Matt Goldenberg, DO

Here, a guide for helping patients understand heroin, its history, and how it impacts our communities. This information is from the National Institute of Drug Abuse (NIDA),

1. What is the history of opioid medications and abuse?


• Opiates were first prescribed for insomnia, pain, and gastrointestinal issues in England in the 17th century. They were considered a 

-all in the beginning of the 19th century, with the 1803 discovery of the active ingredient morphine.


• Opiate dependency is the oldest, most persistent and widespread drug problem, with the exception of Alcohol.


• Heroin is an opioid drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant.
• Bayer marketed liquid heroin as “the best cure for your child’s bronchitis,” as late as 1912.


• Heroin was restricted to prescription-only use in the US in 1914 and eventually banned by the FDA altogether in 1924, except under very strict medical conditions.

4. How is heroin used today and is it common?


• Today, illicit heroin usually appears as a white or brown powder or as a black sticky substance, known as “black tar heroin.”
• Heroin can be injected, inhaled by snorting or sniffing, or smoked.
• In 2012, about 669,000 Americans reported using heroin in the past year, with use rising each year since 2007; 4.2 million Americans aged 12 years or older (or 1.6%) had used heroin 

5. How does heroin affect the brain and cause death?


• When it enters the brain, heroin is converted back into morphine, which activates mu-opioid receptors (MORs). MORs activation in the reward center of the brain leads to dopamine release which causes a sensation of pleasure, a “rush,” that is experienced by users.
• MORs are also located in the brain stem, which controls automatic processes critical for life, including regulation of blood pressure, arousal, and respiration.
• Heroin overdoses deregulate MORs in the brain stem, often causing suppression of breathing, which can be fatal.


• Regular heroin use changes the functioning of the brain

Occurs as more of the drug is needed to achieve the same intensity of effect that was previously experienced.

Heroin addiction presents as the continued need to use the drug to avoid withdrawal symptoms. If a dependent user reduces or stops use of the drug abruptly, they may experience severe symptoms of withdrawal. These symptoms can begin as early as a few hours after the last drug administration and include restlessness, muscle and bone pain, insomnia, diarrhea, and vomiting, cold flashes with goose bumps (“cold turkey”), and kicking movements (“kicking the habit”). Major withdrawal symptoms peak around 24 to 48 hours after last use and typically last around 1 week. However, many ex-users report withdrawal symptoms lasting for months.

You can have dependence and tolerance without being addicted to a medication or substance. Addiction is marked by a pattern of chronic relapsing that goes beyond physical dependence and uncontrollable drug-seeking behaviors, despite negative consequences. Once addicted, the individual’s drug-seeking and using become their primary purpose in life.

7. Does everyone who tries heroin get addicted?


• It is estimated that about 23% of individuals who use heroin become dependent on it.

8. What is the official medical term for heroin addiction?


• DSM-5 no longer differentiates between opiate dependence and abuse. Instead, “opiate use disorder” is all-encompassing and provides criteria based on symptomatology. Diagnostic categories range from mild to severe.

9. What are the other risks of heroin use?


• People who inject drugs are at high risk of contracting HIV and hepatitis C (HCV). These diseases are transmitted through contact with blood and other bodily fluids, which can occur when sharing needles or other injection drug use equipment. HIV (and less often HCV) can also be contracted during unprotected sex, which drug use makes more likely.
• Heroin abuse is also associated with a number of other serious health conditions, including collapsed veins, infection of the heart lining and valves, abscesses, bacterial infections, arthritis and other rheumatologic problems, constipation and gastrointestinal cramping, liver and kidney disease, various types of pneumonia, and spontaneous abortion.
• In addition to the effects of the drug itself, heroin often contains toxic contaminants or additives that can clog blood vessels that lead to the lungs, liver, kidneys, or brain, causing permanent damage to vital organs.
• If a pregnant woman is regularly abusing the drug, an infant may be born physically dependent to heroin and could suffer from neonatal abstinence syndrome (NAS), a drug withdrawal syndrome in infants that requires hospitalization.

10. Are prescription painkillers a gateway to heroin use?


• In recent years, prescriptions for opioid medications for the treatment of pain have significantly increased.
• Subsequently, the harmful consequences of these medications have risen as well. Unintentional poisoning deaths from prescription pain medications have quadrupled form 1999 to 2010, when 16,000 drug related deaths resulted from prescription pain killers.

 Poisoning deaths from prescription pain medications now outnumber those from heroin and cocaine combined.

)
• It is possible that increased use of these prescription medications may open the door to heroin use. In the 1960s, 80% of heroin users initiated heroin first.

 However, nearly half of young people who inject heroin, in 3 recent studies, reported abusing prescription opioids before starting to use heroin.

 Of all heroin users, nationwide, recent data suggests that now, 75% of heroin users start using heroin after initially using opioid painkillers first.


• Many users reported switching to heroin, once they have built up tolerance to their pain medications, because of the lower cost and ease of access of heroin versus the prescription painkillers on the black market.


• Several cities including Chicago have recently sued the manufactures of narcotic pain medications, alleging they knowingly mislead physicians and the public about the safety risks and addiction potential of opioid pain medications. A 

 notes that the court filing directly links the quadrupling in sales of these drugs (from 1999 to 2010) to misleading marketing from pharmaceutical companies.

What is the treatment for opiate use disorder?


• There are both behavioral and pharmacological treatments for heroin addiction. For most people, utilization of both approaches is usually most effective.


• An effective treatment plan not only addresses the symptoms of heroin intoxication and withdrawal but focuses on the disease of addiction itself. Sadly, treatment availability is 

 and stigma often causes patients and their families not to demand access to treatment.


• Medications for the symptomatic treatment of withdrawal symptoms: opioid receptor agonists (ie, methadone, which activates the receptors), partial agonists (ie, buprenorphine), and antagonists (ie, naltrexone, which blocks the receptor and rewarding effects of heroin).
• Behavioral therapies are often delivered in either outpatient or residential care settings. Examples include contingency management, cognitive-behavioral therapy, and motivational interviewing.

What can you do if you suspect opioid addiction?


• It can be very disheartening and frustrating to be a family member or friend of a person with opioid addiction. If you have been in this position, you probably felt helpless and unable to intervene in a meaningful way.

Every overdose is preventable, according to the 

Office of the National Drug Control Policy

 They cite 4 actions you can take to prevent your loved one from being the next opioid overdose death:

If you know someone with the disease of addiction, give them the treatment referral line phone number: 1-800-662-HELP (4357). It is available 24 hours a day, 7 days a week.

Learn the signs and symptoms of overdose and what actions to take. You can download and print a pocket card that explains how to resuscitate someone who is overdosing (

). If you see someone who has overdosed, call 911, and if you have naloxone, administer it!

Get rid of all unused, expired, or unneeded prescription drugs in your home. 

 for instructions on how to dispose of unneeded medications safely.

The Office of the National Drug Control Policy has prepared a helpful guide on how to prevent opioid deaths in your community. The guide contains tips and steps that first responders, prescribers, people in recovery and their family members can take to save lives. 

Dr Goldenberg is a psychiatry resident at Banner Good Samaritan in Phoenix, Arizona. His blog, 

, is dedicated to mental health and addiction topics.

1. National Institute on Drug Abuse: DrugFacts: Heroin. Revised April 2013.
2. Jenkins PN. Heroin Addiction's Fraught History. 

http://www.theatlantic.com/health/archive/2014/02/heroin-addictions-fraught-history/284001

. Accessed June 23, 2014.
3. Edwards J. Yes, Bayer Promoted Heroin for Children-Here Are The Ads That Prove It. 

http://www.businessinsider.com/yes-bayer-promoted-heroin-for-children-here-are-the-ads-that-prove-it-2011-11

. Accessed June 23, 2014.
4. National Institute on Drug Abuse. Research Report Series: Heroin. 

. Revised April 2014. Accessed June 23, 2014.
5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013.


 Office of National Drug Control Policy. 5 things to know about opioid overdoses. February 11, 2014. 

http://www.whitehouse.gov/blog/2014/02/11/5-things-know-about-opioid-overdoses

. Accessed June 23, 2014.
7. Gray E. Chicago Blames Big Pharma for Epidemic Addictions to Painkillers. 

http://time.com/2822381/chicago-blaims-big-pharma-for-epidemic-addictions-to-painkillers

 Publicker M. Jeremiad: heroin deaths go unnoticed. 

http://www.asam.org/magazine/read/article/2014/01/29/jeremiad-heroin-deaths-go-unnoticed

 Office of National Drug Control Policy. Announcement to Medical Community. February 19th, 2014. 

http://pcssmat.org/wp-site/wp-content/uploads/2014/02/White-House-Article-100-people-die.pdf

Articles

A guide for helping patients understand heroin, its history, and how it impacts our communities.

Patient Education: 11 Common Questions on Heroin Abuse

What do Philip Seymour Hoffman, Kurt Cobain, John Belushi, Janis Joplin, and Jim Morrison have in common? If you answered that heroin either caused or contributed to their premature deaths, you are correct.

 However, you do not have to be artistic or famous to die from a drug overdose. In the US, 38,000 drug overdose deaths occur per year, and it is estimated that 75% are opioid-related.

 reported in 2010, a 45% increase from 2006.

Additionally, it is estimated that nearly a quarter of users will suffer a near miss-an overdose from which a person nearly dies but is able to recover. Nationwide, for every fatal overdose, there are an estimated 25 to 50 

 Disturbingly, many overdose deaths and near misses go unreported, so these numbers may underestimate the actual number of individuals affected.

Heroin abuse impacts Americans from all corners of our nation, despite minimal coverage by the mainstream media. Every day, around 100 Americans die from drug overdoses; about half involve opioid drugs.

 Few of these deaths make the evening news. However, if there is a car chase, gun violence, or an execution on death row, it may well be the leading story.

Sparse media coverage and the portraits painted in television and film have created a misconception that addiction affects only minorities, the poor, and those living in urban areas. In fact, the 5 states with the 

 of overdose deaths in 2010 are not typically associated with having large urban or minority populations: West Virginia, New Mexico, Kentucky, Nevada and Oklahoma (

Another common misconception is that much of the heroin found in the US comes from Afghanistan. Today, the US supply of 

 comes primarily from South America and Mexico.

 In fact, the DEA has reported a 320% increase in the amount of heroin seized along the US-Mexican border between 2008 and 2013.

Once heroin reaches the US, it is often cut with additional substances at local distribution centers. Therefore, every batch of heroin is unique. Subsequently, even an experienced user can accidentally take more of the drug than intended to get high. Recently, heroin has been found to be laced with fentanyl, an opiate that is 50 to 100 times more potent than morphine and 30 to 50 times more powerful than heroin. The user is often unaware that their supply stronger than usual, creating an extremely dangerous situation.

[[{"type":"media","view_mode":"media_crop","fid":"25362","attributes":{"alt":"Heroin, naloxone ","class":"media-image","id":"media_crop_1528061697904","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2312","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px;","title":" ","typeof":"foaf:Image"}}]]Some of the increase in accidental heroin overdoses has been attributed to these more potent batches of heroin.

 A consequence of taking a higher dose than intended is cessation of breathing, which can lead to death. The person who is overdosing can be given an opioid receptor antagonist, such as naloxone (Narcan) to reverse intoxication and overdose until they are able to receive medical attention. It can be injected into a vein or muscle or in some cases sprayed into the nose. Naloxone has reportedly been used to reverse more than 10,000 

In April 2014, the Federal Drug Administration (FDA) approved the first naloxone auto-injector, Evzio.

 It can be administered by family members or caregivers to buy time until medical assistance arrives. The auto-injector goes into the muscle or under the skin and rapidly delivers a single dose of naloxone, equivalent to a single dose from a syringe. It provides verbal instructions and works similar to an automated defibrillator. The FDA recommends that families and caregivers of people known to abuse opioids practice with a device trainer before use is needed.

Ultimately, if the effects of heroin cannot be reversed, the user will need mechanical ventilation in a hospital or they will often die. Good Samaritan laws have been passed in 17 states and the District of Columbia; they grant limited immunity to drug users who seek help for someone who has overdosed. The goal is to encourage witnesses to call 911 or bring the person overdosing to a hospital for medical attention. The same number of states have expanded access to naloxone

). Intoxication and overdose are a symptom of opioid addiction.

The more the public learns about heroin addiction, the more it becomes destigmatized and viewed as a chronic medical condition. Philip Seymour Hoffman was sober for over 20 years before he relapsed and an overdose took his life. His story reminds us that, like diabetes or high blood pressure, addiction requires lifelong treatment and relapse prevention. Increased media coverage and reporting of research findings would help to raise public awareness and decrease the number of overdoses.

This article began with the most well-known victims of heroin addiction. However, I hope it helps to raise awareness of how widespread the disease has become. Addiction impacts both the affluent and the poor. Addiction does not discriminate between those living in big cities or in the country. It causes problems for people of all races and nationalities. Addiction is an epidemic that affects all Americans. It is a treatable disease, which leads to preventable deaths. We must start to treat it as such.

Dr Goldenberg is a psychiatry resident at Banner Good Samaritan Medical Center in Phoenix, Arizona. His blog, 

 Drug-related deaths–notable celebrities. Drugs.com. 

http://www.drugs.com/celebrity_deaths.html

 Gorman S. Philip Seymour Hoffman death comes amid rise in heroin abuse, trafficking. Reuters. February 3, 2014. 

http://www.reuters.com/article/2014/02/04/us-seymourphiliphoffman-heroin-idUSBREA1304Z20140204

 Veeravagu A, Lober RM. Heroin: America’s silent assassin. 

http://www.thedailybeast.com/articles/2014/02/03/heroin-america-s-silent-assassin.html

 Ollove M. States combat alarming drug overdose deaths. 

http://www.usatoday.com/story/news/nation/2014/02/20/stateline-drug-overdose-deaths/5637519/

 Reuters Staff. U.S. Attorney General repeats call for naloxone training for law enforcement. Pharmacy Learning Network. March 10, 2014. 

http://www.pharmacylearningnetwork.com/articles/us-attorney-general-repeats-call-naloxone-training-law-enforcement

 Federal Drug Administration. FDA approves hand-held device to rapidly reverse opioid overdose (press release). April 3, 2014. 

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm391465.htm

In the US, 38,000 drug overdose deaths occur per year, and it is estimated that 75% are opioid-related. The good news is that addiction is a treatable disease. More in this discussion of opioid addiction, the use of naloxone, and Good Samaritan laws.

Matt Goldenberg, DO

Articles

Patient Education: 11 Common Questions on Heroin Abuse

Heroin Addiction: A Chronic Disease, Like Any Other