Patient Education: 11 Common Questions on Heroin Abuse

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PATIENT EDUCATION

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 unless otherwise cited.

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 universal cure-all in the beginning of the 19th century, with the 1803 discovery of the active ingredient morphine.²
• Opiate dependency is the oldest, most persistent and widespread drug problem, with the exception of Alcohol.²

2. What is heroin and was it ever legal?
• 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 1912.³
• 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.³

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 at least once in their lives.⁴ (Figure 1)

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.

6. How does addiction to heroin occur?
• Regular heroin use changes the functioning of the brain¹ which causes:

A. Tolerance

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

B. Dependence

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.

C. Addiction

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.⁴

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.⁵9. 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.^1,4

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.⁶ Poisoning deaths from prescription pain medications now outnumber those from heroin and cocaine combined.⁴ (Figure 2)
• 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.⁷ However, nearly half of young people who inject heroin, in 3 recent studies, reported abusing prescription opioids before starting to use heroin.⁴ Of all heroin users, nationwide, recent data suggests that now, 75% of heroin users start using heroin after initially using opioid painkillers first.⁷
• 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.⁴
• 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 Time article notes that the court filing directly links the quadrupling in sales of these drugs (from 1999 to 2010) to misleading marketing from pharmaceutical companies.⁷

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.⁴
• 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 contingent on insurance coverage and stigma often causes patients and their families not to demand access to treatment.⁸
• 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.⁴

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.⁹ 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 (here). 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. Click here 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. Click here to access the Opioid Overdose Prevention Toolkit.

Disclosures:

Dr Goldenberg is a psychiatry resident at Banner Good Samaritan in Phoenix, Arizona. His blog, www.docgoldenberg.com, is dedicated to mental health and addiction topics.

References:

1. National Institute on Drug Abuse: DrugFacts: Heroin. Revised April 2013.
2. Jenkins PN. Heroin Addiction's Fraught History. The Atlantic. February 24 2014. 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. Business Insider. November 17, 2011. 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.
6. 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. Time. June 4, 2014. http://time.com/2822381/chicago-blaims-big-pharma-for-epidemic-addictions-to-painkillers. Acessed June 23, 2014.
8. Publicker M. Jeremiad: heroin deaths go unnoticed. ASAM Magazine. January 29, 2014. http://www.asam.org/magazine/read/article/2014/01/29/jeremiad-heroin-deaths-go-unnoticed. Accessed June 23, 2014.
9. 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. Accessed June 23, 2014.