Heroin – abuse, addiction & recovery
What is the chemistry of heroin?
Heroin is an opioid drug made from morphine, a natural substance taken from the seed pod of the Asian opium poppy plant. Heroin can be a white or brown powder, or a black sticky substance known as black tar heroin.
Heroin is technically considered an opioid not an opiate, since it is chemically manufactured, although molecules from the opium plant are used in the process. Some of heroin’s active ingredient molecules are not found in nature.
Heroin enters the brain rapidly and changes back into morphine. It binds to opioid receptors on cells located in many areas of the brain, especially those involved in feelings of pain and pleasure. Opioid receptors are also located in the brain stem, which controls important processes, such as blood pressure, arousal, and breathing.
Heroin is manufactured from opium poppies cultivated in four primary source areas: South America, Southeast and Southwest Asia, and Mexico. Afghanistan now produces the majority of the world’s heroin, but little or none of the Afghanistan heroin reaches the US. Although 10 years ago, the US got 90% of its heroin from Columbia, today we get 90% of our heroin from Mexico (up from 10% in 2003).
Heroin’s long history
Heroin actually has a very interesting history. Heroin (as well as morphine, and other opiates) trace their origins to a single plant—the opium poppy plant. The earliest reference to opium use and cultivation of opium poppies comes from Mesopotamia around 3400 B.C. Narcotic drugs have been used both recreationally and as a medicine for centuries. Opium-based medicines, including morphine, have been widely used as pain relievers. Heroin, too, was first synthesized for medical use before physicians realized its overwhelming addictive properties.
Opium grew in popularity when it was introduced to China and other parts of Asia, likely in the 6th or 7th century A.D. through trade along the Silk Road, which connected the Mediterranean cultures of Europe to central Asia, India, and China.
There were actually two “opium wars,” – the first was in the 1700s when the British empire conquered a major poppy-growing region in India and began to smuggle opium from India into China. The second was when the British and French fought against China to make opium trade legal in China (between 1856-1860).
Can heroin be prescribed in the US?
Heroin is a schedule I drug secondary to the Controlled Substances Act (CSA) – the statute establishing federal U.S. drug policy under which the manufacture, importation, possession, use and distribution of certain substances is regulated. The CSA was passed in 1970. The Act created five Schedules (classifications), with varying qualifications for a substance to be included in each.
A substance meets criteria for Schedule I classification if:
The drug/substance has a high potential for abuse.
The drug/substance has no currently accepted medical use in treatment in the United States.
There is a lack of accepted safety for use of the drug or other substance under medical supervision.
That said, as already noted, heroin was initially considered a potential cure for morphine addiction, before its high propensity for addiction was recognized. Early heroin marketing also recommended it as treatment for tuberculosis and other diseases with coughing symptoms.
How is heroin used?
In the past 50 years, Heroin has predominantly been g snorted, smoked, and injected, usually in that order. As use progresses as well as the need for more of the drug to stave off withdrawal increases, users used to progress from the less aggressive routes to the higher intensity routes of administration (snorting to IV injection). It was rare to see someone who either who moved from initial use of snorting to IV injections quickly and even more rare to see a patient that started using Heroin by injection. Today, due to the level of dependency on opioids caused by prescription drugs and the new social norms that are more accepting of injection use, it is not uncommon for users to mover directly from prescription opioid abuse and dependence, to injecting heroin.
Seventy-five percent of people addicted to heroin say they were introduced to opioids through prescription drugs, and 94% of people in treatment for opioid addiction say they turned to heroin because prescription drugs were more expensive. It’s currently estimated that 600 people in the US try heroin for the first time every day.
What are the signs of heroin use?
Signs of Heroin use and addiction include: itchy skin and constant scratching, chronic drowsiness or grogginess, dry mouth, impaired judgment, lowered body temperature, slowed breathing and heart rate, constricted pupils, vomiting, evidence of drug paraphernalia such as burnt spoons, syringes, injection kits, sleep difficulties, malnutrition, long sleeves worn in warm weather (to hide needle marks), withdrawal from others, loss of motivation or diminished plans for the future, spending money for undisclosed purposes, “losing” one’s own or a friend’s property, needing increasing amounts of the drug to feel the same effect, inability to cut down, and continued use despite negative consequences.
Symptoms of withdrawal include: runny nose, painful muscle spasms, severe abdominal cramps, body tremors, pounding heart, rapid breathing, heavy perspiration, chills, anxiety, irritability, severe nausea and vomiting, diarrhea, and extreme fatigue.
Symptoms of overdose include: shallow or labored breathing, weak pulse, pinpoint pupils, bluish tinge to lips and fingers, delirium, and unconsciousness. Call for emergency medical help immediately; a heroin overdose is potentially life-threatening. After the immediate danger is dealt with, do everything possible to persuade the patient to continue to heroin and treatment. He/she is at high risk of overdosing again.
How does Recovery Centers of America treat heroin addiction?
A range of treatments including medications and behavioral therapies have been shown to be effective in helping people stop heroin use. It’s important to match the treatment approach to specific needs of each individual patient.
inpatient rehab and detox for heroin
Detoxification from Heroin dependence or addiction is profoundly uncomfortable if done without medical intervention and supervision. It can be life-threatening if the individual is also abusing other drugs such as alcohol or a class of medications known as Benzodiazepines (such as Xanax, Klonopin, Alprazolam, or others).
That said, heroin is a relatively short-acting opioid, this means you feel the effects rapidly and that it is processed through the body fairly quickly. Withdrawal symptoms can start as soon as 6 hours after the last dose, but generally are strongest 36-72 hours after the last dose. Physiological withdrawal generally lasts 5-9 days but can longer for some patients. The severity and duration of withdrawal symptoms will vary based on the amount of heroin used, over what period of time, and the route of administration (intranasal, smoking, injecting).
RCA will monitor the patient round the clock, continually evaluating physiological and psychological symptoms and will use medications to control many of these symptoms. Medications that may be used include opioids to wean off the heroin and palliative or “comfort” medications such as Clonodine, Robaxin, Trazadone, Phenobarbital, Bentyl, Librium, and others.
As noted above, physical/medical aspects of detoxification may last up to 10 days before patients are medically stable. This doesn’t mean they don’t still have symptoms, just that those symptoms may not require round the clock, constant medical attention. Psychiatric symptoms and cravings can continue intermittently for many months.
At intake, RCA staff administer the assessment in a calm environment, providing something to eat and beverages to keep the individual comfortable. If the individual finds it difficult to participate due to an inability to concentrate or onset of withdrawal symptoms, the assessment can be divided into smaller sections.
RCA staff provide a clear orientation to the treatment choices, the process, program rules, and expectations for participation to ensure each patient knows their options and to assist in decreasing any externally related anxiety about the treatment process.
At RCA, we know detoxification doesn’t need to be painful to be effective. A controlled tapering, alleviating many withdrawal symptoms with medications (as noted previously) is the safest, most tolerable method, resulting in the least discomfort.
As with any disorder, it’s also very important to involve significant others. During the initial assessment and intake processes, RCA identifies family members or significant others who will support the patient and their treatment goals and get them involved immediately.
After medical detoxification, treatment will include additional small group therapy sessions, individual sessions, educational seminars, and workshops. For our patients struggling with Heroin, additional services to assist with calming the body and the mind such as mindful meditation, yoga, progressive relaxation, and other therapeutic techniques are provided.
Through wellness seminars, life skills workshops, and various therapies, RCA focuses patients on developing a balanced lifestyle that includes restoring healthy eating and sleeping habits, participation in physical exercise and recreational activities, as well as building healthy relationships and a healthy support group to get them started on the road to long-term recovery.
For patients who plan to detox fully from all opioids, injectable Naltrexone sold under the trade name VIVITROL®, a form of long-term blocker, can be especially helpful. Naltrexone/VIVITROL® are opioid “antagonists,” meaning they block the effects of opioids. VIVITROL® binds to the receptor that opioids use to provide pleasurable feelings and does not allow the opioid to have its effect. In fact, it’s strength in binding to the receptor is so much greater than the opioids ability, it will knock the opioid off the receptions even if they were there first. Therefore, you should have 1-2 weeks without any opioid use to start VIVITROL®, as using it will put an active opioid user into withdrawal. VIVITROL® has also been shown to decrease cravings for both alcohol and opioids.
Medication Assisted Treatment for heroin addiction
For patients who desire ongoing opioid replacement therapy, suboxone and methadone are two scientifically proven options.
The main/active ingredient in Suboxone is buprenorphine. Buprenorphine is a partial agonist. An agonist is a medication that binds to the receptor site – heroin and other opioids are “full agonists,” they bind to the receptors and activate them fully producing the euphoria and pleasurable feelings users often seek. Suboxone is a partial agonist, it binds to and activates the same receptors as other opioids, but has only part of the effect that a full agonist such as Heroin will have on the user. Suboxone remains active in the bloodstream for longer and does not produce quite the same euphoric effect as full agonists like heroin. The pleasurable effects are not as intense if these partial agonists are taken in higher doses, and buprenorphine even has a ceiling so that after a certain amount is taken, it no longer increases in effect.
Interestingly, Suboxone also contains the medication naloxone (that’s where the “oxone” portion of its name comes from). Naloxone, when given alone, is an opioid antagonist (completely blocks the effects of an opioid). If the Suboxone is taken as prescribed, the buprenorphine (opiate agonist) will enter the body slowly, over time and the Naloxone (the opioid antagonist) will be inert or have no effect. If, in an effort to get all the opioid medication into the bloodstream at one time, the user crushes and injects the sublingual tablet, the naloxone effect is activated, it dominates, and the naloxone blocks the receptors, causing opioid withdrawal. This decreases the likelihood that the Suboxone will be abused.
Methadone is another form of medication-assisted treatment. A synthetic opioid, methadone is a longer-acting opioid replacement medication, it binds with the opiate receptors but without quite the euphoria as heroin and other opioids. Methadone is typically taken as a liquid medication and people taking it generally report to a clinic specializing in medication-assisted treatment at least 5 days per week.
Among other benefits, methadone maintenance gives patients a daily, stable dose of opioids, decreases the likelihood that users will be injecting drugs, therefore getting Hepatitis or HIV, eliminates the need to find ways to pay for opioids and helps people move toward a healthy rewarding lifestyle. Although it is not entirely without its own health concerns, methadone is considered effective and safe and is included in the World Health Organization’s (WHO) list of Essential Medications.
One thing all treatment providers agree on – medications alone are never the complete answer for achieving long-term recovery. Addiction is a brain disease that affects many aspects of a person’s physical and mental well-being as well as their personal, family and social relationships. RCA also includes behavioral therapies, pragmatic workshops, counseling sessions, family therapy, and long-term support groups to help individuals achieve long-term, success in recovery and in life!