1. Heroin Addiction

2. What is heroin? Heroin is an opioid, derived from the opium poppy الخشخاش Heroin is an opioid, derived from the opium poppy الخشخاش Morphine is the active ingredient in opium Morphine is the active ingredient in opium

4. Effects of heroin “Positive” effects (the reasons for use) “Positive” effects (the reasons for use) Heroin's main effect is a sudden rush sense of euphoria with dreamy state of complete relaxation for several hours Heroin's main effect is a sudden rush sense of euphoria with dreamy state of complete relaxation for several hours Also, flushing of the skin and heavy extremities Also, flushing of the skin and heavy extremities The onset of these effects differs based on the method of administration The onset of these effects differs based on the method of administration Smoked/snorted = 10-15 min Smoked/snorted = 10-15 min Injected = 7-10 seconds Injected = 7-10 seconds

5. Negative effects Negative effects on CNS: Negative effects on CNS: Drowsiness, and mental cloudiness Drowsiness, and mental cloudiness change in mood with difficult concentration change in mood with difficult concentration Anxiety or fear Anxiety or fear The user may become sleepy and in large doses it may cause deep sleep The user may become sleepy and in large doses it may cause deep sleep Slowed breathing and cardiac function: breathing is slowed down. If in large amount death may occur cardiorespiratory failure. Slowed breathing and cardiac function: breathing is slowed down. If in large amount death may occur cardiorespiratory failure.

6. Negative effects on digestive System: Stomach digestive juices become scanty in amount Stomach digestive juices become scanty in amount Contraction of Stomach muscles and intestines is slowed down, so digestion of food is slowed down Contraction of Stomach muscles and intestines is slowed down, so digestion of food is slowed down Constipation takes place Constipation takes place Nausea and vomiting, or upset Stomach Nausea and vomiting, or upset Stomach Loss of appetite which leads to undernourishment and anemia Loss of appetite which leads to undernourishment and anemia

7. Other effects and health problems Hepatitis from injection with dirty needle Hepatitis from injection with dirty needle Skin problems, Itchy skin Skin problems, Itchy skin Much sweating Much sweating Constipation Constipation Narrowing of pupils Narrowing of pupils Urgency or urinary retention Urgency or urinary retention Hypotension Hypotension The blood vessels of the skin are dilated especially face& neck with feeling of warmth The blood vessels of the skin are dilated especially face& neck with feeling of warmth

8. 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 problems

9. What are the medical complications of chronic heroin use? Medical consequences of chronic heroin injection use include: 1-scarred and/or collapsed veins, 2-bacterial infections of the blood vessels and heart valves, abscesses (boils) and other soft-tissue infections, 3- liver or kidney disease. 4-Lung complications (including various types of pneumonia and tuberculosis) may result from the poor health condition of the abuser as well as from heroin’s depressing effects on respiration. Many of the additives in street heroin may include substances that do not readily dissolve and result in clogging the blood vessels that lead to the lungs, liver, kidneys, or brain. This can cause infection or even death of small patches of cells in vital organs.

10. What are the medical complications of chronic heroin use? 5-Immune reactions to these or other contaminants can cause arthritis or other rheumatologic problems. 6-Of course, sharing of injection equipment or fluids can lead to some of the most severe consequences of heroin abuse— infections with hepatitis B and C, HIV, and a host of other blood borne viruses, which drug abusers can then pass on to their sexual partners and children.

11. How does heroin abuse affect pregnant women? Heroin abuse can cause serious complications during pregnancy, including miscarriage and premature delivery. Heroin abuse can cause serious complications during pregnancy, including miscarriage and premature delivery. Children born to addicted mothers are at greater risk of sudden infant death syndrome (SIDS). Children born to addicted mothers are at greater risk of sudden infant death syndrome (SIDS).

12. How heroin works Heroin cross the blood-brain barrier with much greater efficiency Heroin cross the blood-brain barrier with much greater efficiency Once in the brain, heroin is converted to morphine, and becomes “trapped” by the barrier Once in the brain, heroin is converted to morphine, and becomes “trapped” by the barrier The morphine interacts with receptors and causes the effects. The morphine interacts with receptors and causes the effects.

13. How heroin works Receptors located non-uniformly throughout Central Nervous System Receptors located non-uniformly throughout Central Nervous System Cerebral cortex has most Cerebral cortex has most Spinal cord has significantly less Spinal cord has significantly less

14. How users become addicted The body cannot completely eradicate drugs. It metabolizes them, and the metabolites get stored in fatty tissue. When the fatty tissue is broken down, the metabolites are released and act on the brain again, causing a craving. The body cannot completely eradicate drugs. It metabolizes them, and the metabolites get stored in fatty tissue. When the fatty tissue is broken down, the metabolites are released and act on the brain again, causing a craving.

15. Opioid Tolerance Tolerance develops to Opioids in remarkable degree, more than to general sedatives such as barbiturates and alcohol. Tolerance develops to Opioids in remarkable degree, more than to general sedatives such as barbiturates and alcohol. Cross-tolerance can be developed for drugs within the opoid class. Cross-tolerance can be developed for drugs within the opoid class.

17. Opioid Withdrawal It can be a severe process. It can be a severe process. Symptoms depend on degree of tolerance and the severity of the dependence. Symptoms depend on degree of tolerance and the severity of the dependence. develops within 4-12 hours of cessation of the drug. The symptoms and signs reach their peak by the end of the second day and are mostly resolved within 3-4 days. develops within 4-12 hours of cessation of the drug. The symptoms and signs reach their peak by the end of the second day and are mostly resolved within 3-4 days.

18. Opioid Withdrawal minutes to days: minutes to days: Unhappy mood (Irritability and depression) Unhappy mood (Irritability and depression) Twitching of Muscle, tremors of tongue and aching pain in aches Muscles, bone and joints. Twitching of Muscle, tremors of tongue and aching pain in aches Muscles, bone and joints. Runny nose with sniffing, itching of nose and paroxysm of sneezing Runny nose with sniffing, itching of nose and paroxysm of sneezing Pupillary dilation/Tearing Pupillary dilation/Tearing Subjective feeling of hot or cold occur, marked feeling of coldness with contraction of muscles attached to hair, so hair will erect (Goose bumps-cold turkey) or sweating Subjective feeling of hot or cold occur, marked feeling of coldness with contraction of muscles attached to hair, so hair will erect (Goose bumps-cold turkey) or sweating

19. Opioid Withdrawal  Nausea/Vomiting  Abdominal cramping and Diarrhea –  Fever, increase in breathing rate and blood pressure  Yawning becomes frequent and deep  Nervousness and restlessness  Increased salivation  Anorexia, loss of food intake and loss of weight  Feeling of desperation with obsessive desire to secure more of the drug

20. Opioid Overdose Life threatening they depress the brain (breathing control part of the brain) which results in respiratory failure, coma and death Life threatening they depress the brain (breathing control part of the brain) which results in respiratory failure, coma and death Constricted pupils Constricted pupils Drowsiness or coma Drowsiness or coma Slurred speech Slurred speech Poor attention and memory Poor attention and memory

21. Diagnosis Lab tests Lab tests Urine, blood, others Urine, blood, others 12-36 hrs after use 12-36 hrs after use

22. Acute Intervention Overdose Overdose Emergency Emergency Support vital signs Support vital signs Naloxone: 0.4 mg q 2-3 min. SC/IV Naloxone: 0.4 mg q 2-3 min. SC/IV Withdrawal Withdrawal Opioid substitution with gradual ↓ Opioid substitution with gradual ↓ Symptomatic treatment Symptomatic treatment

23. Pharmacological Treatment 1. Methadone  Once/day dosed  40-60 mg/d: sufficient to block withdrawal sx. 2. Buprenorphine/Naloxone  12-16 mg/d

24. Psychosocial Treatment Specialized programs Specialized programs Cognitive behavioral therapy Cognitive behavioral therapy Group and Family therapy Group and Family therapy

25. Methadone How it works How it works Methadone is broken down in the liver and stored Methadone is broken down in the liver and stored When the brain opiate receptors are ready, methadone is mobilized and fills the receptors When the brain opiate receptors are ready, methadone is mobilized and fills the receptors Methadone is an agonist, so it works similar to heroin, but does not produce the extreme highs and lows Methadone is an agonist, so it works similar to heroin, but does not produce the extreme highs and lows

26. Naltrexone Used mainly for alcoholism treatment Used mainly for alcoholism treatment New method in other countries, currently being researched in the United States New method in other countries, currently being researched in the United States Opioid antagonist – blocks effect of opioids by blocking receptors Opioid antagonist – blocks effect of opioids by blocking receptors Non-addictive Non-addictive

27. Naltrexone How it works How it works Naltrexone is attached to the opioid receptors, competitively inhibiting the attachment of opioids to the receptors Naltrexone is attached to the opioid receptors, competitively inhibiting the attachment of opioids to the receptors Completely blocks euphoria feeling, but some still feel nauseous Completely blocks euphoria feeling, but some still feel nauseous

28. Naltrexone Problems and Questions Problems and Questions Not used in pregnant women Not used in pregnant women High relapse numbers High relapse numbers