Heroin is the most addictive drug known. Simply hearing the word heroin makes parents cringe, communities worry and health care policy-makers lose sleep. It’s hard to turn on the television, radio or read a newspaper without hearing about the growing epidemic of heroin addiction. In fact, residents of New Hampshire considered heroin to be the most important issue facing their state during this year’s Democratic and Republican primaries. Given the widespread concern, I decided to forgo last week’s initial suggestion to discuss COPD and spend this post talking about the heroin epidemic instead.
Heroin use has increased dramatically over the last decade, affecting all demographics of society, including age, gender and socioeconomic status. According to the National Survey on Drug Use and Health, heroin use over this time has increased in women by 100% and in men by 50%. Similarly, young adults ages 18-25 years old have seen a 109% increase in use while those over 25 years old, 58%. For income levels less than $20,000, $20,000-50,000, and over $50,000, the increase has been 62%, 77% and 60%, respectively.
Yet, heroin is rarely used alone and the risk of addiction increases in the setting of other drug use. Specifically, the risk increases two-fold for someone addicted to alcohol, 15-fold for cocaine, and 40-fold for opioids, which are a specific class of painkillers. It is the association with opioids that is particularly concerning. These pain killers, oxycodone and oxycontin, are prescribed by physicians. Usually a person has legitimate reasons for initially taking them, such as treating pain immediately after surgery or injuries from a motor vehicle accident. However, the medicine use sometimes continues longer than necessary and soon the “need” for the drug is about something more than pain control. At some point, a patient’s physician may refuse to continue writing the prescriptions. If the person is addicted, they will look for illegal ways to obtain a comparable high. Heroin treats the same cravings as oxycodone but is only one-fifth of the “street” price. While it is cheaper to buy, heroin raises the degree of addiction and dangers to a new level.
Heroin comes from the Opium Poppy flower, which grows in dry, warm climates such as China, Mexico, Iran, Pakistan and Afghanistan. It does not occur naturally and must be synthesized from the sap of the flower. The sap initially is refined to morphine and then undergoes chemical treatments to form heroin. In its purest form heroin is a white powder but, more often, it is brown, yellow or black. Black is becoming more common and referred to as “Mexican Mud” or “Black Tar”.
Heroin is most often injected. Within seconds it’s converted in the brain to morphine which binds to specific opioid receptors that regulate feelings of pleasure, inhibit pain and slow heart rate and breathing. The high from heroin is almost immediate and the intensity of the high is related to the amount of drug used. With more frequent use, the body becomes tolerant to the effects of the drug and a higher dose is required. But, here is the catch. The tolerance builds up more quickly in the pleasure centers of the brain than in the centers that control breathing and heart rate. Ultimately, the craving for the high can drive a person to use doses that may cause them to stop breathing completely. This difference in tolerance may also explain why people often die of heroin overdose after a period of time free from the drug, such as being in a rehabilitation center. Their brain has lost much of its tolerance during this hiatus but they don’t realize it. As a result, if they relapse they use a dose similar to that which they used before becoming “clean”. Their respiratory center is overwhelmed and they stop breathing.
Heroin overdoses are not new. There have been high profile overdoses for the last forty years. John Belushi, River Phoenix, Kurt Cobain, and more recently, Cory Monteith and Philip Seymour Hoffman are just some of the famous people who died using heroin or heroin mixed with other drugs.
Naloxone is a medicine that can reverse the effects of heroin quickly in the event of an overdose. It must be given soon after a person loses consciousness. Simply, it can save someone’s life. Naloxone is now carried by first-responders in most major cities including EMS workers, firefighters and police. Many cities are wrestling with the idea of providing people who abuse heroin with this antidote to prevent accidental deaths.
Unfortunately, there is no consistent national policy to address the heroin issue. There has been a four-fold increase in heroin-related deaths in the last decade. Sadly, without more efforts to heighten awareness on a local, state and federal level, along with efforts by the medical community to decrease opioid prescriptions, this tragic epidemic will continue and, likely, worsen.
Next week’s post: Living with COPD, a poem
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