Background
Heroin (diacetylmorphine) is a semisynthetic narcotic that was first synthesized in 1874. It was originally marketed as a safer, nonaddictive substitute to morphine. Soon after its introduction, heroin was realized to be clearly as addictive as morphine, prompting the US government to institute measures to control its use. By 1914, the Harrison Narcotics Act prohibited the use of heroin without a prescription. In 1920, the Dangerous Drugs Act prohibited the use of heroin altogether, thus driving it underground. In the United States, heroin remains one of the most frequently abused narcotics.
In its pure form, heroin is a white powder with a bitter taste. Street heroin samples are frequently mixed with other substances so dealers may maximize their profits. Because of these impurities and additives, street heroin may appear in various hues and colors, ranging from white to dark brown. Heroin is occasionally sold as a black, tarry substance, especially when crude processing methods are used to manufacture it.
The presence of impurities and additives also limits heroin absorption through mucous membranes, thus limiting its "rush" and "high" when it is sniffed or snorted. In patients who are dependent on heroin, intravenous injection ("mainlining") becomes the only effective method of heroin use. During the 1990s, the purity of US street heroin increased significantly, and its price sharply dropped. In 1980, for example, the average street sample (100-mg bag) contained 3.6% heroin (3.6 mg of heroin) and cost $3.90, compared with 1999, when the average street sample contained 38.2% heroin and cost $0.80.
Samples from South America appeared to have the highest purity, reaching the 90% range. Not surprisingly, this dramatic increase in heroin purity, coupled with the well-publicized dangers of intravenous drug use, led to a change in the pattern of use. Snorting and smoking became the methods of choice and were especially favored by the younger users and new users. Recent samples, however, have demonstrated a rise in impurities. Analysis of heroin powder seized by the US Food and Drug Administration (FDA) in 2005 revealed a heroin content that ranged from 7.3-75%.
Heroin poisoning occurs when an individual accidentally or intentionally overdoses on the drug or when an ingested heroin packet ruptures in the GI tract of a "body packer" or "body stuffer."
Pathophysiology
Heroin is a highly addictive semisynthetic opioid that is derived from morphine. When used intravenously, it is 3-5 times more potent than its parent compound and is able to modulate pain perception and cause euphoria. Similar to morphine, heroin and its metabolites have mu, kappa, and delta receptor activity. In general, stimulation of the mu receptors results in analgesia, euphoria, CNS depression, respiratory depression, and miosis. Stimulation of the delta and kappa receptors also results in analgesia, but the kappa receptors are mostly involved in spinal analgesia.
Heroin, like morphine and other narcotics, reduces the brain's responsiveness to changes in PCO2 and hypoxia, thus resulting in respiratory depression. It also reduces peripheral vascular resistance (resulting in mild hypotension), causes mild vasodilation of the cutaneous blood vessels (resulting in flushing), and stimulates histamine release (resulting in pruritus).
Heroin's inhibitory effects on baroreceptor reflexes results in bradycardia, even in the face of hypotension.
Finally, heroin decreases gastric motility, inhibits the effect of acetylcholine on the small intestine, and diminishes the colonic propulsive waves, resulting in gastric-emptying time that is prolonged by as much as 12 hours and constipation.
The onset of action, peak effects, and duration of action vary with the different methods of use. Patients experience heroin's effect within 1-2 minutes when injected intravenously and within 15-30 minutes when injected intramuscularly. Heroin's peak therapeutic and toxic effects are generally reached within 10 minutes when injected intravenously, within 30 minutes when injected intramuscularly or when snorted, and within 90 minutes when injected subcutaneously. Analgesic effects generally last 3-5 hours.
Intravenously injected heroin creates a "rush" or a sensation of intense pleasure that begins within one minute of the injection and lasts from one to a few minutes. This "rush" is followed by a period of sedation that lasts about an hour. The initial "rush" is likely due to heroin's high lipid solubility and rapid penetration to the brain. The half-life of heroin is 15-30 minutes.
Heroin is rapidly converted to 6-monoacetylmorphine (6-MAM) by the liver, brain, heart, and kidney and may not be detected in the blood at the time of blood draw. 6-MAM is then converted to morphine. Morphine is metabolized by the liver and excreted as a glucuronide product or in its free form by the kidneys. Morphine's half-life is considerably longer than heroin's, ie, 2-3 hours. A small amount of unchanged 6-MAM is excreted in the urine for up to 24 hours after heroin use. Because 6-MAM can originate only from heroin, its detection in the urine can mean only that the patient used either heroin or 6-MAM.
Epidemiology
Frequency
United States
The true prevalence of heroin use is probably much higher than reported in surveys because surveys depend on self-reporting and may not reach some of the persons who use heroin the heaviest. Results from the SAMHSA 's 2008 National Survey on Drug Use and Health (NSDUH) revealed that the number of current heroin users increased from 136,000 in 2005 to 338,000 and then decreased to 213,000 in 2008 before increasing to 339,000 in 2009. In 2009, 180,000 persons aged 12 or older had used heroin for the first time within the past 12 months. The average age at first use among recent initiates aged 12-49 years was 25.5 years in 2009.[1]
Additionally, for 2009 the Drug Abuse Warning Network (DAWN) estimated that heroin was involved in 200,666 ED patient visits.
International
According to the 2009 report of the United Nations Office on Drug and Crime (UNODC), Afghanistan produced most of the world's opium supply in 2008.[2]
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) estimates the average prevalence of problem opioid use in the European Union and Norway to be between 3.6-4.6 cases per 1,000 population aged 15–64 years (1.2–1.5 million users).[3]
Mortality/Morbidity
According to the American Association of Poison Control Centers' National Poison Data System annual report in 2009, 1919 case mentions of heroin exposure were documented. Nine deaths were reported.[4]
About 3-7% of patients treated for heroin overdose require hospital admission because of complications such as pneumonia, noncardiogenic pulmonary edema (NCPE), and infectious complications.
Most fatalities from heroin overdose occur in long-term users, usually early in their third decade of life. Fatality rates are higher in patients who use alcohol and other drugs such as benzodiazepines and cocaine. Death is most commonly due to respiratory failure or asphyxiation.
Race
Although heroin addiction has traditionally been viewed as a disease of the economically disadvantaged population, addiction among the affluent is grossly underreported. According to the National Institute on Drug Addiction (NIDA), little difference exists in lifetime heroin use among races and ethnic backgrounds.[5]
Sex
Although heroin addiction has traditionally been viewed as a disease of males, addiction among females is grossly underreported. According to NIDA, males were more likely than females to report heroin use during their lifetime.[5]
Age
The National Survey on Drug Use and Health reports stability at low levels of heroin use among young people.
According to the American Association of Poison Control Centers' National Poison Data System annual report in 2009, 144 heroin poisonings occurred in those younger than 19 years.[4]
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