II. Epidemiology

  1. Incidence of Narcotic Addiction U.S.: 0.5 to 1 Million
  2. Associated comorbid conditions
    1. HIV Infection (60%)
    2. Hepatitis B Infection (60 to 80%)
    3. Hepatitis C Infection (60 to 80%)
    4. Tuberculosis

III. Class

IV. Preparations

  1. Direct Opium Derivatives
    1. Morphine (Morphine Sulphate, "White Stuff", "M")
    2. Codeine (methyl-Morphine, "School boy")
  2. Morphine Derivative
    1. Heroin (Diacetyl-morphine)
      1. Street Names: H, Horse, Junk, Smack, Scag, Stuff
      2. Administered: IV, "snorted" or smoked
    2. Dilaudid (Dihydromorphinone)
  3. Semi-Synthetics and Synthetics
    1. Methadone (Dolophine amidone, "Dolly")
    2. LAAM
    3. Propoxyphene
    4. Meperidine
    5. Fentanyl
  4. Other abused Opioids
    1. See Krokodil
    2. Loperamide (Imodium, "Poor-man's Methadone")
      1. Users take more than 64 mg (4 fold higher than the total daily dose) to get high
      2. Misuse increasing in 2016 and associated with arrhythmia and Cardiac Arrest deaths
      3. (2016) Presc Lett 23(7): 37-8
    3. Dextromethorphan
      1. See Dextromethorphan Abuse
    4. Kratom
      1. Herbal stimulant at low dose and with Opioid effects at higher dose
      2. Derived from tropical tree (within coffee family)
      3. Currently legal in U.S. to purchase (as of 2016)
      4. Kratom withdrawal is similar to Opioid Withdrawal
      5. (2016) Presc Lett 23(11)

V. Pharmacokinetics

  1. Methadone (35-180 mg): 18-24 hour duration
  2. Heroin (2-8 mg): 4-6 hour duration
    1. Rapidly metabolized to morphine

VI. Signs: Toxicity

  1. Miosis
  2. Hypoventilation
  3. Bradycardia
  4. Hypotension
  5. Pulmonary edema
  6. Coma
  7. Seizures

VII. Diagnosis: Opioid Use Disorder DSM 5 Criteria

  1. Criteria: Two or more of the following 11 criteria in the last year
    1. Loss of control (2 criteria)
      1. Opioids are taken in larger amounts or for a longer period than intended
      2. Persistent desire or unsuccessful attempts to cut-down or control Opioid use
    2. Compulsivity (2 criteria)
      1. Considerable time spent in trying to obtain, use or recover from Opioids
      2. Craving or strong desire to use Opioids
    3. Continued use despite consequences (5 criteria)
      1. Recurrent Opioid use interferes with obligations at work, home or school
      2. Use continues despite social or interpersonal problems
      3. Important activities (social, occupational, recreational) are reduced or eliminated due to Opioid use
      4. Opioid use in physically hazardous situations
      5. Persistent or recurrent, related physical or psychological problem does not dissuade continued use
    4. Tolerance and Dependence (2 criteria)
      1. Tolerance (e.g. markedly increased amounts to achieve desired effect)
      2. Withdrawal syndrome from Opioids (or related agent used to prevent withdrawal symptoms)
  2. Interpretation
    1. Mild
      1. Symptom Criteria: 2-3
    2. Moderate
      1. Symptom Criteria: 4-5
    3. Severe
      1. Symptom Criteria: 6 or more
  3. References
    1. (2013) DSM5, APA, p. 541

VIII. Management: Toxicity

  1. Antidotes
    1. Nalmefene (Revex)
    2. Naloxone (Narcan)
      1. See Naloxone for dosing protocols for adults and children as well as per clinical circumstance
      2. Consider Naloxone Slow Titration Protocol (minimizes withdrawal effects in longterm use)
        1. Draw up Naloxone 1 ml (0.4 mg/ml) and 9 ml Normal Saline
        2. Inject at 1-2 ml/dose (0.04 mg/ml) titrating and observe for increased responsiveness
  2. Monitoring after heroin Overdose
    1. May discharge if asymptomatic for 3-6 hours after Overdose and >1 hour after last dose of Narcan
    2. References
      1. Deblieux and Swadron in Majoewsky (2012) EM:RAP 12(6): 2
      2. Vilke (2003) Acad Emerg Med 10(8): 893-6 [PubMed]

IX. Management: Treatment Options

  1. See Opioid Withdrawal
  2. Counseling
    1. Chemical Dependency Rehabilitation
    2. Narcotics Anonymous
  3. Medical Management: Single Agents
    1. Methadone
    2. Levomethadyl (Orlaam)
    3. Buprenorphine (Buprenex)
    4. Naltrexone (Trexan)
  4. Medical Management: Combination Agents
    1. Buprenorphine/Naloxone (Suboxone, Zubsolv SL)
  5. Treatment strategy
    1. Used as long-term therapy for uncontrolled, refractory Opioid Abuse as a chronic illness
    2. Goal is prevention of continued uncontrolled Opioid Abuse (e.g. Heroin Overdose)

X. Prevention

  1. See Emergency Department Pain Management
  2. Prescription Naloxone
    1. Available as a home intramuscular prescription for emergency delivery in case of Overdose
    2. Naloxone may also be delivered intranasally with an adapter
    3. Some regions have built take-home kits with informational materials for use
  3. Needle exchange program
    1. Lowers risk of infection transmission
    2. Does not promote IV Drug Abuse

XI. Resources

  1. SAM-HSA Help Line
    1. https://www.samhsa.gov/find-help/national-helpline
    2. Phone: 1800-662-HELP
  2. Narcotics Anonymous (NA)
    1. http://www.na.org
    2. Phone: 818-773-9999
  3. Nar-Anon Family Group Headquarters
    1. http://www.onlinerecovery.org/co/nfg
  4. Narcotic Treatment Programs Directory
    1. http://www.fda.gov/cder/compliance/ntpdir.pdf

XII. References

  1. Mason and Papp in Herbert (2015) EM:Rap 15(3): 13
  2. Krambeer (2001) Am Fam Physician 63(12):2404-10 [PubMed]

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Ontology: Heroin (C0011892)

Definition (MEDLINEPLUS)

Heroin is a white or brown powder or a black, sticky goo. It's made from morphine, a natural substance in the seedpod of the Asian poppy plant. It can be mixed with water and injected with a needle. Heroin can also be smoked or snorted up the nose. All of these ways of taking heroin send it to the brain very quickly. This makes it very addictive.

Major health problems from heroin include miscarriages, heart infections, and death from overdose. People who inject the drug also risk getting infectious diseases, including HIV/AIDS and hepatitis.

Regular use of heroin can lead to tolerance. This means users need more and more drug to have the same effect. At higher doses over time, the body becomes dependent on heroin. If dependent users stop heroin, they have withdrawal symptoms. These symptoms include restlessness, muscle and bone pain, diarrhea and vomiting, and cold flashes with goose bumps.

NIH: National Institute on Drug Abuse

Definition (NCI_NCI-GLOSS) A substance made from morphine. Heroin is very addictive and it is illegal to use or sell it in the United States. It is a type of opiate.
Definition (MSH) A narcotic analgesic that may be habit-forming. It is a controlled substance (opium derivative) listed in the U.S. Code of Federal Regulations, Title 21 Parts 329.1, 1308.11 (1987). Sale is forbidden in the United States by Federal statute. (Merck Index, 11th ed)
Definition (CSP) narcotic analgesic drug prepared from morphine, now prohibited in the United States even for medicinal uses because of the danger of addiction.
Concepts Pharmacologic Substance (T121) , Hazardous or Poisonous Substance (T131) , Organic Chemical (T109)
MSH D003932
SnomedCT 60881009, 387341002
LNC LP16107-2, MTHU003319, LA15258-9
English Diacetylmorphine, Diamorphine, Heroin, Morphinan-3,6-diol, 7,8-didehydro-4,5-epoxy-17-methyl- (5alpha,6alpha)-, diacetate (ester), diacetylmorphine, Heroin [Chemical/Ingredient], acetomorphine, heroin products, heroin (Schedule I substance), Junk, Smack, Skag, H, Acetomorphine, diamorphine, Black tar, DIACETYLMORPHINE, Heroin (product), Heroin (substance), heroin
Swedish Heroin
Czech heroin, diacetylmorfin
Finnish Heroiini
Italian Diamorfina, Diacetilmorfina, Eroina
Russian DIATSETILMORFIN, DIAMORFIN, GEROIN, ATSETOMORFIN, АЦЕТОМОРФИН, ГЕРОИН, ДИАМОРФИН, ДИАЦЕТИЛМОРФИН
Japanese ジアセチルモルフィン, ジアモルフィン, ヘロイン
Spanish Heroína, diacetilmorfina, heroína (producto), heroína (sustancia), heroína, Diacetilmorfina, Diamorfina
Polish Dwuacetylomorfina, Heroina, Diacetylomorfina, Diamorfina
French Acétomorphine, Diamorphine, Héroïne
German Diacetylmorphin, Diamorphin, Heroin
Portuguese Diacetilmorfina, Diamorfina, Heroína

Ontology: Opioid abuse (C0029095)

Concepts Mental or Behavioral Dysfunction (T048)
ICD9 305.5
ICD10 F11.1
SnomedCT 5602001
DSM4 305.50
English Opioid Abuse, opioid abuse, opioid abuse (diagnosis), opiate abuse, abuse opioids, Opioid abuse (disorder), abuse; opioids, opioids; abuse, Opioid abuse
Spanish Abuso de opioides, abuso de opiáceos (trastorno), abuso de opiáceos
French Abus d'opiacés
Dutch opiaatmisbruik, misbruik; opioïden, opioïden; misbruik
Portuguese Abuso de opióides
German Opioidmissbrauch
Italian Abuso di oppioidi
Japanese アヘン類乱用, アヘンルイランヨウ
Czech Abúzus opioidů
Hungarian Opioid abúzus

Ontology: Opioid Use Disorders (C0029103)

Concepts Mental or Behavioral Dysfunction (T048)
English Opioid Use Disorders

Ontology: Opiate Addiction (C0524662)

Concepts Mental or Behavioral Dysfunction (T048)
MSH D009293
ICD9 304.00, 304.0
ICD10 F11.2
SnomedCT 192220003, 191818005, 191817000, 75544000
DSM4 304.00
English Opioid type dependence, Dependence, Opiate, Opioid Dependence, Opioid type dependence, unspecified use, Opioid type drug dependence, Unspecified opioid dependence, Opiate Addiction, opioid dependence (diagnosis), opioid dependence, Addiction, Opiate, Dependence on opiates, Opioid dependence-unspec, dependence narcotic, dependence on opiates, opiate addiction, narcotism, addiction opiate, narcotic dependence, opioid type dependence, opiate dependence, dependence opiates, Opioid type dependence, unspecified, [X]Drug addiction - opioids, Unspecified opioid dependence (disorder), Opioid dependence, Narcotism, Opioid dependence (disorder), dependence; opiate, dependence; opioids, opioids; dependence, Opiate Dependence
Dutch opioïd-type afhankelijkheid, niet-gespecificeerd gebruik, afhankelijkheid van opiaten, opioïd-type afhankelijkheid, afhankelijkheid; opiaat, afhankelijkheid; opioïde, opioïden; afhankelijkheidssyndroom, Opiatenafhankelijkheid
French Dépendance aux opiacés, usage non précisé, Dépendance aux opiacés, Opiodépendance
German Opioidabhaengigkeit, unspezifische Verwendung, Abhaengigkeit von Opiaten, Opioidabhaengigkeit, Opiat-Abhängigkeit
Italian Dipendenza da oppiacei, Dipendenza da oppioidi, Dipendenza da oppioidi, non specificata, Dipendenza dagli oppiacei
Portuguese Dependência de opiáceos, Dependência tipo opióide, Dependência tipo opióide, uso NE, Dependência de Opiáceos, Adição a Opiáceos
Spanish Dependencia de tipo opioide, uso no especificado, Dependencia de tipo opioide, Dependencia a opiaceos, Dependencia de Opiáceos, Adicción a Opiáceos, dependencia a opiodes no especificada, dependencia a opiodes no especificada (trastorno), dependencia de narcóticos, dependencia de opiáceos (trastorno), dependencia de opiáceos, narcodependencia
Japanese アヘン類依存, アヘン剤依存, アヘン類依存、使用の詳細不明, アヘンザイイゾン, アヘンルイイゾン, アヘンルイイゾンシヨウノショウサイフメイ
Czech opiátová závislost, Závislost na opioidech, Závislost na opiátech, Závislost na opioidech, blíže neurčené užívání, závislost na opiátech
Hungarian Opioid típus függőség, Opioid típus függőség, nem meghatározott használat, Függőség, opiatok
Norwegian Opiatavhengighet