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her·o·in ˈherəwən/noun noun: heroin
a highly addictive analgesic drug derived from morphine, often used illicitly as a narcotic producing euphoria.
The greatest increase in heroin use is seen in young adults aged 18-25.
Heroin is an illegal, highly addictive drug processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants. It is typically sold as a white or brownish powder that is “cut” with sugars, starch, powdered milk, or quinine. Pure heroin is a white powder with a bitter taste that predominantly originates in South America and, to a lesser extent, from Southeast Asia, and dominates U.S. markets east of the Mississippi River. Highly pure heroin can be snorted or smoked and may be more appealing to new users because it eliminates the stigma associated with injection drug use. “Black tar” heroin is sticky like roofing tar or hard like coal and is predominantly produced in Mexico and sold in U.S. areas west of the Mississippi River. The dark color associated with black tar heroin results from crude processing methods that leave behind impurities. Impure heroin is usually dissolved, diluted, and injected into veins, muscles, or under the skin.
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Repeated heroin use changes the physical structure and physiology of the brain, creating long-term imbalances in neuronal and hormonal systems that are not easily reversed. Studies have shown some deterioration of the brain’s white matter due to heroin use, which may affect decision-making abilities, the ability to regulate behavior, and responses to stressful situations. Heroin also produces profound degrees of tolerance and physical dependence. Tolerance occurs when more and more of the drug is required to achieve the same effects. With physical dependence, the body adapts to the presence of the drug and withdrawal symptoms occur if use is reduced abruptly. Withdrawal may occur within a few hours after the last time the drug is taken.
Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goose bumps (“cold turkey”), and leg movements. Major withdrawal symptoms peak between 24–48 hours after the last dose of heroin and subside after about a week. However, some people have shown persistent withdrawal signs for many months. Finally, repeated heroin use often results in addiction—a chronic relapsing disease that goes beyond physical dependence and is characterized by uncontrollable drug-seeking no matter the consequences. Heroin is extremely addictive no matter how it is administered, although routes of administration that allow it to reach the brain the fastest (i.e., injection and smoking) increase the risk of addiction. Once a person becomes addicted to heroin, seeking and using the drug becomes their primary purpose in life.
Research has found that drug abuse treatment along with HIV prevention and community-based outreach programs can help people who use drugs change the behaviors that put them at risk for contracting HIV and other infectious diseases. They can reduce drug use and drug-related risk behaviors such as needle sharing and unsafe sexual practices and, in turn, reduce the risk of exposure to HIV/AIDS and other infectious diseases. Only through coordinated utilization of effective antiviral therapies coupled with treatment for drug abuse and mental illness can the health of those suffering from these conditions be restored.
Opioids Act on Many Places in the Brain and Nervous System
Heroin binds to and activates specific receptors in the brain called mu-opioid receptors (MORs). Our bodies contain naturally occurring chemicals called neurotransmitters that bind to these receptors throughout the brain and body to regulate pain, hormone release, and feelings of well-being. When MORs are activated in the reward center of the brain, they stimulate the release of the neurotransmitter dopamine, causing a sensation of pleasure.1 The consequences of activating opioid receptors with externally administered opioid such as heroin (versus naturally occurring chemicals within our bodies) depend on a variety of factors: how much is used, where in the brain or body it binds, how strongly it binds and for how long, how quickly it gets there, and what happens afterward.
A variety of effective treatments are available for heroin addiction, including both behavioral and pharmacological (medications). Both approaches help to restore a degree of normalcy to brain function and behavior, resulting in increased employment rates and lower risk of HIV and other diseases and criminal behavior. Although behavioral and pharmacologic treatments can be extremely useful when utilized alone, research shows that for some people, integrating both types of treatments is the most effective approach.
Pharmacological Treatment (Medications)
Scientific research has established that pharmacological treatment of opioid addiction increases retention in treatment programs and decreases drug use, infectious disease transmission, and criminal activity.
When people addicted to opioids first quit, they undergo withdrawal symptoms (pain, diarrhea, nausea, and vomiting), which may be severe. Medications can be helpful in this detoxification stage to ease craving and other physical symptoms, which often prompt a person to relapse. While not a treatment for addiction itself, detoxification is a useful first step when it is followed by some form of evidence-based treatment.
Medications developed to treat opioid addiction work through the same opioid receptors as the addictive drug, but are safer and less likely to produce the harmful behaviors that characterize addiction. Three types of medications include: (1) agonists, which activate opioid receptors; (2) partial agonists, which also activate opioid receptors but produce a smaller response; and (3) antagonists, which block the receptor and interfere with the rewarding effects of opioids. A particular medication is used based on a patient’s specific medical needs and other factors.
Effective medications include:
The many effective behavioral treatments available for heroin addiction can be delivered in outpatient and residential settings. Approaches such as contingency management and cognitive-behavioral therapy have been shown to effectively treat heroin addiction, especially when applied in concert with medications. Contingency management uses a voucher-based system in which patients earn “points” based on negative drug tests, which they can exchange for items that encourage healthy living. Cognitive-behavioral therapy is designed to help modify the patient’s expectations and behaviors related to drug use and to increase skills in coping with various life stress. An important task is to match the best treatment approach to meet the particular needs of the patient.
Heroin addiction afflicts an estimated 810,000 people in this country, the great majority of who do not either seek or receive treatment. Further, in 2008 1.85 million people in the U.S. met the diagnostic criteria for abuse or dependence on opioid pain relievers, such as Oxycontin and Vicodin (NSDUH, 2009). In fact, opioid abuse (including heroin) is a worldwide problem, with between 12.8 and 21.9 million people abusing opiates in the past year (UNODC, 2010). Two recent developments in the treatment of opioid addiction herald important advances for addressing this worldwide epidemic.
First, the U.S. Food and Drug Administration (FDA) today announced its approval of Vivitrol® for the treatment of opioid addiction. Vivitrol is an extended release formulation of naltrexone, an opioid receptor antagonist. Double-blind, placebo controlled clinical trials have shown Vivitrol to be effective in preventing not only relapse to drug use following detoxification, but also to diminish cravings that often drive it. Vivitrol, initially approved by the FDA in 2006 for treating alcohol dependence, received approval for this new indication based on findings from research conducted in heroin-addicted patients in Russia. Vivitrol is the first non-narcotic, non-addictive, extended release medication approved for the treatment of opioid dependence—marking an important turning point in our approach to treatment.
Traditional treatments have included methadone (an opioid agonist), available only through specialized clinics; and more recently, bupenorphrine (an opioid partial agonist), which can be prescribed in the privacy of a doctor's office. These drugs are effective, especially when combined with counseling, but require daily dosing. As a depot formulation, dosed monthly, Vivitrol obviates the daily need for patients to motivate themselves to stick to a treatment regimen—a formidable task, especially in the face of multiple triggers of craving and relapse. This new option increases the pharmaceutical choices for treating opioid addiction, and may be seen as advantageous by those unwilling to consider agonist or partial agonist approaches to treatment. NIDA is continuing to support research on Vivitrol's effectiveness in this country, including a focus on criminal justice involved populations transitioning back into the community. This is an especially vulnerable period, associated with a high risk of relapse, overdose, and re-arrest.
Second, a new study reported in the Journal of the American Medical Association shows promising findings for an implantable formulation of buprenorphine (Probuphine), which delivers a constant dose of the medication for up to six months. Again, the goal is to improve upon the efficacy of daily administered buprenorphine, which can be undermined by poor treatment adherence, resulting in craving and withdrawal symptoms that increase the likelihood of relapse. NIDA is supporting further research on the clinical efficacy of Probuphine, in the hopes that it too will become part of the arsenal of weapons against the crippling effects of opioid addiction.
According to the National Survey on Drug Use and Health (NSDUH), in 2012 about 669,000 Americans reported using heroin in the past year,1 a number that has been on the rise since 2007. This trend appears to be driven largely by young adults aged 18–25 among whom there have been the greatest increases. The number of people using heroin for the first time is unacceptably high, with 156,000 people starting heroin use in 2012, nearly double the number of people in 2006 (90,000). In contrast, heroin use has been declining among teens aged 12–17. Past-year heroin use among the Nation’s 8th-, 10th-, and 12th-graders is at its lowest levels in the history of the Monitoring the Future survey, at less than 1 percent of those surveyed in all 3 grades from 2005 to 2013.
The impact of heroin use is felt all across the United States, with heroin being identified as the most or one of the most important drug abuse issues affecting several local regions from coast to coast.
Nationally, death rates from prescription opioid pain reliever (OPR) overdoses quadrupled during 1999–2010, whereas rates from heroin overdoses increased by 50%. Individual states and cities have reported substantial increases in deaths from heroin overdose since 2010.
The increase in heroin deaths parallels increases seen in individual states reported previously. Kentucky reported a 279% increase in heroin deaths from 2010 to 2012 . In Ohio, the number of heroin deaths increased approximately 300% from 2007 to 2012, with men aged 25–34 years at highest risk for fatal heroin overdoses. Mortality data for the United States show a 45% increase in heroin deaths from 2010 to 2011, the largest annual percentage increase since 1999. The increasing death rate from heroin also is consistent with the 74% increase in the number of current heroin users among persons aged 12 years in the United States during 2009–2012
The following represents a snapshot of the most current statistics available concern heroin addictions and heroin overdose.
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