1. HEROIN
ADDICTION
Teja Mehendale
Psychiatry- Dr. Martinez

3. ADDICTION, ABUSE, DEPENDENCE
 3 distinct terms: reflect the state of the body and mind of an individual
in relation to an addictive substance
 Addiction: 1) when a lot of time is spent in obtaining a substance,
using a substance or recovering from it 2) Important social,
occupational and recreational activities are given up because of it 3)
the use is continued despite having a physical or psychological
problem
 Abuse: 1) Recurrent substance use severely impacts obligations and
responsibilities at work, school or home 2) Legal problems due to
over use 3) Recurrent use despite social, interpersonal problems 4)
Absence of Dependence
 Dependence: 1) Tolerance 2) Withdrawal 3) Unsuccessful urge,
effort to quit

4. OPIATES
 Opiates belong to the large biosynthetic group of
benzylisoquinoline alkaloids
 Naturally occur in the opium poppy

5. OPIATES
 Major psychoactive opiates are morphine, codeine and thebaine
 Semi synthetic opioids are hydrocodone, hydromorphone,
oxycodone and oxymorphone
 Heroin is a synthetic substance that converts into 6 acetyl
morphine in the body
 Heroin is colloquially known as H, smack, horse, brown, black, tar
etc.

6. PHARMACODYNAMICS
 Reward pathway: modifies the action of dopamine in the nucleus
accumbens and the ventral tegmental area of the brain
 Powerful agonist at the mu opioid receptors subtype
 Binding inhibits the release of GABA from the nerve terminal,
reducing the inhibitory effect of GABA on dopaminergic neurons
 Increased activation of dopaminergic neurons and the release of
dopamine into the synaptic results in sustained activation of the
post-synaptic membrane
 Continued activation of the dopaminergic reward pathway leads to
the feelings of euphoria and the ‗high‘ associated with heroin use
 Also binds to areas involved in the pain pathway (including the
thalamus, brainstem, and spinal cord) which leads to analgesia

7. ROUTES OF ADMINISTRATION
 Heroin is usually injected, sniffed/snorted, or smoked
 Typically, a heroin abuser may inject up to four times a day.
Intravenous injection provides the greatest intensity and most
rapid onset of euphoria (7 to 8 seconds)
 Intramuscular injection produces a relatively slow onset of
euphoria (5 to 8 minutes)
 When sniffed or smoked, peak effects are usually felt within 10 to
15 minutes

9. SHORT TERM EFFECTS
 Mitotic ―pinpoint‖ pupils: Less than 2.9 mm; stimulates the
oculomotor nuclei and affecting the sphincter muscle of the iris
which cause narrowing of pupils

10. SHORT TERM EFFECTS
 Nausea and vomiting occur because heroin stimulates the area
postrema equaling chemoreceptor trigger zone in the medulla and
affects gastrointestinal receptors
 Heroin affects the sphincter pylori, sphincter urethrae, and sphincter
ani externus
 Warm, flushed skin; dry mouth; severe itching
 Binds to the u-receptors that decrease gut motility and cause severe
constipation
 Urinary retention
 Bradycardia
 Badypnea and respiratory depression
 CNS depression
 Spontaneous abortions

11. LONG TERM EFFECTS
 Physical dependence and withdrawal as well as addiction
 Infectious diseases, for example, HIV/AIDS and hepatitis B and C
 Collapsed veins
 Bacterial infections- pneumonia, TB
 Abscesses
 Infective endocarditis
 Arthritis and other rheumatologic problems

12. EFFECTS ON PREGNANCY
 Preeclampsia and third-trimester bleeding
 Malnutrition
 Venereal disease
 Hepatitis
 Pulmonary complications
 Fetal death
 Intrauterine growth retardation,
 Prematurity
 Withdrawal symptoms

13. WITHDRAWAL
 Restlessness
 muscle and bone pain
 insomnia,
 diarrhea, vomiting,
 cold flashes with goose bumps ("cold turkey")
 leg movements
 Withdrawal is not fatal in healthy adults

14. TREATMENT
 Naloxone for acute overdose management
 Detoxification — controlled and medically supervised withdrawal
from the drug
 Naltrexone for management: : opioid antagonist
 Methadone maintenance
 Clonidine is sometimes added to shorten the withdrawal time and
relieve physical symptoms
 Buprenorphine- partial opioid agonist
 Behavioral therapy, contingency management therapy and
cognitive-behavioral interventions

15. METHADONE MAINTENANCE
 Specialized clinics for methadone
 Taken daily in liquid form; a single dose lasts 24–36 hours
 Some methadone clinics also provide other services, including vocational and
educational aid, referrals to other medical and social service agencies, help
for the families of addicts, and treatment for cocaine or alcohol abuse.
 Switching from illicit opiates to methadone avoid the highs and lows and the
medical risks of intravenous injection and the criminal behavior that supports
it.
 less depressed, more likely to hold a job and maintain a family life, less likely
to commit crimes, and less likely to contract HIV or hepatitis
 Methadone can be continued indefinitely, or the dose can be gradually
reduced in preparation for withdrawal.
 estimated that about 25% of patients eventually become abstinent, 25%
continue to take the drug, and 50% go on and off methadone repeatedly.

16. BUPRENORPHINE (SUBOXONE)
 partial opioid agonist
 Taken three times a week as either a tablet or film, sublingually
 It occupies opiate nerve receptors and produces a mild opiate-like
 effect.
 In a person who is physically dependent on opiates, buprenorphine causes a
withdrawal reaction.
 There is some risk of abuse if the tablet is dissolved and injected
 buprenorphine has been made available in combination with naloxone, which
has little effect when absorbed under the tongue but neutralizes the effect of
injected opiates.
 The main advantage of this is that patients do not have to come to clinics to
take it, because there is no illicit market and no danger of diversion.
 Since 2002, individual physicians with proper training and certification have
been allowed to prescribe buprenorphine in their offices for patients to take
home

17. THERAPY
 Residential behavioral therapy most effective.
 Contingency management therapy uses a voucher-based system,
where patients earn "points" based on negative drug tests. They
can exchange these for retail items or e allowed to take home
methadone instead of coming to the clinic
 Cognitive-behavioral interventions are designed to help modify
the patient's expectations and behaviors related to drug use, and
to increase skills in coping with various life stressors.

18. AS A PHYSICIAN…
 Perform HIV, Hepatitis B S Ag, Hepatitis C Ab screening tests on
opioid dependent patient
 Watch out for Latent TB infection
 Immunizations Hep A, Hep B and Tetanus are up to date
 Counsel patient, provide information
 Remember, drug seeking behavior is not a personality trait; do not
judge your patients

19. BIBLIOGRAPHY
 Kaplan and Saddocks Synopsis of Psychiatry
 Kaplan Step 2 CK
 Goljan Rapid Review, Pathology
 http://www.cnsforum.com/imagebank/item/moa_heroin_mu/default.aspx
 http://www.caron.org/substance-abuse-vs-addiction.html
 http://addictionscience.net/b2evolution/blog1.php/2009/03/30/why-
distinguishing-between-drug-dependen
 http://www.drugabuse.gov
 http://review-of-current-
research.stsd.wikispaces.net/file/view/The+Pharmacological+Effects+of+Diac
etylmorphine+(Heroin)+After+Diffusion+Through+the+Blood-Brain+Barrier.pdf
 http://www.health.harvard.edu/newsweek/Treating_opiate_addiction_Detoxific
ation_and_maintenance.htm