Tuesday, January 18, 2022

Ask & Answer: about Heroin

Heroin has a reputation for being one of the most destructive illegal substances out there. It’s earned that reputation. Today, there are more Americans dying from heroin and other opioid-based medications than there are from breast cancer. Each year, the problem seems to get worse. Each year, the number of deaths caused by opioids like heroin increases.

In October of 2017, the President declared a public health emergency. Indeed, the press had been sounding the alarm much earlier in what has now been dubbed “the opioid epidemic”. The Opioid Epidemic is a problem that was created and allowed to fester due to multiple social issues. The problem cannot be solved by tackling any one issue. With the death toll rising and more Americans finding themselves in rehab (or in morgues), health officials find themselves fighting the addiction itself, a symptom of a larger disease.

This page is an attempt to answer some of the most frequently asked questions about heroin, heroin addiction, and heroin treatment. For those who find themselves in the thrall of addiction or who have loved ones who are currently struggling to get themselves clean, this page will provide a resource for understanding what exactly heroin is and its effects on the body.

What is the History of Heroin?

Heroin was once manufactured by major pharmaceutical companies as a “wonder drug” and a better alternative to morphine. It was believed to be and marketed as less addictive than morphine from which it was derived.

The initial experiments and testing of heroin began shortly after it was invented in 1874. By the 1900’s it was being manufactured by the Bayer Corporation. The name “heroin” comes from a feeling of heroism that its users reported when on the drug. Bayer put it in cough medicine, sold it as a pain reliever, and doctors used it as an anesthetic.

However, the powerfully addictive quality of the drug became apparent. In 1924, Congress passed the Heroin Act, effectively making heroin illegal. Its vast potential for abuse made it apparent that the drug could not be safely distributed as a pain reliever.

Today, unlike other drugs that are illegal for public consumption, heroin serves no medical purpose.

Heroin Becomes an Illegal Drug

Heroin abuse ebbed and flowed throughout the years, largely dependent on smuggling tactics and the drug trade. Most of the heroin supplied came from opium grown in Asia. Hence, Asia became one of the key distributors. From 1965 to 1970 there were an estimated 750,000 heroin addicts in the United States. In 1973, Richard Nixon passed the legislation that created the DEA.

At the same time, the Vietnam War was being fought, American troops seized controls of key areas surrounding Saigon. Vietnam was a major source for opium. Between Nixon’s creation of the DEA and the fall of Saigon, heroin abuse abated in the U.S.

But this only left a vacuum for other major suppliers to stake a claim. After U.S. troops sprayed the Vietnamese opium fields with Agent Orange, the poppy growing fields moved to Afghanistan, Pakistan, and Iran.

Today, heroin continues to be grown in both Asia, South America, and Africa. For drug enforcement agents, fighting the drug trade is a bit like playing whack-a-mole.

Credit: https://www.deamuseum.org/ccp/opium/production-distribution.html

Heroin Abuse Today

The Opioid Epidemic of today has seen rates of abuse higher than anything we’ve known before. This is due in large part to the overprescription of prescription pain management medications like oxycodone and Vicodin.

There are many who blame the pharmaceutical companies for these numbers. It’s true that here in the U.S., the number of people who die from opioid-based pain medications is far higher than in Europe and Asia.

It’s also true that pharmaceutical companies are currently being sued by state governments for deceptively marketing their medications, and failing to warn doctors of the potential side effects. Everyone is still looking for the next heroin, an opioid that relieves pain but does not have the same addictive side effects. To date, no one has been successful.

The number of deaths caused annually by heroin and other opioids is similar to the impact that the AIDS virus had on the U.S. population in the late 80’s and early 90’s. Calling it an “epidemic” is not hyperbole. The number of deaths caused by opioids today is now five times greater than it was in 1999. Drug abuse now kills more people than car accidents.

The majority of those in rehab are there because of heroin.

What is Heroin?

Technically speaking, heroin is a synthetic opioid derived from morphine. Colloquially known as smack, skag, dope, or junk, heroin is one of the most lethal and widely abused drugs on the streets today.

There are two different kinds of heroin. The first, coming from Mexico, is known as “black tar” due to its color and sticky consistency. The other form of heroin comes as a white or brown powder and is usually distributed through Asian markets. Of the two, white powdered heroin is the more potent and pure. The manufacturing process involved with producing “black tar” heroin riddles it with impurities. Because of this, black tar heroin must be injected while white powdered heroin can be smoked, snorted, injected, or mixed in tea. On the other hand, white powdered heroin is also more dangerous.

What is an Opioid?

The term “opioid” refers to any number of a class of drugs that bind with opioid receptors in the brain. Opium itself is a naturally grown opioid that has been used (and abused) for millennia. In the last few hundred years, scientists have learned various of ways of honing the effects of opium. The drugs produced are used to treat severe pain.

There are four different classes of opioids. Those include:

  • Endogenous opioids. These are opioids that occur naturally in your body. For instance, endorphins are an example of an endogenous opioid. If you’ve ever heard of a “runner’s high” that is caused by endorphins.
  • Opium alkaloids. Opium alkaloids are directly derived from opium. These were once known as “opiates” in contrast to opioids, which were synthetically derived. Common examples are codeine and morphine.
  • Semi-synthetic opioids. Semi-synthetic opioids are derived from opium alkaloids. Heroin and oxycodone are examples of such opioids.
  • Fully-synthetic opioids. Fully synthetic opioids are not structurally similar to opium alkaloids but still activate opioid receptors in the brain. One example is methadone.

When opioids enter the body, they bond with opioid receptors which slow breathing, reduce pain, and produce a feeling of tranquility. In addition, the produce a temporary euphoria which is directly related to the strength of the opioid. Opioids can successfully reduce pain, but that comes at a very high cost. One cost is that the body and brain form a tolerance to the drug that makes it less effective over time.

How Addictive is Heroin?

In terms of pure potency, Heroin is considered to be the second most addictive opioid that you can find on the streets. This is largely because of a new drug, fentanyl, which is much more potent in terms of size to dosage ratio. Fentanyl is considered 30 to 50 times more powerful than heroin because it only takes a very small amount to produce a single dose. This is relevant for drug traffickers because they can get many more doses out of a smaller weight, but heroin ranks as one of the most addictive substances known to man for a reason. It produces an incredible sense of euphoria.

When heroin bonds with opioid receptors in the brain, it also unleashes a flood of the neurotransmitter dopamine. Dopamine is involved in the pleasure and reward system of the brain. That is what produces the sense of euphoria that users get after ingesting the drug. But this is also true of a number of drugs that are recreationally abused, like cocaine and methamphetamine.

Heroin, on top of the dopamine addiction, is physically addictive as well. Users who attempt to stop abusing the drug will experience an agonizing set of symptoms. Not only does heroin reward users for taking it, but it also punishes them for abstaining. So while statistics might show that a drug like nicotine has a higher relapse rate than heroin, that information does not account for the agony that heroin abusers experience while trying to kick the habit, nor the joy they feel after they’ve shot up.

The Physical Addiction

The physical addiction to heroin is experienced as a kind of negative reinforcement or punishment. Users who stop the drug suddenly will experience withdrawal symptoms that are not pleasant or pleasurable at all. These withdrawal symptoms can begin within 24 hours of the last dose.

In this manner, heroin essentially hijacks the brain’s motivational center. The same parts of the brain that are activated when a person experiences a peak success in life are activated when the drug enters the system. Graduation from college. The birth of a new child. A wedding proposal. A promotion at work. The beginning of a new romantic relationship. Winning the big game. These are all experiences that naturally produce a lot of dopamine.

In addition, dopamine is produced for more mundane pleasures as well. Eating food and having sex, for instance. All of these pleasures, both simple and great fall by the wayside as the heroin addict searches for their next fix.

The Psychological Addiction

Imagine being delivered an electric shock each time you didn’t perform a certain task, but given a huge reward every time you did. In no time, you’d be doing everything in your power to perform that task. In this analogy, the task being referred to is procuring more heroin.

In terms of treating heroin addiction, there are two well understood phases: the acute phase, and the post-acute phase. The acute phase accounts for the detox period where those in recovery experience the withdrawal symptoms caused by heroin addiction. This phase, while remarkably unpleasant, does not last long. It’s usually over after a week to ten days.

The post-acute phase is when the majority of addicts relapse.

When a heroin user takes a hit of heroin, it floods their brain with dopamine. If this continues over a long enough period of time, their brains become dependant on heroin in order to produce dopamine. In the post-acute phase of recovery, heroin addicts experience a prolonged period during which their brains aren’t producing dopamine properly. The simple pleasures that most of us experience life cannot be experienced by the heroin addict during this period. This is called anhedonia and it means the inability to experience joy or pleasure. That’s why the majority of heroin addicts will relapse during the post-acute phase.

Anhedonia is characterized by an extended period of depression, emptiness, and withdrawal. During this phase, those in recovery feel sort of like an emotional zombie. It will take about a year of abstinence before their brain chemistry is restored to its proper functioning. But the passage there is dearly paid.

What is the difference between physical and psychological addiction?

What are the Long-Term Side Effects of Heroin and Opioid Use?

Heroin has a number of deleterious effects on the mind and the body. Some of those cannot be reversed or require an extended period of abstinence in order to repair. Some of these are related to the drug itself. Some of these are related to how the drug was ingested and the lack of good judgment exercised while the user is seized by heroin addiction.

Prolonged Heroin Abuse Causes Brain Damage

Long-term abuse of heroin creates long-term, if not permanent, physiological changes to the structure of the brain. It creates imbalances in neuronal and hormonal systems that can take years to reverse. The longer the abuse goes on for, the more likely that the damage will be irreversible.

Studies conducted on long-time heroin users showed deterioration in the brain’s white matter. White matter is involved in executive functions, decision making, and the ability to regulate one’s own behavior. White matter is necessary to transmit impulses from one part of the brain to the other. With that compromised, different areas of the brain have more difficulty communicating with one another.

Heroin also depletes the gray matter in the prefrontal cortex. The prefrontal cortex is responsible for speech, executive functions, and sensory input.

It’s unclear to what extent prolonged abstinence can repair this sort of damage, if at all.

Prolonged Heroin Abuse Causes Lung Problems

Heroin is a respiratory depressant that also causes fluid to fill up the lungs. When a person overdoses, it’s because their respiration has been depressed to the point of stopping altogether. In other words, they simply stop breathing. Even when they can be revived the lack of oxygen to the brain can cause further brain damage. In addition, heroin addicts are more susceptible to getting respiratory infections.

Generally speaking, heroin addicts don’t take very good care of their health. They don’t get a healthy balanced diet and they do not maintain their hygiene. They often live in squalor. This creates a perfect storm that ultimately causes extensive damage to their lungs. Heroin addicts are at increased risk of  forming abscesses in the lungs, tuberculosis, and scarring of the lung tissue.

Heroin Addicts End Up with Blood Infections and More

On a long enough timescale, most addicts end up using the drug intravenously. This is because it delivers the strongest effect when injected into a vein. It’s carried directly to the heart. If you’re addicted to heroin, you won’t care about things like the cleanliness of needles, or any other sanitary consideration. You just want the drug to be delivered as quickly and effectively as possible.

Heroin addicts end up with collapsed veins, blood infections, and infections in the heart. These types of infections, called endocarditis can destroy tissue in the heart. Sometimes the heart valves need to be replaced entirely, or else the patient will die. The replacement valves must themselves be replaced every few years.

Other Complications

There’s no way of knowing what the heroin users are injecting is cut with. These substances themselves can cause problems, including blocking capillaries, arteries, and veins. Each time a user takes the drug, they are putting their lives at risk.

What Happens During an Overdose?

Heroin and other opioids are respiratory depressants. That means that they make you breathe slower. When a person has taken too much, their respiration may be depressed so completely that it stops altogether. In other words, they just stop breathing.

Are Heroin Overdoses Painful?

No. When a user dies of a heroin overdose they are in a peaceful state of tranquility when they go. They are so tranquil, in fact, that the don’t even know that they’ve stopped breathing. It’s just about the most peaceful and pleasurable way to go. This is why those who are in hospice are given high doses of opioids to ease their passing. There is not one painful thing about a heroin overdose other than grief and loss that loved ones will undoubtedly feel without that person in their lives anymore.

Can Heroin Overdoses Be Reversed?

Yes. If emergency medical teams get there in time, heroin overdoses can be stopped. Drugs like Narcan act as opioid antagonists which block the effects of opioids in the body. However, sometimes there are complications that require surgical intervention or more treatment. Even when overdoses are reversed, sometimes heroin addicts still end up dying.

What Can I Do for Someone Overdosing on Heroin?

Call 911 immediately and tell them the person you’re with has stopped breathing. When help arrives make sure they know the individual took heroin.

How is Heroin Addiction Treated?

If you’ve read all the way through this FAQ then you’re probably wondering how anyone ever kicks a heroin addiction. The fact is, they do. For as many people who die from opioids or heroin, many more survive and go on to live rewarding and meaningful lives. It’s certainly not easy. But that’s doesn’t make it impossible. There’s a lot of help out there for those who genuinely want to turn their lives around. No one has to go through this alone.

There are a number of steps that a heroin addict has to take on their journey toward sobriety. Each of these can be understood as different trials. The first trial is recognizing that there is a problem and taking the necessary steps to do something about it.

But what happens after that?

The Drug Assessment & Pre-Intake

The next step in the process for an individual in recovery is the drug assessment. Drug assessments are designed to determine the extent of a patient’s drug abuse. Doctors will ask questions concerning how long patients have been taking the drug. How they ingested the drug. When they started using the drug. How often they use the drug. Patients might be given a questionnaire to fill out.

In addition, a medical staff may take blood samples or physically examine the patient. This may include identifying infections caused by heroin abuse and IV drug use. They may also be interested in the patient’s psychiatric history. Oftentimes, addiction problems and mental health problems go hand in hand. Drug abuse can create or exacerbate latent mental health problems that will need to be addressed once the patient has detoxed.

In addition, the assessment helps medical staff anticipate any complications that might occur during the process of treatment and detox.

Intake & Detox

The next step is detox. Detox entails the removal of the drugs from the patient’s body. It also means dealing with the withdrawal symptoms that heroin and other opioids cause. Modern rehab clinics provide patients with drugs like methadone and suboxone to help wean them off the drug slowly. By tapering of the drug, many of the worst symptoms of withdrawal can be managed. Nonetheless, the process is not entirely comfortable.

Generally speaking, patients will need to detox from heroin as inpatients. Doctors will need to monitor their symptoms in order to make sure that they are not having an adverse response to the process.

While there are outpatient detox programs, they are not as successful as inpatient programs.

What are the Symptoms of Heroin and Opioid Withdrawal?

  • Runny nose
  • Dehydration
  • Excessive sweating
  • Tearing of the eyes
  • Uncontrollable yawning
  • Agitation and restlessness
  • Insomnia
  • Muscular pain
  • Muscle spasms
  • Inability to concentrate
  • Aches and chills
  • Tremors
  • Rapid heart beat
  • Nausea
  • Diarrhea
  • Hallucinations

What is Rapid Detox?

Rapid detox is a process by which doctors sedate patients and then administer the anti-opioid drug Narcan. Over the course of a few days, all of the drug is removed from the user’s system. They then wake up supposedly free of the drug.

Unfortunately, it doesn’t work as advertised and can often have serious complications. It is more expensive than inpatient detox and probably will not be covered by insurance. Some people have had heart attacks from detoxing in this way, and others have woken up psychotic. Most wake up still feeling some of the effects of withdrawal.

Even when it does work as advertised, detox and rehabilitation are not synonymous. Detox is only one aspect of rehabilitation. The idea that you can remove the heroin from your system and then live happily ever after isn’t going to work. While the drug may be gone from the user’s system, the damage that the drug has caused remains. That includes chemical imbalances in the brain that need to be addressed and the chronic cravings that users will feel in the weeks and months to come.

Rapid detox looks good on paper, but at worst it’s dangerous and at best incomplete.

Post-Acute Heroin Treatment

Most inpatient programs last about 28 days, but there are also programs that last 3 months. Statistically, the longer a patient stays under the care of medical specialists, the better their chances are of not relapsing.

The post-acute phase of treatment begins directly after detox. Typically, a recovering addict will be linked with addiction treatment services on an outpatient basis. Some hospitals have partial in-hospital treatment as well. The latter is when a patient spends their day at the hospital meeting with counselors and talking about their issues in group. Outpatient services are much the same but the patient is not expected to stay at the hospital all day.

For those who read about the psychological addiction of heroin above, the major pitfall of this period is the restoration of the recovering addict’s brain chemistry. Because heroin addict’s brains have become used to the drug producing dopamine, the brain no longer produces dopamine on its own. This period is characterized by an intense feeling of depression.

Things that folks normally look forward to, get excited about, or enjoy don’t have much of an impact on recovering heroin addicts during this period. There is no way that doctors can manipulate their dopamine channel to produce more dopamine. That only kicks the can down the road. The brain must relearn how to produce dopamine on its own. That takes time, patience, and willpower.

There are a couple of different methods that have shown some success. Those are CBD (cognitive behavioral therapy) and something known as MIEDAR, which stands for Motivational Incentives for Enhancing Drug Abuse Recovery. MIEDAR was developed to treat cocaine and methamphetamine abuse which is notoriously difficult to treat, but since addicts of both stripes have problems producing dopamine, the method can be effective for either.

Dopamine is produced when your brain wants to reward you for a job well done. Incentive-based programs like MIEDAR effectively retrain the brain to produce dopamine for achievements that are unrelated to drug abuse. The ultimate goal is to quicken the pace at which the addict’s brain chemistry is restored.

Cognitive behavioral therapy, on the other hand, helps those in recovery understand the reasons why they began using drugs in the first place. It also helps identify their triggers, or stressors, that make them want to use. By identifying these, addicts can develop coping skills for managing cravings.

In addition, 12-step programs and the sponsor system has proven effective for curbing the impulse to use. Instead of using, addicts call their sponsor.

Lastly, some psychiatric medications have shown benefit for those recovering from heroin addiction. Antidepressants and anti-anxiety medications can be beneficial when administered by a doctor.

Is Heroin Addiction a Choice?

At one time or another, the addict had a choice before them. They chose to try heroin. They likely knew the risks. They did it anyway. Some of these people were individuals that had been prescribed prescription opioids. Others were just folks that wanted to see what heroin felt like. Some were fans of famous writers and musicians that abused heroin. They came to glamorize the use of these substances.

At one point or another, they became addicted. At that point, the heroin removed all choice from the equation. They needed more of the drug or they were going to be forced to endure an almost impossible trial. An agonizing trial.

Most addicts enter recovery after they’ve experienced something tragic. The loss of a close companion, the loss of family, a child being taken away from them. These pressures force them to make another choice. They can either continue down the road of addiction or make the effort to rebuild their lives. Some choose to rebuild their lives. Others don’t.

Addiction is a choice, but it’s impossible to kick a heroin addiction on your own. The intense pain of withdrawal coupled with the knowledge that you can make it go away by procuring more of the drug is too tempting for anyone. Recovery is about recovering the capacity to make a choice.

Are Heroin Addicts Ever Really Recovered?

That depends on what you mean by “recovered”. Heroin addicts will live with the cravings for the rest of their lives. Over time, they may become fewer and farther between, but they will be there. Stress at work, a fight in a relationship, someone talking down to you or making you feel small, anxiety over a certain outcome. These are all things that can trigger that craving. Heroin addicts, former or otherwise, will have to combat the urge to use for the rest of their lives.

Nonetheless, lives can be rebuilt, relationships established, and a meaningful purpose in life can be regained.