Heroin Toxicity
No Results
No Results
processing….
Heroin remains one of the most frequently abused narcotics in the United States. It may be injected intravenously (“mainlining”), or subcutaneously (“skin-popping). It also can be ingested, snorted, or smoked. The presence of impurities may limit its absorption through mucous membranes, thus limiting its “rush” and “high” when sniffed or snorted.
Heroin poisoning occurs most commonly when an individual unintentionally overdoses on the drug. Poisoning may also occur in a “body packer,” “body pusher,” or “body stuffer.” Body packers, also called “mules,” are people who swallow and pack their GI tracts with bags of heroin in order to smuggle the illegal drug from one country to another. Body pushers conceal the drugs in their rectum and/or vagina. In both of these groups, the drugs are carefully packaged for safe passage, but poisoning occurs if the packages rupture. Body packing or pushing should be suspected in persons who are found unconscious at airports, during international flights, or soon after a trip to endemic countries.
Body stuffers, on the other hand, are people who ingest all the drugs in their possession in order to conceal the evidence from the police. Because these packages are typically not designed for safe GI transport, they easily rupture and frequently cause poisoning.
Heroin (diacetylmorphine) is a semisynthetic narcotic derived from the opium poppy Papaver somniferum. It was first synthesized in 1874 and was originally marketed as a safer, nonaddictive substitute for 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.
Afghanistan remains the world’s largest cultivator of opium, accounting for more than 60% of the world’s opium poppy cultivation. Myanmar is the second largest, and Mexico is the third largest. Mexico, Colombia, Guatemala, and other Latin American countries are the main suppliers of opium products to North America. [1]
In its pure form, heroin is a white powder with a bitter taste. However, samples are frequently mixed with other substances so dealers can maximize their profits. Because of these impurities and additives, street heroin samples have different purities and may appear in various hues, 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. Heroin samples from South America appear to have the highest purity, reaching at times more than 70% purity.
Heroin is a highly addictive semisynthetic opioid that is derived from morphine. When used intravenously, it is three to five 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. [2]
Heroin, similar to morphine and other narcotics, reduces the brain’s responsiveness to changes in carbon dioxide levels 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). [2]
Heroin’s inhibitory effects on baroreceptor reflexes result in bradycardia, even in the face of hypotension. [2]
Finally, heroin decreases gastric motility, inhibits the effect of acetylcholine on the small intestine, and diminishes the colonic propulsive waves, resulting in prolongation of gastric emptying time by as much as 12 hours, with consequent constipation in habitual users. [2]
The onset of action, peak effects, and duration of action vary with the different methods of heroin use. Onset of action occurs within 1-2 minutes with intravenous injection and within 15-30 minutes with intramuscular injection. Heroin’s peak therapeutic and toxic effects are generally reached within 10 minutes with intravenous injection, within 30 minutes with intramuscular injection or when snorted, and within 90 minutes when injected subcutaneously. Analgesic effects generally last 3-5 hours. [2]
Intravenously injected heroin creates a rush, or a sensation of intense pleasure, that begins within 1 minute of the injection and lasts from 1 minute 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. [2]
Heroin is rapidly converted to 6-monoacetylmorphine (6-MAM) by the liver, brain, heart, and kidneys 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 h). 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. [2]
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. According to the US Substance Abuse and Mental Health Services Administration (SAMHSA) 2016 National Survey on Drug Use and Health (NSDUH), approximately 948,000 persons aged 12 years and older reported using heroin in the past year (about 0.4% of that age group); about 475,000 persons (about 0.2%) were current heroin users, and about 591,000 persons had a heroin use disorder. [3]
NSDUH estimates that the percentage of current heroin users in 2016 were higher than the percentages from 2002 to 2013, but was similar to the percentages in 2014 and 2015. [3]
According to the 2017 report of the United Nations Office on Drug and Crime (UNODC), the global prevalence of opiate (heroin and opium) use was estimated at 0.37% of the population, or 12.9-23.6 million people. Levels of opiate use were much higher than the global average in the Near and Middle East/Southwest Asia (1.40%), Central Asia (0.90%), and Eastern and Southeastern Europe (0.85%). [1]
In its 2018 annual report, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) estimated that in 2016 there were 1.3 million high-risk opioid users in Europe, or 0.4 % of the adult population, with heroin being the most widely used opioid. The EMCDDA reported that although patterns and trends vary among countries, Europe may be witnessing a longer-term decline in heroin use, for reasons that may include reduced interest in the drug and reduced availability of it. [2] The number of primary heroin users in Europe who entered drug treatment for the first time fell by more than half from a peak in 2007 to a low point in 2013, before stabilizing in subsequent years. [4]
Most fatalities from heroin overdose occur in long-term users, usually early in their third decade of life. [5, 6] 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. [6, 7, 8]
The US National Center for Health Statistics reported that drug overdose deaths involving heroin more than tripled from 2011 to 2016, rising from 4,571 to 15,961 (from 11% to 25% of all drug overdose deaths). Of drug overdose deaths in which at least one specific drug was mentioned, heroin ranked first from 2012 to 2015, but was overtaken by fentanyl in 2016. [9] From 2016 to 2017, the death rate from heroin overdose remained stable, at 4.9 deaths per 100,000 population. [10]
About 3-7% of patients treated for heroin overdose require hospital admission because of complications such as pneumonia, noncardiogenic pulmonary edema, and infectious complications. [5]
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 CDC, heroin initiation rates generally increased across most demographic subgroups from 2002-2011. During that time, however, reported rates of heroin initiation were highest among males, persons aged 18–25 years, non-Hispanic whites, those with an annual household income of less than $20,000, and those residing in the Northeast. The racial/ethnic population with the highest previous-year heroin use was non-Hispanic whites. [11]
Sex
Although heroin addiction has traditionally been viewed as a disease of males, addiction among females is grossly underreported. According to the , CDC, the average rate of past-year heroin use per 1,000 population from 2011-2013 was 3.6 in males versus 1.6 in females. [11] The death rate for heroin overdose in 2012 was almost four times higher in males than in females. [12]
Age
According to the American Association of Poison Control Centers’ National Poison Data System, 3873 of the 4319 single exposures to heroin reported in 2016 were in persons 20 years of age and older; 20 were in those younger than 6 years, and 182 were in teenagers. [13] According to the CDC, in 2012 the heroin overdose death rate was highest in those aged 25–34 years. [12]
United Nations Office on Drugs and Crime. World Drug Report 2017. Available at https://www.unodc.org/wdr2017/. June 2017; Accessed: December 16, 2018.
Yaksh TL, Wallace M. Opioids, Analgesia, and Pain Management. Brunten LL, Hilal-Dandan R, Knollmann BC, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 13th ed. New York, NY: McGraw Hill Medical; 2018. 35-37.
US Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Available at https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm#illicit9. 2017; Accessed: December 16, 2018.
European Monitoring Centre for Drugs and Drug Addiction. European Drug Report. EMCDDA. Available at http://www.emcdda.europa.eu/edr2018_en#downloadReport. June 7, 2018; Accessed: December 16, 2018.
Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema : a case series. Chest. 2001 Nov. 120(5):1628-32. [Medline].
Centers for Disease Control and Prevention. Atypical reactions associated with heroin use–five states, January-April 2005. MMWR Morb Mortal Wkly Rep. 2005 Aug 19. 54(32):793-6. [Medline].
Bikell WH, Benar O. Life-threatening opioid toxicity. Prob Crit Care. 1987. 1:106.
Bryant WK, Galea S, Tracy M, Markham Piper T, Tardiff KJ, Vlahov D. Overdose deaths attributed to methadone and heroin in New York City, 1990-1998. Addiction. 2004 Jul. 99(7):846-54. [Medline].
Hedegaard H, Bastian BA, Trinidad JP, Spencer M, Warner M. Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011–2016. National Vital Statistics Reports. Available at https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf. December 12, 2018; Accessed: December 16, 2018.
Hedegaard H, Miniño AM, Warner M. Drug Overdose Deaths in the United States, 1999–2017. NCHS Data Brief. November 2018. Available at https://www.cdc.gov/vitalsigns/pdf/2018-03-vitalsigns.pdf.
Jones CM, Logan J, Gladden RM, Bohm MK. Vital Signs: Demographic and Substance Use Trends Among Heroin Users – United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015 Jul 10. 64 (26):719-25. [Medline]. [Full Text].
Rudd RA, Paulozzi LJ, Bauer MJ, Burleson RW, Carlson RE, et al. Increases in heroin overdose deaths – 28 States, 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014 Oct 3. 63 (39):849-54. [Medline]. [Full Text].
Gummin DD, Mowry JB, Spyker DA, Brooks DE, Fraser MO, Banner W. 2016 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 34th Annual Report. Clin Toxicol (Phila). 2017 Dec. 55 (10):1072-1252. [Medline]. [Full Text].
Darke S, Hall W, Weatherburn D, Lind B. Fluctuations in heroin purity and the incidence of fatal heroin overdose. Drug Alcohol Depend. 1999 Apr 1. 54(2):155-61. [Medline].
Seelye KQ. Heroin Epidemic Is Yielding to a Deadlier Cousin: Fentanyl. NY Times. March 16, 2016. Available at http://www.nytimes.com/2016/03/26/us/heroin-fentanyl.html?_r=0.
Coffin PO, Galea S, Ahern J, Leon AC, Vlahov D, Tardiff K. Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990-98. Addiction. 2003 Jun. 98(6):739-47. [Medline].
Darke S, Zador D. Fatal heroin ‘overdose’: a review. Addiction. 1996 Dec. 91(12):1765-72. [Medline].
Davoli M, Perucci CA, Forastiere F, et al. Risk factors for overdose mortality: a case-control study within a cohort of intravenous drug users. Int J Epidemiol. 1993 Apr. 22(2):273-7. [Medline].
Infante F, Domínguez E, Trujillo D, Luna A. Metal contamination in illicit samples of heroin. J Forensic Sci. 1999 Jan. 44(1):110-3. [Medline].
Hoffman RS, Kirrane BM, Marcus SM. A descriptive study of an outbreak of clenbuterol-containing heroin. Ann Emerg Med. 2008 Nov. 52(5):548-53. [Medline].
Vagi SJ, Sheikh S, Brackney M, Smolinske S, Warrick B, Reuter N, et al. Passive multistate surveillance for neutropenia after use of cocaine or heroin possibly contaminated with levamisole. Ann Emerg Med. 2013 Apr. 61 (4):468-74. [Medline].
Centers for Disease Control and Prevention. Wound botulism among black tar heroin users–Washington, 2003. MMWR Morb Mortal Wkly Rep. 2003 Sep 19. 52(37):885-6. [Medline].
Hoffman RS, Goldfrank LR. The poisoned patient with altered consciousness. Controversies in the use of a ‘coma cocktail’. JAMA. 1995 Aug 16. 274(7):562-9. [Medline].
Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991 Mar. 20(3):246-52. [Medline].
Fentanyl and Fentanyl Analogs. National Drug Early Warning System. Available at http://pub.lucidpress.com/NDEWSFentanyl/#0uATvewBep_i. December 7, 2015; Accessed: December 21, 2017.
Doyon S, Aks SE, Schaeffer S. Expanding access to naloxone in the United States. J Med Toxicol. 2014 Dec. 10 (4):431-4. [Medline]. [Full Text].
Centers for Disease Control and Prevention. Recommendations for Laboratory Testing for Acetyl Fentanyl and Patient Evaluation and Treatment for Overdose with Synthetic Opioids. CDC. Available at https://stacks.cdc.gov/view/cdc/25259. June 20, 2013; Accessed: December 21, 2017.
ACOG Committee on Health Care for Underserved Women., American Society of Addiction Medicine. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol. 2012 May. 119 (5):1070-6. [Medline].
Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths–United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016 Jan 1. 64 (50-51):1378-82. [Medline]. [Full Text].
Centers for Disease Control and Prevention. Scopolamine poisoning among heroin users–New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996. MMWR Morb Mortal Wkly Rep. 1996 Jun 7. 45(22):457-60. [Medline].
Vagi SJ, Sheikh S, Brackney M, et al. Passive multistate surveillance for neutropenia after use of cocaine or heroin possibly contaminated with levamisole. Ann Emerg Med. 2013 Apr. 61(4):468-74. [Medline].
Rania Habal, MD Assistant Professor, Department of Emergency Medicine, New York Medical College
Rania Habal, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.
Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital
Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor – Chief Editor for Medscape.
Laurie Robin Grier, MD Medical Director of MICU, Professor of Medicine, Emergency Medicine, Anesthesiology and Obstetrics/Gynecology, Fellowship Director for Critical Care Medicine, Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Science Center at Shreveport
Laurie Robin Grier, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Society for Parenteral and Enteral Nutrition, Society of Critical Care Medicine
Disclosure: Nothing to disclose.
Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Chair of the Clinical Competency Committee, Pulmonary and Critical Care Fellowship Program, Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Health System; Chair, Guideline Oversight Committee, American College of Chest Physicians
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society
Disclosure: Nothing to disclose.
Heroin Toxicity
Research & References of Heroin Toxicity|A&C Accounting And Tax Services
Source
0 Comments