Heroine addiction

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Heroine addiction is an addiction to heroin. Frequent and regular administration can cause tolerance and a moderate physical dependence to develop. A severe psychological dependence often develops in heroin abusers and as such, heroin has a very high potential for addiction.

Over the years there has been controversy about just how addictive heroine is.

Controversy

It has been claimed that sustained use of heroin for as little as three days can cause withdrawal symptoms to appear if use is stopped, & the myth that "just one shot will hook you for life" has been one of the many sensationalist claims made about the drug, & a belief in its overwhelming ability to addict anyone who tries it one of the main justifications for heroin's continuing prohibition. The truth is that true physical dependence on heroin demonstrated by genuine physical withdrawal symptoms upon discontinuation of consumption, [as opposed to a mental or psychological craving to repeat the heroin experience], is not acquired any faster than with continuous use of any other opiate, normally between three to six weeks in an opiate naive person. Many times patients in UK hospitals are treated with diamorphine daily for many weeks following painful surgery without experiencing any withdrawal upon discontinuation of the drug.

Harm reduction approaches to heroin

Proponents of the harm reduction philosophy seek to minimize the harms that arise from the recreational use of heroin. Safer means of taking the drug, such as smoking or nasal, oral and rectal insertion, are encouraged, due to injection having higher risks of overdose, infections and blood-borne viruses. Where the strength of the drug is unknown, users are encouraged to try a small amount first to gauge the strength, to minimize the risks of overdose. For the same reason, poly drug use (the use of two or more drugs at the same time) is discouraged. Users are also encouraged to not use heroin on their own, as others can assist in the event of an overdose. Heroin users who choose to inject should always use new needles, syringes, spoons/steri-cups and filters every time they inject and not share these with other users. Governments that support a harm reduction approach often run Needle & Syringe exchange programs, which supply new needles and syringes on a confidential basis, as well as education on proper filtering prior to injection, safer injection techniques, safe disposal of used injecting gear and other equipment used when preparing heroin for injection may also be supplied including citric acid sachets/vitamin C sachets, steri-cups, filters, alcohol pre-injection swabs, sterile water ampules and tourniquets (to stop use of shoe laces or belts).

Withdrawal

Main article: Drug withdrawal

Black tar heroin

The withdrawal syndrome from heroin may begin within 6 to 24 hours of discontinuation of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose. Symptoms may include: sweating, malaise, anxiety, depression, priapism, extra sensitivity of the genitals in females, premature ejaculation in males, general feeling of heaviness, cramp-like pains in the limbs, excessive yawning or sneezing, tears, rhinorrhea, sleep difficulties (insomnia), cold sweats, chills, severe muscle and bone aches; nausea and vomiting, diarrhea, spasms, and fever. Many users also complain of a painful condition, the so-called "itchy blood", which often results in compulsive scratching that causes bruises and sometimes ruptures the skin, leaving scabs. Abrupt termination of heroin use often causes muscle spasms in the legs (restless leg syndrome, (also known as "kicking the habit")). The intensity of the withdrawal syndrome is variable depending on the dosage of the drug used and the frequency of use. Withdrawals are most severe with intravenous users, and heavy users can experience physical withdrawals for 5-7 days. Very severe withdrawal can be precipitated by administering an opioid antagonist to a heroin addict.

Three general approaches are available to ease the physical part of opioid withdrawal. The first is to substitute a longer-acting opioid such as methadone or buprenorphine for heroin or occasionally another short-acting opioid and then slowly taper the dose.

In the second approach, benzodiazepines such as diazepam (Valium) may be recommended for opiate withdrawal especially if there is comorbid alcohol withdrawal. Benzodiazepines may temporarily ease the anxiety, muscle spasms, and insomnia associated with opioid withdrawal. The use of benzodiazepines must be carefully monitored because these drugs have a high risk of physical dependence as well as abuse potential and have little or no cross tolerance with opiates and thus are not generally recommended as a first line treatment strategy. Also, although very unpleasant, opioid withdrawal is seldom fatal, whereas complications related to withdrawal from benzodiazepines, barbiturates and alcohol withdrawal (such as psychosis, suicidal depression, epileptic seizures, cardiac arrest, and delirium tremens) can prove hazardous and are potentially life-threatening.

Many symptoms of opioid withdrawal are due to rebound hyperactivity of the sympathetic nervous system, which can be suppressed with clonidine (Catapres), a centrally-acting alpha-2 agonist primarily used to treat hypertension. Another drug sometimes used to relieve the "restless legs" symptom of withdrawal is baclofen, a muscle relaxant. Diarrhoea can likewise be treated with the peripherally active opioid drug loperamide.

Methadone is another μ-opioid agonist most often used to substitute for heroin in treatment for heroin addiction. Compared to heroin, methadone is well (but slowly) absorbed by the gastrointestinal tract and has a much longer duration of action of approximately 24 hours. Thus methadone maintenance avoids the rapid cycling between intoxication and withdrawal associated with heroin addiction. In this way, methadone has shown success as a substitute for heroin; despite bearing about the same addiction potential as heroin, it is recommended for those who have repeatedly failed to complete withdrawal or have recently relapsed. Patients properly stabilized on methadone display few subjective effects to the drug (i.e., it does not make them "high"), and are unable to obtain a "high" from other opioids except with very high doses. Methadone, since it is longer-acting, produces withdrawal symptoms that appear later than with heroin, but usually last considerably longer and can in some cases be more intense. Methadone withdrawal symptoms can potentially persist for over a month, compared to heroin where significant physical symptoms subside within 4 - 7 days.

Buprenorphine is another opioid that was recently licensed for opioid substitution treatment. As a μ-opioid receptor partial agonist, patients develop less tolerance to it than to heroin or methadone due to its partial activation of the opiate receptor. Patients are unable to obtain a "high" from other opioids during buprenorphine treatment except with very high doses. It also has less severe withdrawal symptoms than heroin or other full agonist opiates when discontinued abruptly, although the duration of the withdrawal syndrome is often longer than that seen with heroin. It is usually administered sublingually (dissolved under the tongue) every 24-48 hrs. Buprenorphine is also a κ opioid receptor antagonist, which led to speculation that the drug might have additional antidepressant effects; however, no significant difference was found in symptoms of depression between patients receiving buprenorphine and those receiving methadone.

Researchers at Johns Hopkins University have been testing a sustained-release "depot" form of buprenorphine that can relieve cravings and withdrawal symptoms for up to six weeks. A sustained-release formulation would allow for easier administration and adherence to treatment, and reduce the risk of diversion or misuse.

Three opioid antagonists are available: naloxone and the longer-acting naltrexone and nalmefene. These medications block the ability of heroin, as well as the other opioids to bind to the receptor site.

There is also a controversial treatment for heroin addiction based on an Iboga-derived African drug, ibogaine. Many people travel abroad for ibogaine treatments that generally interrupt substance use disorders for 3-6 months or more in up to 80% of patients.

Heroin prescription

The UK Department of Health's Rolleston Committee report in 1926 established the British approach to heroin prescription to users, which was maintained for the next forty years: dealers were prosecuted, but doctors could prescribe heroin to users when withdrawing from it would cause harm or severe distress to the patient. This "policing and prescribing" policy effectively controlled the perceived heroin problem in the UK until 1959 when the number of heroin addicts doubled every sixteenth month during a period of ten years, 1959-1968. The failure changed the attitudes; in 1964 only specialized clinics and selected approved doctors were allowed to prescribe heroin to users. The law was made more restrictive in 1968. Beginning in the 1970s, the emphasis shifted to abstinence and the use of methadone, until now only a small number of users in the UK are prescribed heroin.

In 1994 Switzerland began a trial heroin maintenance program for users that had failed multiple withdrawal programs. The aim of this program is to maintain the health of the user in order to avoid medical problems stemming from the use of illicit street heroin. Reducing drug-related crime and preventing overdoses were two other goals. The first trial in 1994 involved 340 users, although enrollment was later expanded to 1000 based on the apparent success of the program. Participants are allowed to inject heroin in specially designed pharmacies for 15 Swiss Francs per dose. A national referendum in November 2008 showed 68% of voters supported the plan, introducing heroin prescription into federal law. The trials before were based on time-limited executive ordinances.

The success of the Swiss trials led German, Dutch, and Canadian cities to try out their own heroin prescription programs. Some Australian cities (such as Sydney) have instituted legal heroin supervised injecting centers, in line with other wider harm minimization programs.

Starting in January 2009 Denmark is also going to prescribe heroin to a few addicts that have tried methadone and subutex without success.

See also

• Methadone maintenance