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Health Interventions for Heroin Addiction

Health Interventions for Heroin Addiction

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An essay for the 2012 Undergraduate Awards Competition by Eoin Moore. Originally submitted for Medicine at University College Cork, with lecturer Dr. Aisling Campbell in the category of Medical Sciences
An essay for the 2012 Undergraduate Awards Competition by Eoin Moore. Originally submitted for Medicine at University College Cork, with lecturer Dr. Aisling Campbell in the category of Medical Sciences

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Published by: Undergraduate Awards on Aug 31, 2012
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01/18/2014

 
 
Health Interventionsfor Heroin Addiction
A Description of the Available TreatmentOptions
 
Question
Outline the health interventions which are available to help those who are addicted to heroin. Justify suchintervention with reference to the available evidence.
 Abstract 
Epidemiology
Heroin addiction is a serious global health problem, which affects an estimated 21 million peopleworldwide. The number of heroin users in Ireland is the highest per capita in the EU with an estimated10,000 heroin users who are not engaged in any form of treatment program. In the past, its use wasconcentrated in the Dublin area, but there is evidence that the use of heroin has undergone indiscriminategeographical spread in recent years.
Outcomes
Consequences of this problem have been devastating and are on the rise. Unintentional overdose deathshave soared in the past few years, as have heroin-related criminal offences. Heroin use has also beenlinked to the recent rise in HIV and viral hepatitis, mostly through the use of unsterile drug paraphernalia,but also through the risky behaviour that drug abuse may engender.
Dependence
Opioid dependence is a chronic, relapsing disease, characterised by preoccupation with a strong desire totake the drug and persistent drug-seeking behaviour, as well as meeting other criteria for substancedependence, such as physiological withdrawal and tolerance, primacy of heroin use over alternativeinterests, and continued use despite awarene
ss of the harmful consequences. Heroin’s abuse potentialstems from the intense euphoric “rush” and state of transcendent relaxation that it produces
.
Intervention
There is a wealth of effective interventions available to assist patients suffering from heroin addiction.Pharmacological detoxification and maintenance opioid substitution encompass only one facet of treatment. Psychosocial interventions provided by addiction counsellors are also extremely useful, andintegrating both types of treatment is ultimately the most effective approach. Public health harm-reduction strategies, such as needle exchange programs and safe injection sites, also have a role inreducing the burden of heroin-associated morbidity.
Conclusion
This essay summarises the history of opioid dependence, its mechanism of addiction, the public healthconcerns surrounding heroin use, and the vast array of treatment options available to physicians inmanaging this debilitating disease. The stigma of heroin addiction and the misconceptions regarding the
“futility” of treatment still pervade the public psyche and, indeed, the medical profession. However, with
the advent of new anti-addiction medication, detoxification regimens and effective psychosocialinterventions, there is hope for those whose lives have become enslaved to this destructive narcoticsubstance.
 
“Thou hast the keys of Paradise; oh just, subtle and mighty opium!”
 
Thomas De Quincey, Confessions of an English Opium-Eater 
Papaver somniferum
, the sleep-bringing poppy, was cultivated in Mesopotamia (modern-day Iraq) as farback as 3,400 BC. The narcotic and analgesic properties of opium, the dried latex procured from the plant,were recognised in ancient times, when it was used for anaesthetic and ritualistic purposes. Recreationaluse of opium began in China in the 15
th
Century, and by the 17
th
Century its addictive properties werewell recognised.
The “opium dens” of this time
provide the earliest historical accounts of opioiddependence.Opium contains up to 12% morphine, the narcotic alkaloid which is responsible for most of its activityand which forms the precursor for the synthesis of diacetylmorphine, a drug which is twice as potent asmorphine itself. Diacetylmorphine was first mass-produced in 1898 and was sold under the trademark 
“Heroin” by the Bayer pharmaceutical company. Ironically, it was first marketed as a non
-addictivemorphine substitute and even as a cure for morphine addiction. Diacetylmorphine is still referred to asheroin in non-medical settings.
Heroin’s abuse potential stems from the intense euphoric “rush” and state of transcendent relaxation that 
it produces.
Recreational users prefer heroin to other opioids because of this “rush”, which heroin
exhibits as it crosses the blood-brain barrier more rapidly due to its acetyl groups, which render it morelipophilic. Once in the brain, it is de-acetylated into monoacetylmorphine and then to morphine. Both 6-MAM and morphine bind to µ-opioid receptors, resulting in its euphoric effect. It can be injectedintravenously, insufflated or smoked.Heroin addiction is a chronic, relapsing disease, characterised by preoccupation with a strong desire totake the drug and persistent drug-seeking behaviour, as well as meeting other criteria for substancedependence, such as physiological withdrawal and tolerance, primacy of heroin use over alternativeinterests, and continued use despite awareness of the harmful consequences. The determinants of opioiddependence are multifactorial, comprising a complex interplay of biology, psychology and social issues.The addictive potential of the drug is a major factor and, according to a study published in
The Lancet 
 comparing the addictive potential of 20 different drugs, heroin poses the highest risk for bothpsychological and physical dependence. Tolerance to heroin occurs with repeated use, requiringincreasingly higher doses to produce the same euphoric effect as the original dose. This results fromadaptation and opioid receptor desensitisation. After approximately 3 weeks of daily heroin use, thisopioid receptor dysregulation leads to physical dependence, whereby abrupt cessation of the drug leadsto unpleasant withdrawal symptoms.The heroin withdrawal syndrome is characterised by restlessness, anxiety, insomnia, tremor, muscle andbone pain, diaphoresis, diarrhoea, lacrimation, rhinorrhoea, excessive yawning and sneezing, pruritis,fever, chills, piloerection and tachycardia. Physical dependence and fear of withdrawal are powerfulmotivating factors for continued heroin use and were once believed to be the sole underlying cause of heroin addiction. Some addicted individuals, however, will endure the withdrawal symptoms in order toreduce their tolerance to heroin so that they can experience a stronger rush. Furthermore, it is recognisedthat craving and relapse often occur weeks and months after the withdrawal symptoms are long gone.Therefore, there must factors other than physical dependence responsible for heroin misuse progressingto heroin addiction. Genetic predisposition is reported to account for 40-60% of the risk for developing adrug addiction. Self-medication with heroin for pre-existing emotional problems and psychiatricdisorders, such as depression, is another strong risk factor for addiction. Poor socio-economic status,

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