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Effects of Opioid Abuse

Opiates

Opiates are a group of drugs derived from the opium poppy. Synthetically produced opiates are known as opioids. Therapeutically these drugs can be used as painkillers (for example morphine, pethidine, dihydrocodeine), cough suppressants (for example, codeine linctus) and anti-diarrhoea agents (for example kaolin and morphine mixture). Methadone and buprenorphine are opioids used in the treatment of opiate dependency.

Although all opiates have misuse potential, heroin is the most widely misused and will be the focus here. Heroin (‘gear’, ‘smack’, ‘brown’, ‘scag’) is a brownish white powder that can be snorted, smoked or injected. Smoking (‘chasing’, ‘booting’) involves placing heroin on aluminium foil and heating it. The vapours given off are then inhaled through a tube. Occasionally heroin is mixed with tobacco and smoked in a cigarette. To prepare heroin for injection it is mixed in a spoon with water and citric acid (to help dissolve the powder) and heated. The liquid preparation is then drawn up into a syringe through a filter, usually a cigarette filter, which removes undissolved material. Heroin can then be injected into the tissue under the skin (‘skinpopping’), into muscle, or into a vein (intravenous use).

 Many heroin users never inject. Of those that do, it is common to start by smoking and move to injecting as tolerance develops. Injecting is a more cost-effective way of using; less of the drug is needed to create the desired effect. Heroin is usually bought in ‘bags’. It induces feelings of well-being, warmth and relaxation. People describe feeling as if they have been wrapped in cotton wool. The initial euphoria (‘buzz’), particularly following intravenous use, is intense. When intoxicated, the person is likely to have small ‘pinned’ pupils, heavy eyelids, and appear drowsy – a state described as ‘gouching’. With regular, repeated use physical and psychological dependence develop. Heroin is then needed to stave off withdrawal symptoms: dilated pupils, watery eyes, sneezing, runny nose, yawning, goose flesh, feeling cold and shivery, muscle aches and cramps, and diarrhoea and vomiting. Symptoms are likely to begin 6–8 hours after the drug was last used. While they can be very distressing, they are not life-threatening but the discomfort experienced can be a strong motivator to use again. Not all heroin users become physically dependent, but for many, using heroin becomes the focus of their life. Everything else (for example, relationships, possessions, paying bills, self-care, eating) becomes less important than acquiring the money to obtain heroin. Borrowing, stealing from family and friends, selling possessions, getting involved in prostitution, drug dealing, and a range of other criminal activities from shoplifting to armed robbery are all ways in which money may be raised. Although heroin itself does not have an adverse effect on mental state, psychological and psychiatric symptoms are common in opiate misusers. The National Treatment Outcome Research Study, which followed the progress of 1075 primarily opiate users, reported that, at the point of entering the study, anxiety and depressive mood were ‘common’. Furthermore, 29 per cent of the sample had thought about suicide in the previous three months, 10 per cent had received psychiatric inpatient treatment (for a problem other than drug dependence) in the past two years and 14 per cent had received community psychiatric treatment. Lifestyle factors such as those outlined above may contribute, as may underlying problems, for example, childhood sexual abuse which is common in substance misusers, and has been associated with suicidal thoughts and actions. Death from accidental overdose is another possible consequence of heroin use. This risk increases if the person is injecting, is using other CNS depressant drugs (for example, benzodiazepines and alcohol) or has a reduced level of tolerance (for example, after a period of abstinence in a treatment programme).

Variability in the purity of illicit heroin means that overdose is always a risk. As with alcohol, other accidents may be precipitated due to slowed reactions. Intravenous heroin use brings a range of further complications. Sharing injecting equipment (this include spoons, filters and water, as well as needles and syringes) may result in the transmission of blood-borne viruses, such as HIV and hepatitis B and C. Puncturing the skin to inject can introduce bacteria into the body. These may cause local infections (for example abscesses) or systemic infections (for example septicaemia). Damage to the veins and thromboses are further possible complication of intravenous use. In the early stages of use people generally inject into the veins in their arms but as these collapse they move to other sites, for example, hands and feet. It is not uncommon for people to inject into their groin. This can be particularly dangerous as there is a risk of hitting an artery or nerve rather than the vein. Other dangerous sites are the neck, breast and penis. Smoking heroin can precipitate or exacerbate respiratory problems. Other health concerns associated with opiate use are constipation, reduced libido and amenorrhoea. Women who do become pregnant and continue to use, risk their baby being opiate dependent.

Although methadone (physeptone) and buprenorphine are used in the treatment of opiate dependency both have the potential for misuse. Methadone is available as a liquid, tablet or in injectable form but is most commonly prescribed in its liquid formulation. Complications can arise from injecting liquid and tablet formulations. Buprenorphine comes as a sublingual tablet. Overdose is possible with both drugs, particularly when used in combination with other CNS depressants.

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