By Louise Lazear
Many may think of heroin as a 1970s problem, and indeed we are living with the legacy of those days of addiction in residual health problems, including high rates of HCV infection, among survivors. For others on the frontline of public policy, law enforcement and healthcare, however, today’s heroin addiction is the real and present danger: the UN Drug Control Program estimates eight million abusers worldwide.
Prevalence and health costs
According to the National Household Survey on Drug Abuse, in 2001 an estimated 3.1 million Americans ages 12 and over have used heroin at least once in their lifetime, up from an estimated 2.4 million people from the same survey conducted in 1996. Results from the Monitoring the Future study in 2001 demonstrated that among 1.7 percent of eighth graders, 1.7 percent of tenth graders, and 1.8 percent of twelfth graders surveyed used heroin at least once in their lifetimes. While these rates are lower than the 2.1% usage reported across the same age groups in 1997, rates are still significantly higher than those reported in 1991. Heroin use among school-age children is on the rise, due in part to greater availability, lower prices and higher purity levels that encourage routes of administration other than injection. In addition to this rise in popularity is the growing concern for infectious disease within this population, and the impact of these diseases on current and future healthcare costs.
Costs related to substance abuse are a huge burden on both state and federal budgets. In a study conducted by Columbia University, data collected from 45 states during 1998 demonstrated that state governments spent almost $81.3 billion on substance abuse and addiction, over 13 percent of their total operating budgets. Of these dollars, about 96 percent was spent on the aftermath of abuse, and only four percent on prevention. The study revealed that states spent about $15.2 billion for healthcare related to abuse, nearly 25 percent of the total spent for healthcare.
Heroin, a derivative of morphine, is the most abused and fast-acting of the opiates. According to the Office of National Drug Control Policy (ONDCP), opium production has doubled over the last fifteen years, resulting in higher supplies and lower prices. The world’s heroin comes from three primary regions: Southeast Asia, Southwest Asia, and Latin America. In recent decades, Afghanistan reigned as the top producer accounting for 72 percent of the world’s supply in 2000. However, in 2001 a ban on poppy cultivation in that country reduced production by about 97 percent. Filling the void, Burma and Laos are now major producers, although recent reports indicate that Afghani heroin is resurfacing through Pakistan and other neighboring regions. Based on law enforcement analyses of seized products, primary sources of heroin in the U.S. are Mexico (60 percent) or Columbia (24 percent.)
Heroin is derived from the opium poppy plant, a variety of poppy typically grown by hill tribe farmers using primitive slash-and-burn field preparation techniques. Poppy plants usually mature in about three months after seeding, requiring very little maintenance during the growing phase. After the flowers lose petals, farmers score and scrape the seedpod, and collect the resultant raw opium gum. After a labor-intensive series of scoring and scraping with implements that are often passed from generation to generation, the gum is collected, dried and transported to opium refineries. Seeds are extracted from flower pods for next year’s crop.
Refining the gum into morphine and eventually heroin involves a number of chemicals, including acetic anhydride, chloroform, ether and acetone. Differences in color and consistency of the final product are related to both the refining process and additives that make their way into the drug, including caffeine, powdered milk and baking soda. Black tar heroin, which is produced in Mexico, is a sticky substance ranging in color from brown to black due to the primitive methods used to process the opium gum. Overall, typical purity levels for heroin are at about 40 percent.
Because the strength and production methods for street heroin cannot be determined, overdoses are quite common. In 2001, heroin followed cocaine and marijuana as the most frequent illicit drug reported by U.S. emergency departments, with the number of heroin mentions increasing by 47 percent since 1994. Over the period 1992 through 1996, heroin mentions among those 12 to 17 years of age more than quadrupled. Patients presenting in emergency departments with altered mental status must be evaluated for a number of possible causes, including head injury, psychological illness and glycemic coma, as well as for substance abuse. In order to provide rapid turnaround times and to rule-out drugs of abuse in these situations, many hospitals are instituting the use of smaller hand-held meters or low-cost single step assays in the ED.
Heroin is smoked, snorted or injected. While injection remains the most efficient way to administer low-purity heroin, smoking and inhalation are now more popular due to the fact that overall purity rates are higher, and many users are under the misconception that these forms of administration are less likely to lead to addiction. The absence of puncture marks may also be thought to deter detection. According to recent data from treatment center admissions, snorting and smoking are the most popular method of administration in many large cities, including Chicago and New York. Unlike smoking and snorting which can take ten to 15 minutes to feel effects, intravenous injection of heroin produces a “rush” within ten to eight seconds. After administration, heroin crosses the blood-brain barrier and is converted to morphine that binds to opioid receptors. This causes changes in activity in the brainstem and limbic systems, as well as blocking pain signals from the body. Euphoric feelings are followed by a depression of the CNS leading to a drowsy state and in some cases breathing difficulties that lead to respiratory failure.
Heroin is highly addictive. Repeated use results in increased tolerance, requiring more frequent administration to feel the drug’s affects. Heroin abusers inject three to four times a day; withdrawal symptoms, which include pain, insomnia, involuntary limb movements and cold flashes can occur within hours after administration. Severe withdrawal symptoms typically peak between 24 and 48 hours and subside after about a week, although some addicts may experience withdrawal symptoms for several months.
Health impacts and co-morbid conditions
Other long-term effects of heroin addiction include bacterial infections, scarring of veins, arthritis as well as the most severe of consequences, exposure to and development of infectious disease by sharing injection paraphernalia and/or having unprotected sex with infected partners. According to the National Institute on Drug Abuse (NIDA), injected drug use accounts for nearly one-third of HIV and one-half of hepatitis C cases within the U.S. In a study released in 2001 that followed a cohort of heroin addicts for 33 years, almost 50 percent of study participants died by the end of the study period. Of those deaths, about 22 percent were related to drug overdose, 15 percent to chronic liver disease, and 12 percent each to cancer and cardiovascular disease.
Injection drug users are at risk for a range of co-morbid conditions, including abscess and cellulitis, soft-tissue infections (STIs) that are often complicated by tetanus, botulism, and myonecrosis. Possible factors contributing to STI include poor injection site hygiene, syringe reuse, intramuscular or subcutaneous injection and contaminated drugs. Recently, clinicians have reported that a variety of agents, including Clostridium novi type A and Bacillus cereus have been associated with STI and severe cases of sepsis. Patients with STIs typically undergo antibiotic therapy and surgical debridement with drainage. Clinicians may order microbiological testing of sites of infection as well as the patient’s drug supply in order to target therapy and identify localized trends in infection. Some public health departments have initiated prevention strategies aimed at reducing STIs among IDUs, providing increased access to sterile injection equipment and promoting hygiene among those users who continue to inject despite enrollment in treatment programs.
IDUs may also present with tuberculosis, endocarditis, and less often, arterial mycotic pseudoaneurysms. Tuberculosis among IDUs has prompted public health officials to consider the use of isoniazid preventive therapy among patients with reactive tuberculin tests and no evidence of active tuberculosis. Infective endocarditis (IE) is caused by the adherence of microorganisms to the endocardial surface of the heart, usually the heart valves. While fungal, chlamydial, and rickettsial organisms have been associated with IE, most cases are related to bacterial pathogens, including Staphylococcus, Group D streptococcus and Streptococcus viridans, which is responsible for approximately half of all bacterial endocarditis. Arterial mycotic pseudoaneurysms, although less common, are sometimes mistaken for abscess and if surgically incised, may cause arterial rupture and rapid exsanguination.
HIV/AIDS and HCV infection among IDUs continue to be areas of great concern for public health officials. According to the NIH, IDUs make up the largest group of persons in the U.S. infected with HCV, and most new cases of HCV occur within this group. It is possible that HCV may be more readily transmitted than HIV through the sharing of equipment other than syringes, including devices used to dissolve drugs and filter drugs prior to injection. In order to prevent transmission of these diseases, more than 180 needle exchange programs in over 34 states are now in place, and at least 46 states have enacted legislation allowing physicians to prescribe syringes so that patients have access to sterile equipment.
Subject to state law, syringes may be sold in pharmacies without prescription, but several states have laws that specifically prohibit the sale of syringes when the intended use is known to be injection of illegal drugs. A limited number of states have passed laws specifically allowing the sale of new syringes to IDUs, with the rationale of reducing the spread of such bloodborne infections as HIV, HCV and HBV. Pharmacists, like the general public, have been found to have very strong and divergent opinions on whether they should supply needles they know will be used by addicts. Recent reports show, however, that in states that have changed their laws, pharmacists’ attitudes have also shifted toward acceptance of the public health benefits of new syringe accessibility, and more users have purchased syringes from pharmacies, with a demonstrated reduction in risk behaviors.
Additional challenges to sterile syringe use among IDUs come from laws that prohibit the possession of drug paraphernalia, which means that new or used syringes may not safely be carried to or from a point of purchase or exchange. Advocates for sterile syringe use have also been active in challenging these laws. A recent federal court ruling in New York City, for example, determined that the Police Department may not arrest an IDU with a needle containing drug residue if that person is participating in a syringe exchange program.
A broad range of treatment options exists for addiction, and recent data from NIDA suggests that medication with supportive services is the most successful tool for allowing patients to stop heroin use and return to productive lives. Agents used for therapy include methadone, naloxone, and two additional drugs developed under NIDA, LAAM (levo-alpha-acetyl-methadol) and buprenorphine. Methadone, a Schedule II synthetic opiate that acts to block the effects of heroin for about 24 hours, has been used to treat heroin addiction for over thirty-five years. Methadone administration relieves the craving for opiates, and blocks the euphoria associated with street heroin obviating its use.
According to the Center for Substance Abuse Treatment, over 205,000 people are currently enrolled in methadone treatment programs. According to NIDA research, therapy with methadone significantly decreases the rate of HIV infection for those participating in treatment programs. Also, data indicate that more than 70 percent of patients enrolled in MMT programs are HCV positive. In a recent study of 460 patients enrolled in a California-based MMT program, overall 87 percent tested positive for HCV-Ab. Among drug injectors, the rate increased to 96 percent testing positive for HCV-Ab.
Proponents of MMT suggest these programs ensure patients are followed for infectious disease and other co-morbid conditions, including psychiatric disorders. In addition, therapy has been shown to allow addicts to change the behaviors that put them at risk of contracting all types of infectious disease, including tuberculosis and sexually transmitted diseases. Although MMT costs about $13 per day, it has been shown that for every dollar spent to treat patients, society realizes a four-dollar benefit in terms of total costs, including the expense of incarceration. In an effort to standardize MMT programs and improve outcomes, in 2001 the Center for Substance Abuse Treatment implemented an accreditation program for the nation’s 950 programs. All programs, whether publicly or privately funded must be accredited in order to treat opiate dependence.
While some argue that methadone therapy simply replaces one drug addiction with another, others point to the fact that because the chemistry of the brain undergoes changes with chronic use of opiates, many heroin-dependent individuals may never revert back to the pre-addiction state and consequently require some type of pharmaceutical maintenance. Researchers have found that up to 80 percent of patients maintained with methadone will revert back to heroin use within 12 months of methadone treatment termination.
Critics of MMT also point to the need for daily dosage, and limited access to programs due to strict accreditation requirements. In October 2002, the FDA approved Subutex and Suboxone tablets, two new formulations of buprenorphine for the treatment of opiate dependence. Buprenorphine is especially attractive as a treatment option due to its relatively mild opiate effects, a less than daily dosage regimen, and fewer withdrawal symptoms than that of methadone. More importantly, these new formulations are the first narcotics approved for opioid dependence that may be prescribed in an office setting. According to Charles Curie, administrator at the Substance Abuse and Mental Health Services Administration (SAMHSA), uprenoorphine will allow patients to be treated for addictions in the same manner as they are treated for other chronic illnesses, such as diabetes and hypertension.
In order to qualify for a waiver from the Controlled Substances Act 21 that restricts the use of methadone and other drugs to federally licensed programs, physicians are required to undergo eight hours of training and are limited to treatment of thirty patients at a given time. Additional safeguards include special DEA registration and child resistant packaging.
By moving treatment for opioid dependence into primary care settings, public health officials are hopeful that more patients will seek treatment, and that the co-morbidity associated with heroin abuse will be addressed at the frontline of patient care. It is likely that we will also see a move to implement DAT in this setting, as physicians will need to frequently monitor treatment compliance and to manage other addictions in combination, including alcohol and cocaine. For patients infected with or at risk for HIV and hepatitis B and C, moving treatment to this setting may translate to more testing and improved follow-up, allowing healthcare professionals and public health officials to focus more efforts on prevention and earlier treatment interventions, rather than addressing the aftermath of substance abuse.
Louise Lazear is a freelance writer based in Charlotte, N.C.