AGENDA Current News Quiz 2 review Chapter 9 and short films Mid terms discussions

Riverside City College Narcotics/Opioids Riverside City College Instructor Ed Ramirez

Current News http://www.cnn.com/2016/05/10/health/fentanyl-new-heroin-deadlier/

Figure 09.CO © ermingut/iStockphoto.com

https://www. youtube. com/watch. v=i--yLz_i44c https://www. youtube https://www.youtube.com/watch?v=i--yLz_i44c https://www.youtube.com/watch?v=vbl19waROcA

Narcotics Abuse of prescription painkilers has been described as an epidemic (by the CDC “Centers for Disease Control and Prevention”) The term "narcotic," derived from the Greek word for stupor, originally referred to a variety of substances that dulled the senses and relieved pain. Narcotics are used therapeutically to treat pain, suppress cough, alleviate diarrhea, and induce anesthesia.

Abuse of prescription Deaths from prescription painkillers* have reached epidemic levels in the past decade. The number of overdose deaths is now greater than those of deaths from heroin and cocaine combined. A big part of the problem is nonmedical use of prescription painkillers—using drugs without a prescription, or using drugs just for the "high" they cause. http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html

What is a Narcotic? In a general means, narcotic is a central nervous system (CNS) depressant that produces insensibility or stupor. Stupor- a condition in which someone is not able to think normally because of being drunk, drugged, tired, etc. a state of near-unconsciousness or insensibility. "a drunken stupor"

What is a Narcotic cont’d All opioid narcotics activate opioid receptors and have abuse potential Narcotics are frequently prescribed for pain relief

What Are Narcotics? As we have discussed many times  The word narcotic has been used to label many substances From the Greek word for narkoticos Narcotic is used to refer to those naturally occurring substances derived from the opium poppy and their synthetic substitutes

What are Narcotics (Cont’d) Analgesic- drugs that relieve pain without affecting consciousness Opioid- relating to the drugs that are derived from opium Antitussive- drugs that block coughing

The History of Narcotics A 6,000-year-old Sumerian tablet The Egyptians The Greeks Arab traders China and opium trade The Opium War of 1839 American opium use

History (continued) Sumerian tablet has an ideograph for the poppy shown as “joy” plus “plant” suggesting that the addicting properties of this substance have been appreciated for many centuries.

History (continued) The Greek God of sleep, Hypnos and the Roman God of sleep, Somnus, were portrayed as carrying containers of opium pods, and the Minoan Goddess of sleep wore a crown of opium pods

What is Opium? Opium is a naturally occurring substance found in the seeds of the opium poppy. Opium, which contains morphine, is extracted from the poppy seeds and used to produce heroin. Heroin is an illegal, highly addictive drug and its use is a serious problem in America. It is both the most abused and the most rapidly acting of the opiates.

Figure 09.T01: Commonly Used Opioid Narcotic Drugs and Products

Opium in China The opium poppy had a dramatic impact in China Caused widespread addiction 1729, China outlawed the sale of opium

Figure 09.UN01: Opium poppies such as these are used as a source for natural opioid narcotic drugs such as heroin, morphine, and codeine. © forbis/Shutterstock, Inc.

Opium in China Penalty for disobedience was: Death by strangulation or decapitation Despite these laws, opium smoking became so wide spread, the Chinese government forbade its importation from India

Opium in China During the next 120 years, a complex network of opium smuggling routes developed in China with the help of local merchants Substantial profits and pocketed bribes Opium War of 1839 to 1842

Opium in China Cont’d 10,000 British soldiers had won a victory over 350 million Chinese Island of Hong Kong was ceded to the British 1856, second Opium war broke out Importation of opium continued until 1908

Figure 09.UN02: A famous cartoon, showing a British sailor shoving opium down the throat of a Chinese man, which dates back to the Opium War of 1839-1842.

American Opium Use 1803, a young German named Frederic Serturner, extracted and partially purified the active ingredients in opium. The result was 10 times more potent than opium itself and was named morphine

Morphine

Morphine Morphine, was named after Morpheus, the Greek god of dreams

Codeine By 1832 A second compound had been purified and named Codeine, after the Greek word for “Poppy Capsule”

Figure 09.UN03: With the development of the hypodermic needle and its use during the Civil War, heroin addiction became more likely and more severe. Courtesy of Library of Congress, Prints & Photographs Division, [LC-B811-2531]

Hypodermic Syringe 1853- Alexander Wood perfected the hypodermic syringe Introduced it to Europe and American Hypodermic syringe was used extensively during the Civil War to administer morphine

After the Civil War A large % of soldiers returned home addicted to morphine 1900-Estimated 300,000 Americans were dependent on opiates Known as “soldier’s disease” or “army disease”

Sears and Roebuck 1898, mail order opium or morphine legally as well as Heroin

American Opium Use Cont’d A number of physicians were addicted to morphine One of the best known morphine addicts was William Holsted, a founder of John Hopkins Medical School

Figure 09.UN04: Chinese laborers often smoked heroin at the turn of the 20th century. © National Library of Medicine

Figure 09.UN05: Heroin use by soldiers fighting in Afghanistan is a great concern. © Baris Atayman/Reuters/Landov

American Opium Use Cont’d Heroin was first used in the United States as a cough suppressant 1980s Heroin smoking became popular due to acquired immune deficiency syndrome (AIDS) epidemic Fear of infection from needle use

Pharmacological Effects The most common clinical use of the opioid narcotics is as analgesics to relieve pain. The opioid narcotics relieve pain by activating the same group of receptors that are controlled by the endogenous substances called endorphins. Activation of opioid receptors blocks the transmission of pain through the spinal cord or brain stem.

Pharmacological Effects Effective against most varieties of pain Visceral (internal organs of the body) Somatic (skeletal muscles, bones, skin, and teeth)

Pharmacological Effects (continued) Did you know? The release of natural substances called endorphins can mimic the effects of narcotics such as heroin

Endorphins

Endorphins Are a family of peptides (small proteins) that are released in the brain, spinal cord, and adrenal glands in response to stress and painful experiences. adrenal glands

Endorphines

Other Therapeutic Uses Opioid narcotics are also used to treat conditions not related to pain. For example, these drugs suppress the coughing center of the brain, so they are effective antitussives. i.e. Codeine, a natural opioid narcotic, is commonly included in cough medicine.

Figure 09.HN01: Here and Now: Are Restrictions on Pain Pills Too Painful?

Figure 09.B01: Prescription for Abuse: What Makes People Vulnerable? As already mentioned, the abuse of prescription opioid painkillers has become a major problem in the United States. Described as the “nation’s fastest-growing drug problem” Figure 09.B01: Prescription for Abuse: What Makes People Vulnerable?

Mechanisms of Action Narcotic drugs such as morphine and heroin enhance the endorphin system Stimulation of receptors in the brain by narcotics causes release of transmitter dopamine in limbic brain regions

Pharmacological Effects (continued) Morphine is a particularly potent pain reliever and often is used as the analgesic standard by which other narcotics are compared. With continual use, tolerance develops to the analgesic effects of morphine and other narcotics. Physicians frequently under-prescribe narcotics, for fear of causing narcotic addiction.

Pharmacological Effects (continued) The principal side effects of the opioid narcotics, besides their abuse potential, include: Drowsiness, mental clouding Respiratory depression Nausea, and vomiting Inability to urinate Drop in blood pressure However, one of the most common side effects of the opioid narcotics is constipation.

Abuse, Tolerance, Dependence, and Withdrawal All the opioid narcotic agents that activate opioid receptors have abuse potential and are classified as scheduled drugs. Tolerance begins with the first dose of a narcotic, but does not become clinically evident until after 2 to 3 weeks of frequent use.

Figure 09.T02: Schedule Classification of Some Common Narcotics

Abuse of Opioid Narcotics Tolerance occurs most rapidly with high doses given in short intervals. Doses can be increased as much as 35 times in order to regain the narcotic effect. Physical dependence invariably accompanies severe tolerance. Psychological dependence can also develop with continual narcotic use.

Heroin Abuse Heroin is classified as a Schedule I drug. Heroin is one of the most widely abused illegal drugs in the world. Heroin was illicitly used more than any other drug of abuse in the U.S. (except for marijuana) until 20 years ago, when it was replaced by what drug?

Answer is? Cocaine

Heroin Combinations Smuggled into the United States from: Mexico South America Southeast Asia or Southwest Asia (Afghanistan)

Heroin Combinations Pure Heroin is white powder Brown Mexican heroin, result from unsatisfactory processing Heroin is usually “cut” (diluted) with lactose (milk sugar) to increase profits Can be 95% pure upon entering the U.S. Street purity various from 3% to 70% This can cause

Heroin Combinations cont’d If users are unaware of the variance in purity and do not adjust doses accordingly, results can be fatal.

Heroin Combinations Bitter taste, sometimes cut with quinine Quinine can be a deadly adulterant Adulterants- (to debase or make impure by adding inferior materials or elements; use cheaper, inferior, or less desirable goods in the production of (any professedly genuine article):

Figure 09.HN02: Here and Now: Afghans' Drug War

Heroin

Heroin Combinations (continued) Heroin plus the artificial narcotic fentanyl can be dangerous due to its unexpected potency. Heroin is most frequently used with alcohol. Heroin combined with cocaine is called “speedballing.”

Profile of heroin addicts Estimated that 600,000 to 1 million active heroin addicts live in the United States Hard core addicts often share a common place to stash supplies and equipment. Locations are called, “Shooting Galleries”

Figure 09.UN06: Crude heroin is dark, whereas purified heroin is a white powder. Courtesy of DEA.

Figure 09.UN07: Heroin paraphernalia is usually simple and crude but effective: a spoon and a makeshift syringe. © Feng Yu/Dreamstime.com

Stages of Dependence Initially, the effects of heroin are often unpleasant. Euphoria gradually overcomes the aversive effects. The positive feelings increase with narcotic use, leading to psychological dependence.

Stages of Dependence (continued) After psychological dependence, physical dependence occurs with daily use over a 2-week period. If the user stops taking the drug after physical dependence has developed, severe withdrawal symptoms result.

Figure 09.T03: Prevalence of Heroin and Other Opioid Abuse Among High School Seniors

Figure 09.HN03: Here and Now: Heroin Use in a Small Town

Heroin marks (tracks)

Methods of Administration Sniffing the powder Injecting it into a muscle (intramuscular) Smoking Mainlining (intravenous injection) Most established heroin addicts still prefer to MAINLINE

Figure 09.UN08: A heroin addict "mainlining" his drug. © Oscar Knott/FogStock/Alamy Images

Heroin Addicts and AIDS Over 50% of IV heroin users have been exposed to the AIDS virus Fear of contracting HIV from IV heroin use has contributed to the increase in smoking or snorting heroin Many who start by smoking or snorting progress to IV administration due to its more intense effects

Newer heroin use

New methods of use Cheese heroin

Cheese Heroin A highly addictive drug known as “cheese heroin” is a blend of black tar Mexican heroin (called “black tar” because of its color) and over-the-counter cold medication, such as Tylenol PM.

Figure 09.01: Treatment of heroin addiction: minimizing the very aversive withdrawal effect, preventing relapse, and providing maintenance support.

Withdrawal Symptoms After the effects of the heroin wear off, the addicts have only a few hours in which to find the next dose before severe withdrawal symptoms begin A single “shot” of heroin lasts 4 to 6 hours Withdrawal symptoms—runny nose, tears, minor stomach cramps, loss of appetite, vomiting, diarrhea, abdominal cramps, chills, fever, aching bones, muscle spasms

Figure 09.T04: Symptoms of Withdrawal from Heroin, Morphine, and Methadone

Figure 09.01: Treatment of heroin addiction: minimizing the very aversive withdrawal effect, preventing relapse, and providing maintenance support.

Treatment of heroin Stop using Don’t associate with dealers or users Avoid dangerous activities (sharing needles) Improve employment status Refrain from criminal activity Enjoy normal family and social relationships

Treatment of heroin Methadone is frequently used to help narcotic addicts This drugs block withdrawal symptoms Treatment should also include regular counseling and other supplemental services such as job training Methadone was first synthesized in Germany in 1943. It was first called Dolophine after Adolf Hitler

Advantages of Methadone Methadone is taken orally, not intravenously. It is legal so the addict is not in danger of being arrested It is much cheaper The addict only needs to be dosed once a day, as opposed to two, three, four or more times a day on heroin. It effectively reduces cravings if the dose is high enough Methadone treatment is considered one of the more 'successful' treatments.

Methadone Effective for about 24 to 36 hours Pill form, street name is “Dollies”

Disadvantages to Methadone Treatment: There is no 'high' from methadone. The addict often misses this. The 'high' is the reason people start taking heroin in the first place and is always sought even when addiction and tolerance make it scarce. I occasionally have cravings to get stoned even on methadone and am tempted to score to achieve this on top of the methadone.

Disadvantages to Methadone If an addict does take heroin while on methadone, the effect of the heroin is lessened or even completely wiped out. This has supposedly led to overdoses

Prescription Pain Relievers (Opioids) These drugs have been on the rise. Users unaware of the dangers: We will also cover some prescription opioids such as: Codeine, Fentanyl, OxyContin, Percocet and Vicodin

Other Narcotics Morphine, has been used to relieve pain since it was first isolated in 1803 Morphine has about half the analgesic potency of heroin but 12 times the potency of codeine

Codeine Codeine is a naturally occurring constituent of opium Is the most frequently prescribed of the narcotic analgesics Used principally as a treatment for minor to moderate pain and as a cough suppressant

Oxycodone What is oxycodone? Oxycodone is an opioid pain medication. An opioid is sometimes called a narcotic. Oxycodone is used to treat moderate to severe pain.

OXY Oxycodone can slow or stop your breathing, especially when you start using this medicine or whenever your dose is changed. Never take this medicine in larger amounts, or for longer than prescribed. Do not crush, break, or open an extended-release pill (Oxycontin). Swallow it whole to avoid exposure to a potentially fatal dose. Oxycodone may be habit-forming, even at regular doses

History of OXY It was developed in 1917 in Germany as one of several new semi-synthetic opioids in an attempt to improve on the existing opioids. Is it a popular drug? http://www.wmur.com/news/robber-steals-oxycodone-from-cvs-pharmacy/35957412 http://abcnews.go.com/topics/lifestyle/health/oxycodone.htm

What are the dangers of abuse? Or use Prescription opioids are powerful drugs with a high risk for dependency. Taking in high doses, and/or in combination with other substances — particularly alcohol — can result in life-threatening respiratory distress and death.

Did You Know? One person dies every 19 minutes from drug overdose in the United States and this increasing trend is driven by prescription painkillers. http://www.drugfree.org

What are they? Pain-relieving drugs either naturally derived from poppy flowers or lab-made, semi- synthetic substitutes. They work by attaching to particular sites in the brain called opioid receptors, which carry messages to the brain; the message the brain receives is changed, so that pain is no longer perceived as painful.

Fentanyl Fentanyl is one of the strongest opiate drugs on the market. It is not a long-lasting drug so it is often used for surgery recovery and for breakthrough pain—meaning that when a person is already taking an opiate but has temporary pain that breaks through the opiate barrier, they may be given fentanyl.

Fentanyl Lollipop Time-release formulations for fentanyl provide strong pain relief over time. They come in two forms—a lollipop and a patch

Dangers of Fentanyl In addition to the dangers of overdose and death to fentanyl users and abusers, unintentional fentanyl poisoning is a real threat to anyone who comes in contact with it. And law enforcement are particularly at risk. The DEA warned law enforcement personnel to avoid contact with fentanyl during drug seizures and arrests because it is easily absorbed through the skin, or accidentally inhaled if the powder becomes airborne during handing. http://novusdetox.com

Fentanyl cont’d “Fentanyl is extremely dangerous to law enforcement and anyone else who may come into contact with it. DEA will continue to address this threat by directly attacking the drug trafficking networks producing and importing these deadly drugs,”

Rising problem In the last two years, the DEA says, there’s been a “significant resurgence in fentanyl- related seizures.” State and local labs reported 3,344 fentanyl submissions in 2014, up from 942 in 2013 – a roughly 4 x increase. http://novusdetox.com/dea-issues-nationwide-public-health-warning-about-fentanyl-and-fentanyl-laced-heroin

Purple Drank Purple drank is a slang term for a concoction which includes a prescription-strength cough syrup as a recreational drug. The mixture became popular in the hip hop community in the southern United States, originating in Houston

Discussion Questions Why does heroin addiction contribute to criminal activity? What are the principal clinical uses of opioid narcotics?

Questions??