1. Heroin detoxification Presenter: Dr. Ehab Ali Sorketti Consultant Psychiatrist

2. Introduction Heroin is an illegal drug that is made from the resin or sap of the opium poppy. Other substances made from this resin include morphine, opium and codeine, which are all pain-killing chemicals. These drugs are known as 'opioids' or narcotic analgesics. Other drugs in the opioid class include pethidine and methadone, which are synthetically manufactured

3. Opium poppy: Papaver somniferum

4. The opium poppy, Papaver somniferum

5. Introduction -Heroin is a central nervous system depressant, it slows down the workings of the brain and spinal cord. -Heroin usually takes the form of granules or powder, and can be white, pink or brown. -It is usually injected intravenously, but some users snort or smoke it instead. Common slang terms for heroin include 'smack', 'horse' and 'hammer'.

6. "It's so good. Don't even try it once." intravenous heroin user

7. Heroin is the most fast-acting of all the opiates. When injected, it reaches the brain in 15-30 seconds; smoked heroin reaches the brain in around 7 seconds. The peak experience via this route lasts at most a few minutes.

8. The surge of pleasure seems to start in the abdomen; a delicious warmth then spreads throughout the body. After the intense euphoria, a period of tranquillity ("on the nod") follows, lasting up to an hour. Experienced users will inject between 2-4 times per day. After taking heroin, some people feel cocooned and emotionally self-contained. Others feel stimulated and sociable. Either way, there is a profound sense of control and well- being.

9. The euphoria gradually subsides into a dreamy and relaxed state of contentment. Higher doses of heroin normally make a person feel sleepy. At higher doses still, the user will nod off into a semi-conscious state. The effects usually wear off in 3-5 hours, depending on the dose. Heroin is not toxic to the organ systems of the body. But in prohibitionist society the mortality of street users is high.

10. Diacetylmorphine, or heroin, was first synthesized from morphine in 1874.

11. Commercial production of heroin began in 1898. Heroin was advertised under its well-known trademark by German manufacturers Bayer as "the sedative for coughs".

12. Introduction The effects of heroin depend on the strength of the dose, the blend of chemicals, the physiology of the user and their state of mind at the time of taking the drug.

13. Introduction Generally, some of the immediate effects of taking heroin include: A rush of pleasurable feelings. Cessation of physical pain and discomfort. Shallow breathing. A drop in body temperature. Sleepiness. Narrowing of the pupils. Loss of sex drive.

14. Harvest time

15. Dependence, tolerance and withdrawal Like many other drugs, it is possible to build up a tolerance to heroin. After only a short time, the user will need to take larger and larger doses to achieve the same effect. Soon, their body will come to depend on heroin in order to function at its best.

16. Dependence, tolerance and withdrawal The user craves the drug and this psychological dependence makes them panic if access is denied, even temporarily. For some heroin addicts, nothing else in life matters except the drug. Career, relationships and even basic needs like eating can be ignored.

17. Dependence, tolerance and withdrawal Some users commit crimes in order to support their expensive habit. Withdrawal symptoms can start after a matter of hours and may include cravings, diarrhea, vomiting, goose bumps, restlessness and crying.

18. Acute withdrawal The onset of withdrawal usually begins at the time of the next habitual drug dose, ranging from 4 – 12 hours The most usual withdrawal syndrome is a relatively benign mixture of emotional, behavioral and physical symptoms

19. Acute Opioid (heroin) withdrawal Physical signs and symptoms: Begins in hours, peak in 36 – 72 hours: -- mark drive for the drug Begins in 8 – 12 hours peaks in 48–72 hours: --tearing of the eyes --running nose --sweating --yawning

20. Acute Opioid (heroin) withdrawal Begins in 12–14 hours, beaks in 48-72 hours: --restless sleep --dilated pupils --anorexia --gooseflesh --irritability --tremor-

21. Acute Opioid (heroin) withdrawal At peak, Insomnia Violent yawning Weakness GIT upset Chills flushing Muscle spasm Ejaculation Abdominal pain

22. Heroin addicts Who needs reasons when you've got heroin?"

23. Treatment of withdrawal General support: -Physical and laboratory exam -Rest -Nutrition -Reassurance -honest appraisal of what symptoms are to be expected -Keep one doctor in charge

24. Treatment of withdrawal One type of specific treatment: -eg give methadone 15 – 20 mg orally as a test -Determine dose on day 1 or 2 -Give dose BID -Decrease by 20%/day or over 2 weeks

25. Treatment of withdrawal Give a test dose of about 20 mg of methadone orally and repeat the dose if the symptoms are not alleviated, thus determining the minimum dose needed to control symptoms during the first 24- 36 hours One approach is to give a dose every 4 hours until symptoms disappears

26. Treatment of withdrawal Most people in withdrawal achieve some comfort at doses of 20 to 40 mg of methadone the first day The necessary drug is then divided into twice-to-four-times-daily doses, with daily decrease of 10% to 20% of the first day's dose depending on the symptomatology

27. Treatment of withdrawal An alternate approach is to administer 10 mg of methadone IM and observe the effects, reexamining the patient in 18 hours and monitoring the amount of drug necessary to abolish the symptoms Then the dose can be given orally two to three times a day

28. Treatment of withdrawal Another example is the treatment of withdrawal through use of relatively week opiod like drug Diphenoxylate (lomotil) using 2 or 3 tablets 3 times a day for 3 to 4 days then decreased and stopped

29. Treatment of withdrawal The clinician can detoxify with buprenorphene (Subutex) with 2 mg being the rough equivalent of 30 mg of methadone, 1 st day – 1 st dose 4mg-6mg depends on amount of heroin spend per day 100=6mg 2 nd day,4-16mg, 3 rd day,14 th day 4-16mg – urine test at 5 th day maintenance for 2-3 months Then gradual dose reduction by 2mg

30. Treatment of withdrawal Agitation = benzodiazepines Violence = antipsychotic Tremors = adrenergic agonist Diarrhea = Imodium / lomotil Tearing = anti-H1 Mood changes antidepressant

31. Treatment of withdrawal The most commonly used symptom- oriented nonopioid approach is the use of Clonidine 0.01 to 0.3 mg QID up to 1 mg /day which decreases the sympathetic over activity during withdrawal Side effect include sedation and hypotension –monitor BP carefully

32. The available drug for treatments for heroin dependence include: Methadone buprenorphine and naltrexone

33. Methadone is a synthetic opioid drug used as a substitute for heroin Methadone is cheaper than heroin, and remains active in the body for longer than heroin a single daily dose is all that is required. This allows the person to stabilize their addiction and start looking after themselves

34. Methadone Methadone treatment can be long term (months or years) to help the person reduce the risks of illicit drug use, or short term (two weeks or less) for the purposes of safe withdrawal from heroin

35. Methadone Methadone is an opioid. Unlike heroin, it does not provide the user with a euphoric sensation. However, its effects on the body are similar to heroin in many other ways, including: Pain relief Feelings of general wellbeing Reduced blood pressure Slower heart rate Drop in body temperature.

36. Methadone Methadone can cause unpleasant side effects, but adjusting the dose can help. In other cases, side effects can be caused by taking more than the recommended dose or by using other drugs at the same time, such as alcohol or tranquillizers.

37. Methadone Side effects can include: Sweating Constipation Sexual dysfunction (inability to reach orgasm) Changes to the menstrual cycle Drowsiness Heart palpitations Dizziness Nausea and vomiting Skin rashes.

38. Buprenorphine Buprenorphine is a partial opiate agonist, which means it stimulates the cell receptors that are normally stimulated by opioid drugs like heroin and methadone.

39. Buprenorphine Characteristics include: Buprenorphine is as effective as methadone in managing the symptoms of heroin withdrawal. Methadone withdrawal can be unpleasant and lengthy, while the effects of buprenorphine withdrawal are mild and brief.

40. Buprenorphine A short course of buprenorphine can help a person to withdraw from their methadone maintenance program. Only one daily dose (or less) is needed. Buprenorphine is administered in tablet form. The tablet isn't chewed or swallowed, but dissolved under the tongue for about half an hour.

41. Naltrexone Naltrexone is an opioid antagonist, which means it blocks the effects of opioids. Characteristics include: Naltrexone doesn't appear to be as effective as methadone in controlling the symptoms of heroin withdrawal. Naltrexone offers faster detoxification than methadone.

42. Naltrexone Naltrexone does not, itself, cause physical dependence. Naltrexone does not directly stop someone wanting to use heroin. It is expensive.

43. Naltrexone This treatment may only suit people who are highly committed to giving up heroin. Naltrexone works best as part of a comprehensive treatment program which includes counseling.

44. During detoxification, it is very important to plan for rehabilitation, Many patients enter detoxification solely to decrease their high drug levels or in response to immediate life problems, so the detoxification period is an excellent time to introduce the need for permanent abstinence where psychosocial intervention in needed

45. Thank you