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Heroin addiction


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Heroin addiction

  1. 1. HEROIN ADDICTION Teja Mehendale Psychiatry- Dr. Martinez
  2. 2. ADDICTION, ABUSE, DEPENDENCE  3 distinct terms: reflect the state of the body and mind of an individual in relation to an addictive substance  Addiction: 1) when a lot of time is spent in obtaining a substance, using a substance or recovering from it 2) Important social, occupational and recreational activities are given up because of it 3) the use is continued despite having a physical or psychological problem  Abuse: 1) Recurrent substance use severely impacts obligations and responsibilities at work, school or home 2) Legal problems due to over use 3) Recurrent use despite social, interpersonal problems 4) Absence of Dependence  Dependence: 1) Tolerance 2) Withdrawal 3) Unsuccessful urge, effort to quit
  3. 3. OPIATES  Opiates belong to the large biosynthetic group of benzylisoquinoline alkaloids  Naturally occur in the opium poppy
  4. 4. OPIATES  Major psychoactive opiates are morphine, codeine and thebaine  Semi synthetic opioids are hydrocodone, hydromorphone, oxycodone and oxymorphone  Heroin is a synthetic substance that converts into 6 acetyl morphine in the body  Heroin is colloquially known as H, smack, horse, brown, black, tar etc.
  5. 5. PHARMACODYNAMICS  Reward pathway: modifies the action of dopamine in the nucleus accumbens and the ventral tegmental area of the brain  Powerful agonist at the mu opioid receptors subtype  Binding inhibits the release of GABA from the nerve terminal, reducing the inhibitory effect of GABA on dopaminergic neurons  Increased activation of dopaminergic neurons and the release of dopamine into the synaptic results in sustained activation of the post-synaptic membrane  Continued activation of the dopaminergic reward pathway leads to the feelings of euphoria and the ‗high‘ associated with heroin use  Also binds to areas involved in the pain pathway (including the thalamus, brainstem, and spinal cord) which leads to analgesia
  6. 6. ROUTES OF ADMINISTRATION  Heroin is usually injected, sniffed/snorted, or smoked  Typically, a heroin abuser may inject up to four times a day. Intravenous injection provides the greatest intensity and most rapid onset of euphoria (7 to 8 seconds)  Intramuscular injection produces a relatively slow onset of euphoria (5 to 8 minutes)  When sniffed or smoked, peak effects are usually felt within 10 to 15 minutes
  7. 7. SHORT TERM EFFECTS  Mitotic ―pinpoint‖ pupils: Less than 2.9 mm; stimulates the oculomotor nuclei and affecting the sphincter muscle of the iris which cause narrowing of pupils
  8. 8. SHORT TERM EFFECTS  Nausea and vomiting occur because heroin stimulates the area postrema equaling chemoreceptor trigger zone in the medulla and affects gastrointestinal receptors  Heroin affects the sphincter pylori, sphincter urethrae, and sphincter ani externus  Warm, flushed skin; dry mouth; severe itching  Binds to the u-receptors that decrease gut motility and cause severe constipation  Urinary retention  Bradycardia  Badypnea and respiratory depression  CNS depression  Spontaneous abortions
  9. 9. LONG TERM EFFECTS  Physical dependence and withdrawal as well as addiction  Infectious diseases, for example, HIV/AIDS and hepatitis B and C  Collapsed veins  Bacterial infections- pneumonia, TB  Abscesses  Infective endocarditis  Arthritis and other rheumatologic problems
  10. 10. EFFECTS ON PREGNANCY  Preeclampsia and third-trimester bleeding  Malnutrition  Venereal disease  Hepatitis  Pulmonary complications  Fetal death  Intrauterine growth retardation,  Prematurity  Withdrawal symptoms
  11. 11. WITHDRAWAL  Restlessness  muscle and bone pain  insomnia,  diarrhea, vomiting,  cold flashes with goose bumps ("cold turkey")  leg movements  Withdrawal is not fatal in healthy adults
  12. 12. TREATMENT  Naloxone for acute overdose management  Detoxification — controlled and medically supervised withdrawal from the drug  Naltrexone for management: : opioid antagonist  Methadone maintenance  Clonidine is sometimes added to shorten the withdrawal time and relieve physical symptoms  Buprenorphine- partial opioid agonist  Behavioral therapy, contingency management therapy and cognitive-behavioral interventions
  13. 13. METHADONE MAINTENANCE  Specialized clinics for methadone  Taken daily in liquid form; a single dose lasts 24–36 hours  Some methadone clinics also provide other services, including vocational and educational aid, referrals to other medical and social service agencies, help for the families of addicts, and treatment for cocaine or alcohol abuse.  Switching from illicit opiates to methadone avoid the highs and lows and the medical risks of intravenous injection and the criminal behavior that supports it.  less depressed, more likely to hold a job and maintain a family life, less likely to commit crimes, and less likely to contract HIV or hepatitis  Methadone can be continued indefinitely, or the dose can be gradually reduced in preparation for withdrawal.  estimated that about 25% of patients eventually become abstinent, 25% continue to take the drug, and 50% go on and off methadone repeatedly.
  14. 14. BUPRENORPHINE (SUBOXONE)  partial opioid agonist  Taken three times a week as either a tablet or film, sublingually  It occupies opiate nerve receptors and produces a mild opiate-like  effect.  In a person who is physically dependent on opiates, buprenorphine causes a withdrawal reaction.  There is some risk of abuse if the tablet is dissolved and injected  buprenorphine has been made available in combination with naloxone, which has little effect when absorbed under the tongue but neutralizes the effect of injected opiates.  The main advantage of this is that patients do not have to come to clinics to take it, because there is no illicit market and no danger of diversion.  Since 2002, individual physicians with proper training and certification have been allowed to prescribe buprenorphine in their offices for patients to take home
  15. 15. THERAPY  Residential behavioral therapy most effective.  Contingency management therapy uses a voucher-based system, where patients earn "points" based on negative drug tests. They can exchange these for retail items or e allowed to take home methadone instead of coming to the clinic  Cognitive-behavioral interventions are designed to help modify the patient's expectations and behaviors related to drug use, and to increase skills in coping with various life stressors.
  16. 16. AS A PHYSICIAN…  Perform HIV, Hepatitis B S Ag, Hepatitis C Ab screening tests on opioid dependent patient  Watch out for Latent TB infection  Immunizations Hep A, Hep B and Tetanus are up to date  Counsel patient, provide information  Remember, drug seeking behavior is not a personality trait; do not judge your patients
  17. 17. BIBLIOGRAPHY  Kaplan and Saddocks Synopsis of Psychiatry  Kaplan Step 2 CK  Goljan Rapid Review, Pathology    distinguishing-between-drug-dependen   http://review-of-current- etylmorphine+(Heroin)+After+Diffusion+Through+the+Blood-Brain+Barrier.pdf  ation_and_maintenance.htm