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Drugs & Society Chapter 9
This document provides information about opioids (narcotics) from a class on drugs and society. It discusses various opioids like heroin, morphine, and codeine. It covers topics like opioid abuse patterns in the US, methods of opioid administration, physical and psychological effects of opioids, dependency and withdrawal. The document also discusses medical uses of opioids and harm reduction strategies like needle exchange programs and medications like suboxone and methadone to help treat opioid addiction.
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Drugs & Society Chapter 9
- 1. SOC 204 Drugs& Society Hanson Chapter 9 Narcotics
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- 3. We have completedone half of this entire class. How are you doing in this class? Michelle’s office hour: 9:30-10:30 M-F Email through Canvas Call/text 872-701-0007 6% 65% 29% A. Awesome! B. I’m keeping up. C. I’m lost…help!
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- 5. Do you knowsomeone who has used opioids recreationally in the last 30 days? A. No B. Yes, one person C. Yes, more than one person
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- 8. Heroin Abuse Heroin isclassified as a Schedule I drug. One of the most widely abused illegal drugs in the world; accounts for >$120 billion sales/year Illicitly used more than any other drug of abuse in the United States (except for marijuana) until 20 years ago, when it was replaced by cocaine Some of the recent increases in heroin use likely due to increased abuse of prescription opioid painkillers
- 9. Heroin Combinations Pureheroin is a white powder. More than 90% of world’s heroin is from Afghanistan. Heroin is usually “cut” (diluted) with lactose. When heroin first enters the United States, it may be 95% pure; by the time it is sold, it may be 3% to 70% pure. If users are unaware of the variance in purity and do not adjust doses accordingly, results can be fatal.
- 10. Heroin Combinations (continued) Heroinhas a bitter taste and is often cut with quinine, which can be a deadly adulterant. 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.”
- 11. Facts About HeroinAbuse What is the estimated number of heroin addicts in the United States? 600,000 What are “shooting galleries”? Locations that serve as gathering places for addicts
- 12. Heroin and Crime Factors related to crime: Pharmacological effects encourage antisocial behavior that is crime-related Heroin diminishes inhibition Addicts are often self-centered, impulsive, and governed by need Cost of addiction Similar personality of criminal and addict
- 13. Patterns of HeroinAbuse Heroin has become purer (60% to 70% purity) and cheaper (~$10/bag). Greater purity leads users to administer heroin in less efficient ways. Many youth believe that heroin can be used safely if not injected.
- 14. Patterns of HeroinAbuse (continued) Because of its association with popular fashions and entertainment, heroin has been viewed as glamorous and chic, especially by many young people, although lately this attitude has been changing. Emergency room visits due to narcotic overdoses were over 190,000 in 2009.
- 15. 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. In addition to psychological dependence, physical dependence occurs with daily use over a 2-week period. If the user abruptly stops taking the drug after physical dependence has developed, severe withdrawal symptoms result.
- 16. Methods of Administration Sniffing the powder Injectingit into a muscle (intramuscular) Smoking Mainlining (intravenous injection)
- 17. Heroin Addicts andAIDS More than 250,000 patients in United States contracted AIDS by drug injection, of which most were heroin users. 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.
- 18. Heroin and Pregnancy Heroin use by a pregnant woman leads to: Physical dependence on heroin in the newborn Withdrawal symptoms after birth in the newborn (Note: similar withdrawal occurs in newborns of any woman who uses significant amounts of opiate drugs during pregnancy, including prescribed opiate painkillers)
- 19. At one time,heroin was given to morphine addicts to help them break their addiction to morphine. A. True B. False
- 20. 1914 Harrison Act Madeopioids difficult to obtain Oral use declined Cost and risk increased View of addicts changed
- 21. Vietnam Use among troopswas about 10-15% Most users stopped upon returning to US
- 22. Review: Which twocompounds are in the opium plant resin? A. Oxycontin and heroin B. Morphine and heroin C. Morphine and codeine D. Hydrocodone and codeine Oxycontin and heroin M orphine and heroin M orphine and codeine Hydrocodoneand codeine 6% 0% 94% 0%
- 23. Review: What impactdid the Harrison Act have on opium use? A. Opium use increased B. Opium was no longer readily available C. Illegal IV use decreased D. Oral use increased Opium use increased Opium wasno longerrea... IllegalIV use decreasedOraluse increased 13% 0%0% 88%
- 24. Review: Upon returningto the US, soldiers who used opiates in Vietnam: A. 70% were arrested for illegal drug use B. 67% became homeless C. 95% stopped using the drug 70% w ere arrested forill...67% becam ehom eless 95% stopped usingthe drug 0% 100% 0%
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- 26. Narcotic Doses Drug TherapeuticDose Tolerant Dose Lethal Dose Morphine 15-30 mg 100 mg 500 mg Heroin 10-15 mg 60 mg 200 mg Fentanyl 25 micrograms 2 mg OxyContin 10 mg 40 mg 160 mg 1 mg = 1000 micrograms
- 27. Pharmacology Raw opium isabout 10% morphine, smaller amount of codeine Heroin is made by adding two acetyl groups Allows passing through blood-brain barrier faster Mouse Party Enkephalins – adrenal gland Endorphins – pituitary gland
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- 29. Medical Uses Pain relief Treatmentof intestinal disorders Cough suppressant
- 30. Physical Effects Drowsiness (noddingout), vomiting, nausea, and difficulty concentrating Euphoria Gradually anesthetizing sensations Difficulty urinating, constipation Constricted pupils
- 31. Opioid Side Effects Drowsiness Respiratorydepression Nausea/vomiting Inability to urinate Constricted pupils Constipation Physical dependence and withdrawal
- 32. Emotional Effects Relief fromanxiety, hostility, feelings of inadequacy, and aggression Difficulty regulating inhibitions and frequently make risky decisions
- 33. Social Effects Alienated fromand hostile toward friends and family Correlated with criminal behavior, unemployment, and violence
- 34. Review: Heroin’s effectsdo not include: A. Sleepiness B. Euphoria C. Agitation D. Pain relief
- 35. Review: which ofthe following is NOT a medical use for narcotics? A. Cough suppressant B. Stop diarrhea C. Induce sleep D. Pain relief Cough suppressant Stop diarrhea Inducesleep Pain relief 29% 0% 46% 25%
- 36. Dependency About half ofnarcotic abusers become dependent: Tolerance Positive reinforcement Negative reinforcement Can develop in less than two weeks Average addiction is six to eight years (aging out)
- 37. Acute Toxicity Behavioral Respiratory depressioncan be fatal Synergistic effect when combined with depressants Opioid Triad Coma Depressed respiration Pinpoint pupils
- 38. Chronic Toxicity Blood bornepathogens Contaminants Infections
- 39. Which is anexample of chronic physiologic toxicity? A. Making bad decisions while high B. Committing crimes to obtain the drug C. Acquiring an HIV infection through use of unclean needles D. Depressed respiration M akingbad decisionsw h... Com m ittingcrim esto ob... Acquiringan HIV infecti.. Depressed respiration 0% 0%0%0%
- 40. Withdrawal Factors affecting thedifficulty of withdrawal: Social support network Desire to stop Physical environment during withdrawal Alternative opiates
- 41. Signs Heroin or Morphine Methadone Cravingfor drugs, anxiety 6 24 Yawning, perspiration, running nose, teary eyes 14 34-48 Increase in above signs plus pupil dilation, goose bumps, tremors, hot and cold flashes, aching bones and muscles, loss of appetite 16 48-72 Increased intensity of above, plus insomnia; raised blood pressure; increased temperature, pulse rate, respiratory rate and depth; restlessness; nausea 24-36 Increased intensity of above, plus curled-up position, vomiting, diarrhea, weight loss, spontaneous ejaculation or orgasm, hemoconcentration, increased blood sugar 36-48 (hours after last dose) Narcotic Withdrawal
- 42. Opioid Antagonists/Agonists Naloxone -Narcan Suboxone Naloxone & Buprenorphine Methadone
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- 44. Opinion: Do youagree with the use of suboxone or methadone to help a person quit using opioids? A. Yes B. No
- 45. Which drug hasthe most dangerous withdrawal syndrome? A. Heroin B. Morphine C. LSD D. Alcohol Heroin M orphine LSD Alcohol 33% 59% 7% 0%
- 47. I think NeedleExchange Programs are a good idea. A. True B. False True False 0%0%
Editor's Notes
- #5 Sometimes called opioids. Some texts differentiate between opioids = naturally derived from opium (morphine/codeine), opiates – synthetic reproductions of opioids: heroin, methadone, fentanyl, oxycontin, hydrocodone, and others. Cultivated from an annual flowering plant. Origin in the Middle East. Only available for collection for a few days of the plant’s life. Collectors use a sharp, clawed tool to make shallow cuts into the unripe seedpods. Resinous substance oozes out and is scraped and collected – raw opium. Today most heroin is produced in South America, Mexico and Southeast Asia. By 1906, opium and its derivatives were found in more than 50,000 medicines The hypodermic needle hastened the effects of morphine By the late 1800s, an estimated 4.59 per 1,000 people were dependent on opiates Ironically, the drug promoted to help people overcome morphine dependency was heroin The opium poppy, Papaver somniferum, is cultivated throughout Asia and the Middle East When the seedpod is cut open, it exudes a white, milky sap which dries to a brown, thick, gummy resin (opium) There is only a ten-day window in which opium can be made from the resin of the opium poppy In 1803, Friedrich Serturner of Germany synthesized morphine from opium and called it morphium Morphine is about ten times more potent than opium, although physicians thought it was safer and purer Codeine was isolated from opium 30 years later How morphine is administered and its dosage has a bearing on its effectiveness Heroin (diacetylmorphine) was first synthesized from morphine in 1874 When heroin was introduced, it was believed not to be addicting When smoked, its effects are rapid – it is ineffective when ingested Heroin is three to ten times more powerful than morphine because it is more lipid-soluble The term narcotic currently refers to naturally occurring substances derived from the opium poppy and their synthetic substitutes. These drugs are referred to as the opioid (or opiate) narcotics because of their association with opium. Abuse rate for prescribed opioid narcotics has gone from 2.2% to 10% in the past 10 years Although opioid narcotics possess abuse potential, they also have important clinical value (e.g., analgesic, antitussive, antidiarrheal). The term narcotic has been used to label many substances, from opium to marijuana to cocaine. HISTORY A 6000-year-old Sumerian tablet The Egyptians The Greeks Arab traders China and opium trade The Opium War of 1839 American opium use Abuse problems often associated with war
- #7 Available in patent medications Increased in 1850 as Chinese laborers arrived in the US Dependence not viewed as a major social problem Opium smoking was limited to certain groups Patent medicines were socially acceptable Opioid dependence was viewed as a “vice of middle life” Typical user was a 30-to-50-year-old middle class white woman, wife, and mother Drugs purchased legally in patent medicines High drugs levels in patent medicines meant that withdrawal symptoms were severe and relieved only by taking more Thomas de Quincey 1823 drank laudanum and wrote a book Life of an Opium Eater. Seen as a vice of middle age. By 1906, opium and its derivatives were found in more than 50,000 medicines The hypodermic needle hastened the effects of morphine By the late 1800s, an estimated 4.59 per 1,000 people were dependent on opiates Ironically, the drug promoted to help people overcome morphine dependency was heroin
- #8 Opium was outlawed in China in 1729 The British East India Company was involved in opium trade in India & China, eventually led to war between British and Chinese Morphine is the active ingredient in opium and was isolated in 1806. It’s 10 times as potent as opium. It was named morphium after Morpheus the God of Dreams. In 1832 another alkaloid of opium was discovered and named codeine “poppy head” The hypodermic syringe was invented in 1853 allowing for IV use of morphine. Medically useful characteristics Clinically useful Pure chemical Known potency Use spread due to two developments 1853: Hypodermic syringe allowed delivery of morphine directly into the blood Widespread use during war provided relief from pain and dysentery Many veterans were dependent on morphine, and dependence was later called “soldier’s disease” or “army disease” Two acetyl groups added to morphine given the brand name Heroin and marketed by Bayer 1898. 3X more potent than morphine because the increased lipid solubility of the heroin molecule easily passes the Blood-Brain Barrier. Acts more quickly. Was originally marketed as a non-habit forming substitute for codeine. Most of today’s heroin comes from South America, Mexico and Southeast Asia. Average purity has increased from about 5% to 25% since the 70s. In 2008, retail purity for Mexican heroin 40% and South American heroin 57%. With the invention of the hypodermic syringe, increased IV use. 68% of heroin addicts admitted into treatment are male, 59% are White, and ¾ have been in treatment previously Increase in abuse is significantly higher in rural areas than in metropolitan areas During the Vietnam War, 10-15% of US troops were addicted to heroin More than 15 million people worldwide illegally use opium, morphine, and heroin Afghanistan is the largest heroin producer worldwide China is believed to have the largest number of narcotic addicts An estimated 24 million to 34 million people throughout the world use opium
- #21 Made these drugs available only by prescription. This changed the pattern of opioid use. The only source for these drugs without a prescription was illegal drug dealers. Oral use declined and the primary remaining users were IV users of morphine or heroin. Cost and risk of use increased and so the most potent method of use was favored. Addicts were seen as weak and self-indulgent. Oral use declined and use in low-income areas of large cities increased. By the 60s, heroin use was associated with crime and considered socially unacceptable. The Harrison Act of 1914 made narcotic use without a prescription illegal The typical opiate addict shifted from a middle-class woman to a young, lower-class man Perceptions of the opiate addict went from unfortunate victim to a deviant criminal who was a threat to society During the 1930s, morphine abuse exceeded heroin abuse – by the 1940s, heroin addiction was greater Heroin use increased greatly beginning in the late 1960s and early 1970s. In 2010, about 200,000 Americans had used heroin in the previous month In the US, more than 800,000 people are addicted to heroin and other narcotics
- #22 Heroin was inexpensive and relatively pure. 95%. Most users smoked or sniffed the drug. Contrary to popular opinion, Vietnam showed that under certain conditions a relatively high number of individuals will use opioids recreationally and that dependence and compulsive use are not inevitable among occasional users.
- #26 5% report non-medical use – given as prescription pain relievers/analgesic Most are given orally as prescriptions Dependence & toxicity from misuse – users misuse by crushing and smoking or snorting the pills Police in WW report that prescription opioids are selling for high prices on the street. $1 per mg, so a 20 mg pill would sell for $20. Have seen an increase in opioid abuse/dependency. Most anecdotal stories involve individuals who began with prescription drug use, misused or abused the prescription, and found it expensive to obtain on the streets/illegally. Many then turn to heroin in order to avoid withdrawal. Heroin is much cheaper, but is also unpredictable as far as potency and purity. Morphine Methadone Fentanyl Hydromorphone Oxycodone (OxyContin) Meperidine Dextromethorphan: OTC antitussive Clonidine: Relieves some of the opioid withdrawal symptoms Naloxone/Naltrexone: Narcotic antagonist; used for narcotic overdoses Buprenorphine MPTP Codeine Pentazocine Tramadol
- #28 Naturally occurring opioid-like products of the nervous system and endocrine glands activate brain opioid receptors Enkephalins: morphine like neurotransmitters found in the brain and adrenals Endorphins: morphine like neurotransmitters found in the brain and pituitary gland
- #30 Pain relief Reduces the emotional response to pain and diminishes the patient’s awareness of, and response to, the aversive stimulus Typically causes drowsiness but does not induce sleep Treatment of intestinal disorders Reduces colic and counteracts diarrhea and the resulting dehydration Acts by decreasing the number of peristaltic contractions An opium solution known as paregoric is still available for relief of diarrhea Cough suppressant Codeine has long been used to reduce coughing It remains available in prescription cough medications Nonprescription cough remedies contain the opioid analogue dextromethorphan It produces hallucinogenic effects at high doses
- #31 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 but can also reduce the effects of stress. 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 underprescribe narcotics, for fear of causing narcotic addiction. The principle side effects of opioid narcotics, besides their abuse potential, include: Drowsiness, mental clouding Respiratory depression Nausea, vomiting, and constipation Inability to urinate Drop in blood pressure
- #37 Not all users experience euphoria from initial dose Tolerance to negative effects may develop more rapidly than tolerance to positive effects Withdrawal is often similar to a mild case of the intestinal flu People usually don’t become dependent after one dose Current users: Probably about one million opioid-dependent Americans and two to three times that many heroin chippers (occasional users) 68% of heroin addicts admitted into treatment are male, 59% are White, and ¾ have been in treatment previously Increase in abuse is significantly higher in rural areas than in metropolitan areas During the Vietnam War, 10-15% of US troops were addicted to heroin More than 15 million people worldwide illegally use opium, morphine, and heroin Afghanistan is the largest heroin producer worldwide China is believed to have the largest number of narcotic addicts An estimated 24 million to 34 million people throughout the world use opium Physical and psychological dependence, and tolerance develop quickly Positive reinforcement Negative reinforcement Withdrawal symptoms can be severe Tolerance Tolerance develops to most effects from both medical and recreational usage Higher doses needed to maintain effects Cross-tolerance exists among all the opioids Psychological processes play a key role in tolerance Dependent individuals develop a conditioned reflex response to the stimuli associated with taking the drugs Physical dependence Symptoms of withdrawal appear in sequence following the timing of the most recent dose and the individual’s history of use Opioid withdrawal is unpleasant but rarely life-threatening Methadone (long-lasting synthetic opioid) produces withdrawal symptoms that appear later and are less severe than those from heroin Psychological dependence Positive reinforcement Positive effects reliably follow use of the drug Negative reinforcement Use of the drug removes withdrawal symptoms Fast-acting injectable opioids are most likely to lead to dependence Factors affecting the difficulty of withdrawal: Availability of a social support network Addict’s desire to stop Physical environment during withdrawal Convenience and practicality of alternative opiates About half of narcotic abusers become dependent: People can become drug-dependent in less than two weeks if they take increasing amounts of narcotics Average addiction is six to eight years Narcotics relieve psychic distress arising from anxiety, hostility, feelings of inadequacy, and aggression Heroin addicts have difficulty regulating inhibitions and frequently make risky decisions Users sometimes ignore or become alienated and hostile toward friends and family members Heroin use has been associated with criminal behavior, unemployment, and violence Acute toxicity Opioids depress respiratory centers in the brain Breathing becomes slower and shallower Effects with alcohol are additive Opioid overdose triad Coma Depressed respiration Pinpoint pupils Clouding of consciousness Occasionally, nausea and vomiting Can be counteracted with naloxone Narcotics cause drowsiness, vomiting, nausea, and difficulty concentrating Euphoria is followed by gradually anesthetizing sensations, then sleep and lethargy Opiates impede the ability to urinate, and can cause potentially serious constipation Male addicts have difficulty achieving an erection Chronic toxicity is associated with injection method of use Infections and the spread of blood-borne diseases Narcotics are capable of depressing the respiratory system to the point of death According to the CDC, painkillers kill twice as many people as cocaine and five times more people than heroin Synergistic effect of narcotics and other drugs can be fatal Death from an overdose of heroin is slow – people who die quickly are likely to die from anaphylactic shock ABUSE/DEPENDENCY 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. 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 and typically expresses when these drugs are used for more than 2–4 weeks. Psychological dependence can also develop with continual narcotic use. RECOMMENDATIONS TO AVOID DEPENDENCY Only use opioid analgesics when pain severity warrants Doses and duration of use should be as conservative as possible Patients should store these medications securely to prevent their theft and misuse Do not share with anyone else Doctors should screen patients for abuse risk before prescribing opioid drugs Patients should be educated about potential abuse problems prior to being prescribed opioid drugs If significant abuse is suspected, the clinician should discuss concerns with patient to find appropriate steps to stop the abuse
- #38 Physical and psychological dependence, and tolerance develop quickly Positive reinforcement Negative reinforcement Withdrawal symptoms can be severe Tolerance Tolerance develops to most effects from both medical and recreational usage Higher doses needed to maintain effects Cross-tolerance exists among all the opioids Psychological processes play a key role in tolerance Dependent individuals develop a conditioned reflex response to the stimuli associated with taking the drugs Physical dependence Symptoms of withdrawal appear in sequence following the timing of the most recent dose and the individual’s history of use Opioid withdrawal is unpleasant but rarely life-threatening Methadone (long-lasting synthetic opioid) produces withdrawal symptoms that appear later and are less severe than those from heroin Psychological dependence Positive reinforcement Positive effects reliably follow use of the drug Negative reinforcement Use of the drug removes withdrawal symptoms Fast-acting injectable opioids are most likely to lead to dependence Factors affecting the difficulty of withdrawal: Availability of a social support network Addict’s desire to stop Physical environment during withdrawal Convenience and practicality of alternative opiates About half of narcotic abusers become dependent: People can become drug-dependent in less than two weeks if they take increasing amounts of narcotics Average addiction is six to eight years Narcotics relieve psychic distress arising from anxiety, hostility, feelings of inadequacy, and aggression Heroin addicts have difficulty regulating inhibitions and frequently make risky decisions Users sometimes ignore or become alienated and hostile toward friends and family members Heroin use has been associated with criminal behavior, unemployment, and violence Acute toxicity Opioids depress respiratory centers in the brain Breathing becomes slower and shallower Effects with alcohol are additive Opioid overdose triad Coma Depressed respiration Pinpoint pupils Clouding of consciousness Occasionally, nausea and vomiting Can be counteracted with naloxone Narcotics cause drowsiness, vomiting, nausea, and difficulty concentrating Euphoria is followed by gradually anesthetizing sensations, then sleep and lethargy Opiates impede the ability to urinate, and can cause potentially serious constipation Male addicts have difficulty achieving an erection Chronic toxicity is associated with injection method of use Infections and the spread of blood-borne diseases Narcotics are capable of depressing the respiratory system to the point of death According to the CDC, painkillers kill twice as many people as cocaine and five times more people than heroin Synergistic effect of narcotics and other drugs can be fatal Death from an overdose of heroin is slow – people who die quickly are likely to die from anaphylactic shock
- #41 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, and muscle spasms.
- #43 Reverse depressed respiration from opioid overdose Precipitate withdrawal syndrome Prevent dependent individuals from experiencing a high from subsequent opioid use SUBOXONE is a combination of two drugs: Buprenorphine: an opiate that acts to fill up the brain’s opiate receptors without causing sleepiness or “high” feelings. It has a low risk of overdose. Naloxone , a drug that is not absorbed orally but helps persuade people not to inject Suboxone in the vein as it causes instant withdrawal. Methadone (long-lasting synthetic opioid) produces withdrawal symptoms that appear later and are less severe than those from heroin. Usually administered orally. Can be abused if concentrated and injected. TREATMENT Methadone or buprenorphine are frequently used to help narcotic addicts. These drugs block withdrawal symptoms. Treatment should also include regular counseling and other supplemental services such as job training.
- #47 Three to four injections needed daily to prevent withdrawal Expensive habit (cost of drugs and paraphernalia) Risk of overdose due to variable potency of different batches Health problems associated with injection habit Skin infections Blood-borne infections Masking of early symptoms of illness Some users “mature out” Not all users experience euphoria from initial dose Tolerance to negative effects may develop more rapidly than tolerance to positive effects Withdrawal is often similar to a mild case of the intestinal flu People usually don’t become dependent after one dose Current users: Probably about one million opioid-dependent Americans and two to three times that many heroin chippers (occasional users)