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SCCM-Heroin's Resurgence: Then and Now

SE-SCCM 2016
by

gaylord lopez

on 13 October 2016

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Transcript of SCCM-Heroin's Resurgence: Then and Now

The Heroin Resurgence: Then and Now
The historical use of Opium Poppy
Street names, Slang terms and others
Big H, Black Pearl, Black Tar, Brown Sugar, Junk, China White, Dope, Dragon, H, Hell Dust, Horse
Income Tax, Nose Drops, Smack Theraflu and Mud
Heroin administration
Heroin
1874-Charles Romely Alder Wright synthesized diacetylmorphine
English Chem/Physics researcher at St. Marys hospital medical school in London.
Heroin was originally created- less addictive alternative to morphine
Bayer marketed OTC under trade name of Heroin from 1895-1913. Pain/Coughs
Bayer stopped manufacturing of Heroin due to safety concerns
Controlled Drugs and Substances Act of 1970 made heroin illegal
The UN Int'l Narcotics Control Board regulates cultivation of opium poppy
INDIA only country involved in the LEGAL trade of opium
Drug Poisoning/Overdose
Leading cause of injury related death ~ 47,OOO in 2014
1.5x's more than MVA
Opioid analgesic deaths ~19,000
Heroin- >10,500....(OA+H=61%)
14% increase over 2013
"29"

Weekly MMWR January 2016/64(50):1378-92
Opioid deaths leveled recently
2000-2014- Heroin deaths quadrupled
Age adjusted rate 0.7-2.7/100k
Epidemiology Studies on Heroin Fatalities
2000-Non-Hispanic BLACKS 45-64- @2/100K
2013-Non-Hispanic WHITES 18-44- @7/100k
Hedegaard H, et al. NCHS Data Brief 2015;190:1-8.
Drug-Poisoning Deaths -Regional data
In 2000- NE & West - 0.9/100k
In 2013-
3-Fold increase (0.5-1.7/100k)
11-Fold 0.4-4.3/100k
0.9-1.8/100k
0.9-3.9/100k
One of the oldest known medicinal plants
Ancients Egyptians restricted use to magicians, priests, warriors
Greeks used to execute criminals
Treatment for Plague in late 17th century
Late 19th century in Europe, quiet a noisy babies!
Afghanistan- Biggest player in heroin trafficking- Produces 90% of world's opium. Expanded by 33% (2014)
Mexico- Opium production rose 50%
High demand/guaranteed market for opium
Salt - "white"- Water Soluble-Injectable form
Base- More prevalent- Doesn't dissolve in water- heat or acid needed to liquify
H+Ecstasy=Choc Chip cookies
H+THC= A-bomb
H=LSD=Beast
H+Ritalin=Pineapples
H+Cold meds=Cheese
H+Crack=Moon rocks
"Combinations"
Heroin Metabolism and Kinectics
T 1/2
2-6 min
6-25min
2-3hr
Mechanism of Action

Opioid receptors-brain- Perception of pain, reward pathways
Opioid receptors- brain stem- critical life functions, e.g BP, Respiration, arousal
"Rush" - Enhanced BBB penetration along with metabolic activation in CNS
Heroin Trends in the United States
Peaked in the mid- 1970's
Declined in the mid-1980's
Steadily rising in recent years
Noteworthy Heroin Facts
Increase in supply = Cheaper and more Pure product
>Decade ago - Purity 2-3% ($50-$150)..if you could find it
Today- Standard bag $10...Purity 7-10%
PURITY MATTERS!
When cut with "fillers", users injected to achieve desired high
Pure- Use without needles
Pure= Smoked or Snorted- MORE appealing to teens, college educated, and those wanting nothing to do with needles
The PERFECT Storm
Crackdown on "pill mills"
OxyContin, Percocet, Vicodin- harder to obtain and costly on BLACK market
Establishment of PDMP's
Reclassification of hydrocodone based drugs
OxyContin changed formula-2010
Increase supply of cheap and pure heroin

Gaylord Lopez, PharmD, DABAT
Director - Georgia Poison Center
Disclosure Statement
The Lecturer reports no conflicts of interest
The Lecturer alone is responsible for the content and delivery of this presentation
Celebrity Glamorization of Heroin
Heroin in Pop Culture
"Heroin" (1967) - The Velvet Underground
"The Needle and the Damage Done" (1972)- Neil Young
"Lust for Life (1977)-Pink Floyd
"Under the Bridge" (1992)- Red Hot Chili Peppers
"Fire and Rain" (1969)- James Taylor
"Sam Stone"- (1971) John Prine
"Walk on the wild side"- (1972) Lou Reed
"Hotel California"- (1977)- The Eagles
"Brown Sugar"-(1971)- The Rolling Stones
...Watching Parent Trap will never be the same again!
Heroin Contaminates: Then and Now
1930's
1970-1980's
1990's
Strychnine and Quinine
Quinine
China White
3-MF
Scopolamine
China White
Tango & Cash
2013
Acetyl Fentanyl
2000-2010
Clembuterol
Fentanyl
Acetyl Fentanyl- Whats the big deal?
Opioid analgesic
No recognized medical uses
5-15x more potent than Heroin
Can be used as Heroin substitute
Not "Scheduled" under CSA
Analog of fentanyl
Can evade reg's when labeled..."not for human consumption
Leaves law enforcement and HCP's in the dark
Opioid Antidote
Home Naloxone Kits
Naloxone distribution programs nationwide
Rx naloxone for known IV drug users
Case reports and studies documenting success
Opioid education + Naloxone
Naloxone - Over-the-Counter?
FDA fast-tracked device
NOT approved for OTC...yet
Considerable debate
Needs to be affordable
Not just for ED and ambulances
>200M Rx's for opioids in US
Rx Opioids = home naloxone
Strychnine added to mimic bitter taste of heroin and mislead clients
Quinine may have been added to quell malaria epidemic
Urine screened for quinine as a "surrogate marker" for heroin use

1979-1982-In District of Columbia, Quinine implicated as causative factor in epidemic of heroin-related deaths
Dysrhytmias, Vision issues, Blood related issues
Since the 1970's, Fentanyl adulterated heroin epidemics have been documented. More than 1000 dead
1978- California- "China White" (alpha-MF) - >100 deaths. More potent than morphine
1991- NYC-Fentanyl covertly sold as heroin
difficulties "cutting" drug
"Tango and Cash" - 12 deaths
1995- NE US. Scopolamine tainted heroin
acute psychosis, anticholinergic
treated with physostigmine
1998- Pennsylvania- "China White" resurfaced
Adulterant - 3MF
16 deaths
Eastern US 2005- Clenbuterol- rapidly acting, long duration drug responsible for effects
nausea, tachycardia, hypotension, SOB, tremors. A few deaths
2005-2007-Fentanyl contaminated heroin responsible for 1013 deaths across 6 states
Acetyl Fentanyl
A novel fentanyl analog
Mar-May 2013- Rhode Island
14 overdose deaths reported
FIRST time acetyl fentanyl identified in drug OD in US
Fentanyl/fentanyl precursor identifed in a number of drug samples found at site
May 2015-
Grady Health System ED QA review project
3-week period in May
> 800 UDS run in various patients
11% POSITIVE - Fentanyl!
Management of patients with chronic opioid dependance
DETOXIFICATION
for the highly motivated
for the pt compelled to stop using
tapered withdrawal with opioid agonist
Using opioid antagonist
MAINTENANCE
Use of long-acting opioid antagonist to block effects of additional opioid use
Opioid substitution therapy
Methadone - Slow-acting opioid agonist, used for making up for the "high" the real drug provides. It's been successfully used since the 1960s, mostly for patients who don't respond well to the other medicines.

Buprenorphine - Partial opioid agonist, preventing the drug cravings without the "high", and other dangerous side effects.

Naltrexone - Opioid antagonist that blocks the action of opioids, is not addictive or sedating, and does not result in physical dependence; however, patients often have trouble complying with the treatment, and this has limited its effectiveness.

Other than "simple" drug treatments, drug therapy is perhaps the best option for any heroin addict, controlled by doctors monitoring the patient's activities and dosage, and ensuring full recovery.
JUST GIVE ME THE ANTIDOTE!
CAN SOMEBODY HELP ME PLEASE?
Just the Facts...
Early '90s- "5th Vital Sign" (BP, HR, R, T)
Pills fix EVERYTHING
2014- 4.3 B Rx's in USA (227M-Opioids-$9.6B)
14 Rx's for every man, woman, child!
5% of World's population (319M)
Consume 75% of worlds Rx pills!
HOW DID WE GET HERE?
HOW DO WE GET OUT?
Interesting drug fact:
1990's/2000- OxyContin was aggressively marketed (1 pill=pain relief 12 hrs)
2007- Purdue Pharma pleaded GUILTY for misleading public regarding OC addiction potential ($31B over 2 decades)
$634M fines + 3 executives criminally charged
Narcan Nasal Spray
First/Only FDA approved form of naloxone
Ready to Use..."Needle Free"
Contains one-spray dose (4mg)
Effective within 2-3"
May be effective up to 2 hrs
Health Canada- available OTC!
13
16
80
82
40
119
Case for access to naloxone
77% deaths occur outside of a HCF
56% deaths in homes
85% Opioid OD's occur in presence of others
80% of OD victims found alone by paramedics
How do we get out?
Improve opioid prescribing practices to prevent addiction
Expand treatment access for those addicted
Boost naloxone access/use (OTC?)
Facilitate law enforcement agencies' efforts to decrease heroin supply
OTHER
Good Samaritan Laws
9-1-1 Medical Amnesty Law
Needle exchange programs
Heroin trending up
GBI Crime Lab (2011-2014)- 300% increase in samples of seized heroin
Grady ED- (Discharge Dx)
2012- 80
2013- 96
2014- 126
2015- 279
Grady ED Naloxone doses
2012-
2013- 440
2014- 391
2015- 385
Treatment / /Therapy Facts
SHORT TERM- Our entire Health System is setup for ACUTE
not
CHRONIC treatment
Inadequate treatment results
Private treatment- 30K
Lower level - 15K
Highly regarded - 40K for 6 weeks of residential treatment
POST ASSESSMENT Q'S
T/F- According to the Centers for Disease Control and Prevention, opioid related overdose deaths have DECREASED over the past 5 years primarily due to the shutting down of “Pill Mills” across the US and Canada.
T/F- For the latest year that data is available, heroin deaths combined with opioid analgesic deaths accounted for over 60% of the prescription drug overdose deaths for that year.
President Obama’s drug control priorities for the upcoming fiscal year include all of the following except:
a. Reducing prescription drug and heroin abuse by allocating additional funding to states with prescription drug monitoring programs (PDMP’s)
b. Expanding and improving treatment for addicts
c. Spearheading efforts to make naloxone more readily available to first responders
d. All of the above are true

Fact or Fiction?
A- Individuals who abuse or are dependent on opioid analgesics are 40x's more likely than non-users to abuse or be dependent on heroin
B- 4/5 heroin users started on opiates
C- Although men remain more likely than women to abuse or be dependent on heroin overall, growth in the prevalence of heroin use among women between '02-13 far outstripped that seen among men over the same period
D-During the past decade, most people who used heroin also used at least 3 other drugs
E- Once every 24 hours, a child is born already addicted to morphine
70
94
72
92
88
W
M
*Fentanyl
*Fentanyl
12
H only
F w/o H/?H
22
2013-
31-H/Probably H (no F)
7- F-related (6 were RxDOD*)
70 Statewide combined H+F
2014-
52 H/Probably H (no F)
28 F +/- H
12 F-related (3 were RxDOD*)
152 Statewide combined H+F
2015-
48 H/Probably H (no F)
34 F +/- H
22 F-related (4 were Rx DOD*)
223 Statewide combined H+F
NO COMBINED F/H SINCE 10/21/15 (FULTON ONLY)
JUN & DEC - F-SPIKES
2016- (thru July)
9 H/Probably H (no F)
3 F-related (all Rx DOD*)
34* deaths pending toxicology
120 Statewide combined H+F
Types of Heroin
Pure-"White" powder- bitter
Sold-
Brown (diamorphine "base")
Easier to manufacture
insoluble in H20
less pure and burns at lower Temps (smoke)
White (diamorphine hcl- "salt") powder
More difficult to make (expertise/equipment)
dissolves in H20- injectable
black sticky substance-"black tar" (Mexico)
cheaper, faster to produce
Need to dissolve, dilute (bent spoon/water/heat)
high lasts 4-6 hours
Lots of issues! Destroys veins, bacterial infections, necrotizing fasciitis/cellulites
Street heroin is "cut" (other drugs, sugar, starch, powdered milk, etc)
Learning Objectives:
Review trends in opiate analgesic and heroin fatalities over the past few decades
Review the history of heroin use/abuse over the years
Discuss the pharmacologic and toxicologic characteristics of heroin
Address the concerns and benefits of pre-hospital naloxone use
"...I started with opiates after my car accident. Got hooked and couldn't break free. Opiates NEVER made the pain go away...it just made me feel GOOD about the pain I was feeling...After my meds ran out, I found heroin! ... Being high is like being cradled to sleep by GOD. Your like all wrapped up in a warm blanket that shields you from all your fears and pains..."
Fact or Fiction?
A- Individuals who abuse or are dependent on opioid analgesics are 40x's more likely than non-users to abuse or be dependent on heroin
B- 4/5 heroin users started on opiates
C- Although men remain more likely than women to abuse or be dependent on heroin overall, growth in the prevalence of heroin use among women between '02-13 far outstripped that seen among men over the same period
D-During the past decade, most people who used heroin also used at least 3 other drugs
E- Once every 2 hours a newborn is found to be addicted to morphine
Used to stretch supply of heroin
10K x's > morphine, 100x's > heroin
2mg enough for 1 ton elephant
? naloxone effective
Sold in pill form but Ohio authorities found in syringes used by 100 OD in July 2016
Over 5 day period in Aug 2016- 174 OD's
Georgia- 2015
7.8M Rx opioids!
Per capita rankings- GA 20th (.77)
West Va- 1.13
TN- 1.18
AL- 1.2
Full transcript