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Heroin Overview

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					       Heroin:
 Action in the Brain,
 Action on the Street
      PCPA Conference
      October 13, 2011

      Donna McNelis, PhD
Christopher M. Owens, MA, LPC

Drexel University College of Medicine
Behavioral Healthcare Education
                 Objectives
• Describe the neurobiological aspects of heroin
  use.

• Discuss the biopsychosocial impact of heroin
  use on people with opiate dependence.

• Provide details on cultural features of heroin
  use, including “street” terminology.
                                                   2
               Please Note…
Some of the slides (and resulting
discussion) may contain graphic
imagery and language.

If you are sensitive to the real-
world descriptions of heroin and
how it is used, you may not wish
to continue in this workshop.
                                    3
Overview
 of the
 Brain



           4
            Impulse
             Flow


Neuronal
Structure



                      5
Synaptic Neurotransmission




                             6
Dopamine Neurotransmission




                             7
The Mesolimbic (Reward) Pathway

                 • Natural rewards
                    – Food, water
                    – Sex
                    – Nurturing


                 • Artificial


                                     8
Electrical
Activation
  of the
 Reward
 Pathway


             9
                  Addiction
• Compulsive behaviors

• Behavior is reinforcing (rewarding or
  pleasurable)

• Loss of control in limiting intake
  – Continuing to behave in a manner that will
    hopefully result in the reward

                                                 10
The Action of
   Heroin
 (Morphine)



                11
 Heroin and the
Reward Pathway




                  12
Opiate Receptors




                   13
Self Administration in the Lab




                                 14
                  Tolerance
• Regular dose of the
  drug no longer
  produces the
  desired level of
  intoxication

• Higher dose of the
  drug is required to
  achieve desired
  effect
                              15
 Heroin
Tolerance
  in the
  Brain


            16
              Dependence
• A state in which the
  person functions
  normally only in the
  presence of the drug

• When the drug is
  removed, withdrawal
  occurs

                           17
   Heroin
Dependence
in the Brain



               18
Addiction vs.
Dependence

  Is there a
 difference?



                19
Routes of Administration




                           20
      The
Hypothalamic-
 Pituitary Axis
and Depression

(Future treatment)
           Heroin: Overview
• 1874 - Synthesized from
  morphine
  – via opium poppy
    plants/seeds




                              22
           Heroin: Overview

• Circa 1900 – widely used
  medicinally
  – Analgesic
  – Cough suppressant
  – Anti-diarrheal




                              23
             Heroin: Overview
• Highly addictive
  – Rapidly acting
  – Tolerance develops quickly
  – Withdrawal

• Fatal overdoses often related to respiratory
  suppression

• IDUs at risk for blood born pathogens,
  scarred/collapsed veins, abscesses, pneumonia,
  TB, liver/kidney disease
                                                   24
             Heroin: Overview
• Legislation
  – Harrison Narcotic Tax Act
     • 1914 – medical regulation (tax)
     • 1924 – importation banned


  – Controlled Substances Act (1970); Heroin listed as
    a Schedule I drug
     • High risk for abuse
     • No accepted medical use
     • Low safety
                                                     25
              Heroin: Overview
• Rx opiates as a gateway?

  – Becoming more common to find many users
    (especially adolescents/young adults) begin with
    Rx opiates, but graduate to heroin

  – Heroin produces similar effects as Rx opiates, at a
    cheaper street price
     • Higher risk r/t purity

                                                          26
                Who Uses Heroin?
Results from the 2010 National Survey on Drug Use and Health

• 140,000 people (ages 12+) used heroin for the
  first time within the past 12 months

• Average age at first use among the recent
  initiates aged 12 to 49 was 21.3 years

• Approximately 3.8 million Americans aged 12+
  reported trying heroin at least once during
  their lifetimes
                                                           27
               Who Uses Heroin?
          Treatment Episode Data Sheet, 2007

• Nearly 250,000 admissions for treatment with
  heroin as primary DOC

• Gender
  – 68.5% male; 31.5% female

• Race/ethnicity
  –   52.3% White, non-Hispanic
  –   22.4% Hispanic origin
  –   22.1% African American
  –   3% other
                                                 28
              Who Uses Heroin?
         Treatment Episode Data Sheet, 2007

• Average age at admission
   – 36 years old
   – 83.7% were in the 20-49 range
• Age of first use
   – 85% between the ages of 13 and 30
   – Highest percentage age group – 21-25 years = 21.4%
• 71% were daily users
• Method of use
   – 64% injection       - 2.3% smoking      - 0.4% other
   – 32% inhalation      - 1.3% oral
                                                          29
              Who Uses Heroin?
       Treatment Episode Data Sheet, 2007

• Employment
  – 74.4% not working


• Education
  – 0-8 years           - 7.1%
  – 9-11 years          - 29.4%
  – 12 (or GED)         - 45.5%
  – More than 12        - 18.1%

                                            30
         What Does it Feel Like?
• Initial rush, with powerful feelings of euphoria
  and general well-being
• Wakefulness < - - - > drowsiness (“Nods”)
• Warmth, skin flushing
• Heavy extremities, constriction of pupils, dry
  mouth, itching, slurred speech, loss of
  coordination, nausea…
• Overall mental functioning decreases
• High lasts b/t 4-6 hours on average
   – Individual, dose, and purity factors
                                                     31
          Where Does it Come From?
                 (Institute For Defense Analyses,
         The Price and Purity of Illicit Drugs: 1981 – 2007)

• U.S. heroin market is supplied almost entirely
  from foreign sources of opium
  1. South America (Colombia)
     •      Higher purity
  2. Mexico
     •      Increasing presence
  3. Southeast Asia
     •      Burma
  4. Southwest Asia, Middle East
     •      Afghanistan, Pakistan, India                       32
           How Does it Get Here?
(Heroin in the Northeast: A Regional Drug Threat Assessment)

• Currently, the bulk of heroin in the northeast
  is of South American origin
• Most heroin in the Northeast is transported
  directly into NYC
  – Commercial aircraft
      • “Swallowers” – balloons, etc.
  – Commercial boating
  – FedEx, UPS
  – Private vehicles
                                                           33
34
                     Distribution
 (Heroin in the Northeast: A Regional Drug Threat Assessment)

• NYC as a primary market area for heroin in Northeast
   – Boston, Baltimore, Newark, Philadelphia, Washington, D.C.
   – Pittsburgh  rural Southwestern PA, parts of WV and OH


• Colombian and Dominican DTOs and associated
  criminal groups control majority of wholesale-level
  distribution of South American heroin in the
  Northeast.
• Dominican criminal groups are the primary retail
  distributors in the Northeast, but myriad other retail
  distributors also are active
                                                             35
        Heroin in Philadelphia
(Heroin in the Northeast: A Regional Drug Threat Assessment)


• Heroin is 2nd biggest drug threat (cocaine)
• Rate of ED visits r/t heroin was 3.2 times
  higher than national average
• Colombian, Dominican, Puerto Rican criminal
  groups are primary transporters and
  wholesale distributors
• Hispanic and African American dealers control
  retail-level distribution
                                                               36
          Heroin in Pittsburgh
(Heroin in the Northeast: A Regional Drug Threat Assessment)

• Heroin – most significant drug threat

• Heroin involved in 45% of overdose deaths

• Hispanic and African American criminal groups
  are primary transporters and wholesale
  distributors

• African American criminal groups and local street
  gangs are the primary retail distributors
                                                               37
                          Price
             (Institute For Defense Analyses,
     The Price and Purity of Illicit Drugs: 1981 – 2007)

• Nationally, there has been
  a general steady decrease
  in price (adjusted) since
  the 1990’s
  – Recent highs in late 1980’s – early 1990’s
  – Steady decline in the late 1990s
  – All-time lows in 2002 followed by stabilization
    since 2003
                                                           38
                           Price
              (Institute For Defense Analyses ,
      The Price and Purity of Illicit Drugs: 1981 – 2007)

• Varies
  – Current availability
  – Buyer’s familiarity with the seller
  – Region/location of the sale
  – Quantity sold


• In general, the closer an area is to a primary
  distribution center, the cheaper the heroin
                                                            39
                         Price
(Heroin in the Northeast: A Regional Drug Threat Assessment)

• A typical cost per bag of heroin in the
  Northeast is about $10
  – “Your mileage may vary”


• “Buying in bulk”
  – A bundle (10 bags)
  – A brick (5 bundles, or 50 bags)


                                                           40
                           Purity
• Nationally (Institute For Defense Analyses, The Price and
  Purity of Illicit Drugs: 1981 – 2007)
   • High purity from 1981 through the early 1990s
   • Retail sale level
      – general steady decrease in purity since late 1990’s early
        2000’s


• Northeast (Heroin in the Northeast: A Regional Drug Threat
  Assessment)
   • Wholesale heroin purity levels (85 – 96%)
   • Boston, NYC, and Philadelphia are the highest in the
     nation
                                                                    41
                       Purity
• Cutting
  – Heroin at retail/street level is often mixed
    with other substances
    • Sugar, starch, quinine, powder milk, cocoa,
      brown sugar
       – Most any powdery substance that resembles the
         color of the heroin
       – Poisons; other drugs
  – Reduces purity
  – Increase profits
                                                         42
                   Appearance
• Varies by region
  – Powder varying in color from white to dark brown
  – Northeast - white to off-white
  – Western US
     • Powder – brown to dark brown
     • “Black tar” – dark brown to black
        – Solid (coal)
        – Sticky (tar)
• Bitter taste
• Slight scent like vinegar
                                                   43
Appearance: White Powder




                           44
Appearance: Brown Powder




                           45
Appearance: Black Tar/Coal




                             46
              Methods of Use
• Plugging
  – Modified syringe
  – “Injected” anally or vaginally


• Snorting
  – Sniffing the powder form in through the nose
    using a “straw”


                                                   47
              Methods of Use
• Smoking

  – Heating the heroin
    on a piece of
    aluminum foil
    (bindle), spoon,
    etc. over a flame

  – Inhaling the
    resulting smoke
    through a tube
                               48
    Methods of Use
• Injection
  – Mix powder with water
  – Heat with water (and/or vinegar or
    other acidic agent to break down
    thicker heroin) to form a liquid
    solution, which is then injected
     • Cotton balls as filter


  – Intramuscular
  – Intravenous
     • Most efficient, esp. for low-purity
                                             49
             Methods of Use
• As with other drugs, heroin is often used in
  combination with other drugs
  – Cocaine/crack
  – Alcohol
  – Stimulants
  – Benzos
  – Other opiates
• Danger of use increases with combinations
  – Masking and/or potentiating
  – Unpredictability of effects
                                                 50
                    Subculture
• High value of heroin as drug of choice
• Relationships with other users
• Drug rituals
  – Buying, selling, using
     • Locations
  – Instruments
  – Preparations
• Balance between getting high and avoiding
  addiction/withdrawal
• Language – varies dramatically
                                              51
    Language: Nicknames for Heroin
•   Dope              •   Nose drops
•   H                 •   Mud
•   Smack
•   Heron             •   Skag
•   Junk              •   Brown Sugar
•   Hell dust         •   Brown
•   China White       •   Mr. Brownstone
•   Horse
•   White junk        •   Dr. Feelgood
•   Poppy             •   Duggie
•   Blanco            •   Boogie woogie

                  Others?                  52
     Language: Other Nicknames
• Crack
   – Dragon rock
• Injecting with cocaine
   – Speedball or Powerball
• Injecting with methamphetamines
   – Meth speedball
• Snorting with cocaine
   – Crisscrossing
• Liquefied H sniffed from a nasal spray bottle
   – Shabang
                      What else?                  53
          Language: Packaging
• Bag or “Dime bag” - plastic baggies of varying
  sorts, containing 100mg (0.10g)

• Stamp - small, folded square pieces of paper in
  the shape of a small envelope, containing 100mg
  (0.10g); easily logo branded

• Bundle - 10 bags, 1g

• Deck - 24 bags, 2.4g

• Brick - 5 bundles (50 bags), 5g
                                                    54
Language: Packaging - Bags




                             55
Language: Packaging - Stamps




                               56
Language: Paraphernalia
• Collectively referred to as
   – Works, outfit, rig

• Standard supplies
   –   Tie-off
   –   Spoon
   –   Foil (bindles)
   –   Candles/lighters
   –   Cotton balls/Q tip
   –   Syringes
   –   Straws
   –   Razor blades
   –   Vitamin C
                                57
          Language: Other Terms
• Using                  • Obtaining
  – Shooting               – Copping
  – Booting                – Scoring
  – Mainlining             – Tightening up
  – Skin-popping           – Finding a fix
  – Plugging
  – Getting a fix        • Others
  – Get well               – Junkie
  – Chasing the dragon
                         • Any others terms
                           you’ve heard?
                                              58
                    Daily Life
• Avoiding withdrawal - saving bags
• Copping – finding a trusted, reputable source,
           AND 2-3 backups
• Dealing with impairments (high or coming down)
  – Nods, nausea, coordination, cognition, etc.
  – Hiding use
• Relationships
• Money
  – Employment
  – Crime
• Shelter
                                                  59
                  Daily Life
• To inject, or not to   • Where to inject?
  inject?                  – Veins – “Safety first”
  – Fear of graduating        1.   Upper arm, forearm
  – Addiction                 2.   Hands/wrist
                              3.   Legs
  – Stigma
                              4.   Feet
                              5.   Groin
• To share, or not to         6.   Neck
  share?                   – Intramuscular
                           – Popping
                           – Needle gauge             60
                    Daily Life
• Hiding tracks
  – Clothing
  – Neosporin
  – Vitamin E lotions
  – Makeup
  – Aloe vera

  – Strategic injection sites


                                 61
Questions or Comments?




                         62
  Hats
  Off!
PCPA Conference
October 13, 2011


                   63

				
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