Pill Pushing©

The Best of Pill Pushing - HEROIN - THE KILLING COUGH SYRUP - (10/18/2017)

By Dr. Ron Gasbarro
Society at that time       
The 1890s was a decade of mirth and gaiety, technological advancements and at least 13 massacres and battles around the world. Later called “the Gay Nineties”, because of merriment and optimism, the decade was actually fraught with poverty, crime and a severe economic depression. Yet, advances abounded. X-rays, argon, helium, neon, xenon and krypton were discovered. Aviation was being developed. In 1893, the Duryea brothers tested their first gasoline-powered automobile model and in 1896 established their company to build the Duryea model automobile, the first auto ever commercially manufactured [Berkbile, 1964]. The Kinetoscope, developed by Thomas Edison in 1891, was a precursor to the movie camera. Swedish scientist Svante Arrhenius and US geologist Thomas Chrowder Chamberlin independently suggested that human CO2 emissions might cause global warming. 
There were 3 US presidents during the 1890s: Benjamin Harrison, Grover Cleveland and William McKinley. Mississippi became the first state to require a literacy test to vote, presumably to block uneducated African-Americans from voting. Jim Crow laws were state and local statutes set in place to enforce racial segregation in the southern US.  First class postage stamps cost a penny. Cabinetmakers made about 2 dollars a day – a day belonging to a 60 hour work week [US Dept of Labor, 1934]. Milk was 3 cents a quart. Groucho Marx, Rose Kennedy and Charles De Gaulle were born during this decade. Vincent van Gogh, Sitting Bull and Joseph Merrick (The Elephant Man) died during this period. In 1895, an alternative to morphine and codeine, heroin, was about to become the “next best thing” in medicine.  
The good, the bad, and the ugly
Heroin (diacetylmorphine) was first chemically synthesized in 1874 by English researcher, C.R. Wright. The drug went unstudied and unused until 1895 when Heinrich Dreser working for The Bayer Company of Germany (noted for Bayer Aspirin), found that diluting morphine with acetyls produced a drug without the common morphine side effects. Heroin was considered a highly effective medication for coughs, chest pains, and the discomfort of tuberculosis. This effect was important because pneumonia and tuberculosis were the two leading causes of death at that time, prior to the discovery of antibiotics. Heroin was touted to physicians as stronger than morphine and safer than codeine. It was thought to be non-addictive, and even was believed to be a cure for morphine addiction and for relieving morphine withdrawal symptoms. Because of its supposed great potential, Dreser derived his name for the new drug from the German word for “heroic.” Bayer began production of diacetylmorphine in 1895, although it would not be introduced commercially for another 3 years.  
Trouble started from the get-go. In 1898, The Bayer Company introduced heroin as a substitute for morphine. By 1902, physicians discussed the prudence of using heroin as a morphine step-down cure. Many physicians argued that their patients suffered from heroin withdrawal symptoms that were equal to morphine addiction. By 1903, heroin addiction rose to alarming rates. The philanthropic Saint James Society in the US mounted a campaign to supply free samples of heroin through the mail to morphine addicts who are trying to break their habits. Efforts by the British and French to control opium production in Southeast Asia were successful. Nevertheless, this Southeast region, referred to as the “Golden Triangle” (Myanmar, Laos, Vietnam, Cambodia), eventually became a major player in the profitable opium trade during the 1940's.
Throughout the 20th century, heroin remained a danger as rival drug cartels battled and trade routes continued to grow. From 1965 to 1970, US involvement in Vietnam is blamed for the surge in heroin being smuggled into the States. To aid US allies, the Central Intelligence Agency (CIA) set up a charter airline, Air America, to transport raw opium from Burma and Laos. As well, some of the opium would be transported to Marseille, France by Corsican gangsters to be refined into heroin and shipped to the US via the French Connection, a scheme through which heroin was smuggled from the “Golden Crescent” (Afghanistan, Pakistan) through Turkey to France and then to the United States through Canada . By the 1950s, the number of heroin addicts in the US reaches an estimated 750,000.
Impact of drug on culture
Today, heroin is used globally by 50 million people on a regular basis. The drug could be acquired over–the-counter with consummate ease in the late 19th and early 20th centuries in the UK and the USA. It was commercially produced by Bayer Pharmaceuticals from 1898 onwards for medicinal purposes — including as a cough syrup for children and as a “non-addictive morphine substitute.” Alarmingly, Bayer sold the substance as a cure for morphine addiction only for it to be discovered that the body quickly processes it into morphine, actually making it a faster-acting and doubly potent alternative. It was only with the passing of the Harrison Narcotics Tax Act in 1914 that heroin’s sale and distribution were controlled in the US. Surprisingly, its importation and manufacture was not banned in the United States until as late as 1924. It was widely available without a prescription in the UK until 1926. 
In June 2016, The Drug Enforcement Administration (DEA) came is out with a new report on heroin use in the United States. The report noted that deaths from heroin overdoses have spiked in recent years, tripling from 2010 to 2014, and quintupling from 2000 to 2014, according to the DEA National Heroin Threat Assessment Summary. In 2014, the most recent year of the study, 10,574 people died, compared to 3,036 four years earlier.
The increased demand is being driven by greater availability, as well as prescription drug abusers switching to heroin for the cheaper price tag, according to the DEA. Other possible reasons for the increase in deaths include an increase in new and inexperienced users, as well the use of highly toxic heroin adulterants such as fentanyl in certain markets, according to the DEA.
Methods of using heroin
There are three primary ways to use heroin: smoking, shooting and snorting. Rectal administration is also used. Each of these methods carries with it different effects for the user – as well as different risks [Heroin.net; 2015].
Smoking heroin – Mixing heroin with water or other liquids allows it to be smoked though a pipe. When you mix heroin and cocaine and you can go “freebasing” – a form of smoking both drugs. Freebasing is an incredibly dangerous activity that has claimed the lives of many, including basketball star Len Bias and comedian John Belushi.
Shooting heroin – Injecting heroin into the veins (intravenously) bloodstream is perhaps the most dangerous way of using heroin. IV heroin use delivers the strongest high, but can also lead to the transmission of several potential deadly diseases. Heroin addicts who share dirty needles are at a great risk for HIV/AIDS as well as certain strains of hepatitis. In many states, clean needles are available at pharmacies and clinics over-the-counter for a nominal fee. 
Snorting heroin – When crushed into powder form, heroin can be snorted through the nose much in the same way cocaine is used. Snorting heroin delivers an impactful high, although not quite as fast acting as shooting or smoking heroin. Some people have died of a heroin overdose when they mistakenly snorted heroin, thinking it is cocaine.
Heroin and the media 
Countless terms and nicknames exist for heroin (horse, smack, H, skag, junk, dirt, brown sugar, golden girl, hell dust, white nurse, thunder, etc. etc.) there are also seemingly endless songs and movies about the drug to name a few. 
Hurt – Johnny Cash (2002 – written by Trent Reznor, Nine Inch Nails - 1994)
Straighten up and Fly Right – Nat King Cole (1943 – written by Cole)
Brown Sugar – The Rolling Stones (1971- Mick Jagger & Keith Richards) 
Ain’t it Fun – Guns ‘n Roses (1978 – written by The Dead Boys)
Happiness is a Warm Gun – The Beatles (1968 – written by John Lennon & Paul McCartney)
Under the Bridge – Red Hot Chili Peppers (1991 – written by the Red Hot Chili Peppers)
Trainspotting – 1996 film based on the novel by Irvine Welsh
The Man with the Golden Arm – 1955 film based on the novel by Nelson Algren
The Basketball Diaries – 1995 film based on Jim Carroll’s memoir
Requiem for a Dream – 2000 film based on the novel by Hubert Selby, Jr. 
Sid and Nancy – 1986 biopic  about Sid Vicious and Nancy Spungen
The Panic in Needle Park – 1971 film based on the novel by James Mills 
Where the drug is today
Heroin is alive and well, even though many of the people who take it are not. Using data from the National Vital Statistics System, this data brief provides a description of trends and demographics for heroin-related drug-poisoning deaths in the United States from 2000 through 2013.
According to the CDC’s National Vital Statistics System: [Chen, 2014; Rudd, 2014]
From 2000 through 2013, the age-adjusted rate for drug-poisoning deaths involving heroin nearly quadrupled from 0.7 deaths per 100,000 in 2000 to 2.7 deaths per 100,000 in 2013. Most of the increase occurred after 2010 [Hedegaard, 2015].
The number of drug-poisoning deaths involving heroin was nearly four times higher for men (6,525 deaths) than women (1,732 deaths) in 2013.
In 2000, non-Hispanic black persons aged 45–64 had the highest rate for drug-poisoning deaths involving heroin (2.0 per 100,000). By 2013, the trend shifted to a younger demographic when non-Hispanic white persons aged 18–44 had the highest rate (7.0 per 100,000).
From 2000 through 2013, the age-adjusted rate for drug-poisoning deaths involving heroin increased for all regions of the country, with the greatest increase seen in the Midwest.
Drug poisoning (overdose) is the number one cause of injury-related death in the United States, with 43,982 deaths occurring in 2013 [Chen, 2015]. 
To stem the abuses, authorities over the past decade began cracking down on pain clinics and individual doctors. Drug companies have begun creating pill formulations that make them harder to crush and snort for a quick high. Thus, opiate addicts have found it more difficult, and expensive, to get their fix. An 80 mg OxyContin tablet can cost $60 to $100. In contrast, heroin costs about $45 to $60 for a multiple-dose supply. And the new twist? Heroin is no longer just an inner-city plague. It is now in some of the better suburbs. It is now in the smaller cities, once bastions of clean, crime-free living. Think Akron, Pittsburgh, Denver, Las Vegas. It is pervasive, not just among youth, but to people in their 50s and 60s [Quinones, 2015]. 
Purity of street heroin
Street heroin is almost never pure. As addicts move from legitimate prescriptions to the pill mills of pure, precisely measured narcotic pain pills to the dirty world of dealers, needles and kitchen table chemists, health officials and police are noting sharp increases in overdoses, crime and other public health problems. Unlike the quality-controlled narcotics manufactured until strict Federal guidelines, switching to heroin is a whole new ball game. Street heroin can be stronger, and weaker, or cut with anything from powdered milk or sugar, to morphine or rat poison, to Xanax® or cocaine. The addict does not know what he or she is actually getting. Researchers at Johns Hopkins University in Baltimore say that street heroin can vary in potency from 3% to 99%. Then there is the issue of sharing syringes which can transmit HIV and hepatitis.
Pure heroin looks like a white powder and may be smoked or snorted. Darker, more impure (black tar heroin) heroin is diluted or dissolved, and then injected into one’s skin, muscles, or veins. The nature of the drug’s effects brings an increased risk of overdose. Exacerbating the problem further are variations in purity.
The latest and most deadly filler is fentanyl, a powerful, synthetic opioid analgesic with a rapid onset and short duration of action. This narcotic pain medication is used as a cutting agent or sold as outright as heroin, often without the buyer’s knowledge. It is as much as 100 times more potent than morphine and 50 times more powerful than heroin – a literal crumb can kill you – which is why the House of Representatives Judiciary Committee approved bill H.R. 3713 in 2016 to increase the penalty of trafficking heroin cut with this drug by up to 5 years. Of late, fentanyl-laced heroin has been the reason for many drug-related deaths in the US. 
Treating heroin overdose and addiction
A heroin overdose affects heart rate and breathing such that medical intervention is needed to survive. The presence of other drugs, chemicals, and substances in an impure mixture can affect survival rates and outcomes. Physical and psychological effects from these may alter the required course of treatment. 
Detoxification ("detox") is a common procedure for people with heroin addiction. Some of the medications used include: 
Methadone – An opioid agonist with a slow-acting formulation, methadone is taken orally. It reaches the brain and activates the receptors slowly so the person gets a dampened high. Withdrawal symptoms can be prevented by administering the medication daily and reducing or maintaining the dose over time.
Buprenorphine – Suboxone® and Subutex® are two FDA-approved products used for treating opioid addiction. Both products work to eradicate the influence of opiates on the brain and both allow opiate addicted users to stop taking drugs such as heroin, oxycodone, and hydrocodone without experiencing painful withdrawal symptoms or struggling with drug craving. The primary difference between Suboxone and Subutex is that Suboxone contains buprenorphine, while Subutex contains two active ingredients buprenorphine and naloxone. Naloxone is added to the formulation to keep people from abusing the medication. For example, if you were high on heroin and shot up naloxone, you would crash into an immediate state of opiate withdrawal. Because buprenorphine attaches itself to the brain’s opiate receptors, it tricks the brain into believing it has encountered an opiate. Addicts who take either product can also avoid experiencing withdrawal from the opiate. A six-month subdermal buprenorphine implant is in clinical studies for the long-term maintenance treatment of opioid dependence. 
Naloxone – Overdoses may be treated with naloxone. An opioid receptor antagonist, this medication binds to the receptors and blocks heroin from binding to and activating them. The medication can reverse an overdose. In 2014, the FDA approved a handheld injector (Evzio®) to reverse opioid overdose in an emergency; a single dose under the skin or into muscle is enough to suppress the drug’s effects until the person can receive medical assistance. It can be purchased over-the-counter and will be carried by police, First Responders, school personnel until medical help can be obtained. By all accounts, naloxone is a miracle in a vial. The drug can reverse the effects of an opiate overdose within minutes of administration by stopping potentially fatal respiratory depression. In fact, based on a 2010 nationwide survey of 188 local prevention programs, the CDC reports that from 1996 to 2010, 10,171 lives were likely saved by timely injection or nasal administration of naloxone.
Naltrexone – This non-addictive opioid antagonist blocks heroin without risk of physical dependence. It is also available in an injectable form needed only once a month. Naltrexone is a drug that reverses the effects of opioids and is used primarily in the management of alcohol dependence and opioid dependence. It is marketed as its hydrochloride salt, naltrexone hydrochloride, under the trade names Revia® and Depade®. A once-monthly extended-release injectable formulation is marketed under the trade name Vivitrol®.
Bottom line
According to the CDC, health care providers wrote 259 million prescriptions for opioid-based painkillers in 2012, which is enough for every American adult to have a month’s supply of pills. Americans become addicted to these prescription pills and ultimately turn to heroin as a much cheaper alternative. There are programs, like needle exchanges, that help reduce the spread of HIV and hepatitis, which work to save lives, and others, like methadone clinics that help people transition away from heroin. Heroin is as close as a drug can be to pure evil. It is extremely addictive, has a major and entirely negative societal impact in terms of the medical care required for the existing large population of addicts, and the enormous difficulty in finding a long-term cure for addiction all vastly outweigh the minimal medicinal uses to which it can be applied. As we move forward, our challenge is to unravel the biochemical and psychosocial reasons for why people become addicted. And what exactly does “addiction” mean? There are functioning addicts – able to hold a job and behave normally to the outside word – just as there are functioning alcoholics. Whether there is a magic drug yet to be discovered or we figure out how brain chemistry really works, it will take a multidisciplinary effort to quash addiction rates and save lives. 
As for the tragic 2014 loss of Oscar-winning actor Philip Seymour Hoffman, why did he take that final hit of heroin? A sense of power? A sense of weakness? A sense of freedom? A sense of loathing? We do not know what strength heroin he routinely took before he quit a couple years before. But the final dose was known because the needle was still in his arm when he was found dead on the bathroom floor. 

Ron Gasbarro, PharmD is a registered pharmacist, medical writer, and principal at Rx-Press.com. Write him with any ideas or comments at ron@rx-press.com.

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