Narcotics (Opioids)

Chapter 9
 WHAT ARE NARCOTICS?

 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.
WHAT ARE NARCOTICS?

FIGURE 09.T01: COMMONLY USED OPIOID NARCOTIC DRUGS AND PRODUCTS

WHAT ARE NARCOTICS? (CONTINUED)
 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.
 THE HISTORY OF NARCOTICS
 Dates back some 600 years (6000-year-old Sumerian
tablet)

 Used / traded in the historic Egyptian, Greek,

and Arab cultures (Greek God of sleep = Hypnos)
 China and opium trade
 The Opium War of 1839 (Development of the
British Island of Hong Kong) Second war = 1856
 American opium use (development of morphine and
codeine, and the development of the hypodermic
needle)
 Heroine “heroic” drug was introduced in 1898
as an antitussive.
 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 and can also reduce
the effects of stress.
PHARMACOLOGICAL EFFECTS
(CONTINUED)
 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.
PHARMACOLOGICAL EFFECTS
(CONTINUED)
 The principle side effects of the opioid
narcotics, besides their abuse potential,
include:
 Drowsiness, mental clouding

 Respiratory depression

 Nausea, vomiting, and constipation

 Inability to urinate

 Drop in blood pressure

SIGNS, SYMPTOMS, AND ABUSE
 ABUSE, TOLERANCE,
DEPENDENCE,
AND WITHDRAWAL
 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.
 ABUSE OF OPIOID NARCOTICS
 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.
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 GUIDELINES TO AVOID
PRESCRIBED OPIATE ABUSE
 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
 GUIDELINES TO AVOID
PRESCRIBED OPIATE ABUSE
(CONTINUED)
 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
 OPIOID SIDE EFFECTS
 Drowsiness
 Respiratory depression

 Nausea/vomiting

 Inability to urinate

 Constricted pupils

 Constipation

 Physical dependence and withdrawal

 HEROIN ABUSE
 Heroin is classified 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
 HEROIN COMBINATIONS
 Pure heroin 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.
 HEROIN COMBINATIONS
(CONTINUED)

 Heroin has a bitter taste and is often cut

(diluted) 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.”
FACTS ABOUT HEROIN ABUSE

 What is the estimated number of heroin

addicts in the United States?
 600,000 – 1,000,000

 What are “shooting galleries”?

 Locations that serve as gathering
places for addicts
 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

– begin to engage in crime and heroin use at same time
 PATTERNS OF HEROIN ABUSE
 Heroin has become purer (60% to 70%
purity) and cheaper (~$10/bag).
 Greater purity leads users to administer
heroin in less efficient ways. (smoking and
snorting)
 Many youth believe that heroin can be used
safely if not injected.
 PATTERNS OF HEROIN ABUSE
(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.
 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. (6-12 hrs)
 METHODS OF HEROIN
ADMINISTRATION
 Sniffing the powder
 Injecting it into a muscle (intramuscular)

 Smoking

 Mainlining (intravenous injection)

 HEROIN ADDICTS AND AIDS
 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.
 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)
 WITHDRAWAL SYMPTOMS
 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.
WITHDRAWAL SYMPTOMS
 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.
 See also Figure 9.1, p 289 (next slide)
TREATMENT
OTHER NARCOTICS (READ IN CLASS)

Morphine Buprenorphine
Methadone MPTP
Fentanyl Codeine
Hydromorphone Pentazocine
Oxycodone (OxyContin) Tramadol
Meperidine
NARCOTIC-RELATED DRUGS
 Dextromethorphan: OTC antitussive
 NARCOTIC-RELATED DRUGS

 Clonidine: Relieves some of the opioid

withdrawal symptoms
 Naloxone/Naltrexone: Narcotic
antagonist; used for narcotic overdoses

-- END OF PRESENTATION --