Transcript Heroin*s Resurgence

Heroin’s Resurgence
Tiffany Lewis, M.D., FACP
A Nationwide Epidemic
Objectives
What is heroin?
Who uses heroin?
Why has it resurged?
Where can it be found?
What do we do about it?
What is it?
Processed from morphine: naturally occurring from the
seedpod of poppy plants
Can be snorted, inhaled as smoke “chasing the dragon”,
or injected “mainlining”
In brain converted back to morphine and binds opiate
receptors responsible for perception of pain and reward
(brain stem)
“needle in the arm” phenomenon
Street names: smack, brown sugar, skag, China White
Who uses it?
Historically opium and morphine peaked in the 1890’swhite women with “chronic pain”
Now typical users 20’s, 30’s, 40’s
Over last 3 years- average OD death age 36- 88% white
Biggest problem is in the Great Lakes (Ohio), New
England, mid-Atlantic states, NY, NJ
One apartment in the Bronx, police recently seized 33
pounds of heroin worth $8 million
Who uses it?
Late 1960’s: ghetto heroin, burnt out musicians, and in the
70’s those returning from Vietnam
Today, from AL.COM, it is “middle age suburban moms
who have some sort of injury and get an OxyContin
prescription, and by the time the prescription runs out,
they’re addicted. At some point they can no longer get the
pills legally and they start buying illegally. Then at some
point, heroin becomes amore affordable, palatable
alternative.” U.S. Attorney Joyce White Vance top ranking
federal law official in the Northern District of Alabama.
Who uses it?
Alabamians: again from AL.com:
Heroin deaths in Jefferson county increased 140% in
2014 (123 confirmed, 18 more suspected)
2013: 58 deaths
2012: 57 deaths
2011: 30 deaths
2010: 12 deaths
Vance again “When Birmingham police go out into
areas where there is a high rate of violent crime,
they’re falling all over heroin.”
Why is this happening?
Doctors without moral borders?
Overprescribing equals increased opioid addiction equals
increased deaths and increased heroin use
From 1999-2011 consumption of hydrocodone doubled and
oxycodone increased by 500% and OPR OD death
quadrupled
1997-2011 there was a 900% increase in people seeking
treatment for opiate addiction
4/5 heroin users began with Rx drugs
Why is this happening?
A little more history:
OxyContin was introduced in 1995 and advocated for
“treating non-cancer pain”
Doctors were told it was not addictive
1995 President of the American Pain Society advocated,
“Pain is the Fifth Vital Sign”
And the Joint Commission accepted it
What do we do about it?
First, the acute OD:
Respiratory depression
Miosis
Stupor
Hepatic injury from concurrent acetaminophen
Myoglobinuric renal failure
Hypoactive bowel sounds
Compartment syndrome
Hypothermia
Look for fentanyl patches!
What do we do about it?
Acute OD:
Administer naltraxone (Narcan) initial dose is 0.5 mg
and check for response in 2-3 min (while supporting
with bag ventilation). May escalate dose every few
minutes to a maximum of 15 mg
Watch for immediate withdrawal symptoms
Naloxone
Since 1996, some communities have dispersed naloxone for
bystander administration with education for its use to heroin
addicts
OEND programs: “Overdose education and naloxone
distribution”
Can be given IN, IV, IM, or SQ
As of 2013, 24 states plus D.C. passed laws promoting access to
naloxone and 21 states allow Rx to a third party
21 states have “Good Samaritan” provisions to protect those
who call 911
Naloxone
Some studies have shown decreased mortality with
OEND programs (Massachusetts study showed 46%
decrease in mortality in one community)
Study showed some participants decreased injection
frequency after the educational portion and entered
drug treatment
Evzio- auto-injector device fast tracked for FDA
approval because of opioid OD epidemic
What can we do about
it?
Prevention:
Primary: no literature studies show that using opioids
long term for non-cancer pain is beneficial (Alabama is
#1 opiate Rx per capita in the country)
Secondary: identify abusers early and refer for
treatment; use our state PDMP; try to prevent
transition from oral abuse to intravenous abuse
Tertiary: rehab facilities (some with 6 month wait);
methadone clinics and Suboxone (buprenorphine and
naltrexone)
What can we do about
it?
Heroin in Alabama at WorkPlay March 24, 2015
Narcotics detective from Birmingham PD: “not a blip
on the radar from the early 90’s to 2008”. West
precinct was focused on crack epidemic
Early 90’s heroin was $300/ gram. Now $75 and strong
enough to be snorted
Cost decreased due to switch in supply countries “now
Mexico, Central and South America”
Local HS kids surveyed by police “know where to find
heroin even if they don’t use”
What can we do about
it?
Narcotics detective:
They now find heroin bricks with cartel labels but strength
is inconsistent. One amount one time may give you a high,
another may be a fatal OD
“Just say no isn’t enough”. Kids value harm to family over
any negative consequences (jail, etc.)
At scene of overdose if police can confiscate cell phone and
directly connect dealer, it carries a minimum 20 year
sentence
Top 3 drugs in Jefferson County: Crystal Meth, Heroin (most
fatal OD’s), and cocaine. Heroin kills you quickly, not over
the course of months or years.
What can we do about
it
A few final statistics:
The number of heroin deaths in Jefferson County in
2014 exceeded the number of homicides, suicides,
and accidents
The CDC in 2014declared heroin “ the worst drug
overdose epidemic in U.S. history” and added it to
the top 5 Public Health Challenges
http://www.al.com/news/birmingham/index.ssf/2015/
01/post_197.html