Relief, without Remedy: The Return of Heroin Terrence D. Walton, MSW, CSAC Director of Treatment Pretrial Services Agen

1. Relief, without Remedy: The Return of Heroin Terrence D. Walton, MSW, CSAC Director of Treatment Pretrial Services Agency for the District of Columbia

2. What is A drug?

3. Any substance that alters mood, level of perception, and/or brain functioning

4. Getting the Inteneded Effect • Bottle to Blood to Brain • Route of Administration: • Smoke • Sniff • Snort • Shoot • Swallow • The Blood Brain Barrier • Neuro-compatibility

5. The Great Debate:Who is the MAC Daddy? • Power (receptor affinity) • Popularity (acceptability) • Presence (accessibility) • Pay off (onset & intensity) • Persistence (length of high) • Patterns (of use) • Penalty (onset & intensity)

6. Mood Altering Chemicals • Legal & Illicit • Street Drugs and Prescribed Drugs • Hard Drugs & Soft Drugs • Very Addictive & Less-Addictive • Natural and Synthetic • Stimulants • Depressants • Opioids • Cannabinols • Hallucinogens/ Dissociatives • Inhalants/ Deliriants/Other

7. Prevalence • Number of those 12 and over using heroin rose from 373,000 in 2007 to 669,000 in 2012 • Number of those 15 to 24 dying of heroin overdose rose from 198 in 1999 to 510 in 2009. • Drug overdose was the leading cause of injury death in 2010. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes. • ER visits for opiate misuse doubled from 2004 to 2008 (CDCP 2010) • Prescription drugs (mostly opiates) are the 2nd most commonly abused drugs—behind only marijuana (ONDCP 2007)

8. Prevalence • Those under 18 are among the fastest growing group misusing • Opiates (Vicodin) number one abused prescription drug among adolescent 12th graders—9.7% • Prescription opiate abuse up 345% between 1998-2010

10. Heroin

11. Heroin: The Basics • Heroin is a narcotic that is highly addictive; It is processed from morphine, a naturally occurring substance extracted from the seedpod of the Asian poppy plant. • The most abused and most rapidly acting of the opiates. • Usually seen as a white or brown powder or as a black sticky substance. The differences in color are due to impurities left from the manufacturing process or the presence of additives. • Pure heroin, which is a white powder with a bitter taste, is rarely sold on the streets. • Sometimes cut with other substances such as sugar, powdered milk, cornstarch, or even poisons like strychnine.

12. Street Names • H • Smack • Junk • Horse • China white • Black tar • Brown • Skag

13. Routes of Administration • Injection, smoking, snorting • The user feels the effect of heroin within seconds of taking it. Heroin is converted into morphine when it enters the brain, which disrupts normal brain activity and creates intense feelings of pleasure.

14. Typical Acute Effects • Euphoria • Warm flushing of the skin • Dry mouth • Heavy extremities • Decreased mental ability • Insensitivity to pain • Vomiting • Lowered breathing • Lowered heart rate Death By Overdose

15. Potential Chronic Effects • Addiction • High degree of tolerance • Brain damage • Arthritis • Liver disease • Infection of the heart lining • HIV/AIDS or hepatitis • Abscesses of the skin (at injection sites) Death By Overdose, Disease, Suicide, Injury, Violence

16. Withdrawal • Heroin can cause severe physical and psychological symptoms 6 to 8 hours after the last dosage. Painful withdrawal gets worse as time passes. • Symptoms Include: • Runny nose muscle and bone pain • Emotional distress and restlessness • Diarrhea • Vomiting • Hot flashes and heavy sweating • Cold flashes with goose bumps • Insomnia • An overwhelming need for more heroin

17. Illicit Prescription Use

18. The Old Dealers

19. The New Dealers

22. Addiction is a Brain Disease Any use causes acute and temporary changes and prolong use changes the brain in fundamental, destructive and long lasting ways

23. What is Addiction A brain based disorder associated with impairment within the brain’s reward center that impacts brain executive functions and results in compulsive, repetitive, self-destructive behaviors

26. How Drugs Work • Interact with neurochemistry • Results: • Feel Good – euphoria/reward • Feel Better – reduce negative feelings/relief Opiates Provide Both Relief & Reward

27. Drug-Interacting Neurotransmitters • Dopamine – excitement & reward • Serotonin – feel – “normal” • GABA – lowers anxiety • Endorphin/Enkephalin – pain relief, reward, craving

28. Dishonorable Mentions • Desomorphine (Krokodil) • Zohydro (hydrocodone-based)

29. Treatment That Works

31. Effective Practices

32. Medication Assisted Treatment Goals • To provide relief from withdrawal symptoms • To reduce craving • To prevent drugs from working ~ occupies receptor (antagonist) • To provide replacement ~ activates receptor (agonist)

33. Pharmacological Interventions • Naltrexone – Interrupts actions of opiates (partially blogs alcohol); reduces cravings (antagonist) • Methadone – Opiate addiction – reduces craving, mediates withdrawal symptoms, helps restore normal functioning (agonist) • Buprenorphine(Subuxone) – similar to methadone, may be prescribed by an MD with special training (partial agonist)

34. Emergency Overdose Intervention Naloxone

35. A Big Resource National Registry of Evidenced-based Programs and Practices: www.nrepp.samhsa.gov

36. Relief, without Remedy: Prescription and Illicit Opiate Abuse Terrence D. Walton, MSW, CSAC Director of Treatment Pretrial Services Agency for the District of Columbia Terrencewalton@aol.com