Heroin and Methadone

It is estimated that there are 980,000 long-term users of heroin in the United States, and in 1996 the cost of heroin addiction to society and the healthcare system was estimated at $5 billion and $22 billion, respectively (Mark et al. 2001). About 30% of adolescents who smoke heroin end up as heroin addicts; chance ofrelapse after discontinuation increases the younger and the greater number of years of addiction (Greydanus and Patel 2003).

Apparently, among opioid-dependent patients, only 12-15% are actively enrolled in methadone maintenance (Roundaville and Kosten 2000). This is unfortunate in the sense that methadone maintenance has been found to be effective in curtailing drug use, preventing overdose deaths, and the spread of infectious diseases, as well as reducing crime and enhancing social productivity (Strain et al. 1993).

Heroin was first synthesized in 1889 as a less addicting morphine substitute (Kain 2001). Also known as diacetylmorphine, it is constituted by a slight structural modification of morphine but is about three times as potent as morphine, penetrates the blood-brain barrier due to increased solubility, and produces an intense rush when smoked or injected (Porer 1999).

Opioid overdose is manifested by coma, circulatory collapse, pinpoint pupils, bradycardia, hypothermia, and severe respiratory depression. On the other hand, when symptoms of insomnia, dysphoria, restlessness, tachycardia, tachypnea, hypertension, and mydriasis occur, acute opioid withdrawal should be suspected and may initiate 4-6 h after the last opioid use and peaks about 48-72 h. Rhinorrhea, lacrimation, tremors, piloerection, and yawning are often signs of craving for the drug. Flu-like signs and symptoms such as anorexia, muscle aches, nausea, vomiting, hot and cold flashes, abdominal pain, and increased temperature are common. Heroin overdose can result to the development of pulmonary edema, myocardial involvement, or death.

Among pregnant women, heroin and methadone are the most commonly used opioids. Heroin use (smoked recreationally rather than injected, in formulations that are 1-98% pure) has increased in the past decade. Approximately 7000 opiate-exposed births occur annually (Luty et al. 2003), and there has been up to sixfold reported increase in obstetric complications associated with heroin use (Hulse et al. 1998). Opioid withdrawal syndrome can result in impaired fetal growth and neonatal abstinence syndrome characterized by tremulous-ness, irritability, wakefulness, temperature dysregulation, dysfunctional suck with subsequent failure to thrive, and seizures (Kusche 2007). It is a current standard of care to maintain opioid-dependent women on long-acting narcotics during pregnancy rather than having to resort to a withdrawal protocol in light of reported inferior fetal outcomes that were associated with withdrawal during pregnancy (Luty 2003).

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