Drugs, Society, & Human Behavior – Opioids

This will be the first part in a series of posts on material from the text, Drugs, Society, & Human Behavior, 13th Edition, by Hart, Ksir, and Ray. While my research focus is on drug use and dependence, there has been little in the epidemiology curriculum that teaches specifically about drugs. This text is a good introduction to that topic, and to that end, my goal is to summarize the information. I will not follow the book sequentially by chapter, but rather jump around to that which interests me.

For the first post, I will write a little about opioids (Ch. 13). To keep it short, I’ll just highlight important points in bullet form, taking a lead from the chapter objectives at the beginning of each chapter.

  • Opium comes from the plant Papaver somniferum
  • It likely originated thousands of years ago in the Middle East.
  • Opium can only be harvested in a few days of the plant’s life, by making shallow cuts into the unripe seedpods, allowing the opium resin to ooze out.
  • Its use has been known throughout antiquity, including references in Homer’s Odyssey, Greek physician Galen, and Arabic physicians such as Biruni and Avicenna, the latter of which probably first described opium dependence.
  • Laudanum was a popular opium formulation popularized by such medical luminaries as Paracelsus and Dr. Thomas Syndenham

  • Thomas De Quincey wrote an influential article about opium called “The Confessions of an English Opium-Eater”
  • The Opium Wars (1839) was between the British who wanted to continue to import opium into China, and the Chinese government who wanted to ban it because of its evils.
  • Oddly, it was the earlier banning to tobacco in China that led to the rise in popularity of smoking opium
  • In 1806, a German scientist, Frederich Serturner, first isolated the primary psychoactive ingredient of opium and called it morphium (morphine), after Morpheus, the god of dreams.
  • Later, another important opioid alkaloid, codeine, was isolated.
  • With the development of the hypodermic syringe for injecting morphine, it became a popular medicine during the wars of the latter 19th century.
  • In 1874, it was discovered that adding two acetyl groups to morphine, creating diacetylmorphine (heroin), increased morphine’s potency.
  • Opium was likely introduced in the United States by Chinese immigrants in the 1850s.
  • It was a popular ingredient in patent medicines at the time (potions, elixirs, soft drinks)
  • As opium became illegal, heroin rose to be the popular choice due to its potency.
  • Black tar is a form of Mexican heroin, called such because of the brown or black color.
  • The majority of the world’s heroin comes from Afghanistan, though Colombia and Mexico supplies most of the US.
  • Opioid pain relievers are another important source of opioid dependence, with such medications as Vicodin, Lortab, and Oxycontin.
  • Raw opium is about 10% morphine and a smaller fraction codeine.
  • Heroin is more potent because the two additional acetyl groups make morphine more lipophilic and so can more readily cross the blood-brain barrier.
  • Heroin is two to three times more potent than morphine.
  • Medical chemists have created opioids even more potent than heroin, such as fentanyl, which is about 100 times more potent than morphine.
  • There are also opioid antagonists, such as naloxone and naltrexone.
  • Starting in the 1970s, scientists discovered endogenous morphine-like substances that activate opioid receptors: enkephalins and endorphins.
  • These substances appear to have roles in pain perceptions in the brain and spinal cord.
  • Medical uses for opioids include pain relief and gastrointestinal uses, such as diarrheal dysentery.
  • Repeated use of opioids can result in tolerance, physical dependence, and psychological dependence.
  • Withdrawal symptoms are flu-like, such as nausea, vomiting, diarrhea, aches, pains, and general malaise.
  • Methadone is a synthetic opioid agonist that produces less severe withdrawal symptoms and is used as a treatment for heroin dependence.
  • Clonidine can also reduce withdrawal symptom severity and does not have a narcotic effect.
  • Acute toxicity is marked by depressed respiration.
  • Opioid overdose: opioid triad – coma, depressed respiration, pinpoint pupils.
  • Sharing needles among heroin users is accompanied by a high risk of hepatitis and HIV
  • Heroin users can start to feel withdrawal after as little as four hours after their last use.
  • It is often sold in ‘dime’ bags of $10, but the quality of heroin may vary greatly. It is a habit that may run between $30 to $100 per day.
  • Heroin is typically dissolved in water and heated to speed the process, then injected intravenously (also called ‘banging’)
  • There are several misconceptions about heroin and users. First, not everyone experiences intense euphoria the first time, but may feel nausea and discomfort at first. Second, withdrawal may not be as excruciating as portrayed. Though very subjective, it is often similar to persistent flu. Third, it is untrue that you are ‘hooked’ after the first time.
  • Occasional heroin users are sometimes called chippers.
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