What is Heroin Toxicity?
Heroin, alternatively known as diacetylmorphine, is a powerful drug that is stronger than morphine. Every year, numerous people die worldwide due to heroin overdoses. Heroin can be inhaled, smoked, or injected, and its use is growing. This surge can partly be attributed to initiatives aimed at reducing the misuse of prescription pain medications. Consequently, there has been an increase in deaths linked to heroin overdoses. Notably, 14 American states have reported substantial increases in heroin-related death rates, with the highest rates observed in Washington D.C., West Virginia, and Ohio.
Heroin is frequently used by those who inject drugs. Typically, chemicals extracted from the sap of the opium poppy (Papaver somniferum) are referred to as opiates. Similarly, man-made chemicals that function in the same way are known as opioids. The principal active component in opium poppy sap is morphine. The sap, which contains several opiates, is collected and then processed to extract heroin. Heroin is created from morphine using a chemical process. In the human body, heroin is converted into active opioid compounds, first becoming 6 mono acetyl morphine (6MAM), and then morphine. Heroin is less bulky per dose, which makes it the preferred option for drug traffickers.
What Causes Heroin Toxicity?
Heroin, largely known as an illegal drug, is occasionally prescribed by doctors for pain relief in some countries. It’s generally twice as potent when injected into the muscle. In the United States, it’s illegal for doctors to prescribe heroin. Nevertheless, in some rare cases outside of the USA, prescription heroin can be found.
Once administered into the bloodstream, the average lifespan of heroin is approximately three minutes. However, 6-acetyl morphine – a byproduct of heroin – lasts longer in the body, about 30 minutes. If heroin is consumed through the nose or injected, the highest blood concentration is reached after about 5 minutes. However, it’s important to note that snorted heroin is roughly half as strong as when it’s injected.
Risk Factors and Frequency for Heroin Toxicity
Heroin is one of the most frequently misused opioids globally, mainly due to various economic and social factors. In 2012, the recorded rate for heroin use without a needle was 0.3% for 8th graders and 0.4% for 10th and 12th graders. Across all school grades, the yearly rate for heroin use with a needle was 0.4%. The number of emergency department visits related to heroin has soared from 33,900 in 1990 to 213,118 in 2009. Similarly, deaths linked to heroin overdoses have risen from 2,300 in 1991 to 15,958 in 2017, marking a 7-fold increase in the total number of heroin overdose fatalities during this span.
- Heroin is one of the most commonly abused opioids today due to various economic and social reasons.
- The yearly rates of heroin use without a needle in 2012 were 0.3% for 8th graders and 0.4% for 10th and 12th graders.
- The annual rate of heroin use with a needle across all grades was 0.4%.
- Emergency department visits due to heroin jumped from 33,900 in 1990 to 213,118 in 2009.
- Deaths from heroin overdoses surged from 2,300 in 1991 to 15,958 in 2017.
- There was a staggering seven-fold increase in the total number of heroin overdose deaths over this period.
Signs and Symptoms of Heroin Toxicity
Heroin is a dangerous drug with severe side effects that vary depending on the user’s consumption pattern. Typically, people who use heroin are seen by medical professionals either because of an overdose or withdrawal symptoms.
An overdose from heroin usually causes slow or weak breathing and drowsiness, which can quickly evolve into a life-threatening situation. One may even fall into a coma and could die within minutes if there is no urgent rescue. Wellness may also be marred by contracted pupils.
On the other hand, withdrawal from heroin can cause a host of discomforting symptoms such as alertness, muscle and joint pain, dilated pupils, goosebumps, sweating, vomiting, diarrhea, and even lack of sleep or persistent yawning.
Withdrawal symptoms from heroin are not typically life-threatening, unlike withdrawal from alcohol or benzodiazepines. It’s important to note that the presence of all these symptoms isn’t necessary for a diagnosis of heroin withdrawal. There’re several medications to ease the symptoms such as methadone, buprenorphine, clonidine, and lofexidine.
- Alertness
- Muscle and joint pain
- Dilated pupils
- Goosebumps
- Sweating
- Vomiting and Diarrhea
- Insomnia
- Yawning
Chronic intravenous heroin use can create track marks, which look like fine abrasions on the skin, typically over the veins in the arms and legs. These marks can appear elsewhere too like the neck. Injecting drugs can cause other health issues such as skin infections, blood clot in a vein (thrombophlebitis), inflammation of the heart’s inner lining (endocarditis), septic emboli, and elevated pressure within a muscle compartment that can cause serious damage, a condition referred to as compartment syndrome.
Moreover, heroin is sometimes mixed with other harmful substances, which can create a wide array of confusing symptoms. Authorities can sometimes provide information on the specific mix of substances in the local heroin supply.
Testing for Heroin Toxicity
The first step in assessing a suspected overdose is to check the person’s airway and breathing. Urine drug screening, while not particularly useful in the immediate response, has its applications in situations such as job screening or drug rehabilitation programs. These screenings can detect various opioids such as heroin, morphine, codeine, hydromorphone, and hydrocodone in a person’s system. However, drugs like methadone, oxycodone, fentanyl, buprenorphine, and tramadol may not show up on the test and would need to be checked separately.
Be aware that at-home or office urine drug screening cups can sometimes mistakenly give a positive result (false positive) or fail to detect the drug (false negative). For this reason, the only sure way to confirm heroin use is through the detection of a specific substance called 6-MAM (6 mono acetylmorphine), which is produced when the body metabolizes heroin. This substance will only show up in the urine for up to 8 hours after heroin use.
If there’s any dispute about the urine test results between a patient and healthcare provider, a method called Gas Chromatography and Mass Spectroscopy (GCMS) can be employed to obtain a definitive result. In job-related drug testing in the United States, the information collected is managed by Medical Review Officers.
Treatment Options for Heroin Toxicity
In cases of heroin overdose, a person’s breathing can become dangerously slow or shallow, and may even stop altogether. The medication naloxone is often used to reverse the effects of a heroin overdose. However, it’s important to note that the first step in responding to an overdose should be to ensure the person can breathe adequately. This could involve using a bag valve mask or similar device to facilitate breathing and supply oxygen to essential organs.
Once one responder has focused on restoring the person’s oxygen supply, others can evaluate the best way to administer naloxone. If a person happens to be alone when dealing with an overdose victim, they should prioritize supplying oxygen until additional help is available. During overdose resuscitations, responders should follow advanced and basic life support protocols.
Hospital-grade intravenous access is also necessary to provide the fluids and medication needed for the patient. An initial intravenous dose of 0.4 to 0.8 mg of naloxone is usually enough to quickly reverse the effects of a heroin overdose, unless the heroin has been tainted with substances like carfentanyl.
Patient monitoring is vital to ensuring the heroin is completely cleared from their system. If a person who has overdosed is treated with naloxone, shows normal mental and physical function, and avoids further drug use and co-intoxication, they can be safely discharged without needing to be taken to a hospital. In this scenario, the risk of dying from a rebound of heroin toxicity is extremely low.
What else can Heroin Toxicity be?
If someone has a clear history of using or overdosing on heroin, it can be easier for doctors to start treatment. This usually involves making sure the patient can breathe and considering using drugs that can reverse the effects of the overdose. But if a patient is unresponsive and there’s no information about possible heroin use, deciding on the best treatment can be more difficult.
In the past, doctors would often use a mix of medications, sometimes called a “coma cocktail”. This would usually include thiamine, sugar solution (dextrose), and naloxone, all given through an IV. Naloxone may help wake up someone who’s overdosed on heroin.
But if the heroin has been mixed with a very strong type of drug, like fentanyl, the usual dose of naloxone might not be enough to reverse the effects of the overdose.
Some signs that an unresponsive patient has taken heroin include slow or stopped breathing and pupils that have become very small.
What to expect with Heroin Toxicity
Heroin addiction is a recurring disease that can often be fatal. The best way to manage this disease has been a topic of increasing discussion in the United States throughout the 2010s. The traditional approach emphasized helping the patient become drug-free through supportive communities, but this method often resulted in rapid relapse once the level of care was reduced, for example, after leaving an inpatient rehab facility.
Naltrexone has been a part of the treatment process with mixed results. It tends to be more successful when injected monthly (Vivitrol) as opposed to daily oral dosages.
On the other hand, there is growing evidence to support a harm reduction approach. This approach involves treating patients with other legal opioids like methadone or buprenorphine. The idea is to provide a slower acting and longer lasting alternative to the heroin which caused their addiction. In this model, recovery is defined as stopping illegal and disruptive behavior, without necessarily needing the patient to be completely opioid-free.
This topic remains a source of debate, but the success of the harm reduction model in preventing continued illegal drug use has led to it increasingly being seen as the better approach to managing heroin addiction.
Possible Complications When Diagnosed with Heroin Toxicity
Using drugs through injection can lead to a number of complications. These complications are mainly related to the injection site itself, infections in the blood vessels, and diseases transmitted through sharing needles or risky sexual behaviors.
- At the injection site, the needle can break off and get stuck in the skin or travel further in the vein. Skin infections such as cellulitis (skin inflammation) and abscess (pus-filled pockets) can also occur, which if severe, may lead to compartment syndrome – a painful and dangerous condition caused by pressure buildup.
- Infections can also occur inside blood vessels, particularly on heart valves, mainly the tricuspid valve (one of the four valves in the heart). This may require surgery to remove and replace the infected valve.
- If the infection progresses, bacteria from the infected heart valve can travel to other parts of the body. When the tricuspid valve is involved, these bacteria usually make their way to the lungs, potentially leading to empyema – a condition where pus accumulates in the pleural space in the chest. If the infection moves to the left side of the heart, the bacteria could reach any part of the body.
- Sharing needles is a significant risk factor for transmitting diseases, especially hepatitis B and C, as well as HIV. Intravenous (IV) drug use has also been associated with treponema infestations, a type of bacterial infection.
- Specifically, for heroin, other than the risks stated, most complications stem from damage to body organs due to lack of oxygen. This can happen due to slowed or shallow breathing during a heroin overdose.
Preventing Heroin Toxicity
Efforts are being made to not only enhance treatment for drug overdoses in hospitals and emergency departments, but also to educate the general public about recognizing and treating overdoses early. For example, there’s a push to make naloxone, a drug used to manage overdoses, more easily available to the public and encourage people to seek medical help sooner if they suspect an overdose. It’s also helpful when legal rules are put in place that let medical professionals give prescriptions for naloxone to patients who are using opioids, or to people who are in close contact with these patients. Moreover, legal protection should be given to anyone who uses naloxone to treat an overdose, so they won’t risk being charged with practicing medicine without a license.
