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HEROIN AND RELATED OPIATES
DAVID J. NUTT
Psychopharmacology Unit, Bristol University
Heroin is a derivative of morphine and both belong to a large family of drugs
called the opiates, that were originally extracted from the resin of the opium poppy
and which have been used by humans for millennia. They have strong pain-relieving
actions and play a prominent role in the management of severe traumatic and post-
operative pain, as well as in terminal care. When used in other circumstances, their
profound ability to produce a state of inner tranquility and euphoria can lead to their
misuse. Addiction to opiates is due to the often overwhelming desire to re-experience
this mental state, and on repeated use many individuals become physically dependent
on these drugs. This dependence leads to an unpleasant and sometimes dangerous
withdrawal state when drug use is stopped, and the avoidance of this withdrawal helps
Opiate painkillers include drugs such as morphine and heroin, as well as the
much-used codeine and powerful synthetic analgesics such as fentanyl and
buprenorphine. In the brain there are a number of pathways in which endogenous
opioid peptides (the endorphins and enkephalins) act as transmitters. Opiate drugs act
on the same receptors as natural opioid peptides, but in some circumstances they can
produce excessive stimulation of these receptors, leading to great pleasure but also a
Many factors increase the risk of opiate addiction, but the most important
factor is the speed with which the opiate gets to the receptors in the brain. Over many
centuries of use there has been a series of developments to produce opiates that get
into the brain ever more rapidly. Heroin itself is a version of morphine designed to
enter the brain faster, but once there it is converted back to morphine. Other ways of
accelerating brain-entry involve bypassing the gastrointestinal tract. Taking opiates
by smoking or by the intravenous route gets the drug into the blood and brain very
quickly, producing much higher levels of stimulation for a shorter period. This
pattern of extreme peaks and troughs of opiate action in the brain underpins many
aspects of addiction, including the intense degree of craving and drug-seeking
behaviour. Intravenous use is also a major cause of secondary illness, especially
Understanding of the pharmacology of opiates has helped design and optimize
interventions for the treatment of addicts. Some, such as methadone, replace the
chaotic use of heroin with the controlled and regulated use of a similar drug, with a
longer brain action and a better use profile. Other drugs, such as naltrexone, act to
block the effects of heroin in the brain, so making its use pointless. However, the low
acceptance of this approach by street addicts means that it is rarely used except in
special patient groups such as doctors and pharmacists. Buprenorphine is a new drug
that acts partially like an opiate to encourage compliance with treatment and partly
like an antagonist to block the effects of heroin should it be taken on top. It has
become the main treatment of heroin addiction in France, and is now being used in the
• Heroin is easily classified as a hard drug because repeated use often leads to
physical dependence and there is a dangerous withdrawal syndrome. Also,
• The degree of addictiveness is determined by the speed at which the opiate gets
to the receptors in the brain. Therefore, smoking or intravenous use of heroin
often leads to addiction, while oral use of opium derivatives poses less of a
• A pattern of peaks and troughs of opiate action in the brain contributes to the
craving and drug-seeking behaviour that characterise addiction.
• There are considerable risks related to the route of drug administration.
Intravenous use can result in overdose and lead to infections such as hepatitis
and HIV. There is virtually no risk of overdose with smoking, but there are risks
• There is a potentially lethal dose threshold with full agonists like morphine and
heroin. Partial agonists like buprenorphine blunt the activity of the full agonist,
making it impossible to exceed this threshold.
• Methadone is used as a heroin substitute rather than a treatment.
• Antagonists like naltrexone stop the agonists working completely, but they are
not popular with addicts because they have not even partial heroin-like effects,
• A growing understanding of opiate action is leading to the development of better
treatments. Currently several different combinations of agonists and antagonists
are being developed, in an effort simultaneously to improve compliance and
QUESTIONS AND ANSWERS
What are agonists and antagonists?
Agonists are chemical substances which act to mimic and enhance the action of
naturally occurring chemicals in the brain. Antagonists act to block the action of such
How are antagonists used to block the effects of heroin?
Naltrexone is generally taken orally on a daily basis, but it can be implanted under the
skin. It blocks the effects of heroin completely. However, individuals experiencing
trauma can still be treated for pain whilst taking naltrexone, as some painkillers and
anesthetics are still effective. Naltrexone does not block the effects of cocaine.
What are the ethical challenges associated with making conformance to
treatment with an antagonist a bail condition?
There are other examples of similar bail conditions that are considered ethical. For
example, drink-drivers are offered incentives (shorter ban/smaller fine) if they agree
to attend alcohol-dependency programmes and educational courses. The drawback is
that most medications only work well with compliance, and those addicts who are
willing to comply are likely to be those that least need to take medication to come off
There are severe ups and downs associated with the use of heroin. Do those who
take heroin and manage to live productive lives still have these same usage
All heroin users will experience the highs and lows of addiction over a similar time
course, but controllability is a major factor. Some users can maintain a productive life
with less marked downs, due to maintenance of supply. The fear of withdrawal
increases the motivation for the drug, so the user will seek it more desperately.
Maintenance of supply lessens the compulsive behaviours associated with satisfying
the habit, thereby cutting crime and unproductive preoccupations.
Is it a good idea to prescribe heroin to addicts?
The Dutch and Swiss experiments suggest that there are benefits to the individual, but
with costs to society because of the expense of “shooting galleries.” The question is
not whether shooting-up is bad, because it obviously is, but whether it is more cost-
effective than other methods of treatment. Preventing people fighting and stealing to
feed their habits is bound to be beneficial to society but there are other factors, such as
cost, involved in its potential as a treatment. To make it less expensive a ‘take-home‘
arrangement is needed, so that addicts come in only once a day for the dosage and
then do the rest at home. However, this option has generally been considered
politically unfeasible. Some have recommended that for certain individuals the use of
prescribed heroin can be the best treatment.
Is the vaporisation of diamorphine a potential treatment for heroin addiction?
It is virtually impossible to overdose by smoking, but there is likely to be some lung
damage. If the heroin is pure, smoking is the preferred means of administration by
users. However, due to the impurity of illegal drugs, many addicts prefer to inject as
smoking the impure substance is ineffective. It is very difficult to get addicts who are
used to injecting to switch to smoking. Once the IV route has been experienced,
secondary reinforcers become so powerful that it is difficult for addicts to go back to
What is the role of opioid receptors in addiction?
Studies have shown a relationship between the degree of cocaine-craving and opioid
receptor activity. Endogenous opioids may well be important mediators of the
addictive potential of other drugs, including cannabis.
Heroin and other Opiates
• Used for several mil ennia to reduce pain and alter
• Mimic natural brain chemicals – the endorphins –
• Act at mu opioid receptors in the brain
Speeding up brain entry
Faster brain entry more “rush” and more addiction
Heroin - dosing principle
– short half life means brain levels
fall fast so user loses effects and gets
• slower to peak
• slower offset
M ethadone blocks “on top” heroin
•w hen in brain blocks actions of heroin
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GASTROSCOPY WHAT IS A GASTROSCOPY? This procedure involves an endoscope – a long, thin flexible tube with a ‘video camera’ at the tip measuring approximately 9mm across – being passed through the mouth into the oesophagus, stomach and first part of the smal bowel (duodenum). Gastroscopy is usually performed to evaluate symptoms of indigestion, upper abdominal pain, nausea, vomiting