Heroin Treatment: Medications
Heroin Treatment: Medications
The most common way to take heroin is through injection. The rapid absorption of injected heroin into the bloodstream causes a rush and an intense high. At first, heroin users experience few lingering effects after a dose. The drug effects wear off after about six hours. Over time, however, addicts develop a tolerance to the drug's effects and require larger and larger doses of heroin to achieve the same high or any high at all. They become physically dependent on the drug and experience withdrawal symptoms when they are not using the drug. After several weeks of use, an addict cannot use enough heroin to get a high but must continue to take it just to feel normal.
The first and most common step in treating heroin addiction is detoxification . In the detoxification process, medications are used to treat withdrawal symptoms. Heroin withdrawal symptoms, which are similar to the symptoms of a severe flu, are rarely medically dangerous for those in good health. However, they are extremely uncomfortable. In many addicts, these symptoms make continuing to abuse heroin seem more attractive than detoxification.
An alternative approach to detoxification is methadone maintenance. Methadone, like heroin, is an opioid . The goal of methadone treatment is not to stop the addict from using heroin, but instead to substitute methadone for heroin. Methadone is a clear liquid, usually dissolved in a flavored drink, that is given once a day according to a doctor's prescription. Methadone can ease addicts' withdrawal symptoms and drug craving . The prescription of methadone is closely controlled by state and federal regulations.
The simplest approach to detoxification is to substitute a prescribed opioid, such as methadone or naltrexone, for the heroin that the addict is dependent on. The dose of the opioid is then gradually reduced till the person is taking no drug at all. This method causes the withdrawal from heroin to be less severe, although the withdrawal symptoms may last longer. During detoxification, addicts are monitored to ensure that they are getting the right amount of medication. Too much may cause the person to be overly sedated; too little will not ease the withdrawal symptoms.
If the patient is a multiple-drug abuser, the detoxification process is more complex. If the patient has abused benzodiazepines or other depressants as well as opioids, the doctor usually treats the patient for withdrawal from these drugs first to prevent potentially fatal seizures. The medication phenobarbital is used to treat benzodiazepine withdrawal. The patient is then stabilized on methadone for the heroin addiction.
Clonidine. Prescribing an opioid to a drug addict can be a difficult and complex treatment. Another approach avoids these difficulties. This approach involves the drug clonidine (Catapres), which is prescribed to treat withdrawal symptoms. Clonidine is effective at easing many of the physical signs of heroin withdrawal, but it is less effective against other symptoms such as lethargy, restlessness, and dysphoria . Clonidine's unpleasant side effects, such as low blood pressure, sedation, and blurry vision, make it unpleasant to take and therefore unlikely to be abused by addicts. Although clonidine has not been approved by the Food and Drug Administration for heroin detoxification, it is widely used for this purpose.
Naltrexone. The drug naltrexone can help addicts detoxify quickly and help detoxified addicts stay off heroin. Naltrexone (Trexan) works by binding more strongly than heroin to the specific brain receptors to which heroin binds. If addicts who are dependent on heroin take a dose of naltrexone, the naltrexone will replace the heroin at the brain receptor. The addicts will feel as if all the heroin has been suddenly taken out of their body. This rapid reduction in heroin at the brain receptor causes withdrawal. Although this withdrawal is usually more severe than the withdrawal caused by simply stopping heroin use, it accomplishes detoxification more quickly. As a result, a combination treatment of clonidine to ease withdrawal symptoms and naltrexone to accelerate the pace of withdrawal has been used for rapid detoxification.
After detoxification, naltrexone can prevent addicts from returning to heroin use. Because naltrexone blocks heroin's effects, heroin addicts on naltrexone who use heroin will only be wasting their money. Naltrexone is prescribed as a pill that can be taken as infrequently as three times a week. It has few side effects. On the other hand, many addicts will not voluntarily take naltrexone because it does not satisfy cravings. In addition, naltrexone cannot be given to patients with hepatitis or liver failure.
Methadone is the most common medication used for the maintenance treatment of heroin addicts. Methadone satisfies the heroin user's craving for heroin. The more important effect of methadone, however, is tolerance to it. Addicts maintained on a stable dose of methadone do not get high from each dose because they are tolerant to it. (Methadone-maintained addicts can take methadone doses that would cause a first-time drug user to die of an overdose.) This tolerance extends to heroin, and methadone-maintained addicts who use heroin experience a lesser effect because of the tolerance. Generally, methadone-maintained addicts do not appear to be either intoxicated or in withdrawal. Methadone-maintained addicts may experience some of the side effects of opiates (such as constipation and excessive sweating) that they do not become tolerant to. However, methadone maintenance presents no known medical dangers.
Only licensed programs can dispense methadone, usually on a daily basis. Addicts generally have a positive attitude toward methadone maintenance. The risk of withdrawal symptoms if methadone treatment is interrupted provides a strong incentive for addicts to keep appointments at methadone clinics. The ritual of daily clinic attendance also helps to bring structure to the chaotic lives of most heroin addicts. Methadone treatment is often supplemented with medical, financial, and psychological support services to address the many needs of addicts.
Methadone-maintained addicts show decreases in heroin use, crimes committed, and psychological symptoms. The major drawbacks to methadone maintenance include the great difficulty of achieving detoxification from methadone, methadone side effects, and the possibility of increased use of other illegal drugs such as cocaine.
An opiate addict initially coming in for treatment will usually be put through detoxification and possibly put on naltrexone maintenance. Younger addicts and adolescents are urged to try non- methadone approaches, in order to avoid developing a methadone addiction. Methadone maintenance is usually reserved for patients who have failed at previous detoxifications. An exception is made for pregnant women. For pregnant addicts, methadone maintenance is the treatment of choice, with detoxification of the infant from methadone accomplished after birth. Heroin detoxification is risky in pregnant women because of the negative effects on fetal development in the first and second trimesters, and the risk of miscarriage.
Other Maintenance Medications
Medications other than methadone for maintenance treatment of heroin addiction are coming into wider use. The drug buprenorphine (Buprenex) is safe even at high doses, and causes less severe withdrawal symptoms than methadone after a person stops taking it. Buprenorphine blocks receptors in the brain, thus interfering with heroin's effects. One drawback of buprenorphine is that it causes drowsiness in a majority of patients.
Another medication recently approved for treating heroin dependence is LAAM (levomethadyl acetate). LAAM is similar to methadone but lasts longer, so it is less expensive to use and does not require daily visits to clinics.
Medications for Heroin or Methadone Overdose
Overdosing on heroin is most likely when the street drug is unusually strong or when the heroin has been mixed with a stronger opioid (such as fentanyl). The three major signs of an overdose are coma, pinpoint pupils, and depressed respiration (slowed breathing). If a large over- dose has been taken, the body temperature falls, and the patient's skin becomes cold and clammy. The muscles relax, the jaw loosens, and the tongue may fall back, blocking the patient's airway. Death may occur due to respiratory failure (the person stops breathing).
Naloxone (Narcan) is the treatment of choice for a heroin over- dose. In most cases, the naloxone is given slowly in order to reverse the respiratory depression without causing a withdrawal syndrome. The side effects of naloxone given too rapidly include nausea, vomiting, and sweating. Patients treated for a heroin overdose should be kept in the hospital and observed for at least twenty-four hours, because naloxone is a relatively short-acting drug and the patient's respiratory depression may recur within several hours.
No medication will prevent an addict who wants to use heroin from doing so. Heroin addiction is, in many ways, a physical problem as well as a psychological and behavioral problem. Heroin addicts spend most of their waking lives finding, using, and withdrawing from heroin. The medications used to treat heroin abuse are critically important to break the cycle of addiction. However, addicts whose lives are in chaos require not only medication but other treatments to help them lead normal lives. There is evidence that methadone treatment is more effective if an addict is also receiving rehabilitation and counseling.
see also Babies, Addicted and Drug-Exposed; Complications from Injecting Drugs; Heroin; Heroin Treatment: Behavioral Approaches; Methadone Maintenance Programs; Naltrexone; Opiate and Opioid Drug Abuse.
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