Opiates

This section on opiates covers issues relating to abuse. Opioids, which are manufactured, uses for analgesia is covered in another section. Opiates are present in the seed pod of the poppy Papaver somniferum.

The opiate family includes heroin (aka smack, shit, junk), codeine (often in Vicodin, Tylenol #3), etc.

One of the most popular forms currently is Black Tar , especially from mexico. It is black and gummy, as shown in the picture. Be sure to ask how the person is doing the drug (e.g., orally, IV, rectal, etc) because this can suggest other risks. Black tar is typically smoked, but can be inserted into almost any orifice (one only needs mucosa). It ranges from 40 to 90% pure the remainder being mostly plant impurities.

There are occasional epidemics of Parkinsonian symptoms in young adults. This is often due to contamination of synthetic heroin, commonly 'designer meperidine'. The contaminant in question, MPTP (1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine), is formed during sloppy synthesis. It affects the dopaminergic neurons of the substantia nigra and thus can give rise to Parkinsonian symptoms. Some people have posted instructions for "cleaning" heroin. Sometimes people recover from MPTP poisoning, but more often it is permanent and irreversible.

Opiates have enjoyed their popularity since the 1800's. They were put in just about everything at the time. Morphine was derived in 1806 and, with the advent of the hypodermic syringe in 1848, morphine could be directly injected. Heroin was created in the late 1800's in an effort to find a less addictive form of morphine. This didn't happen: heroin crosses the blood brain barrier more rapidly than morphine and thus gives a quicker rush. Non-medical opiates were declared illegal in the early 1900's.

Heroin, which is actually diacetyl morphine, is derived from the opium poppy, typically in southeast Asia. Heroin is frequently injected, but canbe smoked.

Sometimes people need to be converted to an opioid for detox or maintenance. There is a ★handy conversion table for opiates as well as their half-lives, etc.

Opiate Intoxication

The main features of opiate intoxication are:

• apathy
• dysphoria or euphoria
• psychomotor retardation
• drowsiness
• dysarthria
• pinpoint pupils

Note that although pinpoint pupils are characteristic, respiratory depression or meperidine can cause pupillary dilation.

Opiate Withdrawal

When a patient initially presents, one must be alert for seizures or respiratory depression (if this occurs, naloxone 0.4 mg can be given repeatedly as needed every few minutes) as it is impossible to know the quantity of opiates consume.

★In general, opiate withdrawal is rather safe and people do not die. The most common treatment of opiate withdrawal is symptomatic: ibuprofen, prochlorperazine, and perhaps acetaminophen. Some facilities use buprenorphine for a rather rapid detox. Many institutions also use clonidine 0.1-0.2 mg for hypertension, although an EKG is required beforehand at UCLA.

For withdrawal regimens from prescription opioids, see here.

Pregnancy

A woman who is pregnant and on methadone needs to be monitored carefully as dosage requirements may be necessary during the pregnancy. Methadone withdrawal symptoms are common during the third trimester and may require intramuscular may be necessary if there is severe vomiting. If a pregnant woman is not abstinent and continues to use opiates, then child protective services will need to be involved.