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«Initiative promoted by Dane County  District Attorney Ismael Ozanne. Hired Opiate Substance Abuse Counselor  to focus solely on Opiate-related ...»

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OPIATES AND OPIOIDS

NATURAL, SYNTHETIC, AND SEMI-SYNTHETIC

Opiate Initiative

Initiative promoted by Dane County

District Attorney Ismael Ozanne.

Hired Opiate Substance Abuse Counselor

to focus solely on Opiate-related offenses.

Dane County District Attorney’s Office /

Deferred Prosecution Unit.

Deferred Prosecution Unit

Participants can divert out of formal criminal court  process.

Complete intake and sign contract whereby  agreeing to several tasks to be completed by contract end or sooner.

Goal is to not repeat criminal behavior, make  positive changes, and in turn, the DA’s Office agrees not to proceed with prosecution.

Most participants are able to have charges  dismissed.

Opiate Participants My position from DOJ Grant.

 Contracts and expectations different than most  other DPU Clients.

Weekly face to face meetings, UA’s, treatment  goals proximal; minimum 8 written assignments.

Combined counselor, case manager, monitor,  referral agent, and support.

A diversion program, third tier of Drug Court.

 Opiates Opiates are limited to the natural alkaloids found  in the resin of the opium poppy. This includes morphine, codeine, thebaine, and of course, opium. In some definitions, the semi-synthetic substances that are directly from the opium poppy are also considered opiates, like heroin.

The term, Opiates, therefore, is commonly used  to refer to all opiate/opioid drugs.

Opioids A drug which produces morphine-like activity,  has the functional properties of an opiate.

Semi-synthetics and synthetics.

 This includes a wide variety of “painkillers”,  usually referred to today as Opioid Analgesics, replacing term narcotics and narcotic analgesic.

Fully synthetic opioids created separate from  natural opiates include methadone, meripidine, fentanyl, pethidine, tramadol.

Opioids Semi-synthetic opioids created from natural  opiates include hydrocodone, hydromorphone, oxycodone, oxymorphone, and buprenorphine, to name a few.

Heroin is a semi-synthetic.

 Opioids Endogenous opioids are those that are produced  naturally and stimulate our opioid receptors.

Endorphin: a specific endogenous opioid.

 Endorphins and other endogenous opioids are  proteins that act upon an opioid receptor.

Our bodies produce its own opioids in times of  stress/pain; enkephalins, dynorphins, endorphins.

These are all natural and short acting.

 Abbreviated History Opiates USA An entire semester class could easily be  devoted to the many facets of USA opium/opiate history; including international relationships; US policies, laws, & ramifications; production of drugs;

distribution of drugs; changing sentiments of addictions and its impact; physician roles; and the impact upon addicts.

Prescription Opioids/Analgesics Some painkillers stronger than others.

 The weaker end of the scale are drugs such as  codeine and propoxyphene (Darvon)/end 11/10.

For the higher end: Methadone, morphine,  hydromorphone, fentanyl, oxymorphone, and Buprenorphine.

Some opioids also have good cough-reflex  agents like codeine and hydrocodone.

Prescription Analgesics Some of these drugs retain a substantial degree  of their efficacy when administered orally.

Meperidine (Demerol), methadone, and oxycodone are prime examples.

Yet other drugs, like morphine or  hydromorphone, are greatly administered intravenously.

Many time a prescriber will recommend two  opioids: one for ongoing, chronic pain, and one for break-through pain.

What about Oxycodone OC/OP?

OxyContin (OC), ER Oxycodone, is a very  powerful opioid analgesic. It came without acetaminophen, making the dose pure opioid;

pills crushed to snort or shoot.

It was changed to Oxycodone OP (Opana, 2010)  Pill could not be crushed and abused in the same way as OC. A coating of polyethylene oxide polymer, rendering pill to not crush easily, and when mixed with liquid, it turns to a gel.

Abusers have solvents to extract the oxy, or, a  razor has been used to scrape off coating.

Prescription Opioids According to the CDC, amount of prescription  opioids sold to pharmacies, doctors and hospitals quadrupled from 1999 to 2010.

According to American Society of Interventional  Pain Physicians (ASIPP), US has 4.6% of the world population and consumes 80% of the world’s oxycodone supply and 99% of Hydrocodone, as well as two-thirds of the world’s illegal drugs.

14,800 fatal overdoses involving painkillers in US  in 2008.

Prescription Opioids According to the CDC, 46 people die every day  as result of overdose of an opioid analgesic.

Health care professionals wrote 259 million  scripts for opioid analgesics in 2012.

Some states have more analgesic scripts per  person than others; WI falls into the lowaverage range with 76 analgesic scripts per 100 people. Highest was AL & TN with 143 per 100 people. (2012) Some states have reduced due to PDM’s.

 ER/LA Opioid Analgesics REMS Extended-Release & Long-Acting Opioid  Analgesics Risk Evaluation & Mitigation Strategy.





FDA-Required REMS Program for serious drug  risks.

FDA wants to ensure the benefits of such drugs  outweigh the risk of adverse consequences, therefore, REMS is strategy to better manage this potential.

REMS: prescriber training on all ER/LA’s; The  Patient Counseling Document; Medication Guide Abuse Deterrent Technology FDA working on abuse deterrent formulations  (ADF). Hosted public meeting 10/30/14for development & regulations of abuse-deterrent opioid medications.

Reformulated OxyContin CR, 2010; Nucynta ER  (Tapentadol), 2011, and Opana ER, 2012.

INTAC: Grunenthal’s tamper-resistant  formulation. Uses polyethylenoxide (PEO) in a Hot-melt extrusion process; no aversive add-ins.

Other Deterrents Oxecta: an oxycodone product that is also hard  to crush, same unmanagable gel when wet, and an added substance of sodium laurel sulfate, which irritates nasal passages.

Adding naloxone to opiates, similar to Suboxone.

 Buprenorphine in transdermal patch so that it  could not be extracted.

Punch hole Buprenorphine, which signals  counselor or case manager when a tablet taken.

Forms of Ingestion Opioid pills can be taken orally, crushed and  snorted, crushed and injected.

Fentanyl Patches: cut open and eaten, sucked  on, a cut section placed sublingually, or smoked.

Poppy Seed Tea: brewed with “poppy straw”  (seedpod and/or stem), usually ground; poppy seeds and grapefruit juice shaken together, reducing the pH level, optimal for morphine extraction.

Long-Term Effects… Using opioids frequently and over a long time  period can increase tolerance to the drug, meaning that higher doses, and/or more frequent doses of the medication must be taken to achieve the same effect. It is easy to develop physical dependence, causing a person to experience withdrawal symptoms when the drug is not present.

Severe and chronic constipation.

 Opiate Withdrawal GI Upset: stomach cramping, nausea, vomiting,  diarrhea.

Tremor: slight observable to gross movements  and muscle twitching.

Sweating: chills or flushing, often notice facial  moisture or sweat beads.

Restlessness: difficulty sitting still, shifting  movements of legs or arms.

Anxiety: increased irritability, distraction of  attention.

Opiate Withdrawal Body Aches: self-reported aching of bones,  joints, muscles; rubbing of joints or muscles.

Yawning: pronounced or repeated yawning.

 Gooseflesh: mild to prominent piloerrection of  skin, or hairs standing up.

Pupils: pupils moderately to prominently dilated.

 Pulse: pulse rate 90-120.

 COWS: Clinical Opiate Withdrawal Scale  Medications to Assist Clonidine: ( HPB medicine) 0.1 mg, I tab every 6 hours: helps with cravings with  opiates Ondansetron: (Zofran) 4 mgs., 2 tabs every 6 hours: helps prevent nausea  Promethazine: (Phenergan) 25 mgs., every 4-6 hours: helps prevent nausea  Loperamide: (Imodium AD) 2 mgs., as needed to treat diarrhea; helps rejuvenate  bowels Dicyclomine: (Bentyl) 20 mgs., 1 tab TID: helps with Irritable Bowel  Tizanidine: (Zanaflex) 2 mgs., 1 tab TID: muscle relaxant  Ibuprofen: (Motrin) 200 mgs., 2 tabs every 6 hours, for soreness and pain  Cetirizine: (Zyrtec) 5 & 10 mgs., liquid, chewables, for sleep.

 Diphenhydramine: (Benadryl) 25 mgs., as needed, assist with sleep  Diphenhydramine (25 mgs.) & Acetaminophen (500 mgs.): Tylenol PM, assist with  sleep Withdrawal Aid: Dietary Supplement; 27 herbs, a tapering pill schedule.

 Elimidrol: Dietary Suppliment; ???

 Aloe Vera: can be used to treat hot flashes  Heroin In 2011, 4.2 million Americans 12 and older  used heroin at least once in their lives. It is estimated that approximately 23% of those who use heroin become addicted.

Substance Abuse and Mental Health  Administration (SAMHSA) est. 669,000 heroin addicts in US in 2012, up from 373,000 in 2007.

Both young men and women, ages 18-26.

 Heroin Known by Smack, Mud, Dope, Horse, Junk, China White,  Dragon, Diesel, and many others.

A major CNS Depressant, a Schedule I Controlled  Substance.

The most fast-acting of the opiates: especially when  injected, effects wear off 3-5 hours, or sooner.

Cut with cocoa powder, brown sugar, face make-up,  powder milk, and many other drugs.

Snort, inject, skin-pop, chase the dragon.

 Heroin Is more lipid soluble than morphine, therefore  penetrates the blood brain barrier faster.

Thus, greater euphoria and more intense, due to  a higher concentration.

This includes its major metabolite: 6-MAM,  (monoacetylmorphine) Perceived as a better opiate because of higher  concentrations in less time.

Heroin Overdoses US Attorney General, Eric Holder, released  statistic of a 45% increase in heroin deaths from 2006-2010.

Some states have astronomical increases:

 Maryland at 88% from 2011-2013.

WI heroin related deaths in 2012 was 206;

 increased to 227 in 2013.

2011: Wisconsin state crime labs processed 579  cases in 37 counties; 2012: 648 cases in 56 counties 2013: 1,056 cases from 57 counties.

 Heroin Overdoses Increase in dose or purity.

 Diminished tolerance due to changes in use  patterns, periods of abstinence, jail.

Aspiration of vomit while unconscious.

 Allergic reaction to Quinine, too much Quinine.

Place conditioning or environmental tolerance:

 use in same digs can display increased tolerance where repeated usages occur. Changing rituals/effects.

Psychological states of mind can alter effects.

 Heroin Heroin and Opiate Overdoses Combined Drug Interactions (CDI)  Sedatives/Depressants are deadly: Alcohol,  Barbiturates and Benzodiazepines.

Synergistic effects of these with opiates is  profound.

Long-term, and sometimes short-term, use  affects cognition, interferes with memory, causing potential amnesia.

Cocaine and Downers…speedballing.

 Opioid Intoxication Appearance is that the person is just sleeping.

 Number of breaths decrease and snoring may  be louder, i.e., opioid overdose breathing!

Opioids are potentially coma-producing.

 Death from opioid overdose the result of  respiratory arrest, heart still beats, color blue!

Tendency, as with alcohol, is to think they will  “sleep it off”.

Dane County, WI 2009: 15 Opiate related deaths, mostly heroin;

 81 overdoses.

2010: 23 Opiate related deaths; 97 overdoses.

 2013: 32 heroin related deaths in first 10  months 2013, 30% increase from 2012.

Several heroin addicts have overdosed multiple  times, all the while knowing the risks of death.

Dane Cty hospital visits for non-fatal overdoses  increased from 114/2006; 271/2011; 292/2012.

Heroin Heroin Production Biggest producer is Afghanistan.

 2004: 87% of world’s heroin.

 Cultivation of opium in Afghanistan remains  huge business.

Golden Triangle: Myanmar, Thailand, Vietnam,  Laos, and Yunnan Province of China.

Black Tar Heroin Mostly produced in Latin America and Mexico.

 Has varying degrees of purity due to a very crude  refinement process (Wright-Beckett) Can be very sticky and gummy, or hard like coal.

 Injection more risky over time due to clogged needles  and more rapid hardening of veins.

Mexican Heroin Production For many decades, the crude and less-refined Mexican  heroin was only a “poor man’s” substitute to Asian White, and later to Columbian heroin.

During 1990’s, Mexico capitalized on opportunities,  brought experts, chemists, and “consultants” from Asia to teach them the finer methods of growth and production.

Heroin purity up  Ritual of Heroin Ritual of Heroin Heroin brings up the sun, heroin brings in the  dark.

Heroin is not it; she is/he is.

 You make sure she/he is with you as you leave  town, and your first thought in coming back.

You are wrapped up with her/him in a warm  blanket.

A gentle and constant orgasm.

 Ritual of Heroin A false sense of security and protection, pain  and fear dissipate.

The very fast rush followed by tranquility, “on  the nod”. Time slows, emotion goes.

Cocooned and emotionally safe.

 Even months/years into recovery, in times of  anxiety, stress, pressure, that cocoon appeals.

Heroin is King/Queen: Inner circle connected by  money, incongruence of caring/protection.

The Face of Addiction The faces of addiction are the faces from  addiction.

They are filled with despair.

 Despair: from the Latin root, sperare, or hope.

 De-sperare is to lose all hope.

It presents as a profound dispiritness.

 The faces show the hearts filled with perceived  failure of character in a fertile darkness turned into despair.



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