«Initiative promoted by Dane County District Attorney Ismael Ozanne. Hired Opiate Substance Abuse Counselor to focus solely on Opiate-related ...»
OPIATES AND OPIOIDS
NATURAL, SYNTHETIC, AND SEMI-SYNTHETIC
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;
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.