Route Of Heroin Administration Research Articles

Managing acute opioid withdrawal with tramadol during COVID-19 lockdown in a peri-urban setting.

BackgroundThe coronavirus disease 2019 (COVID-19) has highlighted the scope of heroin dependence and need for evidence-based treatment amongst marginalised people in South Africa. Acute opioid withdrawal management without maintenance therapy carries risks of increased morbidity and mortality. Due to the high costs of methadone, Tshwane’s Community Oriented Substance Use Programme (COSUP) used tramadol for opioid withdrawal management during the initial COVID-19 response.AimTo describe demographics, route of heroin administration and medication-related experiences amongst people accessing tramadol for treatment of opioid withdrawal.SettingThree community-based COSUP sites in Mamelodi (Tshwane, South Africa).MethodsA retrospective cross-sectional study was conducted. Data were collected using an interviewer-administered paper-based tool between April and August 2020. Descriptive statistics were used to analyse data.ResultsOf the 220 service users initiated onto tramadol, almost half (n = 104, 47%) were not contactable. Fifty-eight (26%) people participated, amongst whom most were male (n = 55, 95%). Participants’ median age was 32 years. Most participants injected heroin (n = 36, 62.1%). Most participants experienced at least one side effect (n = 47, 81%) with 37 (64%) experiencing two or more side effects from tramadol. Insomnia occurred most frequently (n = 26, 45%). One person without a history of seizures experienced a seizure. Opioid withdrawal symptoms were experienced by 54 participants (93%) whilst taking tramadol. Over half (n = 38, 66%) reported using less heroin whilst on tramadol.ConclusionTramadol reduced heroin use but was associated with withdrawal symptoms and unfavourable side effects. Findings point to the limitations of tramadol as opioid withdrawal management to retain people in care and the importance of access to first-line opioid agonists.ContributionThis research contributes to the limited data around short-acting tramadol for opioid withdrawal management in the African context, with specific focus on the need for increased access to opioid agonists for those who need them, in primary care settings.

Effectiveness and selectivity of a heroin conjugate vaccine to attenuate heroin, 6-acetylmorphine, and morphine antinociception in rats: Comparison with naltrexone

BackgroundOne emerging strategy to address the opioid crisis includes opioid-targeted immunopharmacotherapies. This study compared effectiveness of a heroin-tetanus toxoid (TT) conjugate vaccine to antagonize heroin, 6-acetylmorphine (6-AM), morphine, and fentanyl antinociception in rats. MethodsAdult male and female Sprague Dawley rats received three doses of active or control vaccine at weeks 0, 2, and 4. Vaccine pharmacological selectivity was assessed by comparing opioid dose-effect curves in 50 °C warm-water tail-withdrawal procedure before and after active or control heroin-TT vaccine. Route of heroin administration [subcutaneous (SC) vs. intravenous [IV)] was also examined as a determinant of vaccine effectiveness. Continuous naltrexone treatment (0.0032-0.032 mg/kg/h) effects on heroin, 6-AM, and morphine antinociceptive potency were also determined as a benchmark for minimal vaccine effectiveness. ResultsThe heroin-TT vaccine decreased potency of SC heroin (5-fold), IV heroin (3-fold), and IV 6-AM (3-fold) for several weeks without affecting IV morphine or SC and IV fentanyl potency. The control vaccine did not alter potency of any opioid. Naltrexone dose-dependently decreased antinociceptive potency of SC heroin, and treatment with 0.01 mg/kg/h naltrexone produced similar, approximate 8-fold decreases in potencies of SC and IV heroin, IV 6-AM, and IV morphine. The combination of naltrexone and active vaccine was more effective than naltrexone alone to antagonize SC heroin but not IV heroin. ConclusionsThe heroin-TT vaccine formulation examined is less effective, but more selective, than chronic naltrexone to attenuate heroin antinociception in rats. Furthermore, these results provide an empirical framework for future preclinical opioid vaccine research to benchmark effectiveness against naltrexone.

Evaluation of Immunomodulatory and Hematologic Cell Outcome in Heroin/Opioid Addicts.

The long-term use of opioids leads alternations in both innate-adaptive immune systems and other diagnostic hematologic cells. The purpose of this study is to evaluate the alterations of these parameters in patients with heroin/opioid addictions. Adults, meeting the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria of the American Psychiatric Association regarding opioid use disorder (Heroin Group or HG, n = 51) and healthy controls (Control Group or CG, n = 50), were included in the study. All hematological parameters, inflammation indexes (neutrophil-lymphocyte ratio and platelet-lymphocyte ratio), and iron panel were compared with the controls. Mean corpuscular volume, red blood cell distribution width, mean corpuscular hemoglobin content, unsaturated iron-binding capacity, and total iron-binding capacity were significantly higher in HG compared to CG, while red blood cell count, hemoglobin, hematocrit, and serum iron levels were significantly lower. Additionally, platelet and platelet distribution width were significantly high while mean platelet volume was low in HG. Regarding the parameters related to immunity, white blood cell, neutrophil count, and neutrophil percentage were significantly high while lymphocyte percentage and basophils count were significantly low. Besides, inflammatory indexes were significantly higher in HG compared to CG. Intravenous administration of heroin resulted in lower levels of hemoglobin, hematocrit, and mean corpuscular volume than inhalation and intranasal administration. Our data demonstrated that chronic use of opioids is related to all of the hematologic series. The chronic use of opioid alters the immunologic balance in favor of innate immunity cells and changes the hematometric/morphometric characteristics of erythrocytes. What is more, the route of heroin administration should be taken into consideration as well. This study may lead to a better understanding of the hematological effects of heroin/opioid use in patients with relevant addictions.

High prevalence but low awareness of hepatitis C virus infection among heroin users who received methadone maintenance therapy in Taiwan

BackgroundThis study investigates the prevalence and correlates of hepatitis C virus (HCV) infections among heroin dependent individuals who received methadone maintenance therapy in Taiwan. Also, we investigate users' awareness of HCV. MethodsParticipants were 773 heroin users entering the methadone maintenance treatment (MMT) program at Tsaotun Psychiatric Center in Taiwan. The presence of HCV antibodies was detected. Multivariate logistic regression was used to identify the relationship between HCV infection and correlates. ResultsThe prevalence of HCV infection was 90.8%. All participants who were HIV-positive were also infected with HCV. Multivariate logistic regression analysis showed that the route of heroin administration (injection), HIV-infection, and criminal records were significantly related to HCV infection. Few (34.8%) HCV positive heroin users were aware of their infection. ConclusionAn extremely high prevalence of HCV infection but low awareness of their infection status was found among MMT patients in Taiwan. These findings highlight the importance of education regarding risky behaviors and the necessity for HCV treatment for this population in Taiwan.

Differences in Cigarette Smoking Behaviors Among Heroin Inhalers Versus Heroin Injectors

The high prevalence of cigarette smoking among heroin users has triggered many studies to explore possible interactions between cigarette smoking and heroin addiction; however, little is known about the relationship between cigarette smoking behaviors and routes of heroin administration. The present study provided the first examination of cigarette smoking status, motivation, and cigarette smoking cue reactivity among injecting or inhaling heroin users. Forty-six heroin-dependent patients were recruited in the present study. A battery of self-report questionnaires was used to assess cigarette smoking status and the reasons for smoking. In the clinical laboratory study, participants completed a cue-reactivity procedure that involved collecting psychophysical and motivational data in response to cigarette smoking slides. The average number of cigarette per day among heroin inhalers was higher than that among heroin injectors. Most heroin inhalers reported that the primary reason for smoking was "maintaining drug pleasure," whereas heroin injectors reported that the primary smoking reason was "nicotine pleasure." Compared with heroin injectors, heroin inhalers provided increased ratings of heroin craving and desire to heroin use when exposed to cigarette smoking cues. Number of cigarettes per day was significantly correlated with cue-induced overall mean motivation in heroin inhalers but not in heroin injectors. Cigarette smoking behaviors were different among heroin inhalers from among heroin injectors. These results emphasize the stronger association between cigarette smoking and heroin inhaling.

Heroin smoking and heroin using trends in Norway

A.L. Bretteville & A. Skretting: Heroin smoking and heroin using trends in Norway The aim is to ascertain whether new ways of administering heroin have gained ground in Norway by examining three series of cross-sectional surveys (D1–D3). D1–D2 are based on postal questionnaires for which D1 is a representative sample of 15–20 year olds in Oslo (1968–2006) and D2 is a corresponding sample of 21–30 year olds (1998, 2002, 2006). D3 is based on personal interviews and consists of users of a needle-exchange service in Oslo (1993–2008). Despite a substantial rise in illegal drug use over the study period, there is no indication of increased heroin use by young people. The prevalence rates are relatively low for all heroin use (1–2%). Routes of heroin administration seem to have changed, however, as more young people (21–30 years) now report having smoked heroin and fewer report having injected the drug. There also seem to be changes in drug use patterns among current injecting drug users (IDUs). Splitting the sample by year of injection debut, we find among those starting since year 2000; i) a rise in average injection debut age of 10 years (25.6 versus 15.5 years); ii) a higher proportion with heroin smoking experience (74% versus 53%); and iii) a higher proportion having smoked heroin before injecting the drug (73% versus 16%), compared to the IDUs debuting before 1980. Consequently, the data suggest changes in drug use patterns, particularly heroin use, among recreational users and heavy drug users. So, in addition to an increase in the number of IDUs, it seems likely that the number of heroin smokers has risen too.

Multi-episode survival analysis: An application modelling readmission rates of heroin dependents at an inpatient detoxification unit

The purpose of this study is to describe the characteristics of a statistical technique appropriate for analysing multi-episode data (multi-episode survival analysis), and to show its application in modelling the flow of readmissions at an inpatient detoxification unit. Data are from 784 opioid-dependent patients admitted at an inpatient detoxification unit, who totalled 1255 admission episodes. Information stored prospectively at the unit database was reviewed for the following variables at the time of each patient discharge: episode serial number, sex, route of heroin administration, reason for discharge, time of discharge, and transition time (re-entry into the inpatient detoxification unit). Cox's semi-parametric regression model seems the most appropriate for describing the series of episodes. Amongst the parametric models, most noteworthy was the superior fit of the Gompertz–Makeham model, suggesting that the transition rate decreases monotonically with time. The influence of the variables assessed differed based on the serial number of the episode. The results suggest that multi-episode survival analysis is a statistical method that can fully address the long-term perspective on treatment utilization.

Factors associated with non-fatal heroin overdose: assessing the effect of frequency and route of heroin administration.

To examine risk factors associated with non-fatal heroin overdose, particularly frequency and route of heroin administration. Data from cross-sectional surveys were analysed as a case-control and as a case cross-over design. 2556 subjects treated for heroin dependence in 164 outpatient facilities in Spain. Prevalence of overdose involving emergency care in the 12 months before treatment admission. CASE CONTROL DESIGN: Odds ratio (OR) adjusted by logistic regression. CASE-CROSSOVER DESIGN: Estimated relative risk (RR) of transient risk of injecting heroin. The prevalence of overdose was 10%. In the case control analysis the cumulative risk of overdose increased as the frequency of heroin use decreased. However, among daily heroin users this risk increased as the frequency of heroin injection rose, with an OR of 6.0 (95% CI: 3.9-9.6) for daily injectors versus non-injectors. Sniffers had a higher risk than smokers among non-daily users, but not among daily users. Other factors associated with increased risk of overdose were: tranquilizers, alcohol or cocaine use, living in certain regions and being long-term HIV+ 0. In the case-crossover analysis, the RR for injecting heroin versus using other routes immediately before overdose was 15.9 (95% CI: 9.5-26.6), and was much higher for non-daily heroin users than for daily users. These findings suggest that the rapid entry of a large quantity of heroin into the blood (as occurs when injecting) involves a high risk of overdose, especially when the heroin tolerance level is low (as occurs in sporadic users).

Differences in severity of heroin dependence by route of administration: the importance of length of heroin use

To explore differences in the severity of heroin dependence by route of administration, we interviewed 909 heroin users in three Spanish cities. Dependence was measured with the severity dependence scale (SDS). No major differences in the severity of heroin dependence were detected among users with 5 or more years of heroin use (long-term users), but differences were found among newer users (SDS mean scores, 7.3 in heroin injectors; 7.9 in smokers and 4.6 in sniffers; P=0.006), especially those with fewer than 3 years of use. Similar differences by route of administration were found when frequency of heroin use (days/month) was considered rather than severity of dependence. However, in the latter case major differences were also found among long-term users. These findings suggest that the route of administration probably influences the rate of progression to dependence but has little influence on the long-run level of dependence. They also help explain some aspects of the transition between routes of heroin administration, which is occurring in different areas.

The Ethnographic Accessing, Sampling and Screening of Hidden Populations: Heroin Sniffers in New York City

This article discusses various ways in which ethnographic methods were employed in a cohort study of HIV risk and transitions to injecting among non-injecting heroin users (NIUs), or ‘sniffers’, in New York City. In preparation for and in conjunction with an epidemiologic questionnaire survey and biological specimen collection, ethnographic methods were used to explore the meaning of non-injecting and injecting routes of heroin administration for NIUs, how non-injecting heroin use was imbedded in the everyday life of the user, and the relationship of users to the retail markets for heroin. The study utilised different ethnographic techniques to access, sample, and screen heroin ‘sniffers’ for the epidemiologic survey. These techniques included ethnographic accessing, targeted canvassing, and interactive screening. The article concludes that ethnographic methods can be fruitfully integrated with epidemiologic survey research and are necessary for conducting research among non-institutionalised, ‘hidden’ populations of drug users.

Heroin Use Among Adolescents in Treatment for Substance Use Disorders

To clarify prevalence rates and describe patterns of adolescent heroin users who are in treatment for substance use disorders. The Treatment Episode Data Set (TEDS) was examined for trends in the number of adolescents admitted to substance abuse treatment centers and for changes in the routes of heroin administration. Thirteen adolescents who used heroin from one treatment program were compared with 536 adolescents who did not. Between 1992 and 1996, heroin-using youths represented 2.0% of youths in treatment and in 1997 they represented 2.6%. Heroin-using youths represented 56% of those using injection drugs. Heroin-using youths from one treatment program had significantly more polysubstance dependence in comparison with adolescents who did not use heroin. Nationally, there has been an increasing number, but not percentage, of heroin-using youths in treatment between 1992 and 1996. In 1997 there was an increase in both the number and percentage of heroin-using youths in treatment. Heroin-using adolescents have the highest rate of injection drug use when compared with youths using other substances. Because of their greater risk of contracting human immunodeficiency virus through injection drug use, treatment trials for these adolescents are needed.

Tracking New Trends in Drug Use

The Netherlands has developed a broad range of information systems and other data sources that focus on various aspects of illicit drug use. Researchers can put these to use for the early detection, tracking, and understanding of changes in drug consumption patterns in various populations. This article first assesses the suitability of existing data sources for this purpose in a series of case studies including (1) the emergence of ecstasy; (2) changing routes of heroin administration; and (3) the introduction of crack cocaine. It then discusses how to develop an effective model for tracking new trends in drug use. In this model, the suitability of different data sources depends on the topic, the population, and the stage in the diffusion process of the trend. Because each data source has its own strengths and weaknesses, changes can only be detected, tracked, and understood by continuously comparing information from various sources.

Transitions between routes of heroin administration: a study of Caucasian and Indochinese heroin users in south-western Sydney, Australia.

To examine patterns and correlates of routes of heroin use among Caucasian and Indochinese heroin users. A cross-sectional survey. Two hundred heroin users resident in South West Sydney. The sample was divided between Caucasian and Indochinese users (each n = 100), with half of each group on methadone maintenance. A semi-structured interview was administered, based on previous studies of transitions between routes of administration. Measures included patterns of drug use, transitions, social, health and legal issues and cultural correlates of use. Almost two-thirds (61%) had smoked heroin. Smoking was more common among the Indochinese (40% were predominantly or exclusively smokers), although injecting was the dominant route for both groups. More than one-quarter (29%) had made a transition from smoking to injecting, primarily due to drug effect and perceived cost-effectiveness. Reverse transitions were rare. Smoking appeared to be more culturally acceptable than injecting among Indochinese users. Among both groups, there was a small but significant risk for the transmission of HIV and other blood-borne viruses. Polydrug use and age were positively associated with having experienced a non-fatal overdose. This research documents the existence of smoking as a popular route of administration among both Indochinese and Caucasian heroin users in the study sample. There is an urgent need to provide smokers and injectors with information explaining the potential risks and ways to minimize harms associated with both routes of use.

Declining prevalence of injection as main route of administration among heroin users treated in Spain, 1991-1993

The objetive of this study was to analyse the temporal and geographic trends and the factors associated with the prevalence of heroin injection (HI) in persons treated for the first time for heroin abuse/dependence in Spain in 1991-1993. The prevalence of HI was studied in 54,132 admissions to treatment reported to the State Information System on Drug Abuse. The factors associated with HI prevalence were studied by stratified analysis and logistic regression. Regions with similar prevalences were grouped together based on correspondenc e analysis. The HI prevalence declined progressively by year (50% in 1991,43% in 1992 and 38% in 1993). The regions were grouped into 3 geographic areas, with rising prevalences in the southwest-northeast. Region was the factor most strongly asociated with HI, with an OR of 6.17 in the high prevalence group as compared with the low prevalence group. A declining trend of HI was seen with the more recent year of first use (OR of 0.15 for those beginning use in the years 1991-1993 as compared with those who began before 1982), later age at first use and increasing years of use. Male sex and cocaine use were associated with higher HI. Chasing is progressively replacing injection as a route of heroin administration because new users primarily use this route and probably because the most common transition is from injecting to chasing. The impact of the HIV epidemic and control programmes does not sufficiently explain this phenomenon. The main explanatory factors could be regional differences in the subculture of drug use or in the heroin market. T, he injecting use of heroin is the major cause of the spread of HIV infection in Spain. Over 60% of reported AIDS cases have been transmitted by sharing injection material and it is estimated that the HIV prevalence in injectors ranges from 40 to 70%. Thus, temporal trends in the injecting use of heroin are probably one of the most important factors influencing the evolution of the HIV epidemic and knowledge of these trends is essential in designing and implementing policies for prevention and control. A national study' found that in 1991 injection was the main route of administration for 64.4% of heroin users at the time of admission to out-patient treatment. This study revealed 2 important facts: first, the existence of considerable regional differences in the prevalence of the injecting use of heroin as the main route of administration in persons admitted for treatment for heroin abuse or

The transition from injecting to smoking heroin in three Spanish cities

To measure the current prevalence of different routes of heroin administration among users and to describe the most frequent patterns in the evolution of the main route from the time of first use to the present and their implications for the control of the HIV epidemic. Cross-sectional study. Face-to-face interviews using a structured questionnaire. Nine hundred and nine regular heroin users from Madrid, Barcelona and Seville (about 300 per city), half of them recruited in treatment centres and the other half out of treatment. Socio-demographic characteristics, current and historical behaviours related to route of administration. Before 1980 injection was the first main route of heroin administration for most users in Barcelona and Madrid; in Seville smoking already predominated, although 40% of users began by injecting. Sniffing subsequently became predominant in Barcelona, while smoking became the predominant first route in Madrid and Seville (smoking has been the only first route in Seville since 1991). The prevalence of injection as the main route of administration during the last 30 days was 77.3% in Barcelona, 24.3% in Madrid and 23.9% in Seville; smoking predominated in the latter two cities. The factors most strongly associated with injection as the preferred route were city of recruitment and having a partner who injected. Some 73% of those who stopped injecting in their last change of route stated that the results of their HIV test or fear of becoming infected had been important in making this decision. The change from injecting to smoking will greatly facilitate the control of HIV infection in Spain. However, the main causal factor does not appear to be the perception of HIV risk, but rather other, ecological factors (cultural or market-related). The absence of these factors in some areas may impede the spread of smoking.

How constant is an individual's route of heroin administration?: Data from treatment and non-treatment samples

Three routes of heroin use were identified—injecting, `chasing the dragon' and snorting. Whilst injecting and `chasing the dragon' accounted for virtually all current heroin use, snorting had been the first route of use for nearly a fifth of heroin users in both the treatment and community samples. Overlap of lifetime experience of the different routes was widespread, with the majority of heroin users in both the treatment and community samples having used heroin by more than one route. Although less than half of the treatment sample had used heroin by injection on the first occasion, more than 90% had injected at least once, and over 80% had at some time used by `chasing the dragon'. Only a quarter of the community sample had first used heroin by injecting, and yet, by the time of interview, two-thirds of the sample had injected. The majority of durable changes in route of heroin use were towards injecting and `chasing the dragon', with transitions to snorting being extremely rare. For both the samples, transitions to injecting were twice as frequent as transitions to `chasing'. Snorting appeared to be an unstable route of use, with almost all who initially snorted their heroin now using by injecting or `chasing the dragon'.