Street Heroin Research Articles

Ranking the harm of non-medically used prescription opioids in the UK

A panel of nine experts applied multi-criteria decision analysis (MCDA) to determine the relative overall harm to users and harms to others of street heroin (injected and smoked) and eleven non-medically used prescription opioids. The experts assessed harm scores for each of the 13 opioids on each of 20 harm criteria, weighted the criteria and explored the resulting weighted harm scores for each opioid.Both forms of heroin scored very high: overall harm score of 99 for injected heroin and 72 for smoked heroin on a scale of 0–100. The main feature that distinguishes both forms of street heroin use is that their harm to others is more than five times that of the other eleven opioids. The overall harm score of fentanyl (including injection of fentanyl extracted from patches) and diamorphine (medically prescribed form of heroin) was 54 and 51, respectively, whereas that of orally used opioids ranged from 32 (pethidine) to 11 (codeine-containing pharmaceuticals). Injected street heroin, fentanyl and diamorphine emerged as most harmful to users, with the latter two very low in harm to others. Pethidine, methadone, morphine and oxycodone are also low in harm to others, while moderate in harm to users.We conclude that the overall harms of non-medically used prescription opioids are less than half that of injected street heroin. These data may give a basis for precautionary regulatory measures that should be considered if the rising trend in non-medical use of prescription opioids were to become evident in the UK.

On the science of heroin injection preparation: A response to Ciccarone and Harris

On the science of heroin injection preparation: A response to Ciccarone and Harris

Possible mechanism for inhibition of morphine formation from 6-acetylmorphine after intake of street heroin

Heroin is de-acetylated in the body to morphine in two steps. The intermediate 6-acetylmorphine (6-AM) is formed rapidly and is considered important for the pharmacological effect of heroin. In urine drug testing, an atypical pattern of morphine and 6-AM is known to occur in low frequency. The aim of this study was to investigate this atypical pattern in more detail and to identify responsible substances for a possible inhibition of the conversion from 6-AM to morphine. Urine samples were selected from a routine flow of samples sent for drug testing. Out of 695 samples containing morphine and 6-acetylmorphine, 11.5% had the atypical pattern of a 6-AM to morphine ratio above 0.26 as derived from a bimodal frequency distribution. An in vitro study of the conversion of 6-acetylmorphine to morphine in human liver homogenates demonstrated that a number of known carboxylesterase inhibitors were able to inhibit the reaction mimicking the situation in vivo. Compound 3 (3,6-Dimethoxy-4-acetoxy-5-[2-(N-methylacetamido)ethyl]phenanthrene) a substance formed from thebaine during the production of heroin was found to be a strong inhibitor. Liquid chromatography–mass spectrometry was used to identify possible inhibitors present in vivo. This part of the investigation demonstrated that several components may contribute to the effect. It is concluded that inhibition of liver carboxylesterase activity is a possible mechanism causing the atypical pattern and that one candidate compound is the result of the heroin production process. An inhibition of 6-AM metabolism is likely to increase the pharmacological effect of heroin and may be related to a higher risk of lethal toxicity.

Efficacy of Heroin-Assisted Treatment in Belgium: A Randomised Controlled Trial

Background/Aims: Heroin-assisted treatment (HAT) can improve the condition of heroin addicts still using street heroin after a methadone treatment. In Belgium, a new trial compared the efficacy of a HAT to existing methadone maintenance treatment. Methods: In this randomised controlled trial, HAT was limited to 12 months. Participants were assessed every 3 months. They were responders if they showed improvement on the level of street heroin use, health or criminal involvement. Results: 74 participants were randomised in the trial. The experimental group (n = 36) counted 30% of responders more than the control group (n = 38) at each assessment point (p < 0.05), except at 12 months where the difference (11%) was no longer significant (p = 0.35). Still, after 12 months, participants in the experimental group reported significantly greater improvements (p < 0.05) than the control group on the level of street heroin use and on the level of physical and mental health. Both groups reported significantly less criminal acts after 12 months (p < 0.001), but with no significant difference between the groups. Conclusions: This trial confirms the short-term efficacy of HAT for severe heroin addicts, who already failed methadone treatment.

Drug use, health and social outcomes of hard-to-treat heroin addicts receiving supervised injectable opiate treatment: secondary outcomes from the Randomized Injectable Opioid Treatment Trial (RIOTT).

The Randomized Injectable Opioid Treatment Trial (RIOTT) compared supervised injectable heroin (SIH) and supervised injectable methadone (SIM) with optimized oral methadone (OOM) (ISRCTN0133807). Heroin addicts (previously unresponsive to treatment) made significant reductions in street heroin use at 6 months when treated with SIH. We now examine secondary outcomes. Multi-site randomized controlled trial (RCT) comparing SIH versus OOM and SIM versus OOM. Three supervised injectable opiate clinics in England. Chronic refractory heroin addicts continuing to inject street heroin virtually daily despite oral substitution treatment (n = 127), randomized to either SIH(n = 43), SIM(n = 42) or OOM(n = 42). All received high levels of medical and psychosocial support. wider drug use, crime, health and social functioning at 6 months. At 6 months, no significant differences were found between treatment groups in wider drug use (crack/cocaine, benzodiazepines, alcohol), physical and mental health (SF-36) or social functioning. Within each treatment group, significant reductions were observed in crime [SIH = odds ratio (OR) 0.05; P < 0.001; SIM = OR 0.11; P = 0.002; OOM = OR 0.11; P = 0.003] and money spent per week on illicit drugs (SIH = mean change £-289.43; P < 0.001; SIM = mean change £-183.41; P < 0.001; OOM = mean change £-162.80; P < 0.001), with SIH significantly more likely to have reduced money spent on illicit drugs versus OOM (mean difference £-92.04; P < 0.001). Significant improvements were seen in physical health for SIH and SIM (SIH = mean change 3.97; P = 0.008; SIM = mean change 4.73; P = 0.002) and mental health for OOM (mean change 6.04; P = 0.013). Supervised injectable heroin treatment and supervised injectable methadone treatment showed no clearly identified benefit over optimized oral methadone in terms of wider drug use, crime, physical and mental health within a 6-month period, despite reducing street heroin use to a greater extent. However, all interventions were associated with improvements in these outcomes.

Chocolate-coloured serum in methaemoglobinaemia

A 53-year-old man presented to the emerge ncy department of our hospital in January, 2014, after a syncopal episode. He was a regular smoker and recreational drug user, and had taken heroin, cannabis, and benzodiazepine during that week. He had a history of glucose-6-phosphate dehydrogenase (G6PD) defi ciency. On examination he had grey pallor and was dyspnoeic at rest (respiratory rate 23 breaths per minute). His oxygen saturation was 70% on 100% inspired oxygen and his blood sample, which showed anaemia (haemoglobin 54 g/L; normal 130–180 g/L), was chocolate brown (fi gure). Arterial blood gas analysis showed pH 7·40 (7·35–7·45) and methaemoglobin 26% (<2%). Oxidant agents like benzocaine or novocaine, which are sometimes added to street heroin and cocaine, oxidise haemoglobin from its ferrous (Fe2) to ferric state (Fe3), and can cause methaemoglobinaemia. This altered form of haemoglobin loses its ability to transport oxygen, and can cause hypoxaemia. Chocolate-coloured blood is typical of methaemoglobinaemia. Unlike deoxyhaemoglobin, methaemoglobin does not brighten on exposure to atmospheric oxygen. In our patient, haemolysis associated with G6PD defi ciency caused release of the methaemoglobin from within the red blood cells into the serum. Lancet 2015; 386: e6

“It's Russian roulette”: Adulteration, adverse effects and drug use transitions during the 2010/2011 United Kingdom heroin shortage

BackgroundBetween late 2010 and mid 2011 there was a significant heroin shortage in the United Kingdom (UK), resulting in a rapid drop in street heroin purity and increase in price. The most well documented event of this kind is the 2000–2001 Australian heroin shortage, with little published research addressing the UK context. In this paper we draw on qualitative data to explore the impact of, and responses to, the 2010/2011 shortage among London-based heroin users. MethodsData collection comprised longitudinal life history and narrative interviews with 37 PWID in 2010–2011. The average age of participants was 40, with a 20-year average duration of injecting. Heroin was the drug of choice for the majority of participants (25), with 12 preferring to inject a crack-cocaine and heroin mix. Recruitment took place through London drug and alcohol services and peer networks. ResultsThe majority of participants continued to source and inject heroin despite reported decline in purity and increased adulteration. Transitions to poly-drug use during the heroin shortage were also common, increasing vulnerability to overdose and other drug related harms. Participants enacted indigenous harm reduction strategies in attempting to manage changes in drug purity and availability, with variable success. ConclusionEpidemiological data gathered during periods of heroin shortage is often drawn on to emphasise the health benefits of reductions in supply. Our findings highlight the importance of understanding the ways in which heroin shortages may increase, as well as reduce, harm. There is a need for enhanced service provision during periods of drug shortage as well as caution in regard to the posited benefits of supply-side drug law enforcement.

Suspect Fentanyl Lacing in Apparent Heroin Overdoses

Suspect Fentanyl Lacing in Apparent Heroin Overdoses

Pharmacological maintenance treatments of opiate addiction

For people seeking treatment, the course of heroin addiction tends to be chronic and relapsing, and longer duration of treatment is associated with better outcomes. Heroin addiction is strongly associated with deviant behaviour and crime, and the objectives in treating heroin addiction have been a blend of humane support, rehabilitation, public health intervention and crime control. Reduction in street heroin use is the foundation on which all these outcomes are based. The pharmacological basis of maintenance treatment of dependent individuals is to minimize withdrawal symptoms and attenuate the reinforcing effects of street heroin, leading to reduction or cessation of street heroin use. Opioid maintenance treatment can be moderately effective in suppressing heroin use, although deviations from evidence-based approaches, particularly the use of suboptimal doses, have meant that treatment as delivered in practice may have resulted in poorer outcomes than predicted by research. Methadone treatment has been 'programmatic', with a one-size-fits-all approach that in part reflects the perceived need to impose discipline on deviant individuals. However, differences in pharmacokinetics and in side-effects mean that many patients do not respond optimally to methadone. Injectable diamorphine (heroin) provides a more reinforcing medication for some 'nonresponders' and can be a valuable option in the rehabilitation of demoralized, socially excluded individuals. Buprenorphine, a partial agonist, is a less reinforcing medication with different side-effects and less risk of overdose. Not only is it a different medication, but also it can be used in a different paradigm of treatment, office-based opioid treatment, with less structure and offering greater patient autonomy.

PLASMA LEVEL MONITORING OF THE MAJOR METABOLITES OF DIACETYLMORPHINE (HEROIN) BY THE “CHASING THE DRAGON” ROUTE IN SEVERE HEROIN ADDICTS

The objective of the present study was to verify if severe physical health problems frequently encountered in heroin addicts and the concomitant use of alcohol and legal or illegal drugs other than heroin influenced the pharmacokinetics of the major metabolites of heroin.We conducted a 90 minutes follow-up of the plasma concentrations of the pharmaceutical heroin, named diacetylmorphine (DAM), in patients recruited in a DAM assisted treatment centre. TADAM (Traitement Assisté par DiAcétylMorphine) aimed to compare the efficacy of heroin-assisted treatment (HAT) compared with methadone maintenance treatment (MMT) for heroin users considered as treatment resistant patients and who have severe physical and mental health problems.Eleven patients were recruited. Blood samples were collected at baseline and 15, 45 and 90 minutes after DAM administration. All patients received DAM by the “chasing the dragon” route. Plasma samples were analyzed by a previously described ultra-high pressure liquid chromatography coupled to tandem mass spectrometry (UHPLC/MS-MS) method.A principal component analysis (PCA) was performed and 8 metabolite concentrations ratios were calculated to evaluate the influence of various factors (DAM dose, patient pathologies, concomitant use of medications, methadone, street heroin, alcohol and cocaine) on heroin metabolite pharmacokinetics. It seemed to be not affected by the DAM dose, patient pathologies and the concomitant use of medications, methadone, street heroin and alcohol. Cocaine use was the only parameter which showed differences in heroin pharmacokinetics.

Chemiluminescence detection of heroin in illicit drug samples

Heroin (3,6-diacetylmorphine) and several important extraction and synthesis impurities (morphine, 6-monoacetylmorphine, codeine and 6-acetylcodeine) were determined in illicit drug samples, using high performance liquid chromatography with ‘parallel segmented flow’, which enabled the simultaneous use of three complementary modes of detection (UV-absorbance, tris(2,2′-bipyridine)ruthenium(III) chemiluminescence and permanganate chemiluminescence). This rapid and sensitive approach for the analysis of street heroin was used to explore the chemistry of a proposed heroin screening test that is based on the relative response with these two chemiluminescence reagents using flow injection analysis. Although heroin was the major constituent of the six drug samples (between 16% and 67% by mass), the synthetic by-product 6-acetylcodeine (2.5–8.3%) made a greater contribution to the total [Ru(bipy)3]3+ chemiluminescence response of the screening test. The signal with permanganate was primarily due to the presence of 6-monoacetylmorphine (0.9–29%), and was therefore indicative of the degree of sample degradation during clandestine manufacture or poor storage conditions prior to the drug seizure. In the second part of the screening test, the sample is treated with sodium hydroxide, which results in a large increase in the signal with permanganate, due to the rapid hydrolysis of heroin to 6-monoacetylmorphine. As the emission of these two reagents with morphinan-alkaloids and their derivatives largely depends on the substituent at the O3 position, the slower hydrolysis of 6-monoacetylmorphine to morphine, and 6-acetylcodeine to codeine, did not have a major impact on the characteristic pattern of responses in the screening test.

First scientific report of a new derivative of street heroin in east of Iran

Dear Editor Drugs and chemicals are easily available in Iran. Therefore, drug abuse and addiction are common [1]. Iran is a significant consumer of opium, and generally of opioid derivatives in the world [2]. Street drugs are being adulterated with lead, steroids, thallium and ... for economical benefits [3,4]. This will lead to further complications. Development of tolerance to opioids in addicts leads to increase the dose or abusing more potent drugs or more harmful routes such as injection. More potent drugs are occasionally launched into the markets [5]. Opioid transitional illicit market is developing very fast. The pattern of usage is moving towards more high risk behaviors including using more potent agents and injections as well as newly developed drugs [6,7]. Coal heroin has been in use in Iran for over 50 years. In 2005, we reported crystal heroin for the first time, which is more potent and it is possible to dissolve in water in room temperature [5,8]. It relatively generates less odors in comparison to coal heroin. Recently, we encountered a new type of highly potent heroin, which took noticed by local public media [9]. Recently a new type of heroin opiate has been introduced to heavy abusers in north east Iran Mashhad. According to the clinical features of the addicts that have been referred to Medical Toxicology Centre, Imam Reza Hospital, the euphoric effects of this opiate is reported to be more potent than coal heroin, crystal heroin and crack heroin. It is called ‘’Se Doodi” (Persian; ی س ه د و د ). It costs 2 to 2.5 times more than crystal heroin. The clinical features are the same as heroin use including sedation, euphoria and myosis. In overdose, a decrease in consciousness level, bradypnea and pinpoint myosis is being observed. Withdrawal symptoms included restlessness, anxiety, insomnia, pain, diarrhea and

Determination of dextromethorphan and levomethorphan in seized heroin samples by enantioselective HPLC and electronic CD

A new enantioselective HPLC method was developed for the resolution and determination of the enantiomers of methorphan, dextromethorphan (DXM) and levomethorphan (LVM), on a Chiralcel® OJ column (250mm×4.6mm I.D.). The resolution of DXM and LVM was obtained using a mobile phase consisting of (n-hexane)-(2-propanol)-diethylamine (70:30:0.1, v/v/v) at a flow rate of 0.5mLmin−1. The enantioselective method was found to be selective (α=1.92) and sensitive (LOD=2.8μgmL−1 for both DXM and LVM). The method was coupled with electronic circular dichroism (CD), allowing the determination of the elution order on the basis of the sign of CD signals of the single enantiomers at 285nm (positive for DXM, negative for LVM).Under the optimized conditions, the validated method was applied to the identification and quantitation of the enantiomers of methorphan in samples of different sources of illicit drugs of abuse (heroin). DXM was found in eight seized samples of street heroin; two of these samples, for which the DXM content was found to be over 5% (w/w) and exceeding a 10% (w/w) ratio with respect to diacetylmorphine, were the cause of two deaths for overdose due to acute narcotism.

Sexual Dysfunction as a Side Effect of Hyperprolactinemia in Methadone Maintenance Therapy

Although endocrine abnormalities are recognized in opiate users, very little is known about the range of hormones affected, their pathophysiology and their clinical relevance. various endocrine abnormalities have been reported in these patients including, increased prolactin levels and abnormalities in sexual hormone. Path physiological mechanism postulated does explain these findings including direct action of heroin or methadone at the hypothalamic pituitary level. The aim of this study was to explore the effects of heroin and methadone maintenance treatment on the plasma prolactin levels and sexual function. We evaluated 20 male narcotic addicts maintained of methadone more than 3 years on oral high dose methadone 60-120 mgr/day. Patients taking neuroleptic therapy were excluded from the study because neuroleptic-included hyperprolactinemia. We also evaluated group of twenty male heroin addicts on the street heroin .The prolactin plasma levels were assayed using the chemiluminescent immunometric essay (CLIA)--high sensitive methods. The normal range of prolactin levels was 1,5-17 ng/ml (53-360 nmol/l) for men and 1,90-25,0 ng/ml for women. The sexual function was assessed using a Questionnaire: International Index of Erectile Function (IIEF) with 15 items in four levels of sexual function. The differences between two examination groups were determined by a students t test. The results show that street heroin addicts (55% of them have high level of prolactin) have significantly higher plasma prolactin levels (p = 0.006) then the group of methadone maintenance patients (only 15% of them have high prolactin level). In our study, when we compared sexual dysfunction in examination groups in some domains, we did not find statistical significant results (sexual desire p = 0.52 and overall satisfaction p = 0.087). But in domains of erectile function p = 0.011 and orgasm function p = 0.033 we got statistical significant results.

Histological Findings of the Atrioventricular Conductive System in Street Heroin Addicts, Victims of Sudden Unexpected Death

A study of the atrioventricular (AV) conducting tissue was considered necessary for the examination of probable histologic changes that could justify the arrhythmias observed in street-heroin addicts. Postmortem coronary angiography and microscopic examination were performed in 50 heroin addicts (group A) and in 50 nonaddicts (group B), all male 16-40 years old. In group A, fatty and/or fibrous tissue replaced the AV node in 50% of cases while in group B in 14%. The main bundle was replaced by fatty and/or fibrous tissue in 44% in group A cases and 10% in group B. Intimal proliferation and fibromuscular dysplasia of the AV arteries in group A were correspondingly 26% and 14% and in group B 6% and 2%. Inflammation with focal and/or diffuse concentration of round cells of the AV node was detected in 54% in group A. These findings could explain a possible arrhythmia mechanism in this population.

Investigation of trace inorganic elements in street doses of heroin

Sixteen trace elements found in 309 street heroin samples, piped water and contaminated water were determined using inductively coupled plasma-mass spectrometry. All the street heroin samples were found to contain high levels of sodium, a reflection of the use of sodium bicarbonate during heroin synthesis. Additionally, this element was also found to be one of the potential contaminants acquired from the piped water. Calcium could be derived from lime while iron, aluminum and zinc could have come from the metallic container used in the processing/cutting stage. The levels of these elements remained low in the heroin and it could be due to the dilution effects from the addition of adulterants. Statistical validation was performed with six links of related heroin samples using principal component analysis to find the best pretreatment for sample classification. It was obtained that normalization followed by fourth root showed promising results with 8% errors in the sample clustering. The technique was then applied to the case samples. Finally, the result suggested that the case samples could have originated from at least two major groups respectively showing unique elemental profiles at the street level.

Development and Validation of a New GC-MS Method for the Detection of Tramadol, O-Desmethyltramadol, 6-Acetylmorphine and Morphine in Blood, Brain, Liver and Kidney of Wistar Rats Treated with the Combination of Heroin and Tramadol

Heroin is one of the most dangerous abused drugs in the world. Tramadol is an additive recently found at high concentration levels in street heroin seizures in Egypt. This substance could affect the usual analytical method for the detection of heroin and metabolites, as well as the pharmacokinetic and disposition of single analytes. One shortfall regarding this issue is present in the literature. This study describes a validated, simple, sensitive and selective method to determine tramadol, O-desmethyltramadol, 6-acetylmorphine and free morphine in the blood, brain, liver and kidney of Wistar rats, intraperitoneally treated with a combination of heroin and tramadol (10 and 70 mg/kg, respectively) using liquid-liquid extraction and gas chromatography-mass spectrometry detection. The calibration curves of tramadol, O-desmethyltramadol and 6-acetylmorphine in blood were linear in the concentration range from 25-5,000 ng/mL and morphine was found in the concentration range 50-5,000 ng/mL. The analytes were detected in all tested matrices, except 6-acetylmorphine, which was not detected in liver. The highest concentrations of tramadol and O-desmethyltramadol were observed in kidney (22,9381 and 28,498 ng/g), while 6-acetylmorphine and morphine were found at the highest levels in brain (3,280 and 3,899 ng/g, respectively). The present method is simple, rapid and sensitive and can be used to study the pharmacokinetics, disposition and interaction of these drugs in several animal models.

Policing the Melbourne Street Heroin Trade: Perspectives of Vietnamese Australian Social Justice Professionals

Drawing on a 4-year research project, ‘Exploring the experience of security in the Vietnamese-Australian community: practical implications for policing,’ this article examines the perspectives of the Melbourne Vietnamese Australian community outreach and legal professionals on policing the drug trade. Engaging with current debates on the tensions between traditional or standard policing styles and community-oriented policing styles, the article argues that the current over-reliance on traditional policing styles, with an emphasis on zero tolerance strategies is diminishing already low trust of the police within the Vietnamese Australian community and undermining longer term community engagement strategies.

Cardiac Complications of Unwitting Co-injection of Quinine/Quinidine with Heroin in an Intravenous Drug User

Adulterants "cut into" street heroin are common and often not detected by standard urine toxicology screening; however, their unwitting co-injection may have clinical consequences. We report a case of accelerated atrioventricular junctional arrhythmia that we determined to have been caused by quinine/quinidine cut into heroin. While identification and discontinuation of the offending agent helps confirm the diagnosis and is the treatment of choice, this is often complicated by the individual's dependence on the street drug in which the adulterant is mixed. This case highlights the need for clinicians to be aware of common adulterants, to know how to test for them, and to consider them as possible causes of medical complications in individuals who use drugs.

New HPLC Method to Detect Individual Opioids (Heroin and Tramadol) and their Metabolites in the Blood of Rats on Combination Treatment

Drug abuse is both an age-old and a constantly evolving problem in society. Trends in illicit drug use are highly fluid, with new formulations increasing in popularity. For this reason, methods for illicit drug detection and analysis need to be continually updated so they remain useful and relevant. A recent trend in street heroin production has seen it diluted with large amounts of tramadol in addition to the classical diluents such as acetaminophen and caffeine. This study describes a sensitive, simple and accurate high-performance liquid chromatographic method with ultraviolet detection for the simultaneous detection of heroin, 6-acetylmorphine, morphine, tramadol and O-desmethyltramadol in the blood of rats using a liquid-liquid back-extraction method. The separation was performed on LichroCART RP-18e with particle size of 5 µm (250 × 4.6 mm) with mobile phase acetonitrile-50 mM KH(2)PO(4) buffer, pH 7.1, using a gradient mode with a 1.0 mL/min flow rate. The calibration curves were linear in the concentration ranges 0.25-100 and 0.1-100 µg/mL for morphine and other analytes, respectively. Recovery values for the substances ranged between 59 and 83%. This technique was successfully used in pharmacokinetic studies measuring 6-acetylmorphine, morphine, tramadol and O-desmethyltramadol in the blood of rats intraperitoneally treated with a blend of 10 mg/kg heroin and 70 mg/kg tramadol. This technique shows promise for analysis of confiscated street heroin.