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8 Narcotics

Did You Know That…  Heterosexual male injecting drug users (IDU) have a significantly higher number of AIDS cases than either female IDU or men who have sex with men.  At one time cocaine was the active ingredient in Coca-Cola.  Cocaine is classified as a narcotic, but it is really a stimulant.  You can not use an antibiotic to kill a virus.  The fever you experience when you are sick is actually brought on by your body’s immune system to kill the invading antigen.  You can teach bacteria not to eat antibiotics.  Compared to heroin and morphine opium is a rather mild narcotic.  A person under the influence of heroin is not combative or aggressive but rather even-tempered and tranquil.  Some of the worst abusers of narcotic drugs are medical professionals.  At one time you could purchase codeine over the counter in a cough syrup called Robatussen 12.

Introduction __________________________________

The term “narcotic” is derived from the Greek word meaning “stupor.” It was originally referred to as a variety of substances that dulled the senses and relieved pain. Today, the term has an assortment of definitions. Some individuals define narcotics as those substances, like heroin or morphine, which bind at opiate receptors in the brain. Other individuals refer to narcotics as any illicit substance. In a legal context, narcotic refers to opium, opium derivatives, and their semisynthetic substitutes. Interestingly, cocaine and coca leaves, which are also classified as narcotics in the Controlled Substances Act (CSA), neither bind to opiate receptors nor produce morphine like effects. Obviously, these substances, although classified by law as narcotics, are in fact stimulants. For the purpose of our text, narcotics will be defined as a drug that produces opium like effects. CRITICAL POINT: The most potent pain-relieving drugs are narcotics. Narcotics are used therapeutically to treat pain, suppress coughing, alleviate diarrhea and induce anesthesia. They are administered in a variety of ways. Some are taken orally, transdermally (skin patches) or injected. They are also available in suppositories…OUCH! When these drugs are illegally used on the streets, they are often smoked, sniffed or injected. More often than not they are injected. I will talk about this in a moment. The effect of the drug depends to a great extent on the dose and the way they are administrated. Aside from their medical use, narcotics

produce a general sense of well-being by reducing tension, anxiety and aggression. They can also bring about an intense feeling of euphoria. CRITICAL POINT: The U.S. Substance Abuse and Mental Health Services (SAMHSA) report that after marijuana, nonmedical use of painkillers is the second most common form of illicit drug use in the United States. According to SAMHSA, 21% of people age 12 and older (5.2 million individuals) reported using prescription pain relievers nonmedically in 2007. The U.S. Drug Enforcement Agency suggests that the number of people abusing any prescription drugs is even higher at 7 million individuals The side effects associated with narcotic use include drowsiness, inability to concentrate, apathy, lessened physical activity, constriction of the pupils, dilation of the subcutaneous blood vessels causing flushing of the face and neck, constipation, nausea and vomiting and most significantly, respiratory depression. As the dose is increased, the subjective, analgesic and toxic effects become more pronounced. Considerable medical complications are common among narcotic abusers, primarily from adulterants found in street drugs and intravenous drug use. Again, understand that street drugs are not FDA regulated. While pharmaceutical products have a known concentration and purity, clandestinely produced street drugs‌well, you don’t know what the hell you are getting. CRITICAL POINT: The most commonly abused illicit narcotic is heroin, but all prescription narcotics have the potential for abuse. In 2008, the Florida Medical Examiners Commission noted that prescription opioid painkillers (such as Vicodin, Percocet, and OxyContin) caused more deaths than illicit substances such as heroin. Of even greater consequence is the practice of drug addicts sharing needles and syringes. This can predispose these individuals to such medical problems as skin, lung and brain abscesses, and endocarditis. Hepatitis and AIDS are also commonly found among narcotic abusers because of the practice of sharing non-sterile needles. Since there is no simple way to determine the concentration and purity of a drug that is sold on the street, the effects of illicit narcotic use are unpredictable and can be fatal. Physical signs of narcotic overdose include constricted pinpoint pupils,

cold, clammy skin, confusion, convulsions, severe drowsiness and slow or troubled breathing. When narcotics are used on a repeated basis, physical dependence can develop. The withdrawal symptoms associated with narcotic addiction are usually experienced shortly before the time of the next scheduled dose. Early symptoms include watery eyes, runny nose and sweating. As the syndrome advances, restlessness, irritability, loss of appetite, nausea and tremors appear. This is also a time when drug craving increases significantly. Moreover, severe depression and vomiting are very common as are horrific stomach cramps. Chills alternating with flushing and excessive sweating are also characteristic symptoms. Additionally, pain in the joints, the bones, muscles and stomach result, as do muscle spasms. The withdrawal syndrome will run its course in about 7 to 10 days. CRITICAL POINT: Narcotics have many useful pain-relieving applications in medicine. They are used not only to relieve pain for people with chronic diseases such as cancer but also to relieve acute pain after operations. The intensity of physical withdrawal is directly related to the type of drug being used, the dose consumed, the interval between doses, and the duration of use. In general, shorter acting narcotics tend to produce shorter but more intense withdrawal symptoms. Longer acting narcotics produce a withdrawal syndrome that is prolonged, but tends to be less severe. Although unpleasant, withdrawal from narcotics is rarely life threatening. Tolerance is also rapidly developed with narcotics. A decreased intensity of analgesia, euphoria and sedation effects characterize the development of tolerance. This can create the need to consume progressively larger doses of the drug to get the initial desired effect. Perhaps the greatest pitfall associated with narcotic addiction is the development of psychological dependence. Long after the physical addiction has passed, the addict may continue to think about the use of drugs and feel overwhelmed trying to cope with their daily activities without being under the influence of drugs. This was especially true of my former girl friend Lori. Remember I talked about Lori in Chapter 1? She would constantly tell me that as much as she wanted to stay away from heroin she wasn’t sure if she ever could. Over the years, she had a number of relapses with heroin. Even to this very day, twenty years later, she still tells me that the drug has such a powerful control over her that not one day goes by that she doesn’t think about using it again. Along these very lines, research indicates that there is a high probability that narcotic relapse will occur after the physical withdrawals. CRITICAL POINT: There is somewhat of a continuum between opioid abuse, opioid dependence, and addiction. Individuals who use narcotics to the extent that they start

to interfere with the person's ability to do routine activities or fulfill regular responsibilities at home, at school, or at work would be considered to be abusing opioids. Other signs that individuals are abusing opioids include maladaptive behaviors that impact adversely on relationships, worsening of interpersonal problems, or frequent involvement with legal problems related to opioid use. According to the Center for Disease Control (CDC) in Atlanta, there are two major patterns of narcotic abuse in the United States. One involves individuals whose drug use was initiated by medical treatment who increased their dose by obtaining the drug through fraudulent prescriptions and “doctor shopping” or going out and procuring illicit drugs on the street. This is basically what renowned radio announcer Rush Limbaugh was accused of doing. CRITICAL POINT: Although uncomfortable, acute narcotic withdrawal for adults is not considered life-threatening unless the person has a medical condition that compromises their health, for example, if someone has severe heart disease. The other, more common pattern of abuse is initiated outside the therapeutic setting by individuals who use narcotics experimentally or recreationally. The majority of these individuals abuse narcotics sporadically for months or even years. Not all, but some experimental users eventually become dependent both physically and psychologically. The younger an individual is when drug use is initiated, the more likely the drug use will progress to dependence and addiction.

The Consequences of Intravenous Narcotic Use _______________________________________________________________________________________________________________________

Generally, narcotics are mainlined because injection of drugs provides instant access to the bloodstream, which in turn provides fast access to the brain producing the drug’s effect within minutes. In fact, most heroin addicts mainline the drug in order to get a “rush.” By injecting drugs, the first line of the immune defense, the skin, is penetrated. Puncturing the skin and, to a far greater consequence, entering the blood stream with a needle is like opening the front door of a fortress to an invading enemy. Of even greater consequence is the practice of drug addicts sharing needles and syringes. This can predispose these individuals to such disease as viral hepatitis and AIDS. Behavior associated with drug abuse is now the single largest factor in the spread of HIV infection in the United States. Since the epidemic began, injection drug use has directly and indirectly accounted for more than 36 percent of AIDS cases in the United States. Amazingly, drug users who inject their drugs account for 20 percent of cases among men, 50 percent of cases among women, and about 55 percent of pediatric cases…children of mothers who are injecting drug abusers or mothers who have sex with male injecting drug abusers. CRITICAL POINT: According to the Center for Disease Control and Prevention (CDC) analysis of

HIV surveillance data of the 859,000 cumulative AIDS cases reported through December 2002, a total of 25 percent were among intravenous drug users. From 1998 to 2007, an estimated 240,268 AIDS diagnoses were due directly to injection drug use, with males accounting for roughly 72 percent of these cases.

∞ DRUGS in Perspective ∞ __________________________________________________________________

Other Concerns with Intravenous Drug Use. HIV infection is not the only concern when sharing injection drugs. Other bloodborne pathogens which sharing injection drugs can transmit are hepatitis B and C. Hepatitis attacks the liver causing a variety of symptoms including fever, headache, nausea, loss of appetite, skin rashes and the yellowing of eyes and skin referred to as jaundice. Hepatitis over time can cause serious persistent liver infections and chronic liver disease which can result in liver cancer and death. Hepatitis B and C should not be confused with their wellknown relative hepatitis A. Hepatitis A is spread by fecal oral contact and result in relatively mild liver ailments. The notoriety of hepatitis A comes from its reputation of being spread by food workers who fail to wash their hands after using the toilet. Rarely, will you see a restaurant that does not display a placard in its restrooms reminding employees to wash their hands after use. There is some question whether the placards exist more to ease the concerns of patrons versus to remind employees to wash. What do you think? Are teens concerned about hand washing before they eat? In the US, the role that injection drug use (IDU) plays in transmitting both HIV and hepatitis is substantial. Figures reported in May 18, 2004 Morbidity Mortality Weekly Report (MMWR) from the Centers for Disease Control and Prevention (CDC) state that roughly 33% of AIDS cases and 50% of hepatitis C cases are attributable to injection drug use. The report also states that some one million people are active IDUs and an unknown number of these individuals die from fatal drug overdose.

Using or sharing unsterile needles, cotton swabs, rinse water and cookers, such as when injecting heroin, cocaine or other drugs leaves a drug abuser vulnerable to contracting or transmitting HIV. As you are probably aware, the actual injection of drugs has little to do with transmitting HIV, but rather it’s the sharing of infected paraphernalia which transmits the virus. Whenever someone injects a substance into his or her body, blood is always deposited on and possibly in the needle. Unless the needle is cleaned thoroughly with bleach, that blood along with the drug being injected will enter into the next person who shoots up. In this respect, the administration of narcotics by injection is significantly more dangerous than the hazards associated with drug use per se. AIDS alone can wipe out an entire neighbourhood. Hell, it has just about wiped out some countries in Africa. CRITICAL POINT: Using or sharing unsterile needles, cotton swabs, rinse water and cookers, such as when injecting heroin, cocaine or other drugs leaves a drug abuser vulnerable to contracting or transmitting HIV and viral hepatitis . With so much at risk, we need to address the AIDS virus somewhere in this text…this is that somewhere.

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CHAPTER Narcotics Introduction CRITICAL POINT: The most potent pain-relieving drugs are narcotics. __________________________________