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Influence of Treatment with Inhalable Heroin on Pulmonary Function
Abstract
This study aims to asses the influence of inhalable heroin on pulmonary function in chronic heroin-dependent patients treated with inhalable heroin. Among 32 patients (all cigarette smokers), a spirometric test was conducted at baseline and after an average period of 10 months of treatment with medically prescribed heroin. Patients showed a high frequency of pulmonary dysfunction at baseline [34%, with percentage of forced expiratory volume in 1 s (%FEV1)<80%]. However, after excluding those who started pulmonary treatment (n=2) or who used heroin intravenously only (n=2), no statistically significant differences in %FEV1 between baseline and follow-up were observed (n=28; mean %FEV1 86% at baseline vs. 91% at follow-up; p=0.09). This small and relatively brief study suggests that 10 months of co-prescribed inhalable heroine base does not seem to (further) deteriorate pulmonary function in chronic, cigarette smoking treatment refractory heroin addicts. Screening for and treatment of pulmonary dysfunction is recommended for methadone patients with and without co-prescribed heroin.
... Varying measures of dyspnoea, coughing and wheezing were reported across seven studies [9][10][11]13,15,36,47]. Various lung function tests were also reported across 11 studies [9][10][11][12][13]36,43,[47][48][49][50]. Key details of all these outcomes are displayed in Supporting information, Table S2. ...
Background and aims:
There are growing concerns over the respiratory health of people who use illicit opioids due to high rates of opioid inhalation and tobacco smoking in this group. This study aimed to summarize the evidence relating illicit opioid use with poor respiratory health.
Methods:
A systematic review of the literature on the association between illicit opioid use and respiratory health was undertaken in accordance with PRISMA guidance (Prospero ID=CRD42017059953). Electronic searches of MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library databases were undertaken (English language, published January 1980 - November 2018). All study designs excluding case studies were considered. Studies were undertaken in community and hospital settings in the US (n= 23), UK (n=7), Australia (n=7), Netherlands (n=2), Canada (n=2), Ireland (n=1), Spain (n=1) and Iran (n=1). Measurements of respiratory disease, including asthma and chronic obstructive pulmonary disease (COPD) and related symptoms were extracted. Data on respiratory related deaths and hospital admissions were also extracted. Meta-analysis of prevalence data was undertaken using a random effects meta-analysis model with parameters estimated using Markov chain Monte Carlo simulation.
Results:
Meta-analyses estimated prevalence of asthma in people who inject illicit opioids as 8.5% (95% predictive interval (PrI): 0.2%, 74.0%) and as 20.2% (95% PrI: 4.2%, 59.2%) in people who inhale illicit opioids. Prevalence of COPD in people who inject illicit opioids was estimated as 2.7% (95% (PrI): 0.0%, 50.4%) and as 17.9% (95% PrI: 0.6%, 89.5%) in people who inhale illicit opioids. There was evidence of moderate to extreme heterogeneity across studies.
Conclusions:
There is evidence of increased burden of respiratory diseases in people who use illicit opioids. Due to heterogeneity of study design and samples it is difficult to gain accurate estimates of the prevalence of respiratory disease in this population.
... This could be related to the already high multi-domain treatment response (more than 40%) within the first two months of HAT before the start of CM. It could also be that the presence of chronic, persisting health problems in this older group of dependent patients, with a long history of heroin and cocaine use, requires specialized medical and psychiatric treatments to further improve overall health and functioning (Buster et al., 2011;Hser et al., 2004;Rosen et al., 2008). ...
Aims - To determine the efficacy of contingency management (CM), targeting cocaine use, as an add-on intervention for heroin dependent patients in supervised heroin-assisted treatment (HAT) with frequent cocaine use.
Design - Multi-center, open-label, parallel group, randomized controlled trial.
Setting - Twelve specialized addiction treatment centers for HAT in the Netherlands; April, 2006–January, 2011.
Participants - 214 chronic, treatment-refractory heroin dependent patients in HAT, with frequent cocaine use.
Interventions - Routine, daily supervised diacetylmorphine treatment, co-prescribed with oral methadone (HAT), with and without 6 months contingency management for cocaine use as an add-on intervention; HAT + CM and HAT-only, respectively.
Measurements - Primary outcome was the longest, uninterrupted duration of cocaine abstinence, based upon laboratory urinalysis. Secondary outcome measures included other cocaine-related measures, treatment retention in HAT, and multi-domain health-related treatment response.
Findings - In an intention-to-treat analysis, HAT + CM was more effective than HAT-only in promoting longer, uninterrupted duration of cocaine abstinence (3.7 weeks versus 1.6 weeks; negative binomial regression: Exp(B) = 2.34, 95%-CI: 1.70–3.23; p < 0.001). This result remained significant in sensitivity analyses and was supported by all secondary, cocaine-related outcome measures. Treatment retention in HAT was high (91.6%) with no difference between the groups. The improvement in multi-domain health-related treatment response during the trial was numerically higher in HAT + CM (from 37.4% to 53.1%; +15.7%) than in HAT-only (from 44.5% to 46.5%; +2.0%), but this difference was statistically not significant.
Conclusions - Contingency management is an effective add-on intervention to promote longer, uninterrupted periods of cocaine abstinence in chronic, treatment-refractory heroin dependent patients in heroin-assisted treatment with frequent cocaine use.
The trial has been registered in the Netherlands National Trial Register under clinical trial registration number NTR4728.
... However, after excluding four patients that started pulmonary treatment (n = 2) or used heroin intravenously (n = 2), the difference was no longer significant (mean %FEV 1 : 86% at baseline vs. 91% at followup; p = 0.09). This study shows that pulmonary function does not decline in treatment-resistant heroin dependent patients when treated with co-prescribed heroin for about 10 months (Buster et al., 2010) Pharmaceutical heroin for inhalation: product development. Diacetylmorphine base was the preferred form of heroin to be used via "chasing the dragon", because it has a lower melting point (173°C) than the hydrochloride salt (243-244°C) (The Merck Index, 1996) and because it is relatively insensitive to degradation (Huizer, 1987;Klous et al., 2005a). ...
This monograph describes the history, findings and international context of heroin-assisted treatment (HAT) in the Netherlands. The monograph consists of (1) a short introduction and seven paragraphs describing the following aspects of HAT in the Netherlands: (2) history of HAT studies and implementation of routine HAT in the Netherlands; (3) main findings on efficacy, safety and cost-effectiveness from the two randomized controlled HAT trials in the Netherlands; (4) new findings from a large cohort study on the effectiveness of HAT in routine clinical practice in the Netherlands; (5) unique data on the patient's perspective of HAT; (6) data on the pharmacological and pharmaceutical basis for HAT in the Netherlands; (7) description of the registration process; and (8) account of the international context of HAT. Together, these data show that HAT can now be considered a safe and proven-effective intervention for the treatment of chronic, treatment-resistant heroin dependent patients.
Heroin (or diacetylmorphine), a depressant nervous central system, is a semi-synthetic opiate. Its main adverse effect, respiratory depression, can lead to death, especially after an intravenous injection. By loss of tolerance, an overdose can be lethal following heroin use after a period of abstinence (voluntary or not). Mortality rate among heroin users is between 1 and 3%. Addiction, following a regular and continuous use, occurs in less than a quarter of persons who ever tried heroine. Heroin addicts often present with different problems (for instance, a criminal behaviour), without any obvious link with addiction. For a fraction of the addicts, addiction becomes a chronic relapsing disease, requiring a long term maintenance substitution therapy. However, relapses and sometimes continuous heroin use are frequent, For treatment resistant and severe heroin addicts, heroin-assisted treatment can be a solution. Despite the numerous available therapies, heroin is considered to be the drug with the most negative effects on the user.
The term opioid refers to a broad class of medications that are used most frequently for their analgesic effects. Along with this effect, they also produce euphoria, and it is for this reason that they have been used illicitly, as well as medicinally, for thousands of years. While the most well-known complications of opioid use and misuse include respiratory and central nervous system depression, there are many other toxicities that have been associated with these drugs. Many complications can occur with multiple different opioids, such as non-cardiogenic pulmonary edema, while many of the complications are unique to the opioid used as well as the route of administration. This review focuses on the pulmonary complications associated with opioid use and abuse, but opioids can affect nearly every organ system. Their effects on the pulmonary system can be direct, such as causing granulomatous change, but they can also work indirectly. For example, opioids cause respiratory depression by decreasing sensitivity of peripheral chemoreceptors to carbon dioxide and decreasing activity in the central respiratory centers. Opioids have also been reported to affect the immune system, and place users at increased risk for many different infectious complications. Patients can have a wide array of signs and symptoms, sometimes making it difficult to recognize opioids as a cause for a patient's clinical picture. Due to the sedative effects of opioids, patients are also often not able to provide a reliable history. Knowledge of the possible toxicities of opioids can help prepare a physician to recognize the many complications associated with opioid use.
This paper is the thirty-fourth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2011 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration (Section 16); and immunological responses (Section 17).
To evaluate an experimental heroin maintenance programme. Design: Randomised trial.
Outpatient clinic in Geneva, Switzerland.
Heroin addicts recruited from the community who were socially marginalised and in poor health and had failed in at least two previous drug treatments.
Patients in the experimental programme (n=27) received intravenous heroin and other health and psychosocial services. Control patients (n=24) received any other conventional drug treatment (usually methadone maintenance). Main outcome measures: Self reported drug use, health status (SF-36), and social functioning.
25 experimental patients completed 6 months in the programme, receiving a median of 480 mg of heroin daily. One experimental subject and 10 control subjects still used street heroin daily at follow up (difference 44%; 95% confidence interval 16% to 71%). Health status scores that improved significantly more in experimental subjects were mental health (0.58 SD; 0.07 to 1.10), role limitations due to emotional problems (0.95 SD; 0.11 to 1.79), and social functioning (0.65 SD; 0.03 to 1.26). Experimental subjects also significantly reduced their illegal income and drug expenses and committed fewer drug and property related offences. There were no benefits in terms of work, housing situation, somatic health status, and use of other drugs. Unexpectedly, only nine (38%) control subjects entered the heroin maintenance programme at follow up.
A heroin maintenance programme is a feasible and clinically effective treatment for heroin users who fail in conventional drug treatment programmes. Even in this population, however, another attempt at methadone maintenance may be successful and help the patient to stop using injectable opioids.
To determine whether supervised medical prescription of heroin can successfully treat addicts who do not sufficiently benefit from methadone maintenance treatment.
Two open label randomised controlled trials.
Methadone maintenance programmes in six cities in the Netherlands.
549 heroin addicts.
Inhalable heroin (n = 375) or injectable heroin (n = 174) prescribed over 12 months. Heroin (maximum 1000 mg per day) plus methadone (maximum 150 mg per day) compared with methadone alone (maximum 150 mg per day). Psychosocial treatment was offered throughout.
Dichotomous, multidomain response index, including validated indicators of physical health, mental status, and social functioning.
Adherence was excellent with 12 month outcome data available for 94% of the randomised participants. With intention to treat analysis, 12 month treatment with heroin plus methadone was significantly more effective than treatment with methadone alone in the trial of inhalable heroin (response rate 49.7% v 26.9%; difference 22.8%, 95% confidence interval 11.0% to 34.6%) and in the trial of injectable heroin (55.5% v 31.2%; difference 24.3%, 9.6% to 39.0%). Discontinuation of the coprescribed heroin resulted in a rapid deterioration in 82% (94/115) of those who responded to the coprescribed heroin. The incidence of serious adverse events was similar across treatment conditions.
Supervised coprescription of heroin is feasible, more effective, and probably as safe as methadone alone in reducing the many physical, mental, and social problems of treatment resistant heroin addicts.
The study examined health conditions among an aging cohort of male narcotics addicts. This prospective cohort study (1964-1998) included interviews and medical testing for 108 surviving subjects who had been admitted to the California Civil Addict Program during the years 1962 through 1964. Medical testing results were: 51.9% had high blood pressure, 22.4% showed hyperlipidemia, 13.3% had elevated levels of blood glucose, 33.6% had abnormal pulmonary function, half of the sample had abnormal liver function, and 94.2% tested positive for hepatitis C, 85.6% for hepatitis B, 3.8% for syphilis, and 27.3% for TB. The study empirically demonstrated poor health conditions and high morbidity among surviving narcotics addicts.
Heroin-assisted substitution treatment for severely opioid-dependent drug users has been available in Switzerland since 1994. Our aim was to ascertain the feasibility, safety, and efficacy of this treatment.
We did a cohort study in 21 community outpatient treatment centres. We assessed 1969 opioid-dependent drug users, who began heroin-assisted substitution treatment between January, 1994, and December, 2000, to ascertain admission and discharge patterns, and patient characteristics. We also followed up a subset of 237 patients who began treatment between Jan 1, 1994, and March 31, 1995, and who stayed with the programme for at least 18 months. We used questionnaires, interviews, and medical examinations done at entry and after 6, 12, and 18 months to assess somatic and mental health, social integration, and treatment outcomes.
More than 70% (1378) of patients remained in treatment for more than a year. Treatment showed positive effects with respect to health and social outcomes. A long stay in treatment was related to a higher chance of starting abstinence-oriented therapy than a short stay.
Heroin-assisted substitution treatment might be an effective option for chronically addicted patients for whom other treatments have failed.
To describe the pulmonary function and prevalence of dyspnoea among methadone patients and to study the relation with exposure to heroin by inhaling.
A sample of 100 patients from methadone maintenance treatment (84% male, average age 42 years).
Questionnaires were used to measure life-time exposure to heroin, cocaine, cannabis, tobacco, and symptoms of dyspnoea. Spirometry was performed and residual difference of measured FEV(1) from the age, sex, height and ethnicity predicted value (delta FEV(1)) was used as a main outcome parameter.
The median delta FEV(1) was -0.26 l (inter quartile range -0.70; +0.12). Twenty per cent experienced dyspnoea while 'walking at a normal pace with someone of their own age'. History of cigarette smoking was reported by 98%; heroin smoking by 88%. Multiple linear regression analysis showed a statistically significant association between heroin-smoking and delta FEV(1), logistic regression analysis showed an association between heroin-smoking and prevalence of dyspnoea.
Chronic heroin smoking seems to be related to an impaired lung function and higher prevalence of dyspnoea. However, part of the observed lung function impairment will be caused by tobacco smoking. Further research is needed to quantify the effect of heroin smoking and disentangle the effect of smoking heroin and tobacco.