3.31.2013

Substance Abuse Disorder: Heroin


by Tina Handrick


Part I Introduction
Heroin is an illegal drug that is processed from morphine, which occurs naturally in the 
Heroin-Addict Inhales Smoke from Heated Heroin
Heroin-Addict Inhales Smoke from Heated Heroin (Photo credit: nicolas - نيكولس)
seedpod of the Asian opium poppy plant. Heroin is the most widely used opiate out there today, and it is fast acting. Most heroin substance is found in a powder form and it is either white or brown in color, but once it is cut on the street is could be off white. There is another form of heroin that is black and sticky, this is usually called black tar heroin and it is illegally trafficked and distributed out on the streets. Heroin is extremely addictive and depending on how an individual uses the drug, and the intensity of use a person can become dependent very fast, and develop a heroin addiction that will require a medical detoxification that can be very mentally and physically challenging because of the effects of the withdrawal process.
At the first use of heroin that is when the abuse can start because of the intense rush and euphoric feelings that the user believes is awesome. A first time user may experience a rush of intense pleasure, which is the followed by a warm sensation in the skin, their mouth will become dry, and their limbs will feel heavy, some people may even experience nausea, vomiting, and intense itching. After a while when these effects begin to wear off the user is usually drowsy and sleepy for a few hours, this can be very dangerous because the users breathing begins to slow down, and if they person has overdosed on heroin this is when they could quit breathing and die (Heroin.org, nd.).
Heroin-Addict Displays Smoking-Paraphernalia
Heroin-Addict Displays Smoking-Paraphernalia (Photo credit: nicolas - نيكولس)
Heroin is very addictive and one of the reasons is because it reaches the brain extremely fast and affects the users both psychologically and physically. Heroin is so addictive because of the neurochemical and molecular changes in the brain that take place when the drug is being used. When the rush is first experienced a surge of dopamine is produces, this is the chemical that is responsible for the rush of euphoria and pleasure that a person experiences. The rush can be so intense that a person can’t wait to achieve the high again and again so they repeat the use as often as they can. After a while a person builds up a tolerance for the drug and when the user has come down off of their high they are no longer experiencing the same emotional and mental rush as they did in the beginning so they will use more and more, they will then begin to experience withdrawals from heroin because of the way they are abusing it. The stronger the level of addiction a person has for the drug, the more intense the physical symptoms are when they need to use again. The withdrawal symptoms that are a part of the addiction and because they're so uncomfortable and the cravings are so intense, the user now isn't just abusing heroin to experience that rush of euphoria, they're using because they are mentally, emotionally, and physically have to because of what it does to their bodies (Heroin.org, nd.).
Published by the American Psychiatric Associat...
Published by the American Psychiatric Association, the DSM-IV-TR provides a common language and standard criteria for the classification of mental disorders. (Photo credit: Wikipedia)
According to the DSM-IV substance abuse has genetic factors that play a role in both the dependency and abuse. There are other theories that involve the use of substances as a means to cover up or to get relief from other problems (e.g. psychosis, relationship issues, stress), which can make the dependency or abuse of a symptom than a disorder in itself (AllPsych & Heffner Media Group, 2011). The pattern of substance use leading to significant impairment in functioning is the following in a twelve month period: (1) recurrent use resulting in a failure to fulfill major obligations at work, school, or home; (2) recurrent use in situations which are physically hazardous (e.g., driving while intoxicated); (3) legal problems resulting from recurrent use; or (4) continued use despite significant social or interpersonal problems caused by the substance use. The symptoms do not meet the criteria for substance dependence as abuse is a part of this disorder (AllPsych & Heffner Media Group, 2011). Research suggests that there is no treatment method that is superior, but that social support is very important for treatment.  An openness to accept the abuse is also paramount in successfully treating the illness.  Organizations such as AA and NA have had better than average success in reducing relapse (AllPsych & Heffner Media Group, 2011). Prognosis is variable, because both substance abuse and dependence is difficult to treat and often involves a cycle of abstinence from the substance and substance use (AllPsych & Heffner Media Group, 2011).
Black tar heroin
Black tar heroin (Photo credit: Wikipedia)
Alcohol dependency and dependence of other drugs frequently occur at the same time, and there is strong evidence suggests that both disorders are, at least in part, are influenced by genetic factors. There are studies using twins that suggest that the overlap between dependence on alcohol and on other drugs largely results from shared genetic factors. This common genetic liability, which also extends to antisocial behavior, has been conceptualized as a general predisposition toward a variety of forms of psychopathology characterized by disinhibited behavior (i.e., externalizing psychopathology). Accordingly, many of the genetic factors affecting risk for dependence on alcohol or other drugs appear to act through a general externalizing factor; however, other genetic factors appear to be specific to a certain disorder. In recent years, researchers have identified numerous genes as affecting risk for dependence on alcohol and other drugs. These include genes involved in alcohol metabolism as well as in the transmission of nerve cell signals and modulation of nerve cell activity (i.e., γ-aminobutyric acid [GABA] and acetylcholinergic neurotransmission and the endogenous opioid and cannabinoid systems) (Dick & Agrawal).
Nick's heroin addiction (1991)
Nick's heroin addiction (1991) (Photo credit: Wikipedia)
Alcohol dependence frequently co-occurs with the dependence on illicit drugs (Hasin et al. 2007). Both alcohol use disorders (i.e., alcohol abuse and alcohol dependence) and drug use disorders (drug abuse and drug dependence) are influenced by several factors. For example, family, twin, and adoption studies have convincingly demonstrated that genes contribute to the development of alcohol dependence, with heritability estimates ranging from 50 to 60 percent for both men and women (McGue 1999) ( For a definition of these and other terms, see the glossary, pp. 177–179). Dependence on illicit drugs only more recently has been investigated in twin studies, but several studies now suggest that illicit drug abuse and dependence also are under significant genetic influence. In these studies of adult samples, heritability estimates ranged from 45 to 79 percent (for reviews, see Agrawal and Lynskey 2006; Kendler et al. 2003a; Tsuang et al. 2001).
Twin studies can also be used to assess the extent to which the co-occurrence of disorders is influenced by genetic and/or environmental factors. Thus, a finding that the correlation between alcohol dependence in twin 1 and drug dependence in twin 2 is higher for identical (i.e., monozygotic) twins, who share 100 percent of their genes, than for fraternal (i.e., dizygotic) twins, who share on average only 50 percent of their genes, indicates that shared genes influence the risk of both alcohol and drug dependence. The twin studies conducted to date support the role of such shared genetic factors. For example, in the largest twin study of the factors underlying psychiatric disorders, Kendler and colleagues (2003b) analyzed data from the Virginia Twin Registry and found that a 
English: Pre-war Bayer heroin bottle, original...
English: Pre-war Bayer heroin bottle, originally containing 5 grams of Heroin substance. (Photo credit: Wikipedia)
common genetic factor contributed to the total variance in alcohol dependence, illicit drug abuse and dependence, conduct disorder, and adult antisocial behavior. This pattern also has been identified in several other independent twin studies (Krueger et al. 2002; Young et al. 2000). Taken together, these findings suggest that a significant portion of the genetic influence on alcohol dependence and drug dependence is through a general predisposition toward externalizing disorders, which may manifest in different ways (e.g., different forms of AOD dependence and/or antisocial behavior) (see figure). However, some evidence also suggests that disorder-specific genetic influences contribute to AOD dependence (Kendler et al. 2003b). These specific influences likely reflect the actions of genes that are involved in the metabolism of individual drugs.
In the case of Ellis, he was a product of his environment because of the alcoholic issues and the physical abuse that his father had shown in the home, and this lead to Ellis first starting with alcohol and marijuana at the age of 11, then because of the drugs that were available in his community it made it easier for him to move into the harsher drug scene. Especially since his father thought it was funny that Ellis and his brothers were coming home drunk and his mother never comforted any of them either. By the time that Ellis was in high school he had already experimented with many different drugs including cocaine, barbiturates, hallucinogens, and heroin and was drunk most of the week. So the genetic code was already in his system because of his father lack of will to stay clean for his family, and because of the abuse that he and his family experienced it made it very easy for him to fall into the wrong crowd.
Part II Biological
AODs (alcohol and other drugs) exert their behavioral effects in part by altering the transmission of signals among nerve cells (i.e., neurons) that are in the brain. This transmission is 
Map showing flow of heroin from Colombia to th...
Map showing flow of heroin from Colombia to the US. (Photo credit: Wikipedia)
mediated by chemical messengers (i.e., neurotransmitters) that are released by the signal-emitting neuron and bind to specific proteins (i.e., receptors) on the signal-receiving neuron. AODs influence the activities of several neurotransmitter systems, including those involving the neurotransmitters γ-aminobutyric acid (GABA), dopamine, and acetylcholine, as well as naturally produced compounds that structurally resemble opioids and cannabinoids. Accordingly, certain genes encoding components of these neurotransmitter systems may contribute to the risk of both alcohol dependence and illicit drug dependence (Dick & Agrawal).
GABA is the major inhibitory neurotransmitter in the human central nervous system that is, it affects neurons in a way that reduces their activity. Several lines of evidence suggest that GABA is involved in many of the behavioral effects of alcohol, including motor incoordination, anxiety reduction (i.e., anxiolysis), sedation, withdrawal signs, and preference for alcohol (Grobin et al. 1998). GABA interacts with several receptors, and much of the research on alcohol’s interactions with the GABA system has focused on the GABAA receptor. This receptor also is the site of action for several medications that frequently are misused and have high addictive potential, such as benzodiazepines, barbiturates, opiates, a-hydroxybutyrates, and other sedative–hypnotic compounds. Accordingly, this receptor likely is involved in dependence on these drugs as well (Orser 2006) (Dick & Agrawal).
The medication that is usually used to help a person suffering from heroin addiction is methadone, and it is used to help a person with the strong withdrawal symptoms of heroin. By using this substance, patients can stabilize and start revalidation or rehabilitation. However, some patients will never be able to stay abstinent for a long time. In that case, it is better to focus on decreasing the physical risk and the chance of death (Moelker, 2008). This can allow for the neurotransmitters to quiet down and to become for normal, but that is not always the case and some abusers will go back to using heroin again or they become addicted to methadone.
The genetic contributions suggest that if a parent is a carrier of drugs and alcohol gene that makes them more easily prone to become addicted then it is more than likely that a child will also have the same genes. There has to be factors that “turns on” this gene, for example if a person lives in an environment that they do not have access to drugs and alcohol then they will most likely never have issues with an addiction, but if they live in an environment where there is drugs and alcohol on every corner then they will most likely try both of these.
English: Modified IM/IV syringe used for
English: Modified IM/IV syringe used for "plugging" heroin. (Photo credit: Wikipedia)
By the time that Ellis was an adult and had a family of his own, he tried to do the right thing and had a good paying job, worked hard to achieve a supervisor position and then it seems as if his addiction finally won the control of Ellis’s world, because of his continued use of heroin, he started to slack on his job duties, coming in late and leaving early. His substance abuse lead to this road: Ellis’s substance dependency history includes the following: (1) substance abuse; (2) continuation of use despite related problems; (3) increase in tolerance (more of the drug is needed to achieve the same effect); and (4) withdrawal symptoms (AllPsych & Heffner Media Group, 2011). Ellis started having issues at home and because he was going to work late and leaving early he was selling property at home to have money to buy more drugs, Ellis wife couldn’t understand what was going on with her husband and they would start physical fighting.
When Ellis realized that he was heading to termination he knew that he needed to take steps to get clean, so he went to his union and explained his problem to see if he can get help. The employee assistance program (EAP) contacted a residential treatment center and setup for Ellis to be admitted into the center the following week. Treatment is very hard for anyone but anyone that is a heroin addict it can be even more severe. Detoxification treatment may need to be administered due to the dangerousness of some of the withdrawal symptoms. Research suggests that no treatment method is superior, but that social support is very important.  Organizations such as AA and NA have had better than average success in reducing relapse (AllPsych & Heffner Media Group, 2011).
Part III Environmental
Roughly 10% of all people who experiment with drugs can become addicted. A combination of environmental and genetic factors influences the likelihood of an addiction (Genetic Science Learning Center, 2012). The environmental risk factors are a characteristic that is in a person's surroundings that can increase their likelihood of becoming addicted to drugs. A person may have many different environments, or domains, some of these influences are the community, family, school and friends. Their risk of addiction can develop in any of these domains depending on what is happening (Genetic Science Learning Center, 2012). Within the community a person can have a connection with either the bad or good elements. According to Eric Kindel, he suggested that the very genetic structure of cells could change as a result of learning, where genes that were inactive or dormant once they interact with the environment in such a way they could become active. So if you live in an environment where everyone knows one another and then you move away and become lost in the sea of people, then that environment could turn on certain genes.
Heroin-Addicts Consume in Sewage-Trench
Heroin-Addicts Consume in Sewage-Trench (Photo credit: nicolas - نيكولس)
Many times people just thought that the environments only had influence on a person as they were growing into adulthood but that once you were grown up that the environment would not have that much of an influence on your structure, functions of our internal organs and most of our physiology were already set in the way that they are going to go, when it comes to the brain but apparently age isn’t a deciding factor. Ellis was a heroin addict and he grew up in a home where his father was an alcoholic, his father did not care what his boys were up and so that allowed Ellis to have a lot of freedom and so he started experimenting with drugs and alcohol by the time he was 11 years old. In the neighborhood that Ellis lived in, drugs were available to him because his friends were daily users, so by the time that Ellis was in high school he had already experimented with a variety of drugs and he was drunk six days a week. So between his father’s influence at home and the environment in which he lived it was very easy for Ellis to walk down this path of addiction.
With the environmental influences and the genetics that a person has are both working together and it all depends on the circumstances in which a person lives and how their genetic codes are made up, that can triggered for them to become active, in the case of Ellis his father would binge drink and then either beat his wife or his sons, but at any other time he was good natured and happy, and because Ellis’s mother was quiet and never confronted her husband or children on their behaviors then just encouraged Ellis to continue his lifestyle.  
Part IV Treatment
For many heroin users methadone is the most common medication to help them get through the withdrawal symptoms when they are trying to become rehabilitated. Psychosocial treatments are an effective parts of the total treatment plan for any patients with opiate disorders. Cognitive behavioral therapy, behavioral therapy, psychodynamic therapy, group therapy and family therapy can be very effective with heroin dependence. The choice for a certain treatment should be made after it is obvious what the patient wants, what problems that need to be solved, whether there are any other psychological problems, and what have been the results of earlier treatments. A patient that has mild or moderate withdrawal symptoms can sometimes deal with these problems at home. The 
Development of a rational scale to assess the ...
Development of a rational scale to assess the harm of drugs of potential misuse, The Lancet, 2007 (Photo credit: Wikipedia)
treatment of a heroin withdrawal syndrome is usually focused on relief of the critical symptoms and the motivation to take part in a long-term treatment of heroin addiction. Methadone can be prescribed temporarily and also Clonidine can be used to suppress the withdrawal symptoms. The use of other narcotics can interfere with or complicate the attempt to kick the habit (Moelker, 2008).
The success of the treatment depends on various things:
•           The quantity and the kind of substances used.
•           The severity of the disorder and the consequences.
•           Simultaneous physical and/or psychological disorders.
•           The strong and weak characteristics of the patient.
•           The patient's motivation!!!
•           The social surroundings of the patient (friends, acquaintances, colleagues, family, etc.)
There are other medicines similar to Methadone, such as Subutex, Subuxone and LAAM (a long-acting preparation) (Moelker, 2008).
In Ellis case it is important for him to get his family involved in his treatment plan, by getting his wife and children to come in and talk about what was going on in the home before he sought help, could in the end help him to understand what his triggers were as the years went by for him to continue using drugs and made it even worse in the end. Ellis also could benefit from group therapy because by his peers holding him accountable and vice versa could help him come to terms with what he needs to do to stay clean once he is back at home. It is better to use more than one treatment practice because then Ellis can see why his life made the turn that it did when he was still an adolescent and continued to adulthood. Ellis also needs to hold his parents accountable for their part in it. So by getting his family, his peers, and the center involved in his treatment then he will have a harder time falling back into old patterns that could lead him back down the road of using.
Conclusion
English: Converting Heroin Tar into
English: Converting Heroin Tar into "Monkey Water" for Administration through the Nasal Cavities, Rectum, or Veins. (Photo credit: Wikipedia)
Cognitive behavior model is a general treatment for several different types of therapies that could look at all kinds of angles that an addict could be using heroin. By allowing the therapist to work on several different areas in a user’s life allows the users to realize that even though they have grown up in an area where drugs were available did not mean that they should have followed along that path. Ellis’s issues were that his father was a binge drinker and when he was drunk he would take out his anger on his wife and children, and by Ellis running around with his peers that were drinking and using drugs opened up away for him to get away from his home issues and then to develop issues of his own. Cognitive model allows a therapist to open up doors in Ellis life that he needs to face and confront so that he can accept that what happened when he was a child, that there wasn’t anything that he could do to change it, and it wasn’t his fault why his father acted the way that he did.
The new research that is out there today that suggests that heroin and morphine addiction can be blocked; researchers at the University of Adelaide in Australia worked with colleagues at the University of Colorado in the United States to pinpoint a "Our studies have shown conclusively that we can block addiction via the immune system of the brain, without targeting the brain's wiring," said Mark Hutchinson from Adelaide's School of Medical Sciences. "Both the central nervous system and the immune system play important roles in creating addiction, but our studies have shown we only need to block the immune response in the brain to prevent cravings for opioid drugs."(AFP Relax News, 2012).
These results will be published Thursday in the Journal of Neuroscience, reveal that laboratory studies showed that the drug known as plus-naloxone, which is not yet in clinical use, will selectively block the immune-addiction response. The researchers said that opioid drugs such as morphine and heroin bind to immune receptors in the brain known as TLR4 which then act as amplifiers for addiction, ramping up the "reward" effect of drugs of abuse to a high degree. The new drug automatically shuts this effect down, Hutchinson said. "It really reduces the reward level down to the equivalent of food, sex, and hugs," he told AFP. Professor Linda Watkins, from the Center for Neuroscience at the University of Colorado, said the work fundamentally changed understanding about opioids, reward and addiction. "We've suspected for some years that TLR4 may be the key to blocking opioid addiction, but now we have the proof," she said in a statement. The researchers believe the discovery could prove useful if plus-naloxone could become a co-formulated drug with morphine, to allow patients who need pain relief to take the drug without fear of addiction (AFP Relax News, 2012). But it could have a second application. "It can be used by itself potentially in 
Heroin-Addicts Dwell under a Flyover
Heroin-Addicts Dwell under a Flyover (Photo credit: nicolas - نيكولس)
addicted people to help their addiction," Hutchinson said. The research team says clinical trials could be underway within 18 months (AFP Relax News, 2012).
Ellis has a chance to come out of treatment and fully recover from his addiction of heroin but it really is all up to Ellis, because he is the one that has to follow through with any outpatient treatment, all group meeting and he needs to make sure that his family gets involved. When someone is an addict it doesn’t just involve that person but the whole family and if he tries to do it on his own he will most likely fail. By making sure the he stays on track with his treatment and that he is going to work and home without making any detours is very important to Ellis recovery, he needs to make sure that he does not hang out with any friends that were involved with his addiction, he cannot go to any facility where the drugs or alcohol are being sold, and he needs to make sure that if he has any issues that he tells his therapist about it. Ellis needs to make sure that he doesn’t let himself down.








References:
Durand, M. & Barlow, D. (2007). Essentials of Abnormal Psychology. Mason, OH: Cengage Learning.
Heroin.Org; Heroin Addiction, Abuse, Detox and Withdrawals; http://www.heroin.org/
AllPsych Online & Heffner Media Group (2011) The Virtual Psychology Classroom: Substance Abuse; http://allpsych.com/disorders/substance/substanceabuse.html
Dick & Agrawal, D. &. A. (n.d.). The genetics of alcohol and other drug dependence. Retrieved from http://pubs.niaaa.nih.gov/publications/arh312/111-118.htm
Hasin, D.S.; Stinson, F.S.; Ogburn, E.; and Grant, B.F. Prevalence, correlates, disability and co-morbidity of DSM-IV alcohol abuse and dependence in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Archives of General Psychiatry 64:830–842, 2007. PMID: 17606817
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Moelker, W. (2008) Treatment of Heroin Addicts/Abusers; http://web4health.info/en/answers/add-heroin-treat.htm

Kendler, K.S.; Prescott, C.A.; Myers, J.; and Neale, M.C. The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Archives of General Psychiatry 60:929–937, 2003b. PMID: 12963675
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Breakthrough research shows heroin addiction can be blocked with new drug, AFP RELAX NEWS (2012). http://www.nydailynews.com/life-style/health/breakthrough-research-shows-heroin-addiction-blocked-new-drug-article-1.1137724
 Dick, D. & Agrawal, A. The Genetics of Alcohol and Other Drug Dependence: nd. http://pubs.niaaa.nih.gov/publications/arh312/111-118.htm













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