Diamorphine or Heroin on prescription

Note -until we add our own detailed information to this section -here is what we think is a useful summary on diamorphine and heroin from the site http://pmocare.com/heroin-information-pmo-care-bellevue/

Under the chemical name diamorphine, diacetylmorphine is prescribed as a strong analgesic in the United Kingdom, where it is given via subcutaneousintramuscularintrathecal or intravenous route. Its use includes treatment for acute pain, such as in severephysical traumamyocardial infarction, post-surgical pain, and chronic pain, including end-stage cancer and other terminal illnesses. In other countries it is more common to use morphine or other strong opioids in these situations. In 2004, the National Institute for Health and Clinical Excellence, a non-departmental public body of the Department of Health in the United Kingdom, produced guidance on the management of caesarian section, which recommended the use of intrathecal or epidural diacetylmorphine for post-operative pain relief.[16]

In 2005, there was a shortage of diacetylmorphine in the UK, because of a problem at the main UK manufacturers.[17] Because of this, many hospitals changed to using morphine instead of diacetylmorphine. Although there is no longer a problem with the manufacturing of diacetylmorphine in the UK, some hospitals there have continued to use morphine. The majority, however, continue to use diacetylmorphine, and diacetylmorphine tablets are supplied for pain management.

Diacetylmorphine continues to be widely used in palliative care in the UK, where it is commonly given by the subcutaneous route, often via a syringe driver, if patients cannot easily swallow oral morphine solution. The advantage of diacetylmorphine over morphine is that diacetylmorphine is more fat soluble and therefore more potent by injection, so smaller doses of it are needed for the same analgesic effect. Both of these factors are advantageous if giving high doses of opioids via the subcutaneous route, which is often necessary inpalliative care.

The medical use of diacetylmorphine, in common with other strong opioids such as morphinefentanyl and oxycodone, is controlled in the UK by the Misuse of Drugs Act 1971. In the UK, it is a class A controlled drug and as such is subject to guidelines surrounding its storage, administration and destruction. Possession of diamorphine without a prescription is an arrestable offense. When diamorphine is prescribed in a hospital or similar environment, its administration must be supervised by two people who must then complete and sign a controlled drugs register (CD register) detailing the patient’s name, amount, time, date and route of administration. In the case of a physician administering diamorphine, then he/she may administer the drug alone, however the rule requiring two registered practitioners, such as anursemidwife or another physician to sign the CD register still applies. The use of a witness when administering diamorphine is to avoid the possibility of the drug being diverted onto the black market.

For safety reasons, many UK National Health Service hospitals now only permit the administration of intravenous diamorphine in designated areas. In practice this usually means a critical care unit, an accident and emergency department, operating theatres by ananaesthetist or nurse anaesthetist or other such areas where close monitoring and support from senior staff is immediately available. However, administration by other routes is permitted in other areas of the hospital. This includes subcutaneous, intramuscular, intravenously as part of a patient controlled analgesia setup, and as an already established epidural infusion pump. Subcutaneous infusion, along with subcutaneous and intramuscular injection (bolus administration) is often used in the patient’s own home, in order to treat severe pain in terminal illness.

Diacetylmorphine is also used as a maintenance drug to treat certain groups of addicts, normally long term chronic intravenous (IV) heroin users, and even in these situations it is only prescribed following exhaustive efforts at treatment via other means. It is thought that heroin users can walk into a clinic and walk out with a prescription, but the process takes many weeks (months or years even -in reality it is extremely hard to receive this prescription – ed) before a prescription for diacetylmorphine is issued. Though this is somewhat controversial among proponents of a zero tolerance drug policy, it has proven superior to methadone in improving the social and health situation of addicts.[18] See: Heroin prescription for addicts

Recreational use

Diacetylmorphine, almost always still called by its original trade name of heroin in non-medical settings, is used as a recreational drug for the transcendent relaxation and intense euphoria it induces. Anthropologist Michael Agar once described heroin as “the perfect whatever drug.”[19] Tolerance develops quickly, and increased doses are needed in order to achieve the same effects. Its popularity with recreational drug users, compared to morphine, reportedly stems from its perceived different effects.[20] In particular, users report an intense rush, an acute transcendent state of euphoria, which occurs while diacetylmorphine is being metabolized into 6-monoacetylmorphine (6-MAM) and morphine in the brain. Some believe that heroin produces more euphoria than other opioids upon injection; one possible explanation is the presence of 6-monoacetylmorphine, a metabolite unique to heroin – although a more likely explanation is the rapidity of onset. While other opioids of recreational use produce only morphine, heroin also leaves 6-MAM, also a psycho-active metabolite. However, this perception is not supported by the results of clinical studies comparing the physiological and subjective effects of injected heroin and morphine in individuals formerly addicted to opioids; these subjects showed no preference for one drug over the other. Equipotent injected doses had comparable action courses, with no difference in subjects’ self-rated feelings of euphoria, ambition, nervousness, relaxation, drowsiness, or sleepiness.[21]

Short-term addiction studies by the same researchers demonstrated that tolerance developed at a similar rate to both heroin and morphine. When compared to the opioidshydromorphonefentanyloxycodone, and pethidine/meperidine, former addicts showed a strong preference for heroin and morphine, suggesting that heroin and morphine are particularly susceptible to abuse and addiction. Morphine and heroin were also much more likely to produce euphoria and other positive subjective effects when compared to these other opioids.[21]

Some researchers have attempted to explain heroin use and the culture that surrounds it through the use of sociological theories. In Righteous Dopefiend, Philippe Bourgois and Jeff Schonberg use anomie theory to explain why people begin using heroin. By analyzing a community in San Francisco, they demonstrated that heroin use was caused in part by internal and external factors such as violent homes and parental neglect. This lack of emotional, social, and financial support causes strain and influences individuals to engage in deviant acts, including heroin usage.[22] They further found that heroin users practiced “retreatism”, a behavior first described by Howard Abadinsky, in which those suffering from such strain reject society’s goals and institutionalized means of achieving them.[23]

Prescription for addicts

The UK Department of Health’s Rolleston Committee Report[24] in 1926 established the British approach to diacetylmorphine prescription to users, which was maintained for the next 40 years: dealers were prosecuted, but doctors could prescribe diacetylmorphine to users when withdrawing from it would cause harm or severe distress to the patient. This “policing and prescribing” policy effectively controlled the perceived diacetylmorphine problem in the UK until 1959 when the number of diacetylmorphine addicts doubled every 16 months during a period of ten years, 1959–1968.[25] In 1964, the Brain Committee recommended that only selected approved doctors working at approved specialised centres be allowed to prescribe diacetylmorphine and benzoylmethylecgonine (cocaine) to users. The law was made more restrictive in 1968. Beginning in the 1970s, the emphasis shifted to abstinence and the use of methadone; until now only a small number of users in the UK are prescribed diacetylmorphine.[26]

In 1994, Switzerland began a trial diamorphine maintenance program for users that had failed multiple withdrawal programs. The aim of this program was to maintain the health of the user by avoiding medical problems stemming from the illicit use of diacetylmorphine. The first trial in 1994 involved 340 users, although enrollment was later expanded to 1000 based on the apparent success of the program.

The trials proved diamorphine maintenance to be superior to other forms of treatment in improving the social and health situation for this group of patients.[27] It has also been shown to save money, despite high treatment expenses, as it significantly reduces costs incurred by trials, incarceration, health interventions and delinquency.[28]

Patients appear twice daily at a treatment center, where they inject their dose of diamorphine under the supervision of medical staff. They are required to contribute about 450Swiss francs per month to the treatment costs.[29] A national referendum in November 2008 showed 68% of voters supported the plan,[30] introducing diacetylmorphine prescription into federal law. The trials before were based on time-limited executive ordinances.

The success of the Swiss trials led German, Dutch,[31] and Canadian[32] cities to try out their own diamorphine prescription programs.[33] Some Australian cities (such as Sydney) have instituted legal diacetylmorphine supervised injecting centers, in line with other wider harm minimization programs.

Since January 2009, Denmark has prescribed diamorphine to a few addicts that have tried methadone and subutex without success.[34] Beginning in February 2010, addicts inCopenhagen and Odense will be eligible to receive free diacetylmorphine. Later in 2010 other cities including Århus and Esbjerg will join the scheme. In total, around 230 addicts will be able to receive free diacetylmorphine.[35] However, Danish addicts will only be able to inject heroin according to the policy set by Danish National Board of Health.[36] Of the estimated 1500 drug users who do not benefit from the current oral substitution treatment, approximately 900 will not be in the target group for treatment with injectable diacetylmorphine, either because of “massive multiple drug abuse of non-opioids” or “not wanting treatment with injectable diacetylmorphine”.[37]

In July 2009, the German Bundestag passed a law allowing diacetylmorphine prescription as a standard treatment for addicts; a large-scale trial of diacetylmorphine prescription had been authorized in that country in 2002.[38]

Detection in biological fluids

The major metabolites of diacetylmorphine, 6-MAM, morphine, morphine-3-glucuronide and morphine-6-glucuronide, may be quantitated in blood, plasma or urine to monitor for abuse, confirm a diagnosis of poisoning or assist in a medicolegal death investigation. Most commercial opiate screening tests cross-react appreciably with these metabolites, as well as with other biotransformation products likely to be present following usage of street-grade diacetylmorphine such as 6-acetylcodeine and codeine. However, chromatographic techniques can easily distinguish and measure each of these substances. When interpreting the results of a test, it is important to consider the diacetylmorphine usage history of the individual, since a chronic user can develop tolerance to doses that would incapacitate an opiate-naive individual, and the chronic user often has high baseline values of these metabolites in his system. Furthermore, some testing procedures employ a hydrolysis step prior to quantitation that converts many of the metabolic products to morphine, yielding a result that may be 2 times larger than with a method that examines each product individually.[39]

Adverse effects

Like most opioids, unadulterated heroin does not cause many long-term complications other than dependence and constipation.[40] The average purity of street heroin in the UK varies between 30% and 50% and heroin that has been seized at the border has purity levels between 40% and 60%; this variation has led to people suffering from overdoses as a result of the heroin missing a stage on its journey from port to end user, as each set of hands that the drug passes through adds further adulterants, the strength of the drug reduces, with the effect that if steps are missed, the purity of the drug reaching the end user is higher than they are used to and because they are unable to tolerate the increase, an overdose ensues.[41] Intravenous use of heroin (and any other substance) with non-sterile needles and syringes or other related equipment may lead to:

  • The risk of contracting blood-borne pathogens such as HIV and hepatitis by the sharing of needles
  • The risk of contracting bacterial or fungal endocarditis and possibly venous sclerosis
  • Abscesses
  • Poisoning from contaminants added to “cut” or dilute heroin
  • Physical dependence can result from prolonged use of all opioids, resulting in withdrawal symptoms on cessation of use
  • Decreased kidney function (although it is not currently known if this is because of adulterants or infectious diseases)[42]

Many countries and local governments have begun funding programs that supply sterile needles to people who inject illegal drugs in an attempt to reduce these contingent risks, and especially the spread of blood-borne diseases. The Drug Policy Alliance reports that up to 75% of new AIDS cases among women and children are directly or indirectly a consequence of drug use by injection .[citation needed] The United States federal government does not operate needle exchanges, although some state and local governments do support needle exchange programs.

Anthropologists Philippe Bourgois and Jeff Schonberg performed a decade of field work among homeless heroin and cocaine addicts in San Francisco, published in 2009. They reported that the African-American addicts they observed were more inclined to “direct deposit” heroin into a vein, while “skin-popping” was a far more widespread practice: “By the midpoint of our fieldwork, most of the whites had given up searching for operable veins and skin-popped. They sank their needles perfunctorily, often through their clothing, into their fatty tissue.” Bourgois and Schonberg describes how the cultural difference between the African-Americans and the whites leads to this contrasting behavior, and also points out that the two different ways to inject heroin comes with different health risks. Skin-popping more often results in abscesses, and direct injection more often leads to fatal overdose and also to hepatitis C and HIV infection.[22]

Heroin overdose is usually treated with an opioid antagonist,[citation needed] such as naloxone (Narcan), or naltrexone, which has high affinity for opioid receptors but does not activate them. This reverses the effects of heroin and other opioid agonists and causes an immediate return of consciousness but may precipitate withdrawal symptoms. The half-life of naloxone is much shorter than that of most opioid agonists, so that antagonist typically has to be administered multiple times until the opioid has been metabolized by the body.

Depending on drug interactions and numerous other factors, death from overdose can take anywhere from several minutes to several hours because of anoxia resulting from the breathing reflex being suppressed by agonism of µ-opioid receptors. An overdose is immediately reversible with an opioid antagonist injection. Heroin overdoses can occur because of an unexpected increase in the dose or purity or because of diminished opioid tolerance. However, many fatalities reported as overdoses are probably caused by interactions with other depressant drugs like alcohol or benzodiazepines.[43] It should also be noted that since heroin can cause nausea and vomiting, a significant number of deaths attributed to heroin overdose are caused by aspiration of vomit by an unconscious victim. Some sources quote the median lethal dose (for an average 75 kg opiate-naive individual) as being between 75 and 600  mg.[44][45] Experiments on simians have demonstrated therapeutic indexes up to 50.[46] Illicit heroin is of widely varying and unpredictable purity. This means that the user may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, tolerance typically decreases after a period of abstinence. If this occurs and the user takes a dose comparable to their previous use, the user may experience drug effects that are much greater than expected, potentially resulting in a dangerous overdose. It has been speculated that an unknown portion of heroin related deaths are the result of an overdose or allergic reaction to quinine, which may sometimes be used as a cutting agent.[47]

A final factor contributing to overdoses is place conditioning. Heroin use is a highly ritualized behavior. While the mechanism has yet to be clearly elucidated, longtime heroin users display increased tolerance to the drug in locations where they have repeatedly administered. When the user injects in a different location, this environment-conditioned tolerance does not occur, resulting in a greater drug effect. The user’s typical dose of the drug, in the face of decreased tolerance, becomes far too high and can be toxic, leading to overdose.[48]

A small percentage of heroin smokers, and occasionally IV users, may develop symptoms of toxic leukoencephalopathy. The cause has yet to be identified, but one speculation is that the disorder is caused by an uncommon adulterant that is only active when heated.[49][50][51] Symptoms include slurred speech and difficulty walking.

Cocaine is sometimes used in combination with heroin, and is referred to as a speedball when injected or moonrocks when smoked together. Cocaine acts as a stimulant, whereas heroin acts as a depressant. Coadministration provides an intense rush of euphoria with a high that combines both effects of the drugs, while excluding the negative effects, such as anxiety and sedation. The effects of cocaine wear off far more quickly than heroin, thus if an overdose of heroin was used to compensate for cocaine, the end result is fatalrespiratory depression.[citation needed]

Withdrawal

Main article: Opioid withdrawal

The withdrawal syndrome from heroin (the so-called “cold turkey“) may begin within 6 to 24 hours of discontinuation of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose. Symptoms may include:[52] sweatingmalaiseanxiety, depression, akathisiapriapism, extra sensitivity of the genitals in females, general feeling of heaviness, excessive yawning or sneezingtearsrhinorrhea, sleep difficulties (insomnia), cold sweats, chills, severe muscle and bone aches, nausea, vomiting, diarrheacramps, watery eyes,[53] fever and cramp-like pains and involuntary spasms in the limbs (thought to be an origin of the term “kicking the habit”[54]).

Routes of administration

Ingestion does not produce a rush as forerunner to the high experienced with the use of heroin, which is most pronounced with intravenous use. While the onset of the rush induced by injection can occur in as little as a few seconds, the oral route of administration requires approximately half an hour before the high sets in. Thus, with both higher the dosage of heroin used and faster the route of administration used, the higher potential risk for psychological addiction.The onset of heroin’s effects depends upon the route of administration. Studies have shown that the subjective pleasure of drug use (the reinforcing component of addiction) is proportional to the rate at which the blood level of the drug increases.[66] Intravenous injection is the fastest route of drug administration, causing blood concentrations to rise the most quickly, followed by smoking,suppository (anal or vaginal insertion), insufflation (snorting), and ingestion (swallowing).

Large doses of heroin can cause fatal respiratory depression, and the drug has been used for suicide or as a murder weapon. The serial killer Dr Harold Shipman used diamorphine on his victims, and the subsequent “Shipman Inquiry” led to a tightening of the regulations surrounding the storage, prescribing and destruction of controlled drugs in the UK. Dr John Bodkin Adams (see his victimEdith Alice Morrell) is also known to have used heroin as a murder weapon.

Because significant tolerance to respiratory depression develops quickly with continued use and is lost just as quickly during withdrawal, it is often difficult to determine whether a heroin lethal overdose was accidental, suicide or homicide. Examples include the overdose deaths of Sid ViciousJanis JoplinTim BuckleyHillel SlovakLayne StaleyBradley NowellTed Binion, and River Phoenix.[67]

Chronic use of heroin and other opioids, has been shown to be a potential cause of hyponatremia, resultant because of excessvasopressin secretion.

Oral

Oral use of heroin is less common than other methods of administration, mainly because there is little to no “rush”, and the effects are less potent.[68] Heroin is entirely converted to morphine by means of first-pass metabolism, resulting in deacetylation when ingested. Heroin’s oral bioavailability is both dose-dependent (as is morphine’s) and significantly higher than oral use of morphine itself, reaching up to 64.2% for high doses and 45.6% for low doses; opiate-naive users showed far less absorption of the drug at low doses, having bioavailabilities of only up to 22.9%. The maximum plasma concentration of morphine following oral administration of heroin was around twice as much as that of oral morphine.[69]

Injection

Injection, also known as “slamming”, “banging”, “shooting up”, “digging” or “mainlining”, is a popular method which carries relatively greater risks than other methods of administration. Heroin base (commonly found in Europe), when prepared for injection will only dissolve in water when mixed with an acid (most commonly citric acid powder or lemon juice) and heated. Heroin in the East coast United States is most commonly found in the hydrochloride salt form, requiring just water (and no heat) to dissolve. Users tend to initially inject in the easily accessible arm veins, but as these veins collapse over time, users resort to more dangerous areas of the body, such as the femoral vein in the groin. Users who have used this route of administration often develop a deep vein thrombosis.[medical citation needed] Intravenous users can use a various single dose range using a hypodermic needle. The dose of heroin used for recreational purposes is dependent on the frequency and level of use, thus a first-time user may use between 5 and 20 mg, while an established addict may require several hundred mg per day. As with the injection of any drug, if a group of usersshare a common needle without sterilization procedures, blood-borne diseases, such as HIV or hepatitis, can be transmitted. The use of a common dispenser for water for the use in the preparation of the injection, as well as the sharing of spoons and/or filters can also cause the spread of blood borne diseases. Many countries now supply small sterile spoons and filters for single use in order to prevent the spread of disease.[70]

Smoking

Smoking heroin refers to vaporizing it to inhale the resulting fumes, not burning it to inhale the resulting smoke. It is commonly smoked in glass pipes made from glassblown Pyrex tubes and light bulbs. It can also be smoked off aluminium foil, which is heated underneath by a flame and the resulting smoke is inhaled through a tube of rolled up foil, This method is also known as “chasing the dragon” (whereas smoking methamphetamine is known as “chasing the white dragon”).

Insufflation

Another popular route to intake heroin is insufflation (snorting), where a user crushes the heroin into a fine powder and then gently inhales it (sometimes with a straw or a rolled up banknote, as with cocaine) into the nose, where heroin is absorbed through the soft tissue in the mucous membrane of the sinus cavity and straight into the bloodstream. This method of administration redirects first pass metabolism, with a quicker onset and higher bioavailability than oral administration, though the duration of action is shortened. This method is sometimes preferred by users who do not want to prepare and administer heroin for injection or smoking, but still experience a fast onset. Snorting heroin becomes an often unwanted route, once a user begins to inject the drug. The user may still get high on the drug from snorting, and experience a nod, but will not get a rush. A “rush” is caused by a large amount of heroin entering the body at once. When the drug is taken in through the nose, the user does not get the rush because the drug is absorbed slowly rather than instantly.

Suppository

Little research has been focused on the suppository (anal insertion) or pessary (vaginal insertion) methods of administration, also known as “plugging”. These methods of administration are commonly carried out using an oral syringe. Heroin can be dissolved and withdrawn into an oral syringe which may then be lubricated and inserted into the anus or vagina before the plunger is pushed. The rectum or the vaginal canal is where the majority of the drug would likely be taken up, through the membranes lining their walls.

Regulation

In the Netherlands, diacetylmorphine is a List I drug of the Opium Law. It is available for prescription under tight regulation exclusively to long-term addicts for whom methadone maintenance treatment has failed. It cannot be used to treat severe pain or other illnesses.[71]

In the United States, diacetylmorphine is a schedule I drug according to the Controlled Substances Act of 1970, making it illegal to possess without a DEA license.[72] Possession of more than 100 grams of diacetylmorphine or a mixture containing diacetylmorphine is punishable with a minimum mandatory sentence of 5 years of imprisonment in a federal prison.

In Canada, diacetylmorphine is a controlled substance[73] under Schedule I of the Controlled Drugs and Substances Act (CDSA).[74] Any person seeking or obtaining diacetylmorphine without disclosing authorization 30 days prior to obtaining another prescription from a practitioner is guilty of an indictable offense and subject to imprisonment for a term not exceeding seven years. Possession of diacetylmorphine for the purpose of trafficking is an indictable offense and subject to imprisonment for life.

In Hong Kong, diacetylmorphine is regulated under Schedule 1 of Hong Kong‘s Chapter 134 Dangerous Drugs Ordinance. It is available by prescription. Anyone supplying diacetylmorphine without a valid prescription can be fined $10,000 (HKD). The penalty for trafficking or manufacturing diacetylmorphine is a $50,000 (HKD) fine and life imprisonment. Possession of diacetylmorphine without a license from the Department of Health is illegal with a $10,000 (HKD) fine and/or 7 years of jail time.[75]

In the United Kingdom, diacetylmorphine is available by prescription, though it is a restricted Class A drug. According to the 50th edition of the British National Formulary (BNF), diamorphine hydrochloride may be used in the treatment of acute pain, myocardial infarction, acute pulmonary oedema, and chronic pain. The treatment of chronic non-malignantpain must be supervised by a specialist. The BNF notes that all opioid analgesics cause dependence and tolerance but that this is “no deterrent in the control of pain in terminal illness”. When used in the palliative care of cancer patients, diacetylmorphine is often injected using a syringe driver.[76]

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