05-31-16 What are the many faces of heroin?

Question of the Week

May 31, 2016

What are the many faces of heroin?

Case scenario: EMS scene call unresponsive individual found with multiple pills stuffed up the nose look like Percocet _RX

Could you tell the difference?

Heroin has made an unsettling resurgence over the last several years. The opiate has many faces, the most recent phenomenon being heroin pills , or often known as Percs . As the name implies: Heroin disguised as Percocet _RX or oxycodone.

The pill comes complete with all of the trimmings: official stamp and color. This form is more profitable for dealers , for example 80 mg of oxycodone can sell for $80-$100. One hit of heroin may sell for $20.00 (ONDCP, 2015). Additionally, there is no other paraphernalia (e.g. needles, spoons) required, although the pills can be liquefied for injection. Many individuals purchase what they thought to be black-market Percocet _Rx, and are actually buying heroin.

This is an extremely disturbing trend. There are many opioid addicted individuals in the country. Statistics from the TN Dept. of Health revealed a drastic increase in the number of heroin related deaths: 147 in 2009 to 700 in 2014. The 2015 statistics are not yet available, however, according to the health department and the CDC, that number is expected to be higher for all forms of opioids. State health department personnel have indicated that the actual numbers are difficulty to assess, as heroin and other pain killers are placed in the same category.

Common side effects: bradycardia, hypotension, miosis, respiratory depression, acute lung injury, death from complications of side effects (Manton, 2014).

Treatment of unresponsive poisoned patient:

NALOXONE

• Naloxone is the specific antidote. Recommendations for children and adults from the Tennessee Poison Center are as follows:
• If patient is unresponsive - Bolus dose of 10 mg. If patient responds, begin infusion starting at 5 mg/hr, titrating down 1 mg/hr as patients condition improves.
• If the initial bolus dose required for reversal is lower than 10 mg, the subsequent

infusion would be � of the bolus e.g. 6 mg bolus/ 3 mg/hr infusion.

CLINICAL ALERTS!

• In an opioid addicted individual, high-dose naloxone may produce acute withdrawal symptoms but they are not life threatening.
• In heroin addicted individuals, (intravenous tracks may be present) administer 2 mg naloxone to avoid precipitating acute life-threatening withdrawal. If there is no response, administer higher doses.
• The duration of the opiate may often exceed the duration of naloxone. Therefore, patients must be observed for a minimum of 2 hours after discontinuation of naloxone

Implications for Health Care providers

The primary implications for HCPs is early identification of risk factors and expanding awareness and education regarding early administration of naloxone and supportive care.

References

American Academy of Pediatrics ( 2015)

Manton, A.( 2014). The Heroin Epidemic. Journal of Emergency Nursing, 40(6), 526-527.

Micromedex ( 2015). Retrieved from https://www.micromedexsolutions.com

ONDCP ( 2015). Heroin Task Force. Retrieved from https://www.whitehouse.gov/ondcp

This question prepared by: Jennifer C. Anderson, MSN, RN, CCRN, CPNP, CSPI (Certified Specialist in Poison Information) Tennessee Poison Center

Prescription opioids become more difficult to obtain due to more available data bases so physicians can check recent prescriptions. And heroin, being much cheaper, is becoming a drug of choice in our own area. Oral heroin (diacetylmorphine) has a very short half -life due to rapid conversion to 6-acetylmorphine and morphine. Both of these are active metabolites of heroin. Oral morphine is not well absorbed (bioavailability of 9%) but heroin acts as a prodrug and increases morphine bioavailability to 67%. Morphine bioavailability may be different in tolerant persons due to intestinal metabolic or transporter alterations. (Bioavailability is the degree to which the drug is absorbed and gets to the intended target organ) One does not get the same rush from oral heroin as from intravenous heroin as it is so rapidly metabolized in the liver (first pass) First pass may be avoided by buccal tablets . hmm /ds