|molecular formula||C21H23NO5 _ _ _ _ _|
|mechanism of action||
opioid receptor agonist
|molar mass||369.42 g mol −1 _|
|Wherever possible and customary, SI units are used. Unless otherwise noted, the data given apply under standard conditions .|
Heroin ( Greek made-up word : ἡρωίνη heroine , see Heros ), also diamorphine or diacetylmorphine (DAM), trade name Diaphin , is a semi-synthetic , strongly analgesic opioid and drug with a very high potential for dependence in any form of consumption. Despite the 1.5 to 3 times higher analgesic effectiveness of diamorphine compared to the parent substance morphine , the therapeutic use of diamorphine ( heroin ) is banned in most countries.
The history of the use of narcotic or euphoric opiates dates back to around 2000 to 3000 BC. to ancient Egypt . From the 19th century, chemists tried to find a synthetic equivalent to the natural substance extract opium and to develop a remedy that could be produced quickly and marketed accordingly.
In 1873, English chemist Charles Romley Alder Wright studied the reactions of alkaloids such as morphine with acetic anhydride . Twenty years later, the chemist and pharmacist Felix Hoffmann , who worked at the Bayer main plant in Elberfeld ( Wuppertal-Elberfeld ), dealt with this reaction, which led directly to diacetylmorphine. From this, Bayer developed a process for the synthesis of diacetylmorphine and had the brand name “Heroin” protected on June 27, 1898.
Heroin was marketed as an oral painkiller and cough suppressant in an advertising campaign in twelve languages . It has also been used for about 40 other indications, including high blood pressure , pulmonary disease, heart disease, labor and anesthetic induction, and as a "non-addictive drug" for morphine and opium withdrawal symptoms . It was thought that heroin had all the benefits of morphine but few side effects —only constipation and mild sexual apathy were thought to be the first. Heroin was initially well received by many doctors and patients. However, by 1904 it was recognized that heroin was even more addictive or more addictive than morphine , and that patients who took it repeatedly would soon need a larger amount of heroin to regain its initial effects. Some doctors have warned that heroin has the same addictive potential as morphine; this knowledge, however, spread only slowly. This was partly due to the fact that the oral dosage form causes the substance to be absorbed relatively slowly , which means that strong states of intoxication usually do not occur.
From about 1910, the danger posed by the drug heroin was recognized , particularly in the United States of America , where morphine and opium addiction was more common and widespread than in Europe . When it became known in the USA that smoked, snorted and especially intravenously injected heroin had a much stronger effect, many opioid addicts switched to the easily available substance, which also had fewer side effects than morphine (regarding histamine reactions ). Addiction grew rapidly, including among Chinese immigrants who were often stigmatized and associated with opium use. Initially, individual states in the USA enacted various laws prohibiting some opioids. Later, at the first Opium Conference in 1912, a nationwide ban was discussed for the first time.
In 1931, Bayer gave in to political pressure and ceased production, thereby removing heroin from its product range.
The first illegal manufacturing laboratories emerged in Marseille in the 1930s , where they were operated by the French Connection , led by Paul Carbone and François Spirito . The raw material came from Indochina and Turkey, was smuggled to France and refined there. This heroin was then brought mainly to the United States.
Despite the bans, the number of heroin addicts increased worldwide, especially after the Second World War and after the Vietnam War , because soldiers had come into contact with morphine and heroin during their deployments. After 1945, it was primarily the Italo-American mafia that organized the smuggling of heroin into the USA in cooperation with the Italian mafia and the French Connection (see Pizza Connection ) . The number of heroin addicts peaked in the 1970s. US President Richard Nixon used the term War on Drugs at a press conference on June 18, 1971, where he declared drug use “ public enemy number one ”. In 1982, the then US Vice President George HW Bush , among others, began using the CIA and US troops to reduce drug cultivation and trafficking abroad.
After temporary successes, the number of heroin addicts in the USA has increased sharply again since 2000, this time with areas away from the metropolitan areas being particularly affected. This is mostly associated with the fact that since the late 1990s American doctors have been increasingly prescribing opioids such as oxycodone , hydrocodone and fentanyl . When patients become addicted to these, they often switch to the much cheaper heroin: Four out of five heroin addicts in the US started with prescription opioids (see US opioid crisis ). This fact is used in particular by Mexican drug cartels, whose illegal heroin production is estimated to have increased by 600 percent between 2005 and 2009 alone in order to meet the growing demand in the USA. The addicts now come more than before from all walks of life and population groups. Nearly 13,000 Americans died from a heroin overdose in 2015, up 23 percent from 2014.
The medical use of heroin is now permitted under strict conditions in several countries – including Germany again since 2009; there is legal heroin production.
Heroin is produced semi-synthetically, the starting substance being morphine . Morphine is obtained as an extract from raw opium , the dried milky sap from the seed pods of the opium poppy (Papaver somniferum) . To produce heroin, the morphine base obtained in the first processing step is acetylated on the two hydroxy groups using acetic anhydride (acetic anhydride) or acetic acid chloride and converted to heroin base. Monoacetylated morphine can be formed as a by-product (e.g. 6-MAM ). With the addition of organic solvents (e.g. acetone ) and hydrochloric acid , what is known as heroin hydrochloride is formed in a further step. Pure heroin, both as the base and as the hydrochloride salt, is a colorless crystalline solid.
Diacetylmorphine has euphoric and analgesic effects similar to morphine , but administration tends to disrupt normal sleep . Depending on the form of administration , it has a half-life of four to six hours and is not toxic to the organs of the human body . Other effects on the unaccustomed body are the emetic ( Greek emesis = nausea) and respiratory depression. The side effect of constipation is not subject to tolerance - the active ingredient was used around the turn of the century as a remedy for diarrhea . In the case of an overdose, the main danger is respiratory depression , which can lead to respiratory arrest with fatal consequences , especially if other sedating psychotropic substances such as alcohol, benzodiazepines or barbiturates are also used in the sense of polytoxicomania (the so-called “ golden shot ”). In order to reverse the effect in the event of an overdose, opioid antagonists ( e.g. naloxone ) are used.
Heroin binds only weakly to the various opioid receptors, but acts as a prodrug (drug precursor) whose active metabolites mainly mediate the effect. The high intrinsic activity of 6-MAM on the µ-opioid receptor is worth mentioning ; it is higher than that of morphine and is therefore one of the decisive factors for the strong feeling of intoxication after intravenous heroin injection.
The doses that a physically addicted heroin takes often exceed 10 to 30 times the original therapeutic dose (single dose for pain relief: 2.5 to 20 mg in adults) of the substance. If you take into account the average degree of purity of black market heroin, which in Europe - apart from the Netherlands - is usually between 5 and 15% for the end customer, rarely more than 20% (as of 2006) - in the USA the degree of purity is now often significantly higher higher - an average long-term intravenous heroin user gets by with an amount that corresponds to 100-200 mg of the pure substance. When determining the not insignificant amount of heroin within the meaning of § 29a of the Narcotics Act , the case law in the Federal Republic of Germany assumed that a dose of 50 mg is lethal in a person who is not addicted to drugs, although this figure is most likely not correct and some studies of a much higher human LD 50 . This number appears to be more applicable to poly-drug use, which is very common and goes undetected in many hospital toxicity reports after fatal overdoses, especially when the substances are undetectable by standard drug screening or when it is the most common fatal poly-drug use, the with ethanol .
The effects of heroin last from 6 hours to often more than 24 hours in non-tolerant users, with after-effects sometimes lasting several days after the first use. In contrast, the effects of heroin in a physically addicted person, when consumed at an average high dose, last no longer than 6-8 hours, after which withdrawal symptoms slowly set in again. Opioids such as the diamorphine substitute methadone have a half-life of up to 24 hours. The dose tolerance of opioids increases rapidly with daily consumption, which is why many addicts constantly increase the dose within the scope of the substance's availability. With daily consumption, the amount that produced the desired effect the day before must be increased 1.5 to 2 times in order to achieve a comparable effect.
The bioavailability depends on the form of consumption. Heroin is significantly more lipophilic (fat-soluble) than morphine and therefore quickly reaches the brain, which leads to a strong flooding of the active receptors; therefore, an IV heroin injection triggers an initial "kick" (also called a flash ). With all forms of consumption other than intravenous injection, this effect is at least greatly weakened, if it exists at all, based on the current state of scientific knowledge due to the slower build-up. Reasons for this are slower absorption , premature hydrolysis and the first-pass effect .
Heroin's main route of metabolism is
- Heroin → 6-MAM → Morphine
Heroin is rapidly deacetylated in the body to 6-monoacetylmorphine (6-MAM) with a plasma half -life of three minutes . There is also the inactive metabolite 3-MAM. Both are further hydrolyzed to morphine (half-life about 20 minutes). About 1-10% of morphine is converted into the also active metabolite morphine-6-glucuronide, which has a significantly longer half-life than morphine itself and can therefore accumulate in patients with impaired renal function with long-term administration. Another 55-75% of morphine is metabolized to inactive morphine-3-glucuronide. It is also metabolized to about 5% to normorphine.
In forensic detection tests, so-called screening tests , the metabolic residues of chemical substances from various analgesics ( e.g. paracetamol ), barbiturates and opiates such as heroin can be toxicologically detected in the human body. For this purpose, in clinical chemistry, screening from blood serum , saliva , semen , heparin plasma or urine is used in suspected intoxication with medicines and drugs .
Chemically standardized, however, semi-synthetic opiates such as heroin can only be detected via urine excretion, since the diacetyl-morphine heroin is metabolized relatively quickly by the organism to form morphine. The urine test can also be falsified by opiate-like substances with the same structure or effect, such as codeine , which is found in commercially available painkillers or in antitussives (cough syrups). In this respect, a positive toxicological result does not necessarily indicate heroin abuse.
With no other common drug is the relative difference between an effective and a lethal dose as small as with heroin, which in combination results in e.g. which also has the highest potential for dependency and a tendency to increase the dose, explains the comparatively high number of deaths. The specific dose that leads to the death of a user depends from person to person and, in particular, heavily on the possible development of tolerance and thus also on the time of the last consumption. A long-term, regular user may "can take" up to 10 times the amount that a first-time user would be fatal. After a few days of non-use, however, this value can drop again and a corresponding high dose can also be fatal for the long-term user. The usual impurities (stretching) are also problematic, which generally cause consumers to take higher dosages that are difficult to calculate, which can then lead to death if the substance is unexpectedly purer.
Some sources put the 50% lethal dose (LD 50 ) at doses of 1 to 5 mg per kg body weight for first-time users (75 to 375 mg for a 75 kg person). Lethal doses have also been observed in humans from as little as 10 mg (absolute).
Antidotes and opioid antagonists
In the case of opiate or heroin-related intoxication , opioid antagonists are used. In Germany, naloxone hydrochloride is often used, which blocks the uptake of the opioid at the opioid receptors. The problem here is the much shorter half-life compared to the opioid. This antagonist acts too briefly (about an hour) and also cancels out the analgesic (pain-relieving) effect of heroin, which lasts about three to four hours, which can immediately lead to the most severe withdrawal syndrome (sweating, pain and cramps up to circulatory collapse ) if the Patient has even a small tolerance to opioids. Due to their side effects, opioid antagonists may only be administered under medical supervision. Particular caution applies to people substituted with the semi-synthetic opioid buprenorphine (e.g. Subutex ), which has a higher receptor affinity than naloxone - all opioid receptor full agonists currently on the market have a significantly lower affinity than naloxone and are therefore quickly displaced by naloxone – on the other hand, for this reason, buprenorphine can only be antagonized with extremely high doses of naloxone. It also has an interindividually variable half-life of up to 48 hours, which is why naltrexone must be given in addition.
forms of consumption
There are different forms of consumption, all of which are associated with risks. Addiction can occur with any form of consumption.
Intravenous consumption (colloquially "pressing", "shooting" or "fixing") is probably the most well-known form of consumption. Since the heroin base, which is mostly available in Europe, is not soluble in water, you need an auxiliary agent to bring it into solution. The heroin is heated (usually on a spoon) with an acid (powdered ascorbic acid (vitamin C) or lemon juice) and water, and then drawn through a filter. When boiling, the acid causes the formation of a water-soluble heroin salt, which is necessary for intravenous injection.
Frequent intravenous injections under non-sterile conditions, such as those found in black market conditions, often result in hematomas and scarring that can cause thrombosis (blockage of the veins). However, injecting pure heroin, like any other injection, can lead to abscesses . Trembling as a withdrawal symptom leads to an increased risk of injury when injecting yourself. There is a risk of missing the vein and injecting a "chamber" under the skin ("shooting an egg"), which, if left untreated, can lead to abscesses.
The use of the same needle by more than one person or the sharing of a boiled preparation carries the risk of infection with HIV /AIDS and other blood-borne diseases (e.g. hepatitis B and especially hepatitis C ). The cutting substances in black market heroin ( strychnine and many others) can lead to life-threatening poisoning.
Puncture sites (not only on the arm) and scarring indicate intravenous heroin use.
For snorting (sniffing, sniffing) through the nose, the heroin is ground into a fine powder. Similar to cocaine , it is then drawn in through the nose with a snuff tube , which causes it to reach the nasal mucosa . There it immediately goes into the bloodstream and then unfolds its effect.
As with injecting cocaine, there is a risk of overdose. If heroin is repeatedly applied to the nasal mucosa over a longer period of time, it dries out and atrophies , which in turn promotes nosebleeds. Since the nasal mucosa can only regenerate to a limited extent after toxic damage, it develops ulcerated substance defects during prolonged, extreme nasal heroin consumption and can – if localized in the area of the nasal septum – eventually perforate it, including the nasal septum cartilage .
Sharing drawing tools with other consumers can lead to the transmission of contagious diseases .
Smoking heroin (slang terms: blowing , chasing the dragon, smoking a foil, smoking a tin , Chinese ) is a form of consumption in which the heroin is consumed in one piece aluminum foil is vaporized. This vapor is then inhaled using an aluminum tube, for example. Since sublimated heroin condenses again very quickly at room temperature, a layer of heroin quickly settles in the inhalation tube, which the consumer then collects and consumes when it has reached a certain amount. The advantage of inhaling heroin is that the dosage is relatively easy to control. Because of the immediate onset of action, an imminent overdose is detected before too much of the drug has been consumed, which is not possible with injecting or "sniffing". With the latter forms of consumption, a certain amount of the drug is supplied and is then in the body. The effect therefore only reaches its peak after the consumer has taken the appropriate amount, so that he has no chance to correct it.
Since 1982, non-specific changes in the white matter of the brain have been associated with inhalation of heroin and have been referred to as spongiform leukoencephalopathy . Although it has been suggested that heating heroin could convert a diluent or other substance in heroin into a brain-damaging form, the etiology and pathogenesis remain unclear.
Oral use of heroin is not widespread. The reason for this is that depending on the state of the digestive system, the onset of effects after consumption is greatly delayed, the effects come on slowly and gradually, and the high can intensify even after hours. In contrast to parenteral consumption, the first-pass effect also occurs , which eliminates part of the active substance before it reaches the receptors. The required dose is therefore larger, more expensive and more difficult to control. In Switzerland, heroin is sold under the name Diaphin in tablet form to patients undergoing heroin-assisted treatment.
Using multiple drugs at the same time can lead to interactions that increase the effects of heroin. There are very few overdoses by heroin addicts that are fatal when heroin is used alone. However, if mixed consumption with other sedative substances such as alcohol or benzodiazepines such as flunitrazepam or diazepam is practiced, the risk of a life-threatening overdose increases enormously.
A mixture of heroin and cocaine is colloquially called a "cocktail" or " speedball " . Here, the effect of the two drugs is opposite, which is a dangerous burden, especially for the circulatory system. The danger of an overdose is particularly high.
If benzodiazepines are taken with heroin, there is a risk of respiratory arrest. Both substances have a respiratory depressive effect, i.e. they cause reduced activity of the respiratory muscles. Heroin can also lead to bleeding in the brain via cerebral vasculitis , mainly in connection with alcohol consumption.
Heroin is mainly used in Western Europe and the USA. Brown heroin (heroinbase) was mainly produced in Afghanistan and other countries in Southwest Asia in 2015. The rarer white heroin (heroin hydrochloride, 'heroin salt') was formerly mainly produced in Southeast Asia, in 2015 primarily in Afghanistan and presumably in Iran and Pakistan . This region, known as the Golden Crescent , is the main supplier for the European market.
In 1979, the raw material opium was mainly produced in the neighboring states of Afghanistan , Pakistan and Iran (altogether 1600 tons) as well as in the golden triangle around Thailand (160 tons) and in Mexico (10 tons, with a recent strong upward trend). Turkey was also a major opium producer up until the 1980s . In Germany, the brown heroin base produced in Afghanistan is the most common, while the white heroin produced mainly in Southeast Asia is of relatively minor importance.
Of the 1,600 tons of opium produced in the three largest producing countries in 1979, 1,000 tons were consumed domestically. The remaining 600 tons were converted into about 55 tons of morphine in chemical laboratories located primarily in Pakistan, Syria , Lebanon , Iran and Turkey.
The poppy , from which the raw opium is obtained, is grown by farmers. These are often small farmers for whom this is the only source of income. They legally sell part of the opium to state institutions, which are also responsible for controlling opium cultivation. The rest is sold to local traders, who often pay many times the official price. In the border triangle of Afghanistan, Iran and Pakistan, a large part of the production is bought up wholesale by their own groups of dealers who resell the opium or the already converted morphine in the Middle East .
In the Middle East , morphine is resold, often involving members of the political and military elite. After that, there are a number of ways that the morphine can get west. The most popular of these is transport via the Balkan route , where the morphine is transported, for example, in trains, cars and mules to Ankara and Istanbul and then shipped further across the Balkans to western Europe. Here the morphine is converted into heroin destined for the European or North American market. A second option is transport via the so-called "southern route", which leads from the Middle East via East Africa to Europe by ship or plane. Less common is the “Northern Black Sea route” via the Caucasus region or Black Sea riparian states .
Heroin is easily transported and concealed, and is light in weight and volume in relation to its value. The authorities are therefore only able to seize a fraction of the heroin in circulation.
Like legal goods, heroin is bought and resold by different dealers, but much more often. The more dealers involved, the more difficult it is to locate the wholesalers. The information that smaller dealers get from the next higher dealer ring (e.g. about the identity of the members) is usually limited to a minimum. In order to be able to buy large supplies, the dealers often involve wealthy people who belong to the legal and recognized world (freelancers, businessmen, merchants). They have nothing to do with the business, they just secretly advance large sums of money to buy the drugs. After the deal is closed and often in a short time, they get back a multiple of the capital invested in the black.
In the 1980s, the wholesale of heroin was carried out to a significant extent by criminal organizations of different nationalities ( e.g. mafia families or clans). These bought in bulk and resold the drugs to smaller, independent groups, who then resell the heroin to non-criminal users. In order to be able to get involved in the heroin business on a larger scale, the criminal organizations first needed capital to buy the drugs and to chemically convert them in secret laboratories. Second , violence to combat competition, to intimidate witnesses, police officers, and officials, and finally to ensure that agreements made are honored. Those recruited to commit violence ranged from unemployed youth to professional killers. While in the final stages of the distribution process almost anyone could operate as a small or medium-sized dealer in the drug market, wholesale was competitive and could only be controlled with organized violence. Smuggler Eric Chalier reported in court in the 1970s that a kilo of morphine cost $2,000 in Afghanistan, $3,500 in Turkey, $8,000 in Greece and $12,000 in Milan . Another way to make high profits is to refine morphine into much more expensive heroin. Here the profits at that time were between 1,000 and 2,000 percent. While in Afghanistan it is still possible for any large farmer to trade in opium, the heroin trade in Europe requires a certain amount of available capital.
The black market price depends heavily on the degree of purity and the place of sale. The purity of "brown heroin" is between 15% and 25% in most European countries. In countries like Austria , Greece and France the figure is below 10% and in the UK it is 41%. The purity of "white heroin" is higher at 45% to 71%. The average price of "brown heroin" in most European countries is between 30 and 45 euros per gram. In Sweden it is 110 euros per gram. In Turkey , on the other hand, it is only 7-10 euros per gram with an average purity between 30 and 50 percent . The price of "white heroin" is much more differentiated and is reported in a few European countries to be between 27 and 110 euros per gram. The prices have a downward trend.
Heroin is one of the substances with the highest potential for dependence due to the overwhelming psychological effect it has on a large proportion of consumers . Depending on the individual constellation, physical withdrawal symptoms can already occur after 2 weeks of daily consumption.
The form and dose of consumption is usually influenced by the degree of physical and psychological dependence. With more frequent smoking or nasal consumption and thus increasing tolerance, this form of administration becomes uneconomical, since with both forms of consumption mentioned, on average about two thirds of the active substance is lost during ingestion without it reaching its site of action, the opioid receptors, and heroin is bought on the black market is extremely expensive. For example, addicts are usually forced to switch to intravenous injections, which increases tolerance even further due to the higher uptake of the active ingredient.
Not every (mentally stable and socially secure) user experimenting with heroin will inevitably become dependent. Nevertheless, the usually rapidly developing and pronounced physical and psychological dependence with its consequences, life in the drug scene (with neglect , social marginalization , distress , delinquency , homelessness ), indirect damage to health (including infections, thrombophlebitis , embolisms with intravenous consumption without appropriate measures for sterility) and the frequently detectable comorbidities lead to a mortality rate that is 20-50 times higher than in the general population . The suicide rate is 14 times higher than in the general population of the same age. It is increasingly recognized that harm reduction should not be limited to the physical and mental problems of the individual consumer, but also requires social (and thus political) solutions to a social problem.
In Germany in 2010, 529 deaths were counted that were directly related to the sole use of heroin. Heroin was also involved in 326 other deaths along with other drugs. Heroin thus played a role in around 70% of all deaths associated with the use of illegal drugs. In 2013, 194 deaths directly related to heroin/morphine were counted in Germany, and heroin was involved in addition to other drugs in 280 other cases. The proportion that has thus fallen to around 47% can be explained by a correspondingly increased proportion of deaths associated with opiate substitution drugs. The federal government's drug commissioner did not publish any specific figures for 2014, but continued to describe heroin abuse as the main cause of drug-related deaths. The mortality rate of opioid addicts in Switzerland is only slightly higher than that of the general population, since around three-quarters are on long-term treatment with opioid agonists (methadone, morphine, heroin) and are being treated for HIV or HCV.
The acute physical symptom of intoxication is mainly a dose -dependent respiratory depression , which is considerably increased by sedatives taken at the same time (usually the concomitant use of benzodiazepines ).
A proven consequence of long-term use is constipation , which, however, can also occur in the short term, since the µ2 receptors in the GI tract are subject to little or no tolerance development, which is why this symptom can also persist in the long term with long-term use. Attributing menstrual cycle irregularities ( oligomenorrhea or amenorrhea ) , infertility , and decreased libido to heroin (or opioids) alone is much more difficult, although opioid effects on the endocrine system have been well documented. This leads to a decrease in the blood levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), but in the course of substitution treatment in many women they also return to normal, which increases the risk of unwanted pregnancies. It is believed that at least a large part of these hormonal changes leading to oligo- or amenorrhea are due to the living conditions of opioid addicts under conditions of prohibition (unbalanced/malnutrition, reduced general condition due to various infections arising from unsafe IV use, social exclusion, etc .) is due.
Newborns of heroin-addicted mothers usually show a newborn withdrawal syndrome , which is not fundamentally life-threatening for the newborn; however, it is assumed that long-term prenatal contact with exogenous opioids causes biochemical/physiological changes in the CNS/neurotransmitter metabolism. What effects this will have in concrete terms is not yet known exactly.
Injection or foil smoking of heroin can lower the seizure threshold by affecting the hippocampus and thus trigger seizures . In the German model project on heroin-assisted treatment of opiate addicts , these were the most common serious undesirable accompanying symptoms in a total of 156 participants over a four-year observation period with a total of ten cases. Epileptic seizures are likely to occur less frequently with methadone substitution.
According to the CASCADE data, the overall excess mortality rate among HIV-infected drug users in 2004/2006 was 3.7 times that of HIV-infected homosexual males.
"Long-term heroin addiction leads in some cases to serious social consequences, among other things due to criminalization through procurement, possession and trafficking of the illegal intoxicant . " be traced back for themselves, but must be explained with the criminalization of procurement. Controlled legalization could eliminate this part of the criminal burden (see successful pilots in Germany, Switzerland, Netherlands, England, etc.).
Often, addicted users cede everything they own to fund the substance, which is associated with social decline (which per se leads to increased ill health). Those affected are usually unable to work and often become homeless, also because they can no longer meet their obligations (going to the office, etc.) or because all the cash is invested in drugs.
However, there is also an unknown number of heroin addicts (who have been repeatedly reported on, e.g. in low-threshold drug help ) who pursue their work in a regulated manner, are socially integrated and are able to hide their dependence from those around them, so that social decline does not necessarily follow .
If severe heroin addicts do not take another dose within eight to 12 hours of their last use, withdrawal symptoms occur . This withdrawal is generally not life-threatening, but is often very feared and physically demanding.
All withdrawal methods are discussed controversially. For example, "turbo withdrawal" with opioid antagonists such as naltrexone ( forced opioid withdrawal under anesthesia ) can be associated with the most serious health risks. After physical withdrawal, there is a risk that the dose you are used to before can lead to an overdose if you take it again due to a reduction in tolerance . Heroin withdrawal leads to increased mortality. In the withdrawal state, the mortality rate is many times higher than that of opioid addicts treated with methadone or other opioids.
Model experiment for diamorphine-supported treatment
The Federal Ministry of Health, in cooperation with the federal states of Hamburg, Hesse, Lower Saxony and North Rhine-Westphalia and the cities of Frankfurt am Main , Hamburg , Cologne , Bonn , Hanover , Munich and Karlsruhe , initiated a model project for the heroin-assisted treatment of opiate addicts. The project started in Bonn in March 2002, with the other cities gradually following suit. Here, opiate addicts for whom previous drug therapies were unsuccessful or for whom methadone substitution was unsatisfactory received pharmacologically pure heroin (diacetylmorphine, diamorphine) for intravenous administration under supervision; a control group received the substitute drug methadone at the same time . Both groups received regular medical care and received accompanying psychosocial therapy. The assignment to the two groups was made at random; Participants in the methadone group could, as an incentive, switch to the heroin group after the year. The separation into experimental group (heroin) and control group (methadone) was necessary because the study was a clinical drug trial, which was a prerequisite for the possible approval of heroin as a drug.
Both groups were further subdivided into subgroups, which received psychosocial care using different methods, either through case management or in the form of drug counseling with psychoeducation . Recruitment lasted until the end of 2003. A total of 1032 patients took part in the project. As a result, more incidents occurred in the diamorphine group, but the health and social situation of the patients improved significantly compared to those in the methadone group.
The project was originally designed to last two or three years (two years of study and one year of evaluation of the study), but was extended to 2006 in August 2004 because the treatment was not to be discontinued, but the decision on the approval of heroin as a drug was only made in 2006 should be. After the CDU had blocked the inclusion of diamorphine-supported treatment in standard care for a long time, this was finally decided in May 2009 with the votes of the SPD, FDP, Left Party and Greens.
In the UK heroin is a prescription pain reliever and is also prescribed by some doctors to heroin addicts with the permission of the Home Office . This treatment practice has existed since the 1920s, but was greatly reduced in the 1970s. Only a few hundred addicts are currently being treated with heroin in the whole of England.
In Switzerland, heroin dispensing was prepared as part of the PROVE trials (projects for the prescription of narcotics) in 1991 by the Federal Office for Public Health FOPH under Flavio Cotti and decided by the Federal Council on October 21, 1992: trials of medically controlled drug dispensing allowed the dispensing of heroin, methadone and morphine in injectable form, heroin (and very limited cocaine) in smokable form and heroin, methadone and morphine in ingestible form. The sale of heroin was permanently permitted in special institutions by referendum in 2008. In theory, heroin could be prescribed for palliative care by any doctor in Switzerland. Today heroin, diacetylmorphine, DAM, is registered in Switzerland under the trade name Diaphin. Since heroin treatment is only allowed in very restrictive special settings, it has never acquired an important role in overcoming the extreme drug problems of the 1990s. At no time were more than 3 percent of addicts in Switzerland being treated for heroin (in contrast, since the mid-1990s more than half of opioid addicts have been in substitution treatment with methadone, morphine retards or buprenorphine).
Since the "zero tolerance strategy" and criminalization could not and cannot reduce the number of heroin addicts, there arose where heroin addicts, due to their number and segregated existence (often in central squares of large cities, such as Zurich 's Platzspitz ), were perceived by a broader public as health and safety issues were perceived, new ways of dealing with heroin addicts. In particular, this gave rise to accepting drug work , the essential feature of which is the establishment of drug consumption rooms as a safe framework for consumption.
heroin and art
Like other drugs, heroin plays a role in the life and work of several musicians. Well-known rock bands addressed the use and consequences of heroin in their songs.
One of the first artist scenes to make frequent use of heroin was the New York jazz scene of the 1940s and 1950s. Partly as a result of Charlie Parker's heroin use, other jazz musicians adopted the habit, some with explicit reference to Charlie Parker's attributed talent for improvisation. Jazz musicians such as Art Blakey , John Coltrane , Miles Davis , Stan Getz , Grant Green , Dexter Gordon , Billie Holiday , Jackie McLean , Hank Mobley , Thelonious Monk , Bud Powell , and Sonny Rollins were prolonged heroin users and at times were junkies .
There have been several prominent heroin deaths with Freddie Webster , Fats Navarro , Charlie Parker, Sonny Clark , Elmo Hope , Paul Chambers and Chet Baker . Charlie Parker created a musical monument to his dealer Emry Bird with the composition Moose the Mooche . Anita O'Day titled her 1981 autobiography High Times, Hard Times.
John Lennon wrote the song Cold Turkey in 1969 . In it he described trying to get off the drug together with Yoko Ono . Janis Joplin died in 1970 after a heroin overdose. The Rolling Stones released the songs Coming Down Again and Before They Make Me Run , written by Keith Richards , about his heroin addiction. Mick Jagger wrote the songs Monkey Man and along with Marianne Faithfull Sister Morphine . The album Sticky Fingers , which reached number one in the UK and US charts, deals with aspects of drug use in every track.
Black Sabbath wrote Hand of Doom , a song that explored the often devastating effects of the drug.
The New York band The Velvet Underground , particularly Lou Reed , wrote several songs about heroin. The songs Waiting for the Man and the unambiguously titled Heroin are considered classics of drug-inspired rock.
Heroin was a common theme in punk rock in the late 1970s. The Ramones refused to perform the song Chinese Rocks , written by Dee Dee Ramone , because it was too obviously about drug abuse. Dee Dee completed the song with Richard Hell of the band The Heartbreakers . The song became one of the group's most popular tracks.
Arguably the Stranglers ' best-known song , Golden Brown , was about heroin, according to then-frontman Hugh Cornwell , but also about a girl to avoid ambiguity in the lyrics. A similar lyrical device was suggested by Lou Reed in his 1972 ballad Perfect Day .
Dutch rock musician Herman Brood was addicted to heroin for decades. He explored heroin in songs like Rock 'n' Roll Junkie and Dope Sucks . Brood took his own life in July 2001 after a detox. In his farewell letter it said that a life without drugs did not seem worth living to him.
Public perception of heroin consumption is influenced, among other things, by feature films in which the drug plays a dominant role, such as Christiane F. – Wir Kinder vom Bahnhof Zoo or Trainspotting – Neue Helden , both of which are based on books.
In July 2009, the Diamorphine-Based Substitution Treatment Act ( Diamorphine Act ) made diamorphine a prescription narcotic that can be dispensed to severely addicted people under state supervision in licensed facilities. The prescribing doctor must be qualified in addiction therapy, the affected person must be at least 23 years old, have been addicted to opiates for at least five years and have at least two unsuccessful therapies. The law amended the Narcotics Act , the Narcotics Prescription Ordinance and the Drugs Act accordingly.
According to the Federal Law on Narcotics and Psychotropic Substances , heroin may not be imported, manufactured or marketed in Switzerland. However, a medically controlled delivery for heroin-assisted treatment (HeGeBe) of severely addicted people is possible under special conditions.
In contrast to other substitution drugs such as methadone, you have to submit an application to the Swiss Confederation to obtain heroin . The patients receive heroin (diacetylmorphine) as a drug to take or can administer it intravenously in special clinics under supervision. The drug is marketed under the trade name Diaphin and is available in three forms of administration: for oral administration with rapid or slower ( delayed ) release of the active ingredient, and as a solution for injection. The transport of Diaphin to the delivery points is subject to the highest security precautions and is comparable to the transport of gold, protected with armored vans and armed personnel.
In Canada and especially the UK , diacetylmorphine is still used as a pain reliever, particularly for chronic pain and in palliative care . It can also be used by licensed physicians in the UK for maintenance treatment of opiate addiction. Great Britain is the only country in the world where heroin addicts can actually get "on prescription", while corresponding forms of treatment in Germany and Switzerland always require taking it under supervision.
In Denmark , possession of a small amount of heroin for personal use is not punished, and in these cases the substance is not seized either, as this could trigger criminal activity in obtaining a new dose. For this reason, one of the most liberal drug laws came into force in the Czech Republic at the beginning of 2010, allowing the possession of up to 1.5 g of heroin. Local aid organizations such as "Sananim" or "Drop" welcome the new legislation because of the decriminalization, but also criticize it with the argument that the state does not take enough care of prevention and care for drug addicts.
Parallel to the presidential election on November 3, 2020 in the United States of America , residents of the US state of Oregon voted in a referendum to decriminalize heroin . Since February 1, 2021, a small amount of heroin has been treated as an administrative offense by consumers.
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