heroin


from Wikipedia, the free encyclopedia
Structural formula
Structural formula of heroin
General
Surname heroin
other names
  • Diamorphine
  • Diacetylmorphine
  • (5 α , 6 α ) -7,8-Didehydro-4,5-epoxy-17-methylmorphinane-3,6-diol diacetate ( IUPAC )
  • (5 R , 6 S ) -4,5-epoxy-17-methylmorphine-7-en-3,6-diyl-diacetate ( IUPAC )
Molecular formula C 21 H 23 NO 5
External identifiers / databases
CAS number
  • 561-27-3 (diamorphine, base)
  • 1502-95-0 (diamorphine hydrochloride )
PubChem 5462328
DrugBank DB01452
Wikidata Q60168
Drug information
ATC code

N07 BC06

Drug class

Opioid - analgesic

Mechanism of action

Opioid receptor agonist

properties
Molar mass 369.42 g · mol -1
Physical state

firmly

Melting point

171-174 ° C

solubility

Base : <0.2 g l −1 in water, 0.6 g l −1 in ethanol

safety instructions
Please note the exemption from the labeling requirement for drugs, medical devices, cosmetics, food and animal feed
GHS labeling of hazardous substances
06 - Toxic or very toxic

danger

H and P phrases H: 300-310-330
P: 260-264-280-284-302 + 350-310
Toxicological data

21.8 mg kg −1 ( LD 50mouseiv )

As far as possible and customary, SI units are used. Unless otherwise noted, the data given apply to standard conditions .

Heroin ( ancient Greek made-up word : ἡρωίνη heroine , see Heros ) or Diaphin (trade name), technically diacetylmorphine (DAM) or diamorphine , is a semi-synthetic , strongly analgesic opioid and drug with a very high potential for dependence in any form of consumption. Despite the pain-relieving efficacy of heroin1.5 to 3 times higherthan that of the parent substance morphine , the therapeutic use of heroin is prohibited in most countries.

history

The history of the consumption of narcotic or euphoric natural opiates dates back to around 2000 to 3000 BC. BC to ancient Egypt and leads to the opium caves of China until modern times . The pain-relieving, calming, sometimes stimulating effects of natural opioids were described by bathers around the year 1400, and chemists tried from the 19th century onwards to find a synthetic equivalent to the natural substance extract opium and to develop a remedy that could be produced quickly and accordingly could be marketed.

Heroin medication bottle from Bayer

In 1873, the 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 Bayer's 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, on June 27, 1898, registered the brand name “Heroin” for it.

Heroin was marketed as an oral pain and cough suppressant in an advertising campaign in twelve languages . It was also used in around 40 other indications, such as high blood pressure , lung disease, heart disease, for induction of childbirth and anesthesia, and as a "non-addictive drug" against the withdrawal symptoms of morphine and opium . It was assumed that heroin had all the benefits of morphine, but hardly any side effects - initially only constipation and mild sexual listlessness were suspected as such. Heroin was initially received positively by many doctors and patients. In 1904 it was recognized that heroin is more or more addictive than morphine and that patients with repeated use soon needed a larger amount of heroin in order to achieve its initial effect again. Some doctors warned that heroin had the same addiction potential as morphine; but this knowledge spread only slowly. Among other things, this was due to the fact that the oral dosage form causes the substance to be absorbed relatively slowly , which means that there is usually no strong intoxication.

From around 1910, the danger posed by the drug heroin was recognized , especially in the United States of America , where morphine and opium addiction occurred more frequently and in broader layers than in Europe . When it became known in the USA that smoked, snuffed and especially intravenous heroin had a much stronger effect, many opioid addicts switched to the readily available substance, which also had fewer side effects than morphine (in terms of histamine reaction ). The number of addicts grew rapidly. The main reason heroin was made illegal, however, is to be found in the stigmatization of Chinese immigrants in the United States at the time, who were associated with frequent opium use and who later also used heroin. As a result, these substances were presumably associated with the already unpleasant Chinese, which is why individual states of the USA first introduced different laws for the purpose of banning. Later, at the first opium conference in 1912, a transnational ban was discussed for the first time, which was exclusively politically and not medically motivated.

In 1931 Bayer gave in to political pressure, stopped production and removed heroin from its product range.

The first illegal manufacturing laboratories were established in Marseille in the 1930s , where they were operated by the French Connection , headed 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 mainly brought to the US.

Despite the bans, the number of heroin addicts rose worldwide , particularly after the Second World War and the Vietnam War , because soldiers came into contact with morphine and heroin during their missions. After 1945, mainly the Italian-American mafia 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 reached its first peak in the 1970s. US President Richard Nixon used the term war on drugs at a press conference on June 18, 1971, at which he declared drug use to be the “ public enemy number one ”. In 1982, among others, the then US Vice President George HW Bush 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 risen sharply again in the years since 2000, with areas away from the metropolitan areas being particularly affected this time. This is mostly associated with the fact that since the late 1990s American doctors have increasingly prescribed opioids such as oxycodone , hydrocodone and fentanyl . If patients have become dependent on them, they often switch to the much cheaper heroin: Four out of five heroin addicts in the USA first took prescription opioids (see opioid crisis in the USA ). This fact is used in particular by Mexican drug cartels, whose illegal heroin production is estimated to have increased by 600 percent in the years between 2005 and 2009 alone in order to meet the growing demand in the USA. The addicts now come from all walks of life to a greater extent than before. In 2015 almost 13,000 Americans died of a heroin overdose, 23 percent more than in 2014. US President Donald Trump raised the issue of the opioid crisis in October 2017 and proclaimed a health emergency .

Heroin was legally sold in the Federal Republic of Germany until 1958. It was then banned in the Narcotics Act.

The medical use of heroin is now permitted under strict conditions in several countries - including Germany again since 2009; there is legal heroin production.

Manufacturing

Milky juice of Papaver somniferum obtained by scratching immature seed
pods provides opium when dried.
Morphine - an opiate
Brown and white heroin

Heroin is produced semi-synthetically, the starting substance is morphine . Morphine is obtained as an extract from raw opium , the dried milky juice from the seed pods of the opium poppy (Papaver somniferum) . For the production of heroin, the morphine base obtained in the first processing step is acetylated on the two hydroxyl groups using acetic anhydride (= acetic anhydride), sodium carbonate or acetic acid chloride and converted to the heroin base. Monoacetylated morphine (e.g. 6-MAM ) can arise as a by-product . 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 is a colorless crystalline solid both as a base and as a hydrochloride salt.

pharmacology

Metabolism

The main metabolic route of heroin 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 approx. 20 minutes). About 1-10% of the morphine is converted into the metabolite morphine-6-glucuronide, which is also active and which has a significantly longer half-life than morphine itself and can therefore accumulate in patients with impaired renal function if administered over a long period of time. Another 55-75% of the morphine is metabolized to inactive morphine-3-glucuronide. About 5% of it is also metabolized to normorphine.

Pharmacokinetics

The bioavailability depends on the form of consumption. Heroin is significantly more lipophilic (fat-soluble) than morphine and therefore reaches the brain quickly, which leads to a strong surge in the active receptors; therefore, an intravenous heroin injection triggers an initial "kick" (also called a flash ). In all forms of consumption other than intravenous injection, this effect is at least greatly weakened, if at all, due to the slower influx according to the current state of science. The reasons for this are the slower absorption , the premature hydrolysis and the first-pass effect .

Pharmacodynamics

Heroin binds only weakly to the various opioid receptors, but acts as a prodrug (drug precursor), the active metabolites of which mainly mediate the effect. It is worth mentioning the high intrinsic activity of 6-MAM at the µ-opioid receptor , 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 heroin addict consumes 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 purity of black market heroin, which in Europe - with the exception of the Netherlands - is usually between 5 and 15% for end customers, rarely more than 20% (as of 2006) - in the USA the purity is now often significant higher - an average long-term intravenous heroin user gets by with an amount corresponding to 100–200 mg of the pure substance. The case law in the Federal Republic of Germany based the determination of the not insignificant amount of heroin within the meaning of Section 29a Narcotics Act on the fact that a dose of 50 mg is lethal for a non-drug addict, although this number is most likely not the truth and some studies from one assume a much higher human LD 50 . This number seems to apply more to mixed use, which is very common and is not recognized in many hospital toxicity reports after fatal overdoses, especially if the substances cannot be detected with standard drug screening or if it is by far the most common fatal mixed use, the with ethanol .

The effects of heroin last for 6 hours to often over 24 hours in non-tolerant users, with after-effects after the first consumption sometimes lasting several days. In contrast, the effects of heroin on a physically addict, if he consumes an average high dose, do not last longer than 6-8 hours, after which the 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 framework of the availability of the substance. With daily consumption, the amount that led to the desired effect the day before must be increased 1.5 to 2 times in order to achieve a comparable effect. However, since most addicts have quickly exhausted their financial possibilities due to the astronomical black market prices, most of them are mostly on the hunt for money in order to achieve a reasonably constant dosage ("steady state") and to prevent withdrawal symptoms. Additional problems arise from the fact that illegally traded heroin cannot tell how high the degree of purity is (which can lead to inadvertent overdoses ) and with which substances the drug was stretched. After oral or rectal administration, heroin can be detected as 6-MAM in the blood; heroin itself can only be detected in the blood for a few hours. Metabolic residues in the urine for 1–4 days and in the hair for several months (see also the following section, Evidence ).

proof

In forensic detection tests, the so-called screening tests ( English screening , review ' ), the metabolic residues of chemical substances of various analgesics (such as paracetamol ), barbiturates and opiates , such as heroin toxicologically be detected in human body. For this purpose in clinical chemistry for suspected is intoxication with medicines and drugs the screening of blood serum , saliva , semen , heparin plasma or urine used.

In a chemically standardized manner, semi-synthetic opiates such as heroin can only be detected through urine excretion, since the diacetyl-morphine heroin is metabolized to morphine by the body relatively quickly. 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 have to indicate heroin abuse. The urine test, however, only records pure opiates and amphetamines ; However, fully synthetic opiate substitutes such as methadone are not included here.

The reliable qualitative and quantitative detection of different test materials is possible after an appropriate sample preparation by chromatographic methods in coupling with mass spectrometry .

toxicology

Comparison of the addiction potential and the ratio between the usual and lethal dose of various drugs.

With no other common drug is the relative difference between an effective and a lethal dose as small as with heroin. a. 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 consumer depends from person to person and, in particular, strongly on a possible development of tolerance and thus also on the time of the last consumption. A long-term permanent consumer "tolerates" u. U. 10 times the amount that would lead to death for a first-time consumer. After a few days of pause in consumption, this value can drop again and a corresponding high dose can end fatally even for long-term consumers. The usual impurities (stretching) are also problematic, which generally cause consumers to use higher dosages that are difficult to calculate, which can then lead to U. with unexpectedly purer material leads to death.

Some sources give doses of 1 to 5 mg per kilogram of body weight for first-time users (75 to 375 mg for a person weighing 75 kg) for the dose (LD 50 ) which is lethal in 50% of cases . Fatal doses have also been observed in humans from 10 mg (absolute).

Antidotes and opioid antagonists

In an opiate or heroin-related intoxication are opioid antagonists 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 works for too short a time (about an hour) and also reverses the analgesic (pain reliever) effect of heroin, which lasts about three to four hours , which can immediately lead to severe withdrawal syndromes (sweats, pain and cramps up to and including circulatory collapse ) if the Patient has even a small tolerance to opioids. Because of their side effects, opioid antagonists may only be administered under medical supervision. Caution applies particularly to those 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 a highly variable half-life of up to 48 hours, which is why naltrexone must also be given.

effect

Similar to morphine, heroin has a euphoric and analgesic effect, but normal sleep is more likely to be disturbed by its administration. Depending on the form of application , it has a half-life of four to six hours and is non- toxic to the organs of the human body . Further effects on the unaccustomed body are the emetic ( Greek: emesis = nausea) and respiratory depressive effects. The side effect of constipation is not subject to any tolerance formation - the active ingredient was used as a remedy for diarrhea around the turn of the century . In the case of an overdose, respiratory depression is mainly dangerous, which, especially if other sedating psychotropic substances such as alcohol, benzodiazepines or barbiturates are added in the sense of polytoxicomania, can lead to respiratory arrest with fatal consequences (the so-called " golden shot "). Opioid antagonists ( e.g. naloxone ) are used to counteract the effect in the event of an overdose .

Forms of consumption

Heroin in powder and pill form
Boiling heroin with ascorbic acid (vitamin C) or lemon juice
Intravenous heroin use of a "fixer"

There are several forms of consumption, all of which involve risks. The addiction can occur with any form of consumption.

Intravenous use

Intravenous consumption (colloquially “press”, “shoot” or “fix”) is probably the best-known form of consumption. Since the heroin base, which is mostly available in Europe, is not soluble in water, you need an auxiliary substance 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 absorbed through a filter. When boiled, 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 under black market conditions, often result in the formation of hematomas and scarring, which can cause thrombosis (vein occlusion). However, like any other injection, injecting pure heroin 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 can lead to abscesses if there is no medical treatment.

The use of the same cannula by several people or the sharing of a boiled preparation carries the risk of infection with HIV / AIDS and other diseases that can be transmitted through the blood (e.g. hepatitis B and especially hepatitis C ). The stretching substances in black market heroin ( strychnine and many others) can lead to life-threatening poisoning.

Injection marks (not just on the arm) and scarring indicate intravenous heroin use.

Intranasal use

For 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 sniff , whereby it reaches the nasal mucosa . There it goes immediately into the bloodstream and then unfolds its effect.

As with the intravenous use of cocaine, there is a risk of overdose. If heroin is repeatedly applied to the nasal mucosa over a long period of time, it dries out and atrophies , which in turn encourages nosebleeds. Since the nasal mucous membrane is only able to regenerate to a limited extent after toxic damage, prolonged, extreme nasal heroin consumption causes it to develop into ulcerated substance defects and - if located in the area of ​​the nasal septum - can eventually perforate these with the involvement of the nasal septum cartilage .

Sharing pulling tools with other users can lead to the transmission of infectious diseases .

inhalation

Occasionally, consumers do not use a spoon or the like to boil the heroin, but use alternative materials such as old tin cans or sufficiently deep metal bottle lids, which can lead to health problems

Smoking of heroin (slang terms: "Blowen" , "Chasing the Dragon" , "The Dragon chasing" , "a film smoke" , "a sheet smoke" , "chineesen" or "Schore" ) is a form of consumption, in which the Heroin is vaporized on a piece of aluminum foil. This vapor is then inhaled using an aluminum tube, for example. Since sublimed heroin condenses again very quickly at room temperature, a layer of heroin is quickly deposited in the inhalation tube, which is then collected and consumed by the consumer when it has reached a certain amount. The advantage of inhaling heroin is the relatively easily controllable dosage. Due to the immediate onset of action, an impending overdose is noticed before too much of the drug has been consumed, which is not possible when injecting or “sniffing”. In the latter forms of consumption, a certain amount of the drug is administered and then found in the body. The effect only reaches its peak after the consumer has consumed the appropriate amount, so that he has no chance of correcting it.

Since 1982, unspecific changes in the white matter of the brain have been associated with the inhalation of heroin and are known as spongiform leukoencephalopathy . Even if it has been suspected that when the heroin is heated, an extender or another substance in heroin could be converted into a form harmful to the brain, the etiology and pathogenesis remain unexplained.

Oral use

Oral application of heroin is not widespread. The reason for this is that, depending on the condition of the digestive system, the onset of action is greatly delayed after consumption, the effect occurs slowly and gradually and the intoxication can intensify even after hours. In contrast to parenteral consumption, there is also the first-pass effect , which eliminates part of the active ingredient before it reaches the receptors. The required dose is therefore larger, more expensive and more difficult to control. In Switzerland, heroin is given in tablet form under the name Diaphin to patients who are receiving heroin-assisted treatment.

Mixed consumption

The use of several drugs at the same time can lead to interactions that increase the effects of heroin. There are very few heroin addicts overdoses that are fatal if only heroin is used alone. However, if mixed consumption with other sedating substances such as alcohol or benzodiazepines such as flunitrazepam or diazepam is used, the risk of a life-threatening overdose increases enormously.

A mixture of heroin and cocaine is colloquially called a “cocktail” or speedball . The effect of the two drugs is opposite, which is especially dangerous for the circulatory system. The risk of overdosing is particularly high.

If benzodiazepines are taken with heroin , there is a risk of breathing arrest. Both substances have a respiratory depressive effect, so cause a reduced activity of the respiratory muscles. Heroin can also cause bleeding in the brain via cerebral vasculitis - primarily in connection with alcohol consumption.

logistics

The Golden Triangle and the Golden Crescent are the main growing areas of opium.

Heroin is mainly used in Western Europe and the United States. Brown heroin (heroin base) was mainly produced in Afghanistan and other countries in Southwest Asia in 2015 . The rarer white heroin (heroin hydrochloride, "heroin salt") used to be produced mainly in Southeast Asia, in 2015 mainly in Afghanistan and probably in Iran and Pakistan . This region, known as the Golden Crescent , is the main supplier to the European market.

Trade routes

The raw material opium was mainly produced in 1979 in the neighboring states of Afghanistan , Pakistan and Iran (together 1,600 tons) as well as in the golden triangle around Thailand (160 tons) and in Mexico (10 tons, with a strong upward trend recently). Turkey was also an important opium producer until the 1980s . In Germany, the brown heroin base produced in Afghanistan is most common, whereas the white heroin produced predominantly in Southeast Asia is of relatively little importance.

Of the 1,600 tons of opium produced in 1979 in the three largest producing countries, 1,000 tons were consumed domestically. The remaining 600 tons were converted into about 55 tons of morphine in chemical laboratories, mostly located in Pakistan, Syria , Lebanon , Iran and Turkey.

The poppy seeds from which the raw opium is extracted is grown by farmers. These are often small farmers for whom this is the only source of income. They sell part of the opium legally to state institutions, which are also responsible for controlling the opium cultivation. The rest is sold to local dealers, who often pay a multiple of the official price. In the border region of Afghanistan, Iran, Pakistan will own dealer groups, much of the production wholesale bought the opium or morphine already converted in the Middle East resell.

In the Middle East , morphine is resold, often involving members of the political and military elites. Then there are different ways in which the morphine comes west. The most popular of these is transport via the Balkans route , where the morphine is transported to Ankara and Istanbul in trains, cars and on mules, for example , and then transported onwards via the Balkans to Western Europe. Here the morphine is converted into heroin, which is intended for the European or North American market. A second option is the transport via the so-called "southern route", which leads from the Middle East via East Africa to Europe by ship or plane. The “northern Black Sea route” via the Caucasus region or countries bordering the Black Sea is less common .

Heroin is easy to transport and hide, and is lightweight and voluminous 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 various traders, 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 (for example about the identity of the members) is usually limited to a minimum. In order to be able to buy large deliveries, the dealers often involve wealthy people who belong to the legal and recognized world (freelancers, businessmen, merchants). These have nothing to do with the business, they just secretly advance large amounts of money with which the drugs are bought. After the deal is concluded, and often for a short time, you get back many times the capital you invested in black.

The wholesale of heroin in the 1980s was to a large extent carried out by criminal organizations of various nationalities (for example mafia families or clans). They bought large quantities and resold the drugs to smaller, independent groups who then resold the heroin to the non-criminal users. In order to be able to get involved in the heroin business on a larger scale, the criminal organizations firstly needed capital to buy the drugs and to convert them to chemical products in secret laboratories. Second, violence to fight competition, intimidate witnesses, police officers and officials, and finally, ensure that agreements are kept. The people recruited for violence ranged from unemployed youth to professional killers. While in the final phases of the distribution process almost anyone could operate as a small or medium-sized dealer in the drug market, wholesaling 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 convert the morphine into the far more expensive heroin. Here the profits were between 1,000 and 2,000 percent. While it is still possible for any large farmer to trade in opium in Afghanistan, heroin trade in Europe requires a certain amount of available capital.

Price developments

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 value is below 10% and in Great Britain 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 at 110 euros per gram. In Turkey, on the other hand, 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 in a few European countries it is reported between 27 and 110 euros per gram. The prices have a falling tendency.

hazards

Comparison of 20 common drugs in terms of addiction potential and health risks
Long-term effects of heroin use

Dependency

Heroin is one of the substances with the highest potential for dependency because of its overwhelming psychological effect for a large number of users . Physical withdrawal symptoms can appear after 2 weeks of daily consumption, depending on the individual constellation.

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 ingestion becomes uneconomical, as with both forms of consumption on average around two thirds of the active ingredient is lost when ingested without reaching their target, the opioid receptors, and buying heroin on the black market is extremely expensive. Addicts are usually forced to switch to intravenous injection, which increases tolerance even further due to the higher drug intake.

Health risks

Not every (mentally stable and socially secure) user who experiments with heroin becomes dependent inevitably. Nonetheless, the usually rapidly developing and pronounced physical and psychological dependency with its consequences leads to life in the drug scene (with neglect , social marginalization , distress , delinquency , homelessness ), indirect damage to health (including infections, thrombophlebitis , embolisms in the case of intravenous Consumption without appropriate measures for sterility) as well as the frequently detectable comorbidities lead to a mortality rate that is 20–50 times higher than that of the normal population . The suicide rate is 14 times higher than that of the normal population of the same age. That is also increasingly recognized harm reduction ( harm reduction ) can not be confined to the physical and psychological problems of the individual consumer, but social (and political) solutions to a social problem requires.

In Germany, 529 deaths were counted in 2010 that were directly related to the sole consumption of heroin. Heroin, along with other drugs, was also involved in 326 other deaths. Heroin thus played a role in around 70% of all deaths associated with the use of illegal drugs. In 2013, 194 deaths in direct connection with heroin / morphine were counted in Germany, in 280 further cases heroin was involved alongside other drugs. The proportion, which has thus fallen to around 47%, can be explained by a correspondingly higher proportion of deaths associated with opiate substitution drugs. The Federal Government's Drugs Commissioner did not publish any specific figures for 2014, but continued to identify heroin abuse as the main cause of the number of drug deaths.

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 use of benzodiazepines ).

A proven consequence of long-term consumption is constipation , which can, however, also occur in the short term, as the µ2 receptors in the GI tract are subject to little or no tolerance development, which is why this symptom can persist in the long term with continuous consumption. Irregularities of the menstrual cycle ( oligomenorrhea or amenorrhea ), infertility and decrease in libido due to heroin (or opioids) alone is already considerably more difficult, although effects were detected in many of opioids on the endocrine system. This leads to a decrease in the blood level of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), but in the course of substitution treatment , many women return to normal, which increases the risk of unwanted pregnancies. It is assumed that at least a large part of these hormonal changes that lead to oligo- or amenorrhea have an effect on the living conditions of opioid addicts under prohibition conditions (unbalanced / malnutrition, reduced general condition due to various infections caused by improper IV consumption, 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 permanent prenatal contact with exogenous opioids causes biochemical / physiological changes in the CNS / neurotransmitter metabolism. It is not yet known exactly what effects this will have.

Injection or film smoking of heroin can lower the seizure threshold by influencing the hippocampus and thus trigger seizures . In the German model project for the heroin-assisted treatment of opiate addicts, these represented the most common serious undesirable accompanying symptom with a total of ten cases among the 156 participants over an observation period of four years. With methadone substitution, epileptic seizures are likely to occur less frequently.

According to the CASCADE data, the excess mortality of HIV-infected drug users in 2004/2006 was 3.7 times higher than that of HIV-infected male homosexuals.

Social consequences

Dirty place in a hiding place for heroin use

"Long-term heroin addiction leads to serious social consequences in some of the cases, among other things due to the criminalization through the acquisition, possession and trading of the illegal intoxicant." The crimes committed by heroin users, which fall into the category of acquisitive crime , cannot refer to the substance be traced back for themselves, but must be explained with the criminalization of procurement. Controlled legalization could remove this part of the criminal burden (see successful pilots in Germany, Switzerland, the Netherlands, England, etc.).

Often dependent users move all their possessions to finance the substance, which is associated with social decline (which per se leads to increased health impairment). Those affected are mostly unable to work and often become homeless, also because they can no longer meet their obligations (office work, etc.) or because all the cash is invested in drugs.

However, there is also an unknown number of heroin addicts (about which, for example, has been repeatedly reported in the low-threshold drug help service ) who carry out their work in a regulated manner, are socially integrated and can conceal their addiction from their environment, so that social decline does not necessarily follow .

withdrawal

If heavily heroin addicts do not take another dose within eight to twelve hours of their last use, withdrawal symptoms occur . This withdrawal is generally not life-threatening, but it is often very feared and very physically demanding.

All withdrawal methods are controversially discussed. For example, “turbo withdrawal” with opioid antagonists such as naltrexone ( forced opioid withdrawal under anesthesia ) can be associated with very serious health risks. After physical withdrawal, there is a risk that the previously used dose may lead to an overdose if the drug is consumed again due to a decrease in tolerance .

Model experiment for diamorphine-assisted treatment

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, the Federal Ministry of Health initiated a model project for the heroin-assisted treatment of opiate addicts. The project in Bonn started in March 2002, and the other cities gradually followed suit. Opiate addicts, for whom previous drug therapies were unsuccessful or for whom the methadone substitution was unsatisfactory, received pharmacologically pure heroin (diacetylmorphine, diamorphine) for intravenous administration under supervision; a control group received the substitute drug methadone in parallel . Both groups received regular medical care and received accompanying psychosocial therapy. The assignment to the two groups was made by chance; As an incentive, participants in the methadone group could switch to the heroin group after the year. It was necessary to separate the experimental group (heroin) and the control group (methadone) because the study was a clinical drug test, which was a prerequisite for the possible approval of heroin as a drug.

Both groups were further subdivided into subgroups that received psychosocial care using different methods, either through case management or in the form of drug counseling with psycho-education . The 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 that of the methadone group.

The project was originally planned for two or three years (two years of study and one year of evaluation of the study), but was extended in August 2004 to 2006 because the treatment was not discontinued, but it was not until 2006 that a decision was made about the approval of heroin as a drug should be. After the CDU blocked the inclusion of diamorphine-based 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 the Greens.

In the UK, heroin can be prescribed as a pain reliever and is also prescribed to heroin addicts by some doctors with home office approval . 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 England.

Heroin-assisted treatment attempts have also been made in the Netherlands, with very positive results, as well as in Spain , Belgium , Canada and Denmark .

In Switzerland, the dispensing of heroin as part of the PROVE experiments (projects for prescribing narcotic drugs) was prepared in 1991 by the Federal Office of Public Health under Flavio Cotti and decided by the Federal Council on October 21, 1992: attempts at medically controlled drug dispensing allowed heroin to be dispensed , Methadone and morphine in injectable form, heroin and (to a very limited extent cocaine) in smokable form and of heroin, methadone and morphine as swallowable preparations. In 2008, the dispensing of heroin was permanently permitted in special institutions by referendum. Theoretically, heroin could be prescribed for palliative care by any doctor in Switzerland. Today heroin, diacethylmorphine, DAM, is registered in Switzerland under the trade name Diaphin. Since heroin treatments are only allowed in very restrictive special settings, they have never achieved an important role in coping with the extreme drug problems of the 1990s. At no point in time were more than 3 percent of addicts in Switzerland undergoing heroin treatment (on the other hand, since the mid-1990s, more than half of opioid addicts have been undergoing substitution treatment with methadone, morphine retards or buprenorphine).

Since no reduction in the number of heroin addicts could and cannot be achieved through the "zero tolerance strategy" and criminalization, where heroin addicts were due to their number and segregated existence (often in central locations in large cities, for example at Zurich's Platzspitz ), a wider public than health emerged - and security issues were perceived, new ways of dealing with heroin addicts. In particular, this resulted in accepting drug work , the essential characteristic 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 lives and works of several musicians. Well-known rock bands addressed the use and consequences of heroin in their songs.

jazz

One of the first artist scenes in which heroin was frequently injected was the New York jazz scene of the 1940s and 1950s. As a result of Charlie Parker's heroin use, other jazz musicians took over the habit, in part with reference to Charlie Parker's ascribed talent for improvisation. Jazz musicians like Art Blakey , Bud Powell , Thelonious Monk , Dexter Gordon , Jackie McLean , John Coltrane , Sonny Rollins , Hank Mobley , Grant Green , Stan Getz and Miles Davis used heroin for long periods of time and were at times junkies .

With Freddie Webster , Fats Navarro , Charlie Parker, Sonny Clark , Elmo Hope , Paul Chambers , Chet Baker and Billie Holiday , there were several prominent Hero-deaths. Charlie Parker created a musical monument for his dealer Emry Bird with the composition Moose the Mooche . Anita O'Day called her 1981 autobiography "High Times, Hard Times".

skirt

John Lennon wrote the song Cold Turkey in 1969 . In it he described the attempt to get rid of 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 and about his heroin addiction. Mick Jagger wrote the songs Monkey Man and Sister Morphine with Marianne Faithfull . The album Sticky Fingers , which reached number one in the British and American charts, deals with aspects of drug use on every track.

Black Sabbath wrote a song called Hand of Doom that dealt with the often devastating effects of the drug.

New York based band The Velvet Underground , especially Lou Reed , wrote several songs about heroin. The songs Waiting for the Man and the clearly titled Heroin are considered classics of drug-inspired rock.

In punk rock heroin was the end of the 1970s, a common theme. The Ramones refused to play the song Chinese Rocks, written by Dee Dee Ramone , because it was too blatant about substance abuse. Dee Dee completed the song with Richard Hell from The Heartbreakers . The song became one of the group's most popular pieces.

The Stranglers ' most famous song , Golden Brown , revolves around heroin, according to their then frontman Hugh Cornwell , but also around a girl in order to preserve the ambiguity in the text. Lou Reed hinted at a similar lyric device in his 1972 ballad Perfect Day .

One of the most famous Red Hot Chili Peppers songs, Under the Bridge , is about the heroin experiences of the singer Anthony Kiedis in the drug regions of Los Angeles.

The Christian Death singer Rozz Williams described in his last solo album before his suicide, From the Whorse's Mouth , his addiction problems.

Kurt Cobain was regularly injecting heroin at the time of Nevermind's release .

Kevin Russell , singer in the band Böhse Onkelz , was addicted to heroin for years. The band explores these feelings in the song H .

Dutch rock musician Herman Brood was addicted to heroin for decades. He dealt with heroin in songs like Rock'n'Roll Junkie and Dope Sucks . Brood committed suicide in July 2001 after being detoxified. His suicide note said that a life without drugs did not seem worth living to him.

Some well-known rock musicians have died as a result of their addiction, including Janis Joplin , Dee Dee Ramone , Phil Lynott , Hillel Slovak , John Belushi and Sid Vicious .

The public perception of heroin use is influenced, among other things, by feature films in which the drug plays a dominant role, for example in Christiane F. - Wir Kinder vom Bahnhof Zoo or in Trainspotting - New Heroes , each of which is based on a book.

Legal position

Germany

With the law on diamorphine-assisted substitution treatment ( Diamorphine Law ) in July 2009, diamorphine became a prescription narcotic that can be dispensed to severely dependent persons under state supervision in facilities that have the appropriate license. The prescribing doctor must be qualified in addiction therapy, those affected must be at least 23 years old, have been addicted to opiates for at least five years and have at least two unsuccessful treatments. The law changed the Narcotics Act , the Narcotics Prescription Ordinance and the Medicines Act accordingly.

Switzerland

According to the Federal Act on Narcotic Drugs and Psychotropic Substances , heroin may not be imported, manufactured or placed on the market in Switzerland . A medically controlled dispensing for heroin-assisted treatment (HeGeBe) of severely addicts 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 purchase heroin . The patients receive heroin (diacetylmorphine) as a drug to be taken or can be administered intravenously in special clinics under supervision. The drug is sold under the trade name Diaphin and is available in three forms of administration: for oral administration with rapid or slowed ( retarded ) 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 a gold transport protected with armored delivery vans and armed personnel.

Other states

In Canada, and especially in the UK , diacetylmorphine is still used as a pain reliever, especially for chronic pain and palliative care . In the UK, licensed doctors may also use it as maintenance therapy for opiate addicts. Great Britain is the only country in the world where addicts can actually get heroin “on prescription”, while corresponding forms of treatment in Germany and Switzerland always require use under supervision.

In Denmark , possession of a small amount of heroin to meet personal needs is not penalized and, in these cases, the substance is not seized, 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 like “Sananim” or “Drop” welcomed the new legislation on the one hand because of its decriminalization, but on the other hand it was also criticized with the argument that the state did not take sufficient care of prevention and care for drug addicts. This brings one of the main problems that drug policy has to face in a nutshell: Partial legalization relieves addicts, but gives rise to the not unfounded fear that the consumption of partially legal drugs will increase as a result.

See also

literature

  • Alfred W. McCoy : The CIA and Heroin. World politics through drug trafficking . Westend Verlag, Frankfurt am Main 2016, ISBN 978-3-86489-134-2 .
  • Michael de Ridder: Heroin. From medicine to drug . Campus, Frankfurt am Main 2000, ISBN 3-593-36464-6 .
  • Herbert Elias: The heroin rush. Thirty-five interviews on the pharmacopsychology of diacetylmorphine . VWB, Berlin 2001, ISBN 3-86135-221-4 .
  • Lutz Klein: Heroin addiction, causal research and therapy. Biographical interviews with heroin addicts . Campus, Frankfurt am Main 1997, ISBN 3-593-35828-X ( Campus Research . Volume 755).
  • Andre Seidenberg, Ueli Honegger: methadone, heroin and other opioids. Medical manual for outpatient opioid-assisted treatment . Huber, Bern 1998, ISBN 3-456-82908-6 .
  • Hans-Georg Behr : world power drug. The business of addiction . Pabel / Moewig, Rastatt 1985, ISBN 3-430-11293-1 .
  • Robert Knoth, Antoinette de Jong: Poppy - Trails of Afghan Heroin . Hatje Cantz, 2012, ISBN 978-3-7757-3337-3 .
  • Hamish Warburton, Paul J. Turnbull, Mike Hough: Occasional and controlled heroin use: Not a problem? Joseph Rowntree Foundation, York 2005, ISBN 1-85935-424-6 .
  • Heroin for Arne B. In: Die Zeit , No. 12/2008
  • Fabric from the state . In: Die Zeit , No. 28/2006

Radio plays

  • Heroin , WDR radio play about the development and marketing of heroin, 2013

Web links

Commons : Heroin  - Collection of pictures, videos and audio files
Wiktionary: Heroin  - explanations of meanings, word origins, synonyms, translations

Web links on the subject of heroin distribution and methadone programs

Other press reports

Individual evidence

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