U.S. In The Midst Of A Heroin Epidemic, But Many Overdose Deaths Can Be Prevented

With proper diagnosis and treatment that begins close to anhour after an overdose, a majority of patients shouldsurvive, says Karl Sporer, MD, UC San Francisco assistantprofessor of medicine and author of the analysis, whichappears in the April 6 issue of Annals of Internal Medicine.

He also emphasizes that overdose preventive measures likemethadone maintenance, in which heroin users receive asynthetic narcotic drug to help treat their addiction, haveproved effective, and increasing the availability of thistype of program could reduce the number of deaths.

A specialist in emergency medicine who treats patients atthe UCSF-affiliated San Francisco General Hospital MedicalCenter, Sporer began researching the medical literature ayear ago for all current information on acute heroinoverdoses when he found no comprehensive update wasavailable.

The Annals article covers the pharmacology of heroin,incidence of fatal overdoses, diagnosis, treatment,complications, and prevention programs.

"One surprise was the documentation of the dramatic activityof heroin in the body compared to morphine and otheropiates," he says. "Heroin is more soluble in the fat cellsso it crosses the blood-brain barrier within 15-20 seconds,rapidly achieving a high level in the brain and centralnervous system, which accounts for both the 'rush'experienced by users and the toxicity."

Heroin produces its effects by acting on key receptors inthe central nervous system that are linked to a slowedbreathing rate, feelings of euphoria, and physicaldependence on the drug, he adds.

In the U.S., heroin-related emergency department visits havedoubled from 33,900 in 1990 to 70,500 in 1996. Of personswho inject heroin, the average annual death rate is twopercent.

The clinical criteria for diagnosis of a heroin overdose issevere coma in combination with factors such as severelydepressed breathing, extremely constricted pupils, orcircumstantial evidence of drug use. There has been varyingmedical opinion about immediate use of the overdoseantidote, naloxone, in all suspected cases, but currentguidelines suggest its use only if the patient is havingcritical breathing problems, according to Sporer.

Other overdose preventive strategies that have proved to beeffective are education programs for heroin users that focuson their peak periods of vulnerability for use--such as thefirst year after discontinuing addiction treatment and thefirst two weeks after release from incarceration--andeducation programs that encourage use of the 911 emergencysystem.

Findings reported in the Annals article include:

--With intravenous use, 68 percent of heroin is absorbedinto the brain compared to less than five percent ofmorphine.

--Heroin is absorbed rapidly through all routes ofadministration. It peaks in the blood serum in less than oneminute with intravenous use. Through the nasal passages orinjection in the muscular tissue, the peak occurs in 3-5minutes. With injection in the subcutaneous tissue beneaththe skin, the peak occurs in 5-10 minutes.

--The route of administration strongly affects heroin'spotential to cause death or overdose. Most fatal andnon-fatal overdoses are linked to intravenousadministration.

--Most deaths occur among heroin users who are in their late20s or early 30s, have used the drug for 5-10 years, andhave significant dependence.

--Multiple drug use is common in heroin-related deaths, withsignificant levels of alcohol in 29 to 75 percent of cases.

-- In most cases of death, medical help was not sought orsought too late. An ambulance was called in about 14percent of overdose cases, with fear of police involvementas the major reason for not calling 911 for help.

--The most common complications of heroin overdose treatmentare pulmonary edema (fluid in the lungs) and pneumonia.

Through its Department of Psychiatry, SFGHMC offerscomprehensive substance abuse treatment services for heroinusers and others, including both inpatients and outpatients. Steven Batki, MD, is director of the SFGHMC Division ofSubstance Abuse.