Heroin

Like many of the drugs used today, heroin is a chemically manufactured and not naturally occurring. Given its relation to organic molecules derived from opium (ie. morphine/codeine), it belongs to the opioide family. This differs from opiates, which are naturally occuring molecules originally derived from the poppy plant. With a simple acetylation reaction (the same synthetic step used to create aspirin from its parent molecule), heroin was born from morphine, and the rest is history. Shortly after its creation it was marketed over the counter as an analgesic. Acetylation is maintained when drug is injected (bipassing the first pass effect) and is what allows fat solubility and movement into the central nervous system.

Heroin use as a recreational drug has been a major health concern for nearly a century, and despite widespread knowledge of its effects, use continues to grow. Sequlae of heroin use includes, overdose, poisening from contaminants, endocarditis, injection site abscesses, renal disease and dependence amongst other things. A publication in The Lancet (2007) identified heroin as having the highest risk of harm to users compared to 20 other illicit substances. The concern of health consequences is what has driven many cities to initate clean needle injection sites. A recently discussed case highlighted the importance of considering the presence of adulterants in heroin, which can have significant consequences.

A review published in 2011 examined the content of heroine samples acquired over a 5 year period. Heroin was found to make up only ~25% of heroin samples, where additional substances made up the rest of the product. Tylenol and caffeine were the most common additives, though levamisole (an anti-helminthic medication) has been identified previously. Levamisole was report to be present in up to 4% of cocaine samples in a European study (Schneider et al.), though much higher values have been identified in US publications (upwards of 70% of samples, JAMA). Ingestion can result in profound neutropenia, leukoencephalitis and vasculitis. Physicians should recognize the heterogeneity of illicit substances and look for symtpoms which may be consistent with their toxicities when patient present with intoxication.

Heroin in Toronto