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H is for Heroin

Neil Wilson
Neil Wilson

The opium poppy has been cultivated by humans for at least 5,000 years. Its use in the form of opium led to moral panic in Victorian England and even the fighting of two rather obscure wars. These were the first and second opium wars fought in the mid 19th century by the British (joined by the French) against China. Britain’s insatiable demand for tea meant that the balance of trade was heavily weighted in the favour of the Chinese. Uninterested in anything Britain produced at the time, opium produced in India, although illegal, balanced thing up for the traders. The various skirmishes led to an eventual legalisation of the trade and the ceding of Hong Kong to the British. A combination of disquiet in Britain about the trade and increasing production within China meant the trade was finally ended by the time World War I came around.

Tales of the opium dens of the Far East and international trade meant that opium dens began to appear elsewhere in the world, usually connected to the Chinese community. The opium dens of the East end of London attracted particular attention with writers such as Charles Dickens, Agatha Christie, Oscar Wilde and Arthur Conan Doyle plundering the area for atmosphere and plotlines. One book, above all others opened the eyes of many to what was happening in some of the more shady parts of the capital. This book helped to spawn a whole new genre of literature: the confessional autobiography. ‘Confessions of an English Opium-Eater’ (1821) by Thomas De Quincey was a huge bestseller in its’ day. De Quincey both sensationalised the use of opium and attempted to warn others of its dangers by the telling of his personal story. Interestingly De Quincey usually consumed opium in the form Laudanum, a tincture (liquid) that variously contained opium, saffron, cinnamon and alcohol. The title is then somewhat misleading, probably used to increase the shock value and thus sales.

A step-change occurred at the end of the 19th century when in 1895 ‘Heroin’ became available, from the German pharmaceutical firm Bayer. Bayer, advanced the synthesis of morphine (again derived from the opium poppy) and began marketing it as an over-the-counter drug. As such ‘Heroin’ is a trademark and should properly be referred to as ‘diamorphine’. Like many other products the original trademark name stuck in the public’s mind from that time on. The word ‘Heroin’ is apparently derived from the German ‘Heroish’, and ultimately the Greek work ‘Heros’. The common mis-spelling of ‘Heroine’ is not unsurprising. Ironically Bayer were looking to produce a cough suppressant without the addictive side effects of morphine.

Another 19th century invention that changed the world was the invention of the hypodermic syringe, allowing for a much more efficient delivery of many drugs. Injection remains one of the main ways in which Heroin is used in the modern day despite the increased risks of the user suffering from collapsed veins, deep-vein thrombosis and the heightened risk of contracting diseases such as HIV/AIDS or Hepatitis through the use of shared needles.

Heroin is also commonly smoked (colloquially known as ‘Chasing the dragon’), where users inhale the smoke created from heating a piece of Heroin, placed on aluminum foil. More unusually it can also be snorted in a similar fashion to cocaine or taken as a suppository.

Users often report an intense feeling of euphoria (or ‘rush’) accompanied by a warm flushing of the skin and a dry mouth. Some report nausea, vomiting, and severe itching. After several hours of drowsiness thinking is clouded and the heart slows. When breathing is also severely slowed it can be life-threatening leading to coma and possible brain damage that maybe permanent.

Longer term, as tolerance increases, dependency can set in as the body seeks to adapt. This may cause further medical issues. The imbalances created in neuronal and hormonal systems present significant challenges when a person undergoes rehabilitation treatments.

The potency to opiates shock, appall and its ability to create headlines continues to the modern day as opiate related deaths in the United States have approached 70,000 per year recently. Many of these deaths were due to the use of newer medically sourced opiates such as Fentanyl. Others had had their medication withdrawn and sought street-bought heroin as a replacement. This has created its own issues and dangers ranging from increased morbidity issues and overdose fatalities. Several important debates continue as to the best way to deal with presenting issues surrounding the misuse of heroin and how best to minimise its pervasive harm. A current model of thinking suggests offering heroin users a safe and medically supervised facility to consume diamorphine.

A Supervised Injecting Facility (SIF) is an example of such a facility. It offers users a clean, safe, healthcare environment where people can inject drugs, obtained elsewhere, under the supervision of trained health professionals. They offer a compassionate, person-centred service which reduces the harms associated with injecting drug use and can help people access appropriate services. A SIF can help health service staff to reach and support vulnerable and marginalised people who often do not/cannot or no longer engage with existing health services. Their use of such sites has been heralded in several countries around the world including several European countries, Canada and Australia. Typically the number of drug related deaths decreases, taking pressure off emergency services. There is also a reduction seen in the level of public injecting that takes place and a consequent reduction in the levels of drug litter found. The effect on crime levels is more difficult to measure as any reductions are usually due to a drop in drug offences such a possession. There is no evidence that areas that install SIF facilities see an increase in crime levels or an increase in the numbers and frequency of injecting heroin users. Such initiatives remain controversial, especially amongst those who support a ‘Zero-tolerance’ approach to drug use.

Despite many positive press releases and announcements a series of legal wrangles means that at the time of writing no facility is yet open in Ireland. Merchant’s Quay in Dublin aim to have their pilot facility open in early 2021. The current delay is due to planning issues and has the overall backing of the Dept of Health.

Another somewhat controversial approach to minimizing harm associated with illicit heroin use is the prescribing of diamorphine (heroin) to users. This is sometimes called ‘The British solution’. Back in 1926 the UK Department of Health released Rolleston Committee Report establishing the approach whereby dealers were prosecuted, but doctors could prescribe diamorphine to users when withdrawing. By the 1970s, the emphasis shifted to abstinence and the use of methadone, as much cheaper alternative. Methadone does not however provide the ‘rush’ of heroin leading to some users to seek alternative supplies which would normally imply a higher level of medical risk.

Prescribing heroin has proven to be superior to methadone in improving the social and health situations of dependent users. A seminal Swiss study in 1994 followed 340 (later expanded to 1,000) users on a diamorphine prescription programme. Overall it was calculated to have saved money, despite high treatment expenses, as it significantly reduced the costs incurred by trials, incarceration and other health interventions. The approach adopted in Switzerland was confirmed by a national referendum held in 2008 when 68% of voters supported the plan to put the programme into full federal Swiss law. The success of the Swiss trials led other German, Dutch and Canadian cities to try out their own heroin prescription programs.

Despite these approaches, overdoses continue to occur on a worrying level. Larger doses of heroin can cause fatal respiratory depression, and the drug has been used by people attempting to take their own lives. It’s also been used as a murder weapon, most notoriously by the serial killer Harold Shipman who used diamorphine on many of his estimated 250 victims.

Due to the fact that significant tolerance to respiratory depression develops quickly with continued use (and is lost quickly again during withdrawal) it is often difficult to determine whether the reason for lethal overdose of heroin was an accidental overdose, suicide or a case of murder. The situation is further complicated by the fact that the purity of street sold heroin varies greatly. An overdose becomes more likely when the purity is higher than expected. The deployment of the very effective and relatively cheap drug naloxone (Narcan in the US) which blocks the effects of any opioid has saved countless lives over the years. I will discuss this opioid antagonist in detail in a future blog on the subject.

In the tradition of Thomas De Quincey, authors continue to grapple with the complexities of heroin use. One such book in recent years is My Booky Wook, which has sold some 600,000+ copies since its release in 2007. The author, Russell Brand, gives many an insightful glimpse into the mind of user:

“The priority of any addict is to anaesthetise the pain of living to ease the passage of day with some purchased relief.”? Russell Brand

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