The main problem in overdose is brainstem respiratory CO2 sensitivity falls and the patient stops breathing. The purity of heroin on the streets is strong enough now that we’re seeing this even with inhaled and smoked heroin sometimes. Now, tolerance occurs rapidly particularly to the nausea and that kind of discomfort and it becomes purely pleasurable at that point but only one in ten people who try heroin tend to become addicted to it. So we have to be realistic about this and reasonable, not that heroin could ever be thought of as a legalized substance, but not everybody who walks in who says, you know, “I used heroin at a party” is a heroin addict and we have to do some work to tease out “Do we have a criteria of dysfunction being met?”
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What’s the withdrawal amount? Well, the locus caeruleus is suppressed by chronic heroin use and when that suppression is released we have up-regulation of noradrenerigic receptors and suddenly the adrenergic arousal goes wild. There isn’t up-regulation of the opioid receptors themselves but there is up-regulation in terms of dopamine activity and the two sides are the ventral tegmental area – VTM – and nucleus accumbens which we talked about before but both of these are involved. Heroin is not a one site reinforcer. It seems to involve this system.
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I’m not going to talk about the long term treatment, for instance methadone. Harm reduction is an important goal nowadays because it reduces HIV transmission. So needle exchange works. Even in areas with lots of severe heroin addicts, we see reduction in HIV transmission thanks to needle exchange regardless of what the government’s policy is. Generic viagra 100 mg online at cheap pharmacy mall. Rapid detox can be done in less than five days with a combination of either these two – clonidine or naltrexone – plus or minus buprenorphine which I think actually improves the experience and retention for the patients and the L Group published on this. I think it’s definitely better combined.
Anesthesia detox. You actually can get a full blown heroin addict onto full dose naltrexone totally blockaded at the mu-receptor – they can’t become high now – in five hours using anesthesia. The problem is you don’t know if the therapeutic change has happened so that the patient doesn’t go out and then try and overcome naltrexone and dose themselves so badly that they overshoot and go into coma which has happened now a few times.
LAM – levo acetyl methadone. LAM is now FDA approved. It’s just a long acting type of methadone. So you can dose 100 mg Monday, 100 mg Wednesday, 150 mg on Friday and the patient is covered in the intervening days. They have more freedom. They can return to a more normal life. The patients like it. They retain better on it. Not available in all states. Call for details.
Buprenorphine. I hope it’s going to come out this year from the FDA. I keep saying that. The slowdown has been that the FDA is being pushed to allow dispensing in physicians’ offices. Buprenorphine is another long acting opioid like LAM, like methadone, safer and we may get to use it in office practice.
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