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Narcotics (Opioids)
Chapter 9
WHAT ARE NARCOTICS?
The term narcotic currently refers to
naturally occurring substances derived
from the opium poppy and their synthetic
substitutes.
 These drugs are referred to as the opioid
(or opiate) narcotics because of their
association with opium.

WHAT ARE NARCOTICS?
FIGURE 09.T01: COMMONLY USED OPIOID NARCOTIC DRUGS AND PRODUCTS
WHAT ARE NARCOTICS? (CONTINUED)
Abuse rate for prescribed opioid narcotics has
gone from 2.2% to 10% in the past 10 years
 Although opioid narcotics possess abuse
potential, they also have important clinical value
(e.g., analgesic, antitussive, antidiarrheal).
 The term narcotic has been used to label many
substances, from opium to marijuana to cocaine.

THE HISTORY OF NARCOTICS

Dates back some 600 years (6000-year-old Sumerian
tablet)

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Used / traded in the historic Egyptian, Greek,
and Arab cultures (Greek God of sleep = Hypnos)
China and opium trade
The Opium War of 1839 (Development of the
British Island of Hong Kong) Second war = 1856
American opium use (development of morphine and
codeine, and the development of the hypodermic
needle)

Heroine “heroic” drug was introduced in 1898
as an antitussive.
PHARMACOLOGICAL EFFECTS
The most common clinical use of the
opioid narcotics is as analgesics to relieve
pain.
 The opioid narcotics relieve pain by
activating the same group of receptors
that are controlled by the endogenous
substances called endorphins.
 Activation of opioid receptors blocks the
transmission of pain through the spinal
cord or brain stem and can also reduce
the effects of stress.

PHARMACOLOGICAL EFFECTS
(CONTINUED)
Morphine is a particularly potent pain reliever
and often is used as the analgesic standard
by which other narcotics are compared.
 With continual use, tolerance develops to the
analgesic effects of morphine and other
narcotics.
 Physicians frequently underprescribe
narcotics, for fear of causing narcotic
addiction.

PHARMACOLOGICAL EFFECTS
(CONTINUED)

The principle side effects of the opioid
narcotics, besides their abuse potential,
include:
 Drowsiness, mental clouding
 Respiratory depression
 Nausea, vomiting, and constipation
 Inability to urinate
 Drop in blood pressure
SIGNS, SYMPTOMS, AND ABUSE
ABUSE, TOLERANCE,
DEPENDENCE,
AND WITHDRAWAL
All the opioid narcotic agents that activate
opioid receptors have abuse potential and
are classified as scheduled drugs.
 Tolerance begins with the first dose of a
narcotic, but does not become clinically
evident until after 2 to 3 weeks of
frequent use.

ABUSE OF OPIOID NARCOTICS
Tolerance occurs most
rapidly with high doses
given in short intervals.
 Doses can be increased as
much as 35 times in order to regain the
narcotic effect.
 Physical dependence invariably accompanies
severe tolerance and typically expresses when
these drugs are used for more than 2–4
weeks.
 Psychological dependence can also develop
with continual narcotic use.

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GUIDELINES TO AVOID
PRESCRIBED OPIATE ABUSE
Only use opioid analgesics when pain severity
warrants
 Doses and duration of use should be as
conservative as possible
 Patients should store these medications
securely to prevent their theft and misuse
 Do not share with anyone else
 Doctors should screen patients for abuse risk
before prescribing opioid drugs

GUIDELINES TO AVOID
PRESCRIBED OPIATE ABUSE
(CONTINUED)
Patients should be educated about potential
abuse problems prior to being prescribed
opioid drugs
 If significant abuse is suspected, the
clinician should discuss concerns with
patient to find appropriate steps to stop the
abuse

OPIOID SIDE EFFECTS
Drowsiness
 Respiratory depression
 Nausea/vomiting
 Inability to urinate
 Constricted pupils
 Constipation
 Physical dependence and withdrawal

HEROIN ABUSE

Heroin is classified as a Schedule I drug.
 One of the most widely abused illegal drugs in
the world; accounts for >$120 billion
sales/year
 Illicitly used more than any other drug of abuse
in the United States (except for marijuana) until
20 years ago, when it was replaced by cocaine
 Some of the recent increases in heroin use
likely due to increased abuse of prescription
opioid painkillers
HEROIN COMBINATIONS
Pure heroin is a white powder.
 More than 90% of world’s heroin is from
Afghanistan.
 Heroin is usually “cut” (diluted) with lactose.



When heroin first enters the United States, it may be
95% pure; by the time it is sold, it may be 3% to 70%
pure.
If users are unaware of the variance in purity and
do not adjust doses accordingly, results can be
fatal.
HEROIN COMBINATIONS
(CONTINUED)
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Heroin has a bitter taste and is often cut
(diluted) with quinine, which can be a deadly
adulterant.
Heroin plus the artificial narcotic fentanyl can be
dangerous due to its unexpected potency.
Heroin is most frequently used with alcohol.
Heroin combined with cocaine is called
“speedballing.”
FACTS ABOUT HEROIN ABUSE

What is the estimated number of heroin
addicts in the United States?
 600,000 – 1,000,000

What are “shooting galleries”?
 Locations that serve as gathering
places for addicts
HEROIN AND CRIME

Factors related to crime:
 Pharmacological effects encourage
antisocial behavior that is crime-related
 Heroin diminishes inhibition
 Addicts are often self-centered, impulsive,
and governed by need
 Cost of addiction
 Similar personality of criminal and addict
– begin to engage in crime and heroin use at same time
PATTERNS OF HEROIN ABUSE
Heroin has become purer (60% to 70%
purity) and cheaper (~$10/bag).
 Greater purity leads users to administer
heroin in less efficient ways. (smoking and
snorting)
 Many youth believe that heroin can be used
safely if not injected.

PATTERNS OF HEROIN ABUSE
(CONTINUED)
Because of its association with popular
fashions and entertainment, heroin has been
viewed as glamorous and chic, especially by
many young people, although lately this
attitude has been changing.
 Emergency room visits due to narcotic
overdoses were over 190,000 in 2009.

STAGES OF DEPENDENCE
Initially, the effects of heroin are often
unpleasant.
 Euphoria gradually overcomes the aversive
effects.
 The positive feelings increase with narcotic
use, leading to psychological dependence.
 In addition to psychological dependence,
physical dependence occurs with daily use
over a 2-week period.
 If the user abruptly stops taking the drug after
physical dependence has developed, severe
withdrawal symptoms result. (6-12 hrs)

METHODS OF HEROIN
ADMINISTRATION
Sniffing the powder
 Injecting it into a muscle (intramuscular)
 Smoking
 Mainlining (intravenous injection)

HEROIN ADDICTS AND AIDS
More than 250,000 patients in United States
contracted AIDS by drug injection, of which
most were heroin users.
 Fear of contracting HIV from IV heroin use has
contributed to the increase in smoking or
snorting heroin.
 Many who start by smoking or snorting
progress to IV administration due to its more
intense effects.

HEROIN AND PREGNANCY

Heroin use by a pregnant woman leads to:
 Physical dependence on heroin in the
newborn
 Withdrawal symptoms after birth in the
newborn (Note: similar withdrawal occurs in
newborns of any woman who uses
significant amounts of opiate drugs during
pregnancy, including prescribed opiate
painkillers)
WITHDRAWAL SYMPTOMS
After the effects of the heroin wear off, the
addicts have only a few hours in which to find
the next dose before severe withdrawal
symptoms begin.
 A single “shot” of heroin lasts 4 to 6 hours.
 Withdrawal symptoms: runny nose, tears,
minor stomach cramps, loss of appetite,
vomiting, diarrhea, abdominal cramps, chills,
fever, aching bones, and muscle spasms.

WITHDRAWAL SYMPTOMS
TREATMENT
Methadone or buprenorphine are
frequently used to help narcotic addicts.
 These drugs block withdrawal symptoms.
 Treatment should also include regular
counseling and other supplemental
services such as job training.
 See also Figure 9.1, p 289 (next slide)

TREATMENT
OTHER NARCOTICS (READ IN CLASS)
Morphine
Methadone
Fentanyl
Hydromorphone
Oxycodone (OxyContin)
Meperidine
Buprenorphine
MPTP
Codeine
Pentazocine
Tramadol
NARCOTIC-RELATED DRUGS

Dextromethorphan: OTC antitussive
NARCOTIC-RELATED DRUGS
Clonidine: Relieves some of the opioid
withdrawal symptoms
 Naloxone/Naltrexone: Narcotic
antagonist; used for narcotic overdoses

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