Addressing psychiatric and psychosocial issues related to children and adolescents
In a previous column, we focused on Jessica, a teen whose recreational use of opioid pills had developed into daily use; only with daily opioid intake could she feel normal. When Jessica tried to stop on her own, she began to experience withdrawal symptoms. Jessica’s stress was made worse when her friend, Tracy, who had introduced her to pills, switched to heroin, and overdosed and died. Tracy’s death sent Jessica into a panic.
The purpose of the current article is to alert psychiatric nurses of the increased use of heroin by teens and its increasing availability at a lower price. Additionally, the authors seek to educate patients and families about in-home diversion of opioid medications and the inherent risks. A brief description of treatment options, including opioid replacement therapy (ORT) and overdose rescue medication, is also provided.
Overview of Heroin Use in the United States
Many Americans have a stereotypical image of a heroin addict: a sickly, bone-thin person living in urban squalor and begging for money for yet another fix. This image is inaccurate; heroin users today are significantly different from heroin users of the past.
In the 1960s, heroin use first had an impact on the consciousness of middle America. Americans who began using heroin then were primarily young urban males (82%) whose initial opioid drug of abuse was heroin (Cicero, Ellis, Surratt, & Kurtz, 2014). Now in the 21st century, 75% of heroin users are in their early 20s, less likely to live in urban areas, and can be either men or women. White and nonwhite ethnicities were equally represented among those who initiated use before 1980; however, users who started abusing heroin in the past decade are predominantly 90% Caucasian. Major factors contributing to the acceleration of heroin use may be its availability and low cost compared to diverted prescription opioid drugs (Cicero et al., 2014; Veilleux, Colvin, Anderson, York, & Heinz, 2010). Furthermore, intoxication induced by heroin is rated by users as more intense when compared to opioid pills (Kerr, Small, Hyshka, Maher, & Shannon, 2013). As such, users see heroin as cheaper, more readily available, and producing an intense high.
Inexpensive Forms of Heroin Found in the United States
The bulk of heroin in the United States mostly originates in Mexico or Colombia (Ciccarone, 2009). Mexican heroin is dark brown or black in color (also called “black tar”) and is sold in solid form. It must be heated to change into its liquid state to be injected. Its parenteral use is often associated with soft tissue infections commonly due to Clostridia bacteria (Ciccarone, 2009). Colombian heroin has a different appearance: it is off-white or light brown and comes in a powdered form. Unlike “black tar,” it has good water solubility, making it easier to convert into a liquid form. Additionally, powdered heroin can be readily snorted or transformed into a solution for injection (Ciccarone, 2009).
Reductions in price and ready availability contribute to the rise in heroin use. For example, South American heroin decreased in cost from $1.75/mg in 2010 to $1.18/mg in 2011 (Drug Enforcement Administration, 2013). A study by Unick, Rosenblum, Mars, and Ciccarone (2014) found that within the United States, each $100 decrease in the price of a pure gram of heroin resulted in a 3% increase in the number of heroin overdose hospitalizations. Prices are even lower now that the European market is flooded with heroin coming from Afghanistan, where opium production was reportedly up 49% during 2012 (Webber, 2014). Being both widely available and cheap, heroin is becoming more attractive to teens looking for the euphoria they previously found from other sources.
Heroin Is Dangerous
Adolescents still possessing immature frontal lobes and thus limited executive judgment may recognize the risks of heroin but still use it if friends apply peer pressure. They may describe it as “the best feeling ever” or use heroin to relieve emotional tension despite perceived risk (Mars, Bourgois, Karandionos, Montero, & Ciccarone, 2014, p. 160). Teens see opioid pills as relatively safe because they have been prescribed by a licensed health care provider; however, increased regulation of pills makes heroin more accessible and attractive (National Institute on Drug Abuse [NIDA], 2013).
The risks of heroin use are substantial. Because different batches of heroin have variable potency, the danger of overdose is not well recognized and, consequently, is high. Heroin users have a significantly higher mortality rate (i.e., 10 to 30 times higher than those who do not use heroin) (Cavacuiti, 2011). Toxic doses of opioid drugs suppress respiration and induce cerebral anoxia, followed by death if there is no intervention. Individuals who are inexperienced with heroin may miscalculate the dose inadvertently, causing lethal overdoses; those who infrequently use heroin may suffer the same fate (Stevens, 2014).
The risk for overdose increases if concomitant use of alcohol, benzodiazepine agents, or both occurs (Stevens, 2014; Wynn, Oesterheld, Cozza, & Armstrong, 2009). In addition, heroin often contains toxic contaminants that can cause permanent damage to vital organs (NIDA, 2013). Those who quit using for a period of time are vulnerable to overdose if they return to using; their tolerance changes, making them more sensitive to the effects of the drug.
Although opiate withdrawal is usually not lethal, it is uncomfortable, painful, and can induce suicidal thinking (Veilleux et al., 2010). The craving, dysphoria, and physical illness related to withdrawal symptoms often drive youths to seek additional opioid agents to quell the symptoms, which becomes a vicious cycle. Interrupting the cycle can be done through managing the withdrawal symptomatically by decreasing the noradrenergic stimulation through use of clonidine (Catapres®) (Cavacuiti, 2011). In some settings, an opioid taper can be conducted using buprenorphine (Buprenex®) or methadone. The taper can stabilize the process and make the pain more manageable (Substance Abuse and Mental Health Services Administration, 2009).
As with all types of addictions, opioid dependence is a chronic relapsing condition (Merrill & Duncan, 2014). Those who have failed to remain opioid-free may benefit from ORT, which is a form of treatment that promotes recovery via a stable opioid-like substance that blocks the use of other opioid agents (Veilleux et al., 2010). While undergoing ORT, patients can return to their daily tasks without the cravings, drug seeking, or intermittent withdrawal. Although the amount of time a patient can stay on ORT is indefinite, the same risk of relapse exists once it is discontinued compared to the risk for individuals who do not use ORT (Veilleux et al., 2010).
The most common form of ORT is daily methadone dispensed from a methadone clinic. Using methadone for ORT is highly regulated and requires daily clinic visits. For some heroin users, remaining on methadone long-term saves their lives. Although teenagers younger than 18 may be enrolled in methadone maintenance programs, it is usually only after two previous attempts of detoxification (Yin, 2014). Parent or guardian consent is required.
Buprenorphine is another ORT option (Merrill & Duncan, 2014) and is a schedule III narcotic (and partial agonist) that acts like an antagonist by occupying receptors but not activating them. In 2002, the U.S. Food and Drug Administration (FDA) approved two new buprenorphine products: Subutex® (buprenorphine only) and Suboxone® (buprenorphine/naloxone combination) (Merrill & Duncan, 2014). Again, parent or guardian consent for use in adolescents is required (Yin, 2014).
Barriers to Opioid Replacement Therapy
Although methadone replacement is a valid treatment, federal law mandates when, where, and how methadone is prescribed as ORT, thereby only allowing for dispensing provisions through an approved methadone clinic. However, a barrier to methadone treatment is that rural communities often do not have methadone clinics, resulting in daily long-distance drives to obtain treatment. The same is true for buprenorphine; the number of clinicians who have prescriptive authority for buprenorphine is limited (Forneli & Burda, 2009).
Naloxone (Narcan®), an opioid receptor antagonist, saves lives in opioid drug overdoses, is the standard of care for reversing opioid drug overdoses, and is well known in emergency departments (Centers for Disease Control and Prevention [CDC], 2012). In 2014, the FDA approved naloxone (Evzio®) in an auto-injector form that delivers 0.4 mg intramuscularly. In an emergency situation, naloxone is given when the respiratory system is compromised by opiate toxicity. The drug blocks the opioid receptor and causes abrupt opioid withdrawal.
Because naloxone has a brief half-life, most users require ongoing monitoring or a naloxone infusion to prevent recurrent sedation and respiratory suppression. Intranasal administration of naloxone has an effectiveness similar to the intramuscular route as first-line treatment for opioid drug overdose in the home setting (Stevens, 2014; Veilleux et al., 2010). Several U.S. cities with a high prevalence of heroin use have provided their police forces with emergency doses of naloxone, and reports from several cities indicate that having an antidote available for use by first responders has saved many lives (CDC, 2012). However, some locales are reluctant to adopt this life-saving practice due to budgets that cannot afford the added cost of the medication.
Understanding the physiological effects of heroin on the brain can help psychiatric nurses guide adolescents with heroin dependence to recovery. A nonjudgmental, respectful approach is helpful to teens who are in withdrawal.
Nurses can also help inform the public (including adolescents and young adults) about the risks of opiate drug use as well as treatment options, and media outlets play a major role in sharing informative material. NIDA (2014) has created a website to help keep teens informed about opioid drugs (access http://teens.drugabuse.gov/educators/nida-teaching-guides/mind-over-matter/opioids). There is also a peer network to help adolescents connect (access http://teens.drugabuse.gov/peerx).
Jessica told her parents how she was able to hide her opioid drug use. Aware of the death of her friend, they were frightened for their daughter. Jessica was referred to a facility that treated adolescent substance use and received an immediate assessment in the treatment center that could help manage her withdrawal symptoms and begin treatment for her substance use.
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