Announcement: 2017 – 4th of July Holiday Hours

Our office will be closed Monday, July 3rd, 2017 at 5pm through the 4th of the July Holiday. We will return on Wednesday at our normal operating hours.

Happy 4th of July!

Drug Overview

opiates-bloom

Important information regarding OPIATES drug use.

opiates-bloomThe poppy Papaver somniferum is the source for nonsynthetic (natural) narcotics. It was grown in the Mediterranean region as early as 5000 B.C., and has since been cultivated in a number of countries throughout the world. The milky fluid that seeps from incisions in the unripe seed pod of this poppy has, since ancient times, been scraped by hand and air dried to produce what is known as opium.

opiates-beeThe pretty little (“cousin”) flower, the European Poppy, was worn for years by millions of Americans as a symbol of patriotism on many holidays… especially on Veterans day. This custom has apparently disappeared… perhaps as the poppy’s role in America’s drug problem is now well known.

 

opiates-powderThe term narcotic, derived from the Greek word for stupor, originally referred to a variety of substances that induced sleep. In a legal context, narcotic refers to opium, opium derivatives, and their semisynthetic or totally synthetic substitutes. Cocaine and coca leaves, which are classified as “narcotics” in the Controlled Substances Act (CSA), are technically not narcotics and are discussed in the section on Cocain. Narcotics can be administered in a variety of ways. Some are taken orally, transdermally (skin patches) or injected. They are also available in suppositories. As drugs of abuse, they are often smoked, sniffed or self- administered by the more direct routes of subcutaneous (“skin popping”) and intravenous (“mainlining”) injection.

Drug effects depend heavily on the dose, route of administration, previous exposure to the drug, and the expectation of the user. Aside from their clinical use in the treatment of pain, cough suppression and acute diarrhea, narcotics produce a general sense of well-being by reducing tension, anxiety, and aggression. These effects are helpful in a therapeutic setting but contribute to their abuse.

Narcotic use is associated with a variety of unwanted effects including drowsiness, inability to concentrate, apathy, lessened physical activity, constriction of the pupils, dilation of the subcutaneous blood vessels causing flushing of the face and neck, constipation, nausea and vomiting and, most significantly, respiratory depression. As the dose is increased, the subjective, analgesic, and toxic effects become more pronounced. Except in cases of acute intoxication, there is no loss of motor coordination or slurred speech as occurs with many depressants.

Among the hazards of illicit drug use is the ever-increasing risk of infection, disease and overdose. Medical complications common among narcotic abusers arise primarily from adulterants found in street drugs and in the non-sterile practices of injecting. Skin, lung and brain abscesses, endocarditis, hepatitis and AIDS are commonly found among narcotic abusers. Since there is no simple way to determine the purity of a drug that is sold on the street, the effects of illicit narcotic use are unpredictable and can be fatal.

With repeated use of narcotics, tolerance and dependence develop. The development of tolerance is characterized by a shortened duration and a decreased intensity of analgesia, euphoria and sedation, which creates the need to administer progressively larger doses to attain the desired effect. Tolerance does not develop uniformly for all actions of these drugs, giving rise to a number of toxic effects. Although the lethal dose is increased significantly in tolerant users, there is always a dose at which death can occur from respiratory depression.

Physical dependence refers to an alteration of normal body functions that necessitates the continued presence of a drug in order to prevent the withdrawal or abstinence syndrome. The intensity and character of the physical symptoms experienced during withdrawal are directly related to the particular drug of abuse, the total daily dose, the interval between doses, the duration of use and the health and personality of the addict. In general, narcotics with shorter durations of action tend to produce shorter, more intense withdrawal symptoms, while drugs that produce longer narcotic effects have prolonged symptoms that tend to be less severe.

The withdrawal symptoms experienced from heroin/morphine-like addiction are usually experienced shortly before the time of the next scheduled dose. Early symptoms include watery eyes, runny nose, yawning and sweating. Restlessness, irritability, loss of appetite, tremors and severe sneezing appear as the syndrome progresses. Severe depression and vomiting are not uncommon. The heart rate and blood pressure are elevated. Chills alternating with flushing and excessive sweating are also characteristic symptoms. Pains in the bones and muscles of the back and extremitites occur as do muscle spasms and kicking movements, which may be the source of the expression “kicking the habit.” At any point during this process, a suitable narcotic can be administered that will dramatically reverse the withdrawal symptoms. Without intervention, the syndrome will run its course and most of the overt physical symptoms will disappear within 7 to 10 days.

The psychological dependence that is associated with narcotic addiction is complex and protracted. Long after the physical need for the drug has passed, the addict may continue to think and talk about the use of drugs. There is a high probability that relapse will occur after narcotic withdrawal when neither the physical environment nor the behavioral motivators that contributed to the abuse have been altered.

There are two major patterns of narcotic abuse or dependence seen in the United States. One involves individuals whose drug use was initiated within the context of medical treatment who escalate their dose through “doctor shopping” or branch out to illicit drugs. A very small percentage of addicts are in this group.

The other more common pattern of abuse is initiated outside the therapeutic setting with experimental or recreational use of narcotics. The majority of individuals in this category may abuse narcotics sporadically for months or even years. These occasional users are called “chippers.” Although they are neither tolerant of nor dependent on narcotics, the social, medical and legal consequences of their behavior is very serious. Some experierimental users will escalate their narcotic use and will eventually become dependent, both physically and psychologically. The earlier drug that use begins, the more likely it is to progress to abuse and dependence. Heroin use among males in inner cities is generally initiated in adolescence, and dependence develops in about 1 or 2 years.

Narcotics (opiates) of Natural Origin are harvested from the poppy seed. and ARE CURRENTLY INCLUDED IN ALMOST ALL TESTING SYSTEMS!

opiate-toolsA more modern method of harvesting is by the industrial poppy straw process of extracting alkaloids from the mature dried plant. The extract may be in liquid, solid or powder form, although most poppy straw concentrate available commercially is a fine brownish powder. More than 500 tons of opium or its equivalent in poppy straw concentrate are legally imported into the United States annually for legitimate medical use.

opiates-gradesThere were no legal restrictions on the importation or use of opium until the early 1900s. In the United States, the unrestricted availability of opium, the influx of opium smoking immigrants from the Orient, and the invention of the hypodermic needle contributed to the more severe variety of compulsive drug abuse seen at the turn of this century. In those days, medicines often contained opium without any warning label. Today, there are state, federal, and international laws governing the production and distribution of narcotic substances.

opiates-codeineAlthough opium is used in the form of paragoric to treat diarrhea, most opium imported into the United States is broken down into its alkaloid constituents. These alkaloids are divided into two distinct chemical classes, phenanthrenes and isoquinolines. The principal phenanthrenes are morphine, codeine and thebaine, while the isoquinolines have no significant central nervous system effects and are not regulated under the CSA.

 

MORPHINE
Morphine, the principal constituent of opium, can range in concentration from 4 to 21 percent (note: commercial opium is standardized to contain 10% morphine). It is one of the most effective drugs known for the relief of pain, and remains the standard against which new analgesics are measured.

Morphine is marketed in a variety of forms including oral solutions (Roxanol), sustained-release tablets (MSIR and MS-Contin), suppositories and injectable preparations. It may be administered orally, subcutaneously, intramuscularly, and intravenously, the latter method being the one most frequently used by addicts. Tolerance and physical dependence develop rapidly in the user. Only a small part of the morphine obtained from opium is used directly; most of it is converted to codeine and other derivatives.

CODEINE
This alkaloid is found in opium in concentrations ranging from 0.7 to 2.5 percent. Most codeine used in the United States is produced from morphine. Compared to morphine, codeine produces less analgesia, sedation and respiratory depression, and is frequently taken orally.

Codeine is medically prescribed for the relief of moderate pain. It is made into tablets either alone or in combination with aspirin or acetaminophen (Tylenol). Codeine is an effective cough suppressant and is found in a number of liquid preparations. Codeine products are also used to a lesser extent as an injectable solution for the treatment of pain. It is by far the most widely used naturally occurring narcotic in medical treatment in the world. Codeine products are encountered on the illicit market, frequently in combination with glutethimide (Doriden) or carisoprodol (Soma).

THEBAINE
A minor constituent of opium, thebaine, is chemically similar to both morphine and codeine, but produces stimulatory rather than depressant effects. Thebaine is not used therapeutically, but is converted into a variety of compounds including codeine, hydrocodone, oxycodone, oxymorphone, nalbuphine, naloxone, naltrexone and buprenorphine. It is controlled in Schedule II of the CSA as well as under international law.

SYNTHETIC NARCOTICS
Semi-synthetic narcotics include Heroin, Hydromorphone, Oxycodone, and Hydrocodone.Ê Synthetic narcotics include Meperidine, Methadone, Fentanyl, Pentazocine, and many other less potent drugs.

Synthesized from morphine in 1874, heroin was not extensively used in medicine until the beginning of this century. Commercial production of the new pain remedy was first started in 1898. While it received widespread acceptance from the medical profession, physicians remained unaware of its potential for addiction for years. The first comprehensive control of heroin in the United States was established with the Harrison Narcotic Act of 1914.

Pure heroin is a white powder with a bitter taste. Most illicit heroin is a powder which may vary in color from white to dark brown because of impurities left from the manufacturing process or the presence of additives. Pure heroin is rarely sold on the street. A “bag”–slang for a single dosage unit of heroin–may contain 100 mg of powder, only a portion of which is heroin; the remainder could be sugars, starch, powdered milk, or quinine. Traditionally, the purity of heroin in a bag has ranged from 1 to 10 percent; more recently heroin purity has ranged from 1 to 98 percent, with a national average of 35 percent.

Another form of heroin known as “black tar” has also become increasingly available in the western United States. The color and consistency of black tar heroin result from the crude processing methods used to illicitly manufacture heroin in Mexico. Black tar heroin may be sticky like roofing tar or hard like coal, and its color may vary from dark brown to black. Black tar heroin is often sold on the street in its tar-like state at purities ranging from 20 to 80 percent. Black tar heroin is most frequently dissolved, diluted and injected.

The typical heroin user today consumes more heroin than a typical use did just a decade ago, which is not surprising given the higher purity currently available at the street level. Until recently, heroin in the United States almost exclusively was injected either intravenously, subcutaneously, (skin-popping), or intracuscularly. Injection is the most practical and efficient way to administer low-purity heroin. The availability of higher purity heroin has meant that users now can snort or smoke the narcotic. Evidence suggests that heroin snorting is widespread or increasing in those areas of the country where high purity heroin is available, generally in the northeastern United States. This method of administration may be more appealing to new users because it eliminates both the fear of acquiring syringe-borne diseases such as HIV/AIDS and hepatitis, and the historical stigma attached to intravenous heroin use.

[Abstracted from D.E.A. website]

Drug Effects

OPIATES
Effects
Heroin is usually injected directly into the blood stream by the abuser. (Mainlining!) The newer “pure” heroin is potent enough to be “snorted” (which is seen by the abuser as a “real convenience!”) It can also be injected under the skin, which is called skin-popping. Today it is popular to smoke heroin just like “crack” cocaine. The effects of heroin (and all the opiates) are sedation, euphoria, reduced anxiety, relief from unpleasant feelings or thoughts, and a feeling of “depersonalization” … like being in “another world.” The euphoric effects are very short in duration. The side effects last much longer and include pinpoint pupils, reduced vision, drowsiness, apathy, decreased physical activity, constipation, sleep, nausea, vomiting and respiratory depression! The symptoms of withdrawl last from 7 to 10 days and include severe anxiety/panic, runny nose, watery eyes, perspiration, yawning, restlessness, irritability, loss of appetite, diarrhea, stomach cramps, chills, pain, and muscle cramps.
Incidence of Abuse
Heroin is becoming “THE DRUG OF THE NINETIES.” E.R. Visits involving Heroin increased from 40,000 in 1992 to 62,000 in 1993 in U.S. alone! [See also “Drugs of Abuse: An Update” in July 1995 issue of “Emergency Medicine.”]
Chemical Name
Codein (Phosphate), Morphine, Heroin (Diacetylmorphine), etc. (see below).
Forms and Street Names
Heroin: Horse, Big H, Harry, Dope, Boy, WhiteJunk, Smack, TNT, “H” “China White” and “China Cat” is extremely (90%) pure & dangerous Heroin! b M, Miss Emma, Mister Blue, Morph Codeine = Schoolboy Dilaudid = Lords Methadone = Fizzies, Dollies
Length of time detectable after user
Heroin: > 6 AM > Morphine cascade is very rapid ! Therefore: 6 AM only found in urine collected within 8-10 hours of Heroin use! Codeine & Morphine: detectable for maximum of 2-3 days
Metabolite Actually sought in urine
Morphine, Codeine, 6 AM [6-mono-acetyl-morphine.
Confounding drugs (or factors):
Current regs. provide for testing of Codeine, Morphine, and 6-M.A.M. in verification process! The most difficult part of the MRO review is the requirement for “clinical proof” (see below!
Screening Cut-off:
Older cut-offs were in effect till August, ’02. Thereafter: Screening cut-off is 2,000 ng/ml
Confirmation GC/MS Cut-of
Older cut-offs were in effect till August, ’02. Thereafter: Standard cut-off is 2,000 ng/ml
6 AM is “automatic” in DOT testing.
“Burden of Proof” Cut-off is 15,000 ng/ml
Facts for Verifying M.R.O
Remember that 6 MAM is now automatically run by lab whenever a specimen tests above 2,000 ng/ml for Morpine or codeine. POSITIVE 6 AM is SPECIFIC FOR HEROIN, 6 AM is always gc/ms and cut-off is 10 ng/ml When 6 AM is positive, usually, Morphine level above 6,000. UNIQUE REQUIREMENT IN VERIFICATION OF OPIATE ABUSE:

CLINICAL EVIDENCE

is required to report a POSITIVE opiate test. EXCEPT FOR:

1.6 AM POSITIVE DONOR WHO IS HEROIN-POSITIVE WITHOUT EXAM! …OR

2. DONOR ABOVE 15,000 ng/ml who bears burden of proof of legitimate use.

WHAT ABOUT POPPY SEEDS?? YES! Ingestion of poppy seeds (legal) can and does cause a TRUE positive test! END OF ITEM! (Save yourself hours of reading!)

NOTE: This would be an INNOCENT POSITIVE test.. NOT A FALSE POSITIVE.
Morphine levels can be several hundred following poppy seed ingestion… but There is only ONE REPORTED CASE of a level above 5,000 from poppy seeds!

A POPPY SEED CLAIM REQUIRES MRO ACTION! Poppy seeds are almost pure morphine… and contain almost no codein! Therefore, QUANTS SHOULD BE REQUESTED …. A morphine/codeine ratio less than 2 is proof of codein use from a source other than poppy seeds. [M/C<2] … with apologies to Einstein.

Because of the strict requirement for clinical evidence and the handy appeal to “poppy seed use” … 95% OF LAB-POSITIVE OPIATE RESULTS ARE REPORTED AS “M.R.O. NEGATIVE” FOLLOWING THE VERIFICATION PROCESS!

IN CASES OF CODEIN USE OR ABUSE:

The PROPORTION OF CODEINE / MORPHINE gives clue as to TIME of Codeine use:

EARLY: (shortly after abuse) Codeine is high & Morphine is low!

LATER: Codeine is low (degradation) and Morphine is high!

CLAIM OF O.T.C. CODEINE USE: can be legitimate (both U.S. and Canada) but if this claim is made, donor must provide all info for MRO to verify and MRO must verify!

FINAL REMINDER: POSITIVE 6 AM =POSITIVE FOR HEROIN … DOES NOT REQUIRE “CLINICAL” EVIDENCE! (EXAM)