Героин: свойства, применение и риски опиоидной зависимости.

Opioid used as an analgesic and a recreational drug for its euphoric effects

Heroin, also known as diacetylmorphine and diamorphine among other names, Heroin is used medically in several countries to relieve pain, such as during childbirth or a heart attack, as well as in opioid replacement therapy. It is typically injected, usually into a vein, but it can also be snorted, smoked, or inhaled. In a clinical context, the route of administration is most commonly intravenous injection; it may also be given by intramuscular or subcutaneous injection, as well as orally in the form of tablets. The onset of effects is usually rapid and lasts for a few hours. Treatment of heroin addiction often includes behavioral therapy and medications. and opioid use resulted in 122,000 deaths. The total number of heroin users worldwide as of 2015 is believed to have increased in Africa, the Americas, and Asia since 2000. When people die from overdosing on a drug, the drug is usually an opioid and often heroin. Heroin was first made by C. R. Alder Wright in 1874 from morphine, a natural product of the opium poppy. Internationally, heroin is controlled under Schedules I and IV of the Single Convention on Narcotic Drugs, and it is generally illegal to make, possess, or sell without a license. About 448 tons of heroin were made in 2016. In 2015, Afghanistan produced about 66% of the world's opium.

Bayer's original trade name of heroin is typically used in non medical settings. It is used as a recreational drug for the euphoria it induces. Anthropologist Michael Agar once described heroin as "the perfect whatever drug." Tolerance develops quickly, and increased doses are needed in order to achieve the same effects. Its popularity with recreational drug users, compared to morphine, reportedly stems from its perceived different effects. Short term addiction studies by the same researchers demonstrated that tolerance developed at a similar rate to both heroin and morphine. When compared to the opioids hydromorphone, fentanyl, oxycodone, and pethidine (meperidine), former addicts showed a strong preference for heroin and morphine, suggesting that heroin and morphine are particularly susceptible to misuse and causing dependence. Morphine and heroin were also much more likely to produce euphoria and other positive subjective effects when compared to these other opioids.

In the United States, heroin is not accepted as medically useful. Diamorphine continues to be widely used in palliative care in the UK, where it is commonly given by the subcutaneous route, often via a syringe driver if patients cannot easily swallow morphine solution. The advantage of diamorphine over morphine is that diamorphine is more fat soluble and therefore more potent by injection, so smaller doses of it are needed for the same effect on pain. Both of these factors are advantageous if giving high doses of opioids via the subcutaneous route, which is often necessary for palliative care. It is also used in the palliative management of bone fractures and other trauma, especially in children. In the trauma context, it is primarily given by nose in hospital; although a prepared nasal spray is available. It has traditionally been made by the attending physician, generally from the same "dry" ampoules as used for injection. In children, Ayendi nasal spray is available at 720 micrograms and 1600 micrograms per 50 microlitres actuation of the spray, which may be preferable as a non invasive alternative in pediatric care, avoiding the fear of injection in children.

A number of European countries prescribe heroin for treatment of heroin addiction. The initial Swiss HAT (heroin assisted treatment) trial ("PROVE" study) was conducted as a prospective cohort study with some 1,000 participants in 18 treatment centers between 1994 and 1996, at the end of 2004, 1,200 patients were enrolled in HAT in 23 treatment centers across Switzerland. Diamorphine may be used as a maintenance drug to assist the treatment of opiate addiction, normally in long term chronic intravenous (IV) heroin users. It is only prescribed following exhaustive efforts at treatment via other means. It is sometimes thought that heroin users can walk into a clinic and walk out with a prescription, but the process takes many weeks before a prescription for diamorphine is issued. Though this is somewhat controversial among proponents of a zero tolerance drug policy, it has proven superior to methadone in improving the social and health situations of addicts. The UK Department of Health's Rolleston Committee Report in 1926 established the British approach to diamorphine prescription to users, which was maintained for the next 40 years: dealers were prosecuted, but doctors could prescribe diamorphine to users when withdrawing. In 1964, the Brain Committee recommended that only selected approved doctors working at approved specialized centres be allowed to prescribe diamorphine and cocaine to users. The law was made more restrictive in 1968. Beginning in the 1970s, the emphasis shifted to abstinence and the use of methadone; currently, only a small number of users in the UK are prescribed diamorphine. In 1994, Switzerland began a trial diamorphine maintenance program for users that had failed multiple withdrawal programs. The aim of this program was to maintain the health of the user by avoiding medical problems stemming from the illicit use of diamorphine. The first trial in 1994 involved 340 users, although enrollment was later expanded to 1000, based on the apparent success of the program. The trials proved diamorphine maintenance to be superior to other forms of treatment in improving the social and health situation for this group of patients. Patients appear twice daily at a treatment center, where they inject their dose of diamorphine under the supervision of medical staff. They are required to contribute about 450 Swiss francs per month to the treatment costs. A national referendum in November 2008 showed 68% of voters supported the plan, introducing diamorphine prescription into federal law. The previous trials were based on time limited executive ordinances. The success of the Swiss trials led German, Dutch, and Canadian cities to try out their own diamorphine prescription programs. Some Australian cities (such as Sydney) have instituted legal diamorphine supervised injecting centers, in line with other wider harm minimization programs. Since January 2009, Denmark has prescribed diamorphine to a few addicts who have tried methadone and buprenorphine without success. Beginning in February 2010, addicts in Copenhagen and Odense became eligible to receive free diamorphine. Later in 2010, other cities including Århus and Esbjerg joined the scheme. It was estimated that around 230 addicts would be able to receive free diamorphine. However, Danish addicts would only be able to inject heroin according to the policy set by Danish National Board of Health. Of the estimated 1500 drug users who did not benefit from the then current oral substitution treatment, approximately 900 would not be in the target group for treatment with injectable diamorphine, either because of "massive multiple drug abuse of non opioids" or "not wanting treatment with injectable diamorphine". In July 2009, the German Bundestag passed a law allowing diamorphine prescription as a standard treatment for addicts; a large scale trial of diamorphine prescription had been authorized in the country in 2002. On 26 August 2016, Health Canada issued regulations amending prior regulations it had issued under the Controlled Drugs and Substances Act; the "New Classes of Practitioners Regulations", the "Narcotic Control Regulations", and the "Food and Drug Regulations", to allow doctors to prescribe diamorphine to people who have a severe opioid addiction who have not responded to other treatments. The prescription heroin can be accessed by doctors through Health Canada's Special Access Programme (SAP) for "emergency access to drugs for patients with serious or life threatening conditions when conventional treatments have failed, are unsuitable, or are unavailable." These are followed by suppository (anal or vaginal insertion), insufflation (snorting), and ingestion (swallowing). A 2002 study suggests that a fast onset of action increases the reinforcing effects of addictive drugs. Ingestion does not produce a rush as a forerunner to the high experienced with the use of heroin, which is most pronounced with intravenous use. While the onset of the rush induced by injection can occur in as little as a few seconds, the oral route of administration requires approximately half an hour before the high sets in. Thus, with both higher the dosage of heroin used and faster the route of administration used, the higher the potential risk for psychological dependence/addiction. Large doses of heroin can cause fatal respiratory depression, and the drug has been used for suicide or as a murder weapon. The serial killer Harold Shipman used diamorphine on his victims, and the subsequent Shipman Inquiry led to a tightening of the regulations surrounding the storage, prescribing and destruction of controlled drugs in the UK. Because significant tolerance to respiratory depression develops quickly with continued use and is lost just as quickly during withdrawal, it is often difficult to determine whether a heroin lethal overdose was accidental, suicide or homicide. Examples include the overdose deaths of Sid Vicious, Janis Joplin, Tim Buckley, Hillel Slovak, Layne Staley, Bradley Nowell, Ted Binion, and River Phoenix.

Use of heroin by mouth is less common than other methods of administration, mainly because there is little to no "rush", and the effects are less potent. Heroin is entirely converted to morphine by means of first pass metabolism, resulting in deacetylation when ingested. Heroin's oral bioavailability is both dose dependent (as is morphine's) and significantly higher than oral use of morphine itself, reaching up to 64.2% for high doses and 45.6% for low doses; opiate naive users showed far less absorption of the drug at low doses, having bioavailabilities of only up to 22.9%. The maximum plasma concentration of morphine following oral administration of heroin was around twice as much as that of oral morphine.

Injection, also known as "slamming", "banging", "shooting up", "digging" or "mainlining", is a popular method which carries relatively greater risks than other methods of administration. Heroin base (commonly found in Europe), when prepared for injection, will only dissolve in water when mixed with an acid (most commonly citric acid powder or lemon juice) and heated. Heroin in the east coast United States is most commonly found in the hydrochloride salt form, requiring just water (and no heat) to dissolve. Users tend to initially inject in the easily accessible arm veins, but as these veins collapse over time, users resort to more dangerous areas of the body, such as the femoral vein in the groin. Some medical professionals have expressed concern over this route of administration, as they suspect that it can lead to deep vein thrombosis. Intravenous users can use a variable single dose range using a hypodermic needle. The dose of heroin used for recreational purposes is dependent on the frequency and level of use. As with the injection of any drug, if a group of users share a common needle without sterilization procedures, blood borne diseases, such as HIV/AIDS or hepatitis, can be transmitted. The use of a common dispenser for water for the use in the preparation of the injection, as well as the sharing of spoons and filters can also cause the spread of blood borne diseases. Many countries now supply small sterile spoons and filters for single use in order to prevent the spread of disease.

Smoking heroin refers to vaporizing it to inhale the resulting fumes, rather than burning and inhaling the smoke. It is commonly smoked in glass pipes made from glassblown Pyrex tubes and light bulbs. Heroin may be smoked from aluminium foil that is heated by a flame underneath it, with the resulting smoke inhaled through a tube of rolled up foil, a method also known as "chasing the dragon".

Another popular route to intake heroin is insufflation (snorting), where a user crushes the heroin into a fine powder and then gently inhales it (sometimes with a straw or a rolled up banknote, as with cocaine) into the nose, where heroin is absorbed through the soft tissue in the mucous membrane of the sinus cavity and straight into the bloodstream. This method of administration redirects first pass metabolism, with a quicker onset and higher bioavailability than oral administration, though the duration of action is shortened. This method is sometimes preferred by users who do not want to prepare and administer heroin for injection or smoking but still want to experience a fast onset. Snorting heroin becomes an often unwanted route, once a user begins to inject the drug. The user may still get high on the drug from snorting, and experience a nod, but will not get a rush. A "rush" is caused by a large amount of heroin entering the body at once. When the drug is taken in through the nose, the user does not get the rush because the drug is absorbed slowly rather than instantly. Heroin for pain has been mixed with sterile water on site by the attending physician, and administered using a syringe with a nebulizer tip. Heroin may be used for fractures, burns, finger tip injuries, suturing, and wound re dressing, but is inappropriate in head injuries.]] Heroin is classified as a hard drug in terms of drug harmfulness. Like most opioids, unadulterated heroin may lead to adverse effects. The purity of street heroin varies greatly, leading to overdoses when the purity is higher than expected.

Users report an intense rush, an acute transcendent state of euphoria, which occurs while diamorphine is being metabolized into 6 monoacetylmorphine (6 MAM) and morphine in the brain. Some believe that heroin produces more euphoria than other opioids; one possible explanation is the presence of 6 monoacetylmorphine, a metabolite unique to heroin – although a more likely explanation is the rapidity of onset. While other opioids of recreational use produce only morphine, heroin also leaves 6 MAM, also a psycho active metabolite. However, this perception is not supported by the results of clinical studies comparing the physiological and subjective effects of injected heroin and morphine in individuals formerly addicted to opioids; these subjects showed no preference for one drug over the other. Equipotent injected doses had comparable action courses, with no difference in subjects' self rated feelings of euphoria, ambition, nervousness, relaxation, drowsiness, or sleepiness. Heroin use has also been associated with myocardial infarction.

[[File:Long term effects of heroin. png|thumb|Long term effects of intravenous usage, including – and indeed primarily because of – the effects of the contaminants common in illegal heroin and contaminated needles which may affect decision making abilities, the ability to regulate behavior, and responses to stressful situations. Heroin also produces profound degrees of tolerance and physical dependence. Tolerance occurs when more and more of the drug is required to achieve the same effects. With physical dependence, the body adapts to the presence of the drug, and withdrawal symptoms occur if use is reduced abruptly.

The withdrawal syndrome from heroin may begin within as little as two hours of discontinuation of the drug; however, this time frame can fluctuate with the degree of tolerance as well as the amount of the last consumed dose, and more typically begins within 6–24 hours after cessation. Symptoms may include sweating, malaise, anxiety, depression, akathisia, priapism, extra sensitivity of the genitals in females, general feeling of heaviness, excessive yawning or sneezing, rhinorrhea, insomnia, cold sweats, chills, severe muscle and bone aches, nausea, vomiting, diarrhea, cramps, watery eyes, fever, cramp like pains, and involuntary spasms in the limbs (thought to be an origin of the term "kicking the habit").

Heroin overdose is usually treated with the opioid antagonist naloxone. This reverses the effects of heroin and causes an immediate return of consciousness but may result in withdrawal symptoms. The half life of naloxone is shorter than some opioids, such that it may need to be given multiple times until the opioid has been metabolized by the body. Between 2012 and 2015, heroin was the leading cause of drug related deaths in the United States. Since then, fentanyl has been a more common cause of drug related deaths. Since heroin can cause nausea and vomiting, a significant number of deaths attributed to heroin overdose are caused by aspiration of vomit by an unconscious person. Some sources quote the median lethal dose (for an average 75 kg opiate naive individual) as being between 75 and 600 mg. Illicit heroin is of widely varying and unpredictable purity. This means that the user may prepare what they consider to be a moderate dose while actually taking far more than intended. Also, tolerance typically decreases after a period of abstinence. If this occurs and the user takes a dose comparable to their previous use, the user may experience drug effects that are much greater than expected, potentially resulting in an overdose. It has been speculated that an unknown portion of heroin related deaths are the result of an overdose or allergic reaction to quinine, which may sometimes be used as a cutting agent.

Diamorphine is produced from acetylation of morphine derived from natural opium sources, generally using acetic anhydride. The major metabolites of diamorphine, 6 MAM, morphine, morphine 3 glucuronide, and morphine 6 glucuronide, may be quantitated in blood, plasma or urine to monitor for use, confirm a diagnosis of poisoning, or assist in a medicolegal death investigation. Most commercial opiate screening tests cross react appreciably with these metabolites, as well as with other biotransformation products likely to be present following usage of street grade diamorphine such as 6 Monoacetylcodeine and codeine. However, chromatographic techniques can easily distinguish and measure each of these substances. When interpreting the results of a test, it is important to consider the diamorphine usage history of the individual, since a chronic user can develop tolerance to doses that would incapacitate an opiate naive individual, and the chronic user often has high baseline values of these metabolites in his system. Furthermore, some testing procedures employ a hydrolysis step before quantitation that converts many of the metabolic products to morphine, yielding a result that may be 2 times larger than with a method that examines each product individually.

"Diamorphine" is the Recommended International Nonproprietary Name and British Approved Name. Other synonyms for heroin include: diacetylmorphine, and morphine diacetate. Heroin is also known by many street names including dope, H, smack, junk, horse, scag, and brown, among others.

In Hong Kong, diamorphine is regulated under Schedule 1 of Hong Kong's Chapter 134 Dangerous Drugs Ordinance. It is available by prescription. Anyone supplying diamorphine without a valid prescription can be fined $5,000,000 (HKD) and imprisoned for life. The penalty for trafficking or manufacturing diamorphine is a $5,000,000 (HKD) fine and life imprisonment. Possession of diamorphine without a license from the Department of Health is illegal with a $1,000,000 (HKD) fine and 7 years of jail time.

In the Netherlands, diamorphine is a List I drug of the Opium Law. It is available for prescription under tight regulation exclusively to long term addicts for whom methadone maintenance treatment has failed. It cannot be used to treat severe pain or other illnesses. In the United Kingdom, diamorphine is available by prescription, though it is a restricted Class A drug. According to the 50th edition of the British National Formulary (BNF), diamorphine hydrochloride may be used in the treatment of acute pain, myocardial infarction, acute pulmonary oedema, and chronic pain. The treatment of chronic non malignant pain must be supervised by a specialist. The BNF notes that all opioid analgesics cause dependence and tolerance but that this is "no deterrent in the control of pain in terminal illness". When used in the palliative care of cancer patients, diamorphine is often injected using a syringe driver. In Switzerland, heroin is produced in injectable or tablet form under the name Diaphin by a private company under contract to the Swiss government. Swiss produced heroin has been imported into Canada with government approval.

In Australia, diamorphine is listed as a schedule 9 prohibited substance under the Poisons Standard (October 2015). The state of Western Australia, in its Poisons Act 1964 (Reprint 6: amendments as at 10 Sep 2004), described a schedule 9 drug as: "Poisons that are drugs of abuse, the manufacture, possession, sale or use of which should be prohibited by law except for amounts which may be necessary for educational, experimental or research purposes conducted with the approval of the Governor."

In Canada, diamorphine is a controlled substance under Schedule I of the Controlled Drugs and Substances Act (CDSA). Any person seeking or obtaining diamorphine without disclosing authorization 30 days before obtaining another prescription from a practitioner is guilty of an indictable offense and subject to imprisonment for a term not exceeding seven years. Possession of diamorphine for the purpose of trafficking is an indictable offense and subject to imprisonment for life. In the United States, diamorphine is a Schedule I drug according to the Controlled Substances Act of 1970, making it illegal to possess without a DEA license. Possession of more than 100 grams of diamorphine or a mixture containing diamorphine is punishable with a minimum mandatory sentence of 5 years of imprisonment in a federal prison. In 2021, the US state of Oregon became the first state to decriminalize the use of heroin after voters passed Ballot Measure 110 in 2020. This measure will allow people with small amounts to avoid arrest.

Turkey maintains strict laws against the use, possession or trafficking of illegal drugs. If convicted under these offences, one could receive a heavy fine or a prison sentence of 4 to 24 years.

Misused prescription medicine, such as opioids, can lead to heroin use and dependence. The number of death from illegal opioid overdose follows the increasing number of death caused by prescription opioid overdoses. Prescription opioids are relatively easy to obtain. This may ultimately lead to heroin injection because heroin is cheaper than prescribed pills.

Researchers are attempting to reproduce the biosynthetic pathway that produces morphine in genetically engineered yeast. In June 2015 the S reticuline could be produced from sugar and R reticuline could be converted to morphine, but the intermediate reaction could not be performed.