21 DRUG DEPENDENCE

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heating of heroin powder and inhaling the fumes through a rolled note. The use ofintravenous route is rare here.The amount of heroin used varies from individual to individual. However, highlevels of tolerance occur with chronic use. Some studies indicate that the chronic usercould tolerate up to 1.0 gm doses i.v. without serious effect. In the body, heroin like anyother opiate, binds to the opiate receptor sites. It also stimulates the mood regulatingcenters of the brain, such as the hypothalamus, to produce euphoria. It depresses theCNS and regulates the perception of pain.Heroin effects are dose-dependent like most other street drugs. Like the others itis contaminated with a variety of other chemicals and impurities. Heroin and syntheticopiates are very powerful and dangerous drugs. Heroin Addiction is also one of the mostdifficult drug habits to kick.Withdrawal Syndrome and TreatmentThe signs and symptoms of opiate withdrawal may be graded to indicate thedifferent stages and severity of the syndrome. But the grading is somewhat arbitrary, asthe symptoms and signs of any particular grade may not all be present simultaneously.Table 1. Opiate Withdrawal Syndrome(adapted from Hamid Ghodse: Drugs and Addictive Behaviour. Blackwell Science)Grade 1:Grade 2:Grade 3:YawningSweatingRunning eyes and noseRestless sleepDilated pupilsGoosefleshMuscle twitchingHot and cold flushes: shiveringAching bones and musclesLoss of appetiteIrritabilityInsomniaLow-grade feverIncreased pulse rateIncreased respiratory rateIncreased blood pressureRestlessnessAbdominal crampsNausea and vomitingDiarrhoeaWeight loss2
The nature and severity of the drug withdrawal depend on:i. The total daily amount used. In general the larger the amount, the more severethe withdrawal.ii. Duration and regularity of use. To obtain a clinically significant withdrawal, theremust be at least three weeks of regular usage. On the other hand, if the durationof usage is more than 2-3 months, there is no suggestion of greater severity ofsymptomsiii. Psychological factors. If the user expects that his suffering will be relieved bymedication, the more severe the withdrawal symptoms. If he is in a setting wherethere is little hope of getting relief (e.g. cold turkey), there seems to be adiminution in the intensity of the withdrawal symptoms. His personality, physicalhealth, stress coping mechanism can all influence the withdrawal symptoms.TreatmentFor withdrawal symptoms, the treatment options are as follow:i. Do nothing. “Cold Turkey” withdrawal is not life threatening.ii. Narcotic substitute. The preferred drug is Methadone. Usually up to 30-40mg/day is required to control the symptoms. The dose is gradually reduced by afixed percentage, e.g. 10% every 1 to 2 days. This method is not generallyfavoured by physicians in Singapore because methadone is easily abused.iii. Non-narcotic alternative. Clonidine has been used as a successful alternative. Inhospital, the usual starting dose is 200-400 mcg daily in divided doses, increasinggradually to a maximum of 1 mg daily. Beware of hypotension if diastolic BP is
Page 1: 21 DRUG DEPENDENCELim Yun ChinDefin
Page 5: References1. Drugs and Addictive Be

21 DRUG DEPENDENCE

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