Heroin was introduced to medicine and the public in the early part of the 20th century as a replacement for morphine and codeine. When introduced, one of the claims made for it was that it was non-addictive. While it does have certain therapeutic advantages over morphine and codeine, heroin is much more addictive. Because of this, it is not used therapeutically. Until the widespread introduction of cocaine to the American population, heroin was probably the most popular of the "hard" drugs. Depending on geographical area, it is sold in small plastic envelopes, capsules, or balloons. It has typically been cut with a sugar such as lactose. On the East Coast, quinine is often added, giving it a bitter taste. The typical "bag" of heroin traditionally contained a 1-2% concentration of the drug. With the intro duction of the cheaper black tar form of heroin from Mexico, the quality of heroin being sold increased dramatically. Bags of heroin showing 20-30% purity, with some up to 50%, are now routine in some parts of the country (personal communication Samantha A. Di Maio). For many years, people hypothesized that deaths due to heroin were caused by an allergic reaction to some component used as a cutting agent. It is now realized that these are just overdose deaths from a very strong CNS depressant — heroin. In virtually all cases, individuals who die of an overdose of heroin are either under the influence of alcohol or intoxicated at the time of death. More recently, we have seen a number of deaths caused by "speedballs," a combination of heroin and cocaine.14,18
In the Far East, where heroin is cheap and plentiful, it has been smoked. In the U.S., it is injected intravenously. The addict places the powder in either a bottle cap or spoon, adds water, and then heats the mixture over a flame (Figure 23.1). A piece of cotton may be added to the mixture to "strain out" the impurities. The solution is then taken up into a syringe and injected intravenously. With repeated injection into veins, the addicts will develop "needle tracks" (Figure 23.2). These are raised hyperpigmented scars produced by the repeated intravenous injection of the solutions, usually with a dull contaminated needle. Needle tracks are seen in hard-core addicts, especially on the East Coast. Needle tracks are often more prominent in geographical areas where the addict has a difficult time acquiring syringes and needles. In a state like Texas, where no prescription is necessary to buy a
syringe and needle, the addicts tend to buy tuberculin or insulin syringes that have very fine needles. Thus, in this population, needle tracks are not as prominent as on the East Coast. In fact, in many deaths, the injection site is often not discovered.
At autopsy of an individual who has died of an overdose of heroin, the lungs are heavy and show congestion, though the classic pulmonary edema mentioned in some of the older textbooks is not always present. Microscopic examination of the lungs commonly reveals foreign-body granulomas with talc crystals and cotton fibers. The cotton originates from the "strainer." The talc probably has been used as a cutting agent. There is usually enlargement of the periportal lymph nodes. Microscopic examination of the liver will reveal a chronic triaditis with a mononuclear cell infiltrate.
Following injection, heroin (diacetylmorphine) is almost immediately metabolized to monoacetyl morphine (half-life 9 min). Monoacetyl morphine is then hydrolyzed to morphine (half-life 38 min). Because of this, if one performs a toxicologic analysis on an individual who died from an overdose of heroin, one does not detect heroin in the blood, but rather morphine and monoacetyl morphine. If both monoacetylmor-phine and morphine are detected in the blood, then the individual took heroin. Both monoacetylmorphine and morphine can also be detected in the vitreous in heroin overdoses if death is not immediate.
Small amounts of codeine may be detected in the blood or urine. Morphine is not metabolized to codeine, rather the codeine detected represents impurities in the compound used. Thus, in heroin overdoses, on toxicological analysis one may detect morphine, monoacetylmorphine, and extremely low levels of codeine. The morphine and codeine are excreted into the bile, where the former drug may be detected for several days. Following injection, morphine and monoacety1morphine enter the urine almost immediately. In some very acute deaths from heroin overdose, the urine is negative but the blood positive. Death is not directly related to blood concentration, due to the high tolerance individuals can build up. Thus, a level that makes one individual "high" will kill another.
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