Hi everyone Joseph here,

Today I wanted to address the heroin epidemic after the recent events in Ohio addressing the morality of reducing dispatch to chronic heroin overdose users, as well as look at a few mechanisms of action by which heroin acts on the body. Heroin’s rising abuse in the US is my impetus for writing about this drug. As an issue that has worked its way all the way up to Congress, heroin overdose is a pressing problem in America that has led to both state lawsuits and federal precedents. [1]

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Figure 1: Heroin use has been rising in the recent years, leading to a CDC statement and guidelines for use of synthetic opioids. [2]
To start off, last week, the controversy behind opioid addiction really took off in Ohio, after Dan Picard, the councilman of a small city of Middletown, argued that EMS dispatchers, as well as the city, have been put under financial pressure by the repeated EMS calls for heroin overdose. From the city’s allotted $10,000 for treatment, 10x that amount had been withdrawn in dealing with treatment of addicts.

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Figure 2: An interesting slide on a proposed neural circuit for addiction. I personally enjoy learning about neural circuits and the theory behind them because they’re testable aspects of neurology. [3]
Understandably, his statement infuriated a large swathe of Americans, who accused his his plan of action as deliberate manslaughter and murder. However, Dan’s counterargument was that rising costs of opioid addiction would eventually overwhelm the city. From a fiscal perspective, Picard’s argument are logical. Heroin users are no stranger to repeat offenses and studies have been published regarding inmates and their high incidence of repeat use. [4] Like many case studies in medicine, we have found ourselves in a moral gray area. If Middletown were to continue treating these patients, committing more hospital beds to these patients, what would happen to the cardiac arrest patients or the pregnant patients? Would a lower standard of care be justified by users who repeatedly OD on heroin?

I believe that the answer to the question lies in approach to treatment for heroin addiction. Because recent research done has described addiction as a treatable disease of the brain, I believe that the answer lies in changing practices around heroin and subsequent opioid abuse disorders, and never should come to cutting off treatment for patients. I believe Picard’s polarizing comment was meant to be polarizing to draw attention to the issue. [4] In Middletown as we speak, patients that have ODed on heroin are continuing to get treatment, but Dan Picard had brought up a valid point- has opioid use grown into an epidemic? (Picard’s comment on his blog: [5])

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Figure 3: Heroin addiction in the brain and other common substances abused. [6]
There is plenty of evidence for problems of practice. Maggie Fox from NBC wrote an article that highlighted a recent journal study that saw that 21% of Blue Cross and Blue Shield insured users had at some point, accessed opioid medications in 2015. The opioid epidemic was further highlighted by an approximate 500% increase in insurance claims for opioids from 2010 to 2015. [7] Even scarier was that the study excluded cancer patients and terminal illness patients like my late grandfather, the user group whose opioid use is most validated.

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Figure 4: Ohio was mentioned in the paragraphs earlier, but the South is quickly growing in deaths from synthetic opioid overdose. [8]
Moreover, the problem is a recurrent issue in national news. A pregnant Pennsylvania mother who overdosed on heroin had to deliver her child via emergency c-section, and her child is not expected to survive. [9] Cases just like these, highlight the moral gray area that heroin overdose brings to light. Should she stand on trial for killing her child and if so, to what degree? [10]

Fortunately, the NIH (main sponsor of research in the US) recognizes the problem as a critical one, even while our president has wanted to slash the NIH budget. Research on opioid drug antagonists like Naloxone are merited, but the problem lies at the feet of addiction. Scientists from Yale (Dr. William Becker and Dr. David Fiellin) are looking to reformulate the opioids to reduce addiction, but to little success. [11] Perhaps in the future, other opioid analgesics (pain dullers) could be used, but currently their research have not brought fruitful results. [12]

Biologically, the mechanism of action of opioids can be summarized fairly quickly without necessity to delve into detail. There are three receptors for opioids spread throughout the CNS and PNS, m, d, and k. All are coupled to gPCR receptors and essentially inhibit the neurotransmitter release of acetylcholine, norepinephrine, serotonin, glutamate, substance P. [13] This in turn inhibits the next neuron over from firing, by preventing depolarization of the postsynaptic membrane. [14]

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Figure 5: A quick picture of a possible mechanism of action by which opioids work [15]
In fact, our body has endogenous (we make them ourselves) opioids that we call endorphins (named for endogenous opioids). The contents of the drugs pass from the digestive system mainly into the hepatic portal system, where they contact the liver and are broken down further into metabolites. Depending on the type of opioid (synthetic) or opiate (natural), the products could get secreted as active analgesics in the case of heroine as monoacetylmorphine, or excreted via the kidneys. It becomes quickly apparent that the strength of the drug matters highly. In fact fentanyl, a stronger, faster acting version of heroine is a large contributor to the heroin epidemic. These drugs go on to promote systemic effects like miosis (pupil dilation), respiratory depression (due to a decreased response to the partial pressure of CO2 in our blood), or even coma. [16]

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Figure: The first pass metabolism within the hepatic portal system [17]
In brief, I just wanted to acknowledge that the heroin epidemic is growing in the US, and I felt compelled to share information on its growth. Physicians, families, and drug users all benefit from increased exposure to the problems that opioids present and perhaps may contribute to resolving this endemic problem that is the heroin epidemic.

Your friend signing off,

Joseph Maa


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