Heroin is back with a vengeance and taking a high toll on American families and community resources. With an estimated 2 million users across the U.S,1 heroin is involved in over 213,000 emergency department visits annually.2
It is important for laboratorians to understand that opiate screening tests cannot differentiate heroin from opiates prescribed for pain relief. Sending out positive opiate screens to confirm the presence of opiate versus heroin by gas chromatography/mass spectrometry (GC-MS) can be costly and time-consuming. An automated, on-site test for 6-acetylmorphine (6-AM) - a heroin metabolite in urine - accurately differentiates heroin use from prescribed or over-the-counter pain medications.
Gateway to Heroin
According to the U.S. Drug Enforcement Agency (DEA), nearly 7 million Americans are abusing prescription drugs, with one-in-10 high school seniors admitting to abusing pills. Michele Leonhart, DEA administrator, has called abuse of prescription pain relievers the gateway activity to heroin addiction, especially among the young. "As they turn to these opiates, they become heroin addicts," Leonhart said.3
Also, heroin is becoming easier to find and less expensive than illicitly obtained prescription painkillers. In New Orleans, high school students can now buy enough heroin to get high for hours for the same price as a Happy Meal. "Twenty dollars worth of heroin is enough to get a new user high for two days," said Arun Rahman, a former National Merit Scholarship finalist addicted to heroin at 17.4
The heroin problem is not confined to urban populations in large cities. "We're a small town of 1,700 in the middle of nowhere - farmers, fishermen and hunters - yet it's easy and inexpensive to get a bag of heroin here for $10-$15," said Victor Montgomery III, MAEd, CMAC, RAS, an addiction specialist and primary therapist in the idyllic Finger Lakes region of upstate New York.5
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Heroin is a powerful opioid analgesic that has been rated the most addictive and harmful of commonly abused legal and illegal drugs (Figure).6 It is produced from morphine, a principal component of opium - a naturally occurring substance found in the seed pod of the opium poppy.
Easier to Start
According to the National Drug Intelligence Center (NDIC), "Many new, younger users begin by snorting or smoking heroin and often mistakenly believe that snorting or smoking heroin will not lead to addiction. Users who snort or smoke heroin at times graduate to injection because as their bodies become conditioned to the drug, the effects it produces are less intense. They then turn to injection - a more efficient means of administering the drug - to try to attain the more intense effects they experienced when they began using the drug. Both new and experienced users risk overdosing on heroin because it is impossible for them to know the purity of the heroin they are using."7
The World Drug Report 2010 notes that "more than 15 million people worldwide consume illicit opiates. The large majority use heroin, the most lethal form. Among illicit narcotics, opiates are also the most costly in terms of treatment, medical care and, arguably, drug-related violence. In addition, heroin is the drug most associated with addiction, which brings about a host of acute and chronic health problems, including the transmission of bloodborne diseases such as HIV/AIDS and Hepatitis C."8
In addition to the effects of the drug itself, street heroin often contains toxic contaminants or additives that can clog blood vessels leading to the lungs, liver, kidneys or brain, causing permanent damage to vital organs.7 The substances used to "cut" pure heroin are responsible for a number of unanticipated problems for patients undergoing anesthesia.9 Heroin users also have a higher tolerance to anesthesia and pain medications.9 Illicit opioid users, now from every social class and profession, may not acknowledge using heroin due to stigma and legal concerns.9
6-Acetylmorphine: Accurate Urine Screening
Screening for 6-AM can identify heroin users and ensure a correct care pathway. 6-AM is not produced metabolically in humans from either codeine or morphine. Current instrumented, on-site immunoassay methods are accurate, specific and efficient. One such example, the Siemens Syva EMIT II Plus 6-Acetylmorphine Assay, has a 98% agreement with GC-MS, a wide dynamic range, up to four weeks of on-instrument stability, and can deliver results in as little as 11 minutes. With a cutoff of 10 ng/mL, the reagents provide qualitative and semi-quantitative results utilizing a monoclonal antibody to ensure accuracy and specificity. Applications are available on a range of chemistry analyzers.10
Connie Mardis is director, marketing communications programs, at Siemens Healthcare Diagnostics.
1. Heroin and Opium Consumption, Central Intelligence Agency, accessed 11/9/12: https://www.cia.gov/library/publications/additional-publications/heroin-movement-worldwide/consumption.html
2. 2009 SAMHSA Drug Abuse Warning Network (DAWN) Report.
3. Leonhart M. quoted in Heroin Use Explodes Across Indiana, Channel 6 News Online, theINDYchannel.com. Posted February 16, 2011.
4. Davis M. Heroin: It's cheap, it's deadly and teens think it is no big deal. Gambit BestofNew Orleans.com. Posted Sep 13, 2010.
5. Mardis C. Treatment in reach for every veteran in need. All Rise 2011;2(5):20-21.
6. Nutt, et al. Development of a rational scale to assess the harm of drugs of potential misuse. The Lancet 2007;369(9566):1047-1053.
7. National Institute on Drug Abuse, InfoFacts: Heroin (Rockville, MD: US Department of Health and Human Services, September 2009) http://www.nida.nih.gov/infofacts/heroin.html accessed 11/3/12.
8. United Nations Office on Drugs and Crime (UNODC 2010). World Drug Report 2010. (United Nations Publication Sales No. E.10.XI.13).
9. Bryson E. The anesthetic implications of illicit opioid abuse. International Anesthesiology Clinics 2011; 49:1, 67-78.
10. Morjana N, et al. New Emit® II Plus 6-Acetylmorphine assay on the V-Twin®/Viva-E® Analyzers. Toxichem Krimtech. 2010;77(3):210.