WARNING: This page may not be appropriate for all audiences, due to the explicit imagery and colloquial language used whilst raising awareness of pain interventions for under 18 year olds with HIV/AIDS.

"love and common sense form the cornerstone for speaking out" Rachel Chapple, PhD

Pain intervention for a child or teenager is the responsibility of every adult gifted with the power (as either parent, legal guardian or care-provider/giver), to control the level of pain experienced.  In the context of today's HIV/AIDS pandemic, it is the responsibility of adults to speak about the pain being endured by under 18 years old and seek ways to alleviate their suffering. We will begin by exploring the thoughts and practices and believes surrounding existing pain interventions that are 'permitted' and those potentially available.  We will also listen to the invaluable experiences and thoughts offered today, by adults working on the front line with children and teenagers experiencing intolerable pain due to HIV/AIDS.  It is particularly urgent that adults speak up, as children and teenagers do not have the right to control the pain interventions they receive.  One of the greatest fears and obstacles surrounding administering effective and sustainable pain interventions for children and teenagers, centers around the concept of ADDICTION.

**Real Stories Gallery wishes to thank everyone for sharing their experiences here today.  Please feel free to email your 'stories' to us, or upload directly with a photographic image to the gallery.  All forms of storytelling in any language are welcome.

**Tim Barrus is a visual poet who Founded The Studio/Cinemateque: a safe-shelter and art program for battered boys with HIV/AIDS.

 

Professor Paul Webley

(Director of School of Oriental & African Studies, University of London, U.K.)

Stories and narratives help define who we are, and help us understand our world and what it means to be human.

 

Professor Philip Goulder

(Pediatrician & Research Immunologist (HIV), University of Oxford, U.K.)

We watch carefully the people who inspire us, and listen to the stories they tell us; what we learn from them shapes what we understand, how we feel and how we act in the world.

 

Professor Andrew Tomkins, CICH

(Institute of Child Health, University of London, U.K.)

Working with children who are infected or affected by HIV/AIDS involves pain and passion but words are often inadequate to express the deepest feelings and responses.  Art and poetry however often communicate in deeper ways reaching our inner lives to bring truth and realisation.  They also release new strength for respect, care and compassion.

 

"A lingua que eu falo" by Sónia Sultuane (artist, Mozambique; © Art For Humanity)

A Sonia poem.  The human tongue walks on foot across the world.  The Tongue speaks of all languages of communication, representation, expression.  The Foot is our movement, experience and energy for life.

 

"A lingua que eu falo" by Tembo Danc

(poet, Mozambique; © Art For Humanity)

A língua queeu falo
não tem nações, rostos, ou cores,
a língua que eu falo
não tem idades, padrões ou religiões,
a língua muda que eu falo
é a linguagem universal dos corações, o amor.

 
"The language I speak" (English translation)

The language I speak
has no nations, faces or colors,
the language I speak
has no age, standards or religions,
the mute language I speak
is the universal language of the hearts, love.

 
Ulimi engilukhulumayo (Zulu Translation)

Ulimi engilukhulumayo
alunazizwe, buso noma imibala,
ulumi engilukhulumayo
alunaminyaka, mabanga, noma zinkolo,
ulimi oluthule engilukhulumayo
ulimi olumbandakanya zonke izinhliziyo,
uthando.

 

"The human voice can never reach the distance that is covered by the still, small voice of conscience"

(Mahatma Gandhi)

"grasp finding weight" by Timothée Barrus (visual poet, USA)

grasp finding weight bearing him down/

there was pain/ he was in a lot of pain/

i did not know/ i would say: are you in pain?/

and he would smile and say no or he would just say nothing/

i failed him/

he was in enormous pain/

i had a french anesthesiologist, a pain specialist, examine him today/

he’s in a great deal of pain but he did not want to bother you with it/

so we have banished the pain to wherever it is the pain goes/

my ominous camera to the beach and then to the woods alone today/

pain is a figure in white/ a goatwoman/

reports of executions/

i see the goatwomen with their vacant black eyes in the woods/

shimmering/

how do you say pain visually/

i fucking hate language/

the goatwomen have arrived to shatter him/

 

"the calligraphy of cicatrices records a past" by Timothée Barrus (visual poet, USA)

The world inscribes itself, some marks on purpose and some as accidents.
What we see — the stigmata themselves — is responding paper skin.
Lines we see, stitching on the surface, mean scars deep within, on our very hearts.

Strokes of whip on backs only write in agony.
Inner scars cripple us with anguish, the rhythms of our hearts forever dissyncopated, one erratic beat altering all others.
No salve can touch those weals.
No breathing exercise relieve the pain

On black skin ridges and dots of keloids become tribal braille but on white skin even the new red blood shows bright.
Lion’s claws or razor slashing, accidents or madmen, the story forms so we can recognize one another:
lover, brother, friends, and warriors

**Cicatrices:(Medicine / Pathology) the tissue that forms in a wound during healing; scar.  (Life Sciences & Allied Applications / Botany) a scar on a plant indicating the former point of attachment of a part, esp a leaf [from Latin: scar, of obscure origin]. Keloid: raised pinkish scar tissue at the site of an injury; results from excessive tissue repair.

 

"So. How do I love this child even as I watch him die" by Timothée Barrus (visual poet, USA)

So. I have this responsibility. I can clothe him. I can feed him. I am given the resources to do that. None of that is the issue here.

I do fight Spirit with the dying ones. Spirit is such a Super Bitch Fuck.

I refuse to call her god. She doesn’t give a rat’s ass what I call her.

She has only given me two things in this life. It has not been much of a life, but she has given me two things. Writing and death.

They find me.

I have lived in the most remote parts of the planet. Places you cannot even imagine. Places where NO ONE lives.

Spirit finds me. Writing finds me. Death finds me. So. That is only how it is. Now, this.

She drops this one at the door and laughs. Thank you, you fucking witch. The kid smells of death and really bad piss.

I ask her how much time I will have with him. She laughs again. The bitter laugh. Not much.

“You know what to do, you just don’t have the courage to do it.” And then she smiles. I can see her breath as though the two of us are fighting in the snow. Tonight is a storm of it.

You are impotent,” she snarls.

True enough. My cock lost its ability to get hard a long time ago. HIV will do that. It came as a shock to me that I could live my life without my soldier cock stuck permanently in my head. The old me would have thought that life without a hard cock would not be worth living. Now, I do not even miss it. I SEE things I never SAW with my cock in my eye like that.

The boy is suicidal and he’s dying anyway. None of this is gentle.

Anyone who thinks my responsibilities are limited to food and clothing is so stupid I can’t even go there. These are the kind of people I have lived in remote places to ESCAPE.

The cultures these people have built have failed everyone. They are only empty. Western medicine is empty.

We have kept this boy alive but alive for what.

I would expand his world. Not limit it to his dying of AIDS and cancer.

The cancer has turned his cock black. He is riddled with tumors.

 

It is the morphine hour.

He gets his morphine. I get mine.

His pain is different from mine. Mine is dead bone pain. His is tumor pain. Pain is not just pain. That is how the emptiness of Western medicine sees pain. It is all the same pain. Western medicine sees pain this way because it is a cultural institution. It is empty. Pain is the dipper down and dredged.

The morphine and the weed are medical and legal.

There are many ways to expand consciousness. To see the province of life and death as not invisible to us.

Things arcane in silver fires and the skins of entire stars. Bodiless. Oh, purple dot a great frayed rope. The snarls unraveling and the storm of snow outside.

Did you really think I would leave the beating of that heart to a marshmallow. Then. You do not know me. I don’t do cute.

It honestly disturbs me that people would buy the marshmallow scenario like Little Women. Do I appear to be Louisa May Alcott to you.

I could lie and tell you that I do cute. Most people prefer the lie.

AIDS does not exist and all children are happy happy and live with mummy and daddy and everyone is white and no one is hungry ever ever ever and we all go to school in our shiny shoes where we all sit nicely for the teacher with our little hands folded and our smiley smiles.

There. I wrote it. It must be so. Shit. I hate god. I hate religion. And I hate Barney. I am haunted by SPIRIT and the beast is an apparition with claws and teeth.

So. How do I love this child even as I watch him die.

It didn’t disappear like a marshmallow just because you wanted us all cozy in our jamies by the fire. Get a grip. This is drugs and AIDS.

With our eyes now in this quiet house lifted toward an August sun. Take my hand and we will doze by the mulberry tree. Beyond the cornfield and the dusty towns. I will show you the world.

So. Are there places you cannot see.

Most of you can’t see the room you live in. Places.

We will stand in streets and laugh and fire will pour from our lips like birds. From this cage, I will run you down corridors of sound. Beyond them and their televisions I call them teleblindness. Beyond them. Forget the suitcase and the summerhouse. Our feet will sink into the soldier dust upon the wind. Knowledge is the incalculable center of the thing. We will outrun Spirit even as she waits for our return upon the shore.

Tonight, boy. Now. Let us run. Run, boy, run.

http://www.real-stories-gallery.org/content/there-are-places-i-go-when-madness-comes-tim-barrus

“the morphine hour” by Timothée Barrus (visual poet, USA)

so you have washed yourself with mud again/

the housedog is the poppy plant/ it’s the best they have to offer/

the solution from your veins distilled/

2:am thumbs up god himself creeps his grief through pain/

fentanyl, fentanil, sublimaze, actiq, durogesic, duragesic, fentora, onsolis, iInstany, dilaudid, oxycontin,

my favorite is actiq; whose witchery breaks the rims of memory,

into softer wheels sitting in the silences of sadomechanisms,

the masochist’s deceit that the strongbox can easily be plundered/

no/

the plundering will be of you and any number of your other selves/

the edge of nighttime’s fence/ vibrates doorframes of my tomb of mud and stones

and small deceptions, whirl over and around the rain-soaked grass/

a stir of wonders with the plastic lightness of a blowing grocery bag/

the wandering pill-to-pill/ and mud again, shines the summits of a rapture/

sleepwalks among the bones up and down the walls painted with the demon’s face/

such threads of veins have been gnawed on by the bodies of a fertile land

now entangled with the voices of the talking to the lesser saints/

the awfulness of sorrow and the vanishing of the bleeding doors to sleep/

how hard they close with a clang

just as the sun licks the horizon gently with its numb the mud again and melancholy tongue/

 

"Pain-Interventions for Children/Teenagers" by Tim Barrus (December 2010)

As anyone who has ever had a child or teenager hospitalized in the US knows, the idea of providing patients with pain-interventions during difficult procedures is nonexistent.

Even an ordinary catheterization on a male is done with no regard for pain in the US.

This is not the case in France.

“Adverse events of premixed nitrous oxide and oxygen for procedural sedation in children,” by Olivier Gall, Daniel Annequin, Guy Benoit, Emmanuel Van Glabeke, Françoise Vrancea, Isabelle Murat.

In France, administration of premixed 50% nitrous oxide and oxygen for procedural sedation is under close supervision by the French Drug Agency before final approval for use. We have examined the frequency of adverse events in children sedated with 50% nitrous oxide and oxygen over a broad range of non-specialised facilities.

A mean of 0·33% (SD0·10) children had major adverse events.

Thus, premixed 50% nitrous oxide and oxygen seems to be a safe option for procedural sedation in children.

The number of pediatric procedures in which sedation or analgesia is used has increased greatly over past years.

Reports of mishaps and life-threatening complications.

Although several guidelines have been published, there is little agreement on which drugs can be safely given in a non-specialised environment. Sury and colleagues have shown that oral sedation with chloral hydrate or benzodiazepine supervised by specialised nurses is effective and safe for diagnostic imaging.

Yet the safety of regimens suitable for painful procedures seems less well established. 2–4 Nitrous oxide is an anaesthetic gas with analgesic properties. The panel lists contraindications for its use.

In France, the government has not yet approved the premixed cylinder of 50% nitrous oxide in oxygen for use as a medical drug. A temporary licence was delivered in March, 1998, by the French Drug Agency (Agence Française de Sécurité Sanitaire des Produits de Santé), with strict guidelines for use of this combination by non-doctors.

Administration by non-doctors was restricted to nurses who had attended training sessions. The guidelines also restricted use to children older than 4 years who were not receiving psychotropic drugs.

The French Drug Agency further recommends that nitrous oxide be administered for 3 mins before the start of the procedure and that total duration does not exceed 30 mins.

All administrations of premixed 50% nitrous oxide in oxygen have to be declared on a standardised form that records data from the procedure, associated medications, and adverse events. We prospectively collected all such data from patients aged younger than 19 years from 46 institutions to which AGA Medical provided the cylinders, with premixed 50% nitrous oxide in oxygen. Declaration sheets were individually checked and registered in hospital pharmacies. Two physicians trained in paediatric anaesthesiology reviewed the data. Premixed 50% nitrous oxide in oxygen was given on 7511 occasions.

 

HIV/AIDS

The Courage of Adolescents

http://www.real-stories-gallery.org/content/i-took-them-desert-tim-barrus

I am not normally aware of the extent to which my life is lived outside of the parameters.

Every now and then, I am reminded.

 

“Hope” by Yusuf Arakkal (artist, India; © Art For Humanity)

Creative human beings
are God's gift to
this world.

http://www.real-stories-gallery.org/content/no-point-burning-tim-barrus

http:// http://www.real-stories-gallery.org/content/shigao-tim-barrus

---

Information compiled by Rachel Chapple, PhD

 

What is an opioid?

Opioids are among the world's oldest known drugs; commonly used for its therapeutic benefits since pre-recorded history. The analgesic (painkiller) effects of opioids are due to decreased perception of pain, decreased reaction to pain as well as increased pain tolerance.

An opioid is a chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract.  The receptors in these organ systems mediate both the beneficial effects and the side effects of opioids.  **Patients taking opioids regularly for pain relief, rapidly build up a tolerance to the side-effect of respiratory depression, so that it is not a clinical problem.

Although the term Opiate is often used as a synonym for opioid, the term opiate is properly limited to only the natural alkaloids found in the resin of the opium poppy (Papaver Somniferum).

Heroin is a highly addictive and rapidly acting opiate (a drug that is derived from opium). Specifically, heroin is produced from morphine, which is a principal component of opium. Opium is a naturally occurring substance that is extracted from the seedpod of the opium poppy.

There are a lot of other “opiates” that are available as prescription medication, which are legal and have similar side-effects as heroin.   For instance, Morphine, Codeine, Hydrocodone, Oxycodone, Methadone, Fentanyl, Mepridine…

 

Morphine and Heroin

The opium gum extracted from the opium poppy (Papaver Somniferum), may be crudely refined and smoked (e.g., “brown sugar”) or converted to morphine and heroin.

In 1810, Morphine, a derivative of opium, was developed as a pain killer. It eliminated pain caused by medical operations and severe injuries. Soon after it was administered, it produced an intense, dream-like state of euphoria. Hence, it came to be christened "morphine", after Morpheus, the Greek god of dreams.

In 1874, a British chemist synthesized heroin (diacetylmorphine), when he boiled morphine and a common chemical, acetic anhydride, over a stove for several hours. The modern technique entails a complicated series of steps in a good laboratory. Bayer of Germany registered this new drug as a trademark under the name "Heroin" and marketed it as a 'safe alternative' to Morphine.

 

Legal/ Illegal Heroin

Heroin's link with violent crime to the transfer of HIV among users who share needles and its' highly addictive nature, has resulted in much social fear surrounding this drug.

 

Heroin:

Heroin is a Scheduled 1 drug in the United States, Canada, and Norway.  In both U.K. and New Zealand heroin is a Class A, and in U.K. it is also a Schedule II.

Some countries, such as UK and Switzerland, prescribe heroin to addicts to slowly wean them off of it. These countries have led others such as Canada, Germany, and Australia to test the prescription programs of heroin.

Heroin is controlled in Australia.  It was listed in Schedule I of the Narcotic Drugs Act of 1967.  It is unclear whether the control system has changed since then.

In Brazil heroin is listed as a controlled substance, making production, distribution, or possession illegal.

In Finland Heroin is a controlled substance, making production, distribution, and possession illegal without a license.

In Germany in May 2009, it became legal to prescribe heroin to addicts over 23 years old, who have been addicted for at least 5 years and tried 2 other therapies to get off heroin.

In Norway Heroin is Schedule I and it is illegal to buy or possess heroin without a special license. There have been some projects to establish "needle rooms" in Norway by the government, where heroin addicts are allowed to get fresh needles for injecting heroin, but the chemical is still Schedule I.

In Portugal effective from July 2001, personal use of heroin was decriminalized by Law 30/2000. Possession of less than 1 g is not regarded as a criminal offense, though the substance is liable to be seized and the possessor can be referred to mandatory treatment. Sale, or possession of quantities greater than the personal possession limit, are criminal offenses punishable by jail time.

In Switzerland Heroin is legally available for addicts under an ongoing experiment.

 

Some street terms for Heroin:  Big H, Boy, Capital H, China White, Chiva, Dead on arrival, Diesel, Dope, Eighth, Good H, H, Hell Dust, Horse, Junk Mexican Horse, Mud, Poppy, Smack, Thunder, Train White Junk, Brother, Chick, Harry Jones, Judas, Black Pearl, Blanco, and many more

Appearance:

The appearance of heroin can vary dramatically.  In the USA for instance:

In the eastern United States, heroin generally is sold as a powder that is white (or off-white) in color (generally, the purer the heroin the whiter the color, because variations in color result from the presence of impurities.)

In the western United States, most of the heroin available is a solid substance that is black in color. This type of heroin, known as black tar, may be sticky (like tar) or hard to the touch. Powdered heroin that is a dirty brown color also is sold in the western United States.

UCSF researchers have found that use of black tar heroin by injection drug users in West Coast cities accounts for a dramatically lower percentage of IDUs in these locations who are infected with HIV. The finding is based on comparison to East Coast cities, where powder heroin is commonly used.

In cities west of the Mississippi, black tar heroin - a dark, gummy, resinous substance from Mexico - is the type of heroin predominately available.

On the East Coast, white and light brown powder heroin from South Asia and South America is the type predominately available.

Study findings showed the percentage of IDUs infected with HIV was sharply lower in cities where black tar heroin use predominated compared to cities where powder heroin use predominated, a pattern that was not mirrored in the percentages of HIV-infected gay men.

In addition, black tar heroin clogs syringes, they note. Frequent rinsing and flushing is required, reducing the amount of residual blood and HIV virus present.

 

Global shortage of poppy-based medicines

Morphine and other poppy-based medicines have been identified by The World Health Organization (WHO) as essential in the treatment of severe pain. However, only six countries use 77% of the world's morphine supplies, leaving many emerging countries lacking in pain relief medication.  The current system of supply of raw poppy materials to make poppy-based medicines is regulated by the International Narcotics Control Board under the provision of the 1961 Single Convention of Narcotic Drugs.  The amount of raw poppy materials that each country can demand annually based on these provisions must correspond to an estimate of the country's needs taken from the national consumption within the preceding two years. In many countries, under-prescription of morphine is rampant because of the high prices and the lack of training in the prescription of poppy-based drugs.

The World Health Organization is working with different countries' national administrations to train health-workers and to develop national regulations regarding drug prescription to facilitate a greater prescription of poppy-based medicines.

Another idea to increase morphine availability is proposed by the Senlis Council, who suggest, through their proposal for Afghan Morphine, that could provide cheap pain relief solutions to emerging countries as part of a second-tier system of supply that would complement the current INCB regulated system by maintaining the balance and closed system that it establishes while providing finished product morphine to those suffering from severe pain and unable to access poppy-based drugs under the current system.

 

Fentanyl

Fentanyl is a powerful synthetic opiate analgesic similar to but more potent than morphine. It is typically used to treat patients with severe pain, or to manage pain after surgery. It is also sometimes used to treat people with chronic pain who are physically tolerant to opiates. It is a schedule II prescription drug.

In its prescription form, fentanyl is known as Actiq, Duragesic, and Sublimaze. Street names for the drug include Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, as well as Tango and Cash.

Like heroin, morphine, and other opioid drugs, fentanyl works by binding to the body's opiate receptors, highly concentrated in areas of the brain that control pain and emotions. When opiate drugs bind to these receptors, they can drive up dopamine levels in the brain's reward areas, producing a state of euphoria and relaxation.

Medications called opiate receptor antagonists act by blocking the effects of opiate drugs. Naloxone is one such antagonist. Overdoses of fentanyl should be treated immediately with an opiate antagonist.

When prescribed by a physician, fentanyl is often administered via injection, transdermal patch, or in lozenge form. However, the type of fentanyl associated with recent overdoses was produced in clandestine laboratories and mixed with (or substituted for) heroin in a powder form.

Mixing fentanyl with street-sold heroin or cocaine markedly amplifies their potency and potential dangers. Effects include: euphoria, drowsiness/respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, coma, tolerance, and addiction.

NOTE:  There have been several fentanyl patch recalls over the years.  The recalls have covered the brand name Duragesic fentanyl patches, as well as generic patches made by Sandoz, Actavis, and Watson.

 

Duragesic and Durogesic

Duragesic and Durogesic are trade names of fentanyl transdermal therapeutic systems,  and are used for relief of moderate to severe pain. Since Duragesic and Durogesic release Fentanyl, a potent, opioid, slowly through the skin, one patch may provide 72 hours of pain relief. Its initial onset after a patch has been applied is roughly 8–12 hours under normal conditions, thus Duragesic patches are often prescribed with another opioid (such as morphine sulfate) to handle breakthrough pain.

Duragesic is manufactured by ALZA Corporation and marketed by Janssen Pharmaceutica (both subsidiaries of Johnson & Johnson). From June 2002 - June 2003, Duragesic sales totaled over one billion.

Pain clinic physicians who prescribe Duragesic may also recommend dextromethorphan, a non-prescription cough syrup, as it helps opioids work better and help with withdrawal symptoms felt during patch change over time.

As of July 2009, construction of the Duragesic patch had been changed from the problematic gel pouch and membrane design to "a drug-in-adhesive matrix designed formulation," to eliminate the possibility of leakage and leakage-related accidental overdosing. 

 

 Onsolis

Onsolis is a mouth patch, and it isn’t supposed to be used as a substitute for the Duragesic patch or the other generic fentanyl patches.

In July 2009 the U.S. Food and Drug Administration formally approved Onsolis, Raleigh-based BDSI's mouth patch that delivers the painkilling drug fentanyl to cancer patients suffering severe “breakthrough pain” that doesn't respond to other medications.

Onsolis is manufactured by Veva Drug Delivery Systems of Florida and marketed under license from BDSI (Nasdaq: BDSI) by Meda Pharmaceuticals.  With FDA approval of Onsolis, BDSI is due about $27 million in milestone payments, which Sirgo said would be directed to the company's drug pipeline.

The company also is developing the product BEMA Buprenorphine, a form of painkilling drug buprenorphine that is often given intravenously to treat chronic pain. Like Onsolis, the product uses the company's BEMA technology, which delivers drugs through mucous membranes in the mouth via a small patch.

 

Dilaudid

Hydromorphone, a more common synonym for dihydromorphinone and dimorphone, commonly a hydrochloride (trade names Palladone, Dilaudid, and numerous others) is a potent centrally-acting analgesic drug of the opioid class. It is a derivative of morphine, and therefore a semi-synthetic drug. It is, in medical terms, an opioid analgesic and, in legal terms, a narcotic. 

Hydromorphone is known in various countries around the world by the trade names Hydal, Sophidone, Hydrostat Hydromorfan, Hydromorphan, Laudicon,

Hymorphan, Opidol, Palladone and others (warning: the brand names are inconsistent from country to country). An extended-release version of hydromorphone called Palladone was available for a short time in the United States before being voluntarily withdrawn from the market after a July 2005 FDA advisory warned of a high overdose potential when taken with alcohol.  As of March 2010, it is still available in the United Kingdom under the brand name Palladone SR, and in most other European countries.

Another extended-release version called Hydromorph Contin, manufactured as controlled-release capsules, continues to be produced and distributed in Canada by Purdue Pharma Inc. of Pickering, Ontario. The newest extended-release preparation (and the first to last 24 hours - see below) is Jurnista, made by Janssen-Cilag. In addition to Purdue-Frederick and Janssen-Cilag, manufacturers of hydromorphone products include Knoll, Abbott, Endo, Mallinckrodt, Merck, Mundipharma, and Lannacher, among others.

 

Oxycodone / OxyContin

Oxycodone is an opioid analgesic medication synthesized from opium-derived thebaine.  

OxyContin is the brand name of a time-release formula of oxycodone produced by the pharmaceutical company Purdue Pharma (the manufacturing rights to time-released generic oxycodone are under dispute).  It was approved by the U.S. Food and Drug Administration in 1995 and first introduced to the U.S. market in 1996.

By 2001, OxyContin was the best-selling non-generic narcotic pain reliever in the U.S.; 2008 sales in the U.S. totaled $2.5 billion. An analysis of data from the U.S. Drug Enforcement Administration found that retail sales of oxycodone "jumped nearly six-fold between 1997 and 2005." Mundipharma distributes OxyContin in Australia, China and Europe.  Beginning in 2010, the brand name OxyContin by Purdue was reformulated to prevent the misuse and abuse of the tablets.

** Critics have accused Purdue Pharma of putting profits ahead of public interest by applying "significant political pressure" to attempt to reverse South Carolina's requiring prior approval before a person with Medicaid can receive the drug.  In May 2007 Purdue Pharma and three of its top executives pleaded guilty in a Virginia federal court to charges that they misbranded OxyContin, and were ordered to pay $634 million in fines for felony and misdemeanor misbranding.

**The slang term hillbilly heroin for OxyContin refers to the occurrence of the "earliest reported cases of Oxycontin abuse" in the U.S. in rural areas such as Appalachia. 

 

Endogenous opioids

Opioid-peptides that are produced in the body include:

Endorphins

Enkephalins

Dynorphins

Endomorphins

 

Opium alkaloids

Phenanthrenes naturally occurring in opium:

Codeine

Morphine

Thebaine

Oripavine

Preparations of mixed opium alkaloids, including papaveretum, are still occasionally used.

 

Semisynthetic derivatives

Diacetylmorphine (heroin)

Dihydrocodeine

Hydrocodone

Hydromorphone

Nicomorphine

Oxycodone

Oxymorphone

 

Synthetic opioids

Anilidopiperidines

Fentanyl

Alphamethylfentanyl

Alfentanil

Sufentanil

Remifentanil

Carfentanyl

Ohmefentanyl

Phenylpiperidines

Pethidine (meperidine)

Ketobemidone

MPPP

Allylprodine

Prodine

PEPAP

Diphenylpropylamine derivatives

Propoxyphene

Dextropropoxyphene

Dextromoramide

Bezitramide

Piritramide

Methadone

Dipipanone

Levomethadyl Acetate (LAAM)

Difenoxin

Diphenoxylate

Loperamide (used for diarrhoea, does not cross the blood-brain barrier)

Benzomorphan derivatives

Dezocine - agonist/antagonist

Pentazocine - agonist/antagonist

Phenazocine

Oripavine derivatives

Buprenorphine - partial agonist

Dihydroetorphine

Etorphine

Morphinan derivatives

Butorphanol - agonist/antagonist

Nalbuphine - agonist/antagonist

Levorphanol

Levomethorphan

 

Others

Lefetamine

Meptazinol

Tilidine

Tramadol

Tapentadol

 

Opioid antagonists (to counter the effects of opioids)

Nalmefene

Naloxone

Naltrexone

 

Witnesses at the US Senate Commerce Committee in 2004 repeatedly warned of the somatic effects of pornography and that internet pornography is the new addictive drug.  As Dr Jeffrey Satinover, a psychiatrist, stressed: "Pornography really does, unlike other addictions, biologically cause direct release of the most perfect addictive substance. That is, it causes masturbation, which causes release of the naturally occurring opioids.  It does what heroin can't do, in effect."

Mary Anne Layden, the co-director of the Sexual Trauma and Psychopathology Program, echoed Satinover when she commented: “The internet is a perfect drug delivery system, because you are anonymous, aroused and have role models for these behaviors. To have a drug pumped into your house 24/7, free, and children know how to use it better than grown-ups know how to use it -- it's a perfect delivery system, if we want to have a whole generation of young addicts who will never have the drug out of their mind.  Pornography addicts have a more difficult time recovering from their addiction than cocaine addicts, since coke users can get the drug out of their system, but pornographic images stay in the brain forever.”

 

"Marinol (synthetic THC) Decreases Mortality and Viral Load?" by Sean  Strub (December 14, 2010)

A study recently found that administration of chronic THC (the active ingredient in marijuana; administered in this study via the prescription product Marinol) decreased mortality, helped retain body mass and reduced viral load in plasma and cerebralspinal fluid (CSF).

Researchers at the Louisiana State University Health Services Center, used a “well established nonhuman primate model of HIV disease”, and reported surprise at their findings, writing that the results were “contrary to what we expected”.  Not quite so surprising to me, and perhaps not to others familiar with the anti-inflammatory effects of marijuana.

I have been fascinated with Marinol, the prescription drug that delivers a synthetic form of THC, since it was introduced in the early 1990s.  It was approved for HIV-related wasting (and chemo-induced nausea) in part as a response to demands for the legalization of medicinal marijuana.  For many people with HIV, myself included, it has been an important part of our ability to regain weight.

But Marinol is expensive and inaccessible to many people with HIV, even though it is preferable to smoking pot, which carries smoking-associated health risks.

Marinol is typically prescribed for daily dosing and the side effects can include a disorienting effect for a few days until one’s body gets accustomed to the drug.  That disorienting effect is remarkably similar to what others would characterize as “getting high”; but more like the slower and extended effect of a pot brownie rather than the more immediate impact of smoking weed. If one takes it daily, the high quickly goes away.  I’ve found it curious that the “abuse” of Marinol involves taking too little of it (which retains the psychotropic effect).

 

“Opium” by Mike Adams, (Editor of NaturalNews.com; June 11, 2009)

The medicinal properties of opium have been known from the earliest times, and it was used as a narcotic in Sumerian and European cultures at least as early as 4000 B.C. The drug was introduced into India by the Muslims and its use spread to China. Early in the 19th century, against Chinese prohibitions, British merchants began smuggling opium into China in order to balance their purchases of tea for export to Britain, an act that set the stage for the Opium Wars. Chinese emigrants to the United States, who were employed to build the transcontinental railroad, brought the opium-smoking habit to the West Coast.

During the 19th century opium was grown in the United States as well as imported. Besides indiscriminate medical use, opiates were available in the United States in myriad tonics and patent medicines, and smoking in opium dens was unhindered, resulting in an epidemic of opiate addiction by the late 1800s. The generous use of morphine in treating wounded soldiers during the Civil War also produced many addicts.

Importation of opium by Chinese nationals was prohibited in 1887; in 1906 the Pure Food and Drug Act required accurate labeling of patent medicines. The Harrison Narcotics Act of 1914 taxed and regulated the sale of narcotics and prohibited giving maintenance doses to addicts who made no effort to recover, leading to the arrest of some physicians and the closing of maintenance-treatment clinics. Since then, numerous laws attempting to regulate importation, availability, use, and treatment have been passed, and the concern with opium addiction per se has largely been replaced by concern with heroin, cocaine, marijuana, and other illegal drugs.

Large quantities of opium are still grown, some for legitimate use, on opium poppy farms in Southwest Asia (primarily Afghanistan and Pakistan), Southeast Asia (the “Golden Triangle,” primarily in Myanmar), and Latin America (primarily Colombia). The opium gum may be crudely refined and smoked (e.g., “brown sugar”) or converted to morphine and heroin. Growers usually make more for opium than for other crops, and the cultivation and refining employ hundreds of thousands of people, but the real profits go to the drug traffickers. It is estimated that the street price for heroin is 153 to 183 times that of the opium bought from the farmer. Despite laws and agreements to control its use, a worldwide illicit opium traffic persists.

The first to process heroin was C.R. Wright, an English researcher who unwittingly synthesized heroin (diacetylmorphine) in 1874 when he boiled morphine and a common chemical, acetic anhydride, over a stove for several hours. The modern technique entails a complicated series of steps in a good laboratory.

In the late 1800s, opium was a popular, commonly available drug. Drug users frequented opium dens which dotted the 'Wild West' region of America. It was smuggled in and sold by Chinese immigrants who came here to work on the railroads.

In 1810, morphine, a derivative of opium, was developed as a pain killer. It eliminated pain caused by medical operations and severe injuries. Soon after it was administered, it produced an intense, dream-like state of euphoria. Hence, it came to be christened "morphine", after Morpheus, the Greek god of dreams. It was hailed by doctors as a miraculous cure for pain and used extensively and freely. In the euphoria however, its detrimental addictive properties went unnoticed until after the Civil War.

Thousands of soldiers became morphine addicts during the civil war and within a span of ten years since its invention America was in the grip of a major morphine epidemic.

In 1874, a British chemist working in London invented a new drug. Bayer of Germany registered it as a trademark under the name "Heroin". Shortly, it was imported into America and aggressively marketed to doctors and their patients as a "safe, non-addictive" substitute for morphine. For the next several decades, it was sold legally all over the country by drug companies.

Eventually, in 1920, the US Congress passed the Dangerous Drug Act, banning the sale of heroin over the counter and making its distribution federally regulated. However, it was too late already. Tens of thousands of citizens had already been addicted and a market for heroin had been created. Today this market still exists and is, in fact, ever growing.

 

Heroin Users Today:

In the USA individuals of all ages have been found to use heroin--data reported in the National Household Survey on Drug Abuse indicate that an estimated 3,091,000 U.S. residents aged 12 and older have used heroin at least once in their lifetime. The survey also revealed that many teenagers and young adults have used heroin at least once--76,000 individuals aged 12 to 17 and 474,000 individuals aged 18 to 25.

Heroin use among high school students is a particular problem. Nearly 2 percent of high school seniors in the United States used the drug at least once in their lifetime, and nearly half of those injected the drug, according to the University of Michigan's Monitoring the Future Survey.

 

How Is Heroin Used:

Heroin is injected, snorted, or smoked. Many new, younger users begin by snorting or smoking heroin because they wish to avoid the social stigma attached to injection drug use. These users 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.

 

Risks:

Heroin overdoses--which can result whether the drug is snorted, smoked, or injected--can cause slow and shallow breathing, convulsions, coma, and even death

Addiction:  individuals who abuse heroin over time develop a tolerance for the drug, meaning that they must use increasingly larger doses to achieve the same intensity or effect they experienced when they first began using the drug. Heroin ceases to produce feelings of pleasure in users who develop tolerance; instead, these users must continue taking the drug simply to feel normal.

Withdrawal symptoms:  addicted individuals who stop using the drug may experience withdrawal symptoms, which include heroin craving, restlessness, muscle and bone pain, and vomiting.

Heroin users who inject heroin expose themselves to additional risks, including contracting human immunodeficiency virus (HIV), hepatitis B and C, and other blood-borne viruses.

Chronic users who inject heroin also risk scarred or collapsed veins, infection of the heart lining and valves, abscesses, pneumonia, tuberculosis, and liver and kidney disease.

 

Heroin Withdrawal:

Heroin withdrawal can begin as soon as four hours. Without another dose, withdrawal becomes worse. Sometimes referred to as “dope sickness”. For those brave enough to undergo a complete withdrawal, the situation deteriorates over the next 48 to 72 hours and then slowly resolves

Intense feelings of restlessness and insomnia take over. Along with this comes diarrhea, nausea and vomiting, and shivering. The physical component of the restlessness sometimes becomes an uncontrollable kicking motion, and this is where the phrase, “kicking the habit” arises.

Other symptoms of heroin withdrawal: Temperature regulation problems, with sweating and chills.  Repeated yawning.  Runny nose and watery eyes.  Irritability and anxiety.  Intense craving for the drug

 

Medical withdrawal:

Some withdrawal methods that seek to eliminate the harshest physical symptoms. Because there are drugs available that will quickly clear heroin from its active sites in the body, medically supervised withdrawal can be less severe than someone trying it on their own. Called opioid antagonists, drugs like Narcan (Naloxone) or Naltrexone can be used to block heroin’s effects and bring someone rapidly off a high (or an overdose).

Combined with anesthesia, so called ‘rapid detox’ is used to try to limit withdrawal symptoms in patients. The user is knocked out and the antagonist is administered. After several hours (up to 8) the person is then allowed to wake up and the heroin is cleared from their system. Various studies show that withdrawal symptoms can be lessened with this method, but that long-term success is no better than traditional withdrawal.

 

Resources:

http://en.wikipedia.org/wiki/Opioids

http://www.dangerousdrugs.us/fentanyl

http://www.nida.nih.gov/scienceofaddiction/

http://www.drugabuse.gov/coe/pdf/Prescription-Drug-Abuse_An-Introduction.pdf

http://www.dangerousdrugs.us/2009/07/new-fentanyl-patch-approved-but-it-isnt-a-substitute-for-duragesic.html

http://www.bizjournals.com/triangle/stories/2009/07/13/daily53.html

http://www.findtherightfentanylpatchlawyer.com/