HEROIN DEPENDENCE: HISTORICAL CONTEXT, PHARMACOLOGY, THEORY AND MAJOR INTERVENTION MODALITIES

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PHARMACOLOGICAL INTERVENTION FOR HEROIN DEPENDENCE

For some individuals, general support, encouragement and understanding of the symptomatology may suffice, enabling symptomatic relief of heroin withdrawal without medication. As indicated, studies of selfrecovery by heroin dependants’ show that shifts in identity and lifestyle, together with changes in the individual’s environment, are important in the pathway out of dependence. For others, however, a history of serious withdrawal complications, a lack of social support or other problems, may make substitute prescribing a viable option. Withdrawal symptoms may also differ depending on the pharmacological profile of the heroin dependant. The severity of heroin withdrawal symptoms are also not clearly related to the quantity of heroin taken. When assessing withdrawal, for the purposes of dose titration, it is better to place greater weight on observable signs rather than subjective symptoms. Untreated heroin withdrawal typically reaches its peak 36-72 hours after the last dose and symptoms will have subsided substantially after five days (Department of Health, The Scottish Office Department of Health, Welsh Office, Department of Health and Social Services, Northern Ireland, 1999).

Treatment of heroin withdrawal syndrome with opioids/substitute opioids

Heroin maintenance
Legally sanctioned clinics dispensing narcotics existed in the United States and in the United Kingdom. With the United States’ Harrison Act of 1914, the Department of the Treasury moved to eliminate suppliers of narcotics. Realising that the sudden confiscation of large amounts of opioids would create an extreme hardship and panic among opioid dependent persons, the Department urged the creation of special clinics to detoxify those individuals who could no longer obtain narcotics from their usual source. A maximum of 15 grains of morphine or heroin was usually prescribed. The initial dose was then decreased by a half-grain every other day until some discomfort was experienced. The patient would then be offered the choice of hospitalisation for the remainder of the detoxification or completely withdrawn on an ambulatory basis (Stimmel, 1975).
In the United Kingdom, guidelines were subsequently established under which specially licensed physicians could detoxify heroin dependants or provide long-term treatment in instances where narcotic use or provide long-term treatment in instances where narcotic use enabled continued functioning and previous detoxification and all other treatment was unsuccessful (Kenny, 1999). Physicians prescribing narcotics notify the Home Office, which then enters the heroin dependant individual’s name in a central index or register. This register is a means of recording the number of heroin dependent persons undergoing treatment in the United Kingdom and has continued to do so up to the present time; returns are submitted to the WHO. With the Dangerous Drug Act of 1967, clinics were established for dispensing of prescriptions for heroin and other narcotics, as well as rehabilitative services. Those who enrolled in the clinics were reported to the central register. There is no specific system; each clinic differs with respect to approach, staffing and effectiveness in rehabilitation (Stimmel, 1975).

Methadone or buprenorphine?

For people dependent on heroin, the prescribing of substitute drugs is a very significant, albeit controversial, aspect of harm reduction that has become an integral part of many drug treatment strategies. Although abstinence remains the ultimate goal of substitute prescribing programmes, where this is not achievable interventions now focus on risk reduction, harm minimisation and intermediate service aims. The value of substitute prescribing has been argued that harm reduction initiatives, including substitute prescribing, lessen the social, medical and economic cost of illegal drug use to users and to society at large. Methadone remains the most common substitute drug used for the treatment of opioid dependence. Methadone has roved to be an effective substitute drug for opioid dependence for a number of reasons, including its long half-life resulting in it only having to be consumed on a daily basis, unlike heroin which has a short half-life thus having to be consumed numerous times a day to prevent withdrawal symptoms. As methadone is also available in liquid form it deters injecting behaviours, thus reducing the risk of disease transmission.
Numerous researchers have produced compelling evidence that methadone programmes reduce the rates of illicit drug use, injecting behaviour, criminal behaviour, other HIV risk behaviours, overdose and death among treatment participants (James & Clark, 2006; Langendam et al., 2000)).

CHAPTER ONE: INTRODUCTION
1.1 INTRODUCTION
1.2 OBJECTIVES OF THE STUDY
1.3 ANALYSIS OF KEY CONCEPTS
1.4 SUMMARY
CHAPTER TWO: HEROIN DEPENDENCE: HISTORICAL CONTEXT, PHARMACOLOGY,
THEORY AND MAJOR INTERVENTION MODALITIES
2.1 INTRODUCTION
2.2 THE HISTORICAL-LEGAL CONTEXT OF HEROIN DEPENDENCE
2.3 THE EMERGENCE OF HEROIN DEPENDENCE IN SOUTH AFRICA
2.4 HEROIN ADMINISTRATION, PHARMACOLOGY AND ADDICTIVE POTENTIAL
2.5 PHARMACOLOGICAL INTERVENTION FOR HEROIN DEPENDENCE
2.6 PSYCOSOCIAL THEORIES OF HEROIN DEPENDENCE 65
2.7 THERAPEUTIC INTERVENTION MODALITIES FOR HEROIN
DEPENDENCE
2.8 DEFEATING THE DRAGON: HEROIN DEPENDENCE RECOVERY
2.9 SUMMARY
CHAPTER THREE: METHODOLOGICAL PARADIGM AND RESEARCH DESIGN
3.1 INTRODUCTION
3.2 RESEARCH DESIGN
3.3 ETHICAL CONSIDERATIONS
3.4 SUMMARY
CHAPTER FOUR: RESULTS
4.1 INTRODUCTION
4.2 BIOGRAPHIC AND SOCIODEMOGRAPHIC CHARACTERISTICS
4.3 PROFILE OF FAMILY BACKGROUND CHARACTERISTICS
4.4 HEROIN DEPENDENCE HISTORY
4.5 DESCRIPTIVE STATISTICS OF BIOGRAPHIC AND DEMOGRAPHIC INDICES
4.6 STATISTICAL ANALYSES
4.7 CONTENT ANALYSIS
4.8 SUMMARY
CHAPTER FIVE: DISCUSSION AND CONCLUSION
5.1 INTRODUCTION
5.2 DISCUSSION OF BIOGRAPHIC, DEMOGRAPHIC, PARENT AND HEROIN
DEPENDENCE PROFILE FINDINGS
5.4 FRAMEWORK FOR THE DEVELOPMENT OF A CONTEXTUAL HEROIN
DEPENDANCE RECOVERY MODEL
5.5 STRENGHTS, CONTRAINTS, LIMITATIONS AND RECOMMENDATIONS
REFERENCES
APPENDIX A
APPENDIX B
APPENDIX C
APPENDIX D

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DEFEATING THE DRAGON: HEROIN DEPENDENCE RECOVERY

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