Understanding Narcotic Analgesics: History, Names, Effects, and Administration

1. Session 17 180 Minutes Narcotic Analgesics

2. Learning Objectives • Explain a brief history of the Narcotic Analgesic category of drugs • Identify common drug names and terms associated with this category • Identify common methods of administration for this category • Describe the symptoms, observable signs and other effects associated with this category

3. Learning Objectives (Cont.) • Describe the typical time parameters, i.e. Onset and duration of effects associated with this category • List the clues that are likely to emerge when the drug influence evaluation is conducted for a person under the influence of this drug category • Describe the procedures for examining and determining the ages of injection sites • Correctly answer the “topics for study” questions at the end of this session

4. Narcotic Analgesic • An “Analgesic” is a medication or drug that relieves pain. It differs from an anesthetic, in that it lowers one’s perception or sensations of pain, rather than stopping nerve transmission • A Narcotic is a drug derived from Opium, or produced synthetically that relieves pain, but also induces euphoria, alters mood, and produces sedation

5. Narcotic Analgesic (Cont.) Non-Narcotic Analgesics such as: • Aspirin • Tylenol • Motrin Do NOT produce narcosis

6. Types of Narcotic Analgesics • Opiates • Natural alkaloids • Opium derivatives • Synthetics

7. Types of Narcotic Analgesics (Cont.) • Opiates • Natural alkaloids • Opium derivatives • Synthetics

8. Three Characteristics Common to All Narcotic Analgesics • Relieve pain • Produce withdrawal signs and symptoms • Suppress the withdrawal signs and symptoms of chronic narcotic analgesic administration

9. Raw Opium Other Alkaloids Powdered Opium (Smoking Opium) Thebaine Morphine Commonly-Abused Opiates and Their Derivation From Opium Codeine Thebaine Codeine Morphine Buprenorphine (Subutex) Diacetyl Morphine (Heroin) Hydrocodone (Lortab) Oxycodone (Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Numorphan)

10. Raw Opium Other Alkaloids Powdered Opium (Smoking Opium) Thebaine Morphine Commonly-Abused Opiates and Their Derivation From Opium (Cont.) Codeine Thebaine Codeine Morphine Buprenorphine (Subutex) Diacetyl Morphine (Heroin) Hydrocodone (Lortab) Oxycodone (Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Numorphan)

11. Raw Opium Other Alkaloids Powdered Opium (Smoking Opium) Thebaine Morphine Commonly-Abused Opiates and Their Derivation From Opium (Cont.) Codeine Thebaine Codeine Morphine Buprenorphine (Subutex) Diacetyl Morphine (Heroin) Hydrocodone (Lortab) Oxycodone (Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Numorphan)

12. Commonly-Abused Opiates and Their Derivation From Opium (Cont.) Raw Opium Other Alkaloids Powdered Opium (Smoking Opium) Thebaine Morphine Codeine Thebaine Codeine Morphine Buprenorphine (Subutex) Diacetyl Morphine (Heroin) Hydrocodone (Lortab) Oxycodone (Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Numorphan)

13. Commonly-Abused Opiates and Their Derivation From Opium (Cont.) Raw Opium Other Alkaloids Powdered Opium (Smoking Opium) Thebaine Morphine Codeine Thebaine Codeine Morphine Buprenorphine (Subutex) Diacetyl Morphine (Heroin) Hydrocodone (Lortab) Oxycodone (Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Numorphan)

14. Raw Opium Other Alkaloids Powdered Opium (Smoking Opium) Thebaine Morphine Commonly-Abused Opiates and Their Derivation From Opium (Cont.) Codeine Thebaine Codeine Morphine Buprenorphine (Subutex) Diacetyl Morphine (Heroin) Hydrocodone (Lortab) Oxycodone (Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Numorphan)

15. Raw Opium Other Alkaloids Powdered Opium (Smoking Opium) Thebaine Morphine Commonly-Abused Opiates and Their Derivation From Opium (Cont.) Codeine Thebaine Codeine Morphine Buprenorphine (Subutex) Diacetyl Morphine (Heroin) Hydrocodone (Lortab) Oxycodone (Oxycontin) Hydromorphone (Dilaudid) Oxymorphone (Numorphan)

16. Common Synthetic Opiates • Demerol • Methadone • Fentanyl

17. Common Synthetic Opiates (Cont.) • Demerol • Methadone • Fentanyl

18. Common Synthetic Opiates (Cont.) • Demerol • Methadone • Fentanyl

19. Methods of Administration • Orally • Smoked • Snorted • Suppositories • Injected • Transdermal (Patches)

20. The Concept of Tolerance for a Drug • The same dose of the drug will produce diminishing effects • A steadily larger dose is needed to produce the same effects

21. Observable Effects of Narcotic Analgesics “On the Nod” • Semiconscious • Droopy eyelids (Ptosis) • Head slumped forward, chin on chest • Easily awakened • Normally alert to questions

22. Other Effects • Slowed reflexes • Slow and raspy speech • Slow, deliberate movements • Inability to concentrate • Slowed breathing • Skin cool to the touch • Possible vomiting • Itching of the face, arms or body

23. Onset and Duration of Effects Immediate: • Pleasure or euphoria • Relief from withdrawal • Relief from pain

24. Onset and Duration of Effects (Cont.) 5-30 minutes: Onset of physical effects • “On the nod” • Poor motor coordination • Depressed reflexes • Slowed breathing

25. Onset andDuration of Effects (Cont.) Physical effects usually are observable for up to 4-6 hours

26. Signs and Symptoms of Withdrawal From Heroin Symptoms normally begin 4-6 hours following injection: • Aches • Chills • Insomnia • Nausea

27. Signs and Symptoms of Withdrawal From Heroin (Cont.) Signs appear 8-12 hours following injection: • Goose bumps • Sweating • Runny nose Withdrawal signs and symptoms closely resemble those of Influenza or the common cold • Tearing • Vomiting • Yawning

28. Signs and Symptoms of Withdrawal From Heroin (Cont.) Signs and symptoms intensify 14 - 24 hours after injection: • Dilation of pupils • Goosebumps • Loss of appetite • Slight tremors

29. Signs and Symptoms of Withdrawal From Heroin (Cont.) Situation worsens 24 - 36 hours after injection: • Depression • Diarrhea • Hot and cold flashes • Insomnia • Vomiting • Weakness

30. Signs and Symptoms of Withdrawal From Heroin (Cont.) Reaching the peak 2 - 3 days after injection: • Muscular and abdominal cramps • Severe tremors and twitching • Elevated temperature • Sharp loss of weight

31. Overdose Signs and Symptoms • Breathing will become slow and shallow • Death can occur from severe respiratory depression

32. Overdose Signs and Symptoms (Cont.) Other signs: • clammy skin • convulsions and coma • blue lips and pale or blue body • extremely constricted pupils • recent needle marks

33. Evaluation of Subjects Under the Influence of Narcotic Analgesics • HGN - None • VGN - None • Lack of convergence - None

34. Evaluation of Subjects Under the Influence of Narcotic Analgesics (Cont.) Psychophysical Tests: Performance on Modified Romberg Balance, Walk and Turn, One Leg Stand and Finger to Nose will be impaired and will reflect slow and deliberate movements

35. Evaluation of Subjects Under the Influence of Narcotic Analgesics (Cont.) Vital Signs: • Pulse - Down • Blood pressure - Down • Body temperature - Down Muscle tone - Flaccid

36. Evaluation of Subjects Under the Influence of Narcotic Analgesics (Cont.) Dark Room: • Pupils - Constricted (Miosis) • Reaction to light - Little or none visible

37. Evaluation of Subjects Under the Influence of Narcotic Analgesics (Cont.) General Indicators • Constricted pupils • Depressed reflexes • Droopy eyelids • Drowsiness • Dry mouth • Euphoria • Facial itching

38. Evaluation of Subjects Under the Influence of Narcotic Analgesics (Cont.) General Indicators • Nausea • “On the nod” • Puncture marks • Slowed reflexes • Slow, low, raspy speech • Slowed breathing

39. Narcotic Analgesic Symptomatology Chart 17-39

40. Injection Sites 17-40

41. Types of Injections • Intramuscular • Intravenous • Subcutaneous 17-41

42. Primary Injection Instrument Hypodermic syringe • Greater the number of gauge, the smaller diameter of the needle • Most illegal drug users prefer a larger gauge needle Top to bottom Brown - 26G Orange - 25G Black - 22G Green - 21G Yellow - 20G White - 19G 17-42

43. User’s Equipment – Hype Kit • Cooker • Handle • Lighter • Tourniquet • Cottons 17-43

44. Medical Injection Site • Medical mark is usually intramuscular • There may be multiple injections, if the technician is unable to find a vein during the first try • Usually there will be only one mark and it will be larger than the typical illegal injection. • Legal injections are made with new, sterile needles 17-44

45. Non-Medical Injection Site • Non-Medical (illicit) mark is usually over a vein • Usually multiple marks in various stages of healing • Use of same needle over and over again causes them to be dull or barbed • Injection sites may be jagged 17-45

46. Injection Site Terms “Thrombosed” “Tunnel” or “Corn” 17-46

47. Puncture Healing “Scabbing” and “Trap Dooring” 17-47

48. Puncture Healing Timetable • Scabs develop in about 18-24 hours • Scab peels, flakes, falls off in about 14 days 17-48

49. Classifying the Age of Puncture Wounds • Fresh - Under 12 hours after injection; • will be a red dot and have an oozing appearance or blood crater with no scab formation • Early - 12-96 hours after injection; • will have a light scab, light bruise, reddened border and a crater appearance

50. Classifying the Age of Puncture Wounds (Cont.) • Late - 5-14 days after injection; • will have a dark scab, dark bruise and the crater will flatten • Healing - Over 14 days after injection; • scab will be flaking and falling off with shriveled light-colored skin underneath