Our new core lesson, Prescription Opioids and Heroin, has arrived! Over the last 18 months, Project ALERT staff have been working to develop material on opioids that would be relevant for the times and would resonate with young students.  Given the current opioid epidemic we are experiencing in the United States, the consensus among researchers, educators, clinicians, and public health officials is that drug prevention education programming in 2018 should include a focus on opioids.  Additional support for the new addition to the curriculum stems from the fact that prescription pain medication is the most common gateway drug to heroin.

We knew that developing a new core component would be quite an undertaking. Although it is a time-sensitive topic, we felt it necessary to carefully review the current research literature on youth prevention of opioid misuse and craft a research- and theory-informed module that was consistent with the overall theme and structure of Project ALERT. Familiar elements of student-involved lecture, roleplays, homework, and informational handouts comprise the lesson. The lesson has been reviewed by a staff of behavioral research professionals with expertise in areas of substance use prevention, adolescent health, program evaluation, research methods, and implementation science. We pilot tested the lesson in several classrooms in the spring of 2018 to obtain facilitator, student, and teacher feedback. Based on some excellent comments we received, we made some refinements to ensure that that lesson is engaging and appropriate for the target audience of Project ALERT.  However, given the urgency of prescription drug misuse by youth and the increasing number of deaths related to opioid use disorder, we believe it is prudent and most responsible to release this lesson now, prior to subjecting the lesson to the same rigorous evaluation that the original Project ALERT curriculum received. Such randomized controlled trials are infrequent in the school-based drug prevention world, but are nonetheless necessary. Thus, we plan to include this lesson within the larger Project ALERT curriculum as part of a large research study in which we again evaluate the effectiveness of the program on preventing youth substance use. If any schools or organization are interested in partnering with us on this effort, please contact us at projectalert@rand.org. Partner schools will receive multiple incentives for working with us on this research effort, including enhanced training opportunities and monetary incentives.

We believe prevention is critically important for youth to avoid the development of problematic drug use. Thus, we are excited to release our lesson on prescription opioids and heroin. We know that educators have many demands and that using class time for prevention efforts can be a challenge. Therefore, the new lesson is not meant to create an additional burden for instructors; rather, it is meant to provide them with an additional tool in their arsenal of teaching resources.  In the most ideal situation, the new lesson would be an add-on to Project ALERT's solid curriculum.  However, if time is an issue in your setting, we are recommending that this lesson replace the current core lesson 8 on Inhalants.  (In fact, we are calling it "Alternate Core Lesson 8.")

Note that the new lesson does not have an online training component, and if you are new to Project ALERT and have not yet finished the online facilitator training course, the absence of the component will not affect your training certification.

You can find the new lesson, Power Point slides, and all supplementary materials and handouts here.

As always, we are looking for your feedback.  Please let us know how the implementation of this new lesson goes!

 

The phone rings… she does not recognize the number but decides to take the call.  The caller announces himself as the medical examiner for Seattle, Washington. Her heart begins to pound when he asks her to confirm her identity. The man clears his throat and says, “I am sorry, but we found your father dead in a tenement house here in Seattle.” More was said, but the bottom line was that her father, Danny, was gone -  and that his death was due to a heroin overdose. Nettie’s heart broke - Danny’s addiction had taken its final toll.

I met this same man long ago when we were in high school; he was a sort of cool-rebel type that played guitar and was hoping to hit the big time in a band. He dropped out of school, started using drugs like alcohol and marijuana, then progressed to prescription painkillers, and along the way he became addicted to heroin. During his nearly 40 years of drug addiction he attended inpatient programs and tried methadone clinics. He also had bouts of sobriety, yet the need to use heroin always won out.

Danny never believed he would become dependent on heroin; he was just looking for a high, an escape, a sort of a “mental vacation”- and heroin gave him that--at first--but it stole something far greater in return. He realized he did not want the life that heroin gave him. He was broken and broke, tormented by the unrelenting grip it had on him.

This is exactly why youth need to know about the risk of using opiates, and specifically, heroin. Those who don’t know or ignore these risks may find themselves addicted, broken, alone, or far worse, the subject of a phone call from a coroner to a loved one - like Danny was.

Police officers, rescue workers, drug counselors, and social workers all recognize this story; it replays, over and over, in towns large and small, affecting both rich and poor, every day. The use of opioids[1] such as heroin is rampant.  In the U.S., the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) are calling it an “epidemic.”

So let’s break it down. What should people working with youth know about heroin and other opioids?

Where does heroin come from?

Heroin and other opioids are made from the sap of the opium poppy seed pod. The main regions of the world where opium crops are grown on a large scale are Southwest Asia, Southeast Asia, and Latin America. According to the United Nations, Afghanistan supplies about 75% of the world’s heroin, yet most of what is found in the U.S. market comes from Mexico and Columbia.

Once harvested, it takes several processing steps for opium to become heroin.  In powder form, its color can vary from white to brownish (usually coming from Asia), or it can be dark and sticky or hard, a variety known as “black tar” heroin (coming from Mexico). Generally, the whiter the powder the higher the purity; black tar and hard forms are considered to be crude, low-grade versions.

By the time it is harvested, processed, and passed along distribution channels to get to street dealers and users, heroin has often been “cut,” or combined, with other substances ranging from sugar to brick dust to glass to a host of dangerous and deadly chemicals, such as Fentanyl, another synthetic opioid, which can be 50 times stronger than heroin. Fentanyl’s availability on the street is increasing, showing up either in a pressed pill form, in tablets posing as Oxycodone, or in other drugs that come in powdered form, like cocaine. These practices further confirm that the user has no guarantee on the final contents and purity of what they are buying; thus, and often, this results in adverse and sometimes fatal outcomes.  

Laws regarding the use of heroin differ around the world but in the U.S., heroin is classified as a Schedule I drug, meaning it is not approved for medical use and cannot be prescribed; therefore, possession is illegal.

What are opioids?

Opioids are a class of drugs that include prescription pain medications and heroin. They are often prescribed for people with high levels of physical pain. Opioid drugs work by attaching themselves to pain receptors mainly in the brain and spinal cord to reduce the perception of pain in addition to triggering the release of dopamine (a neurotransmitter), which brings about a feeling of euphoria and pleasure. However, common side-effects of opioid use are drowsiness, confusion, slowed or depressed breathing, constipation, constriction of pupils, nausea, vomiting, and dry mouth.

Other opioid drugs prescribed by medical doctors to manage moderate to severe pain include oxycodone, hydrocodone, methadone, and morphine. Brand names include OxyContin, Vicodin, Norco, and Percocet. These are most often distributed in a pill form but can be dissolved in a liquid. These drugs are legally manufactured in pharmaceutical labs. Differences in these similarly-derived drugs include combining them with an analgesic or employing a time-release component.

How are opioids used and abused?

Prescribed opioids are most often swallowed. Abusers of opioid pills may also crush them so that they can be snorted, or mix them with water and “cook” them to dissolve the powder and inject the solution into the blood stream with a needle and syringe. Heroin users can also snort, smoke, or inject the drug into their blood stream in a similar way.

Opioid drugs can be very addictive, as the body soon develops a physiological dependency, increasingly relying on the drug to reduce pain. In addition, opioids and especially heroin bring on an enhanced feeling of euphoria that is sought out by the user. It is a much-heightened sensation that the body is unable to produce on its own. Even after a few weeks of use, and sometimes sooner, users develop a tolerance for the drug and will need to increase the dosage to get the desired effect. They will also experience symptoms of withdrawal when they try to stop using the drug. Typical withdrawal symptoms can be mild to severe and are often flu-like: runny nose, nausea, chills, and aches, progressing to extreme vomiting, diarrhea, shivering, joint pain, and muscle cramping.  Because withdrawal can be so difficult to endure, the addicted person will often revert to using the drug rather than pursuing or continuing treatment.

How big of a problem is opioid abuse?

Both the prescribed and illegal use of opioids has risen dramatically over the past several years. The CDC recently reported that heroin use has more than doubled among young adults ages 18-25 in the past decade, and that heroin-related deaths have increased fivefold. The statistics are similar for prescription opioids. Federal agencies note that, in the U.S., more people die annually from drug overdose, most of which are opioids, than from motor vehicle accidents or guns. 

The rapid rise in opioid abuse has been attributed to the escalation in painkiller prescriptions and the availability of heroin. Health care providers wrote 259 million prescriptions for opiates in 2012, enough for every American adult to have a bottle of pills. The highly aggressive marketing campaign for OxyContin, one of the most abused opiates, is also considered by many to be a key culprit in today’s epidemic. Exacerbating the problem, heroin is inexpensive and relatively easy to get. As prescription opioids become more difficult to get, the user can readily find heroin on the street. Add to this the powerfully addictive properties of opiates and you have the recipe for the current epidemic. 

Studies have shown that a heroin user typically used/abused other “gateway” drugs, particularly prescription opioids, prior to using heroin. It can also be quite common for users to combine heroin with other psychoactive substances. This is known as poly-drug use. Mixing any opiate with other drugs such as alcohol, cocaine, or marijuana increases the likelihood of harmful effects as the drugs interact and the results are magnified and unpredictable. An overdose causes very slow breathing to the point of suffocation, low heart rate or heart failure, convulsions, coma, and even death.

Although most school-age youth are not addicted to opioids, misuse increases sharply as teens transition into early adulthood.  Educating youth about this looming risk is critical before they venture ill-equipped down an unsafe path, ignorant of the serious consequences that could result.

Risks of using injectable drugs

Injecting drugs like heroin using syringes and needles, particularly when shared with others or used in non-sterile conditions, carries significant risk for contracting aggressive skin infections, as well as viruses and diseases like HIV and Hepatitis C. In an effort to minimize risk of disease transmission, governments have implemented needle exchange programs in many states and countries. This occurs when a needle user goes to a specified place or person, authorized by state and/or local governments, that is licensed to exchange used needles and syringes for sterile ones. This has been proven to be effective strategy in reducing the transmission of disease by sharing contaminated needles.

Treating opioid addiction and overdose

Medical Assisted Treatment or MAT for opioid dependency includes behavioral therapy, counseling, and drugs.  Buprenorphine and methadone are legally-manufactured synthetic opioids and are often used to transition people off heroin while avoiding the negative withdrawal symptoms. These do not provide the euphoric high of heroin, but the effect is typically longer-lasting than heroin and requires fewer doses. For example, methadone treatment requires one daily dose, in contrast to needing several daily doses of heroin. Unfortunately, these transitional drugs are also addictive. Under a physician’s supervision and over an extended period of time, the dosage can be gradually reduced to eventually wean the person off of methadone or other drug therapies.

The drug naloxone, commonly known as Narcan or Evzio, is used to reverse the deadly effects of an opiate overdose. It is given either by injection under the skin, into a large muscle (thigh, buttocks, shoulder) or via nasal spray. Most emergency medical personnel have it available to use on overdose patients, and some states and countries will even prescribe naloxone to non-medical people such as family members or friends of those using opioids, especially heroin, to have on-hand in case of a serious overdose event. It must be administered soon after the onset of overdose symptoms, such as slow or stopped breathing and loss of consciousness. Once given, breathing typically will return to a near normal rate and the person will awaken. However, multiple doses may be required for the user to regain consciousness and sustain breathing; urgent medical attention is still needed to stabilize the overdose victim and seek recovery.

What can educators do?

It the midst of this public health crisis it is critical to look upstream to see what can be done to prevent use. Educators play a key role in informing youth and parents about opioids and related risks. Teachers can designate some class time for informational and role-playing sessions to help youth develop the motivation and requisite social skills to confront the pressures to use drugs. Keep current with updates from reliable and trusted sources such as the DEA, NIH, and CDC and the materials listed in the resources section below. Reach out to other colleagues in schools, law enforcement, and health professions to work together in combating the opiate epidemic. Also inform parents, grandparents, and guardians of this escalating problem, and remind them to store prescribed medications out of the reach of youth.

It is essential to use evidence-based instructional materials that have been demonstrated to be effective in lowering drug use and changing related attitudes and intentions. Project ALERT, developed by RAND, is one such program. Please check out the newest addition to our curriculum, Prescription Opioids and Heroin. The lesson and all supplemental materials and handouts are now available online for free download.

One of the most satisfying rewards of working with youth is helping them to achieve their hopes and dreams; drug addiction is a sure way to derail someone’s future and deprive us all of the contributions and talents they could have given to the world.  

We don’t need more stories like Danny’s.

 

Note: This article was originally published in the Summer 2016 edition of the ALERT Educator. It was updated and republished in the Fall 2018 edition of the ALERT Educator to coincide with the release of the new Project ALERT lesson: Prescription Opioids and Heroin.

Sources and further reading

Anderson, K. (2013). Why Needle Exchange Is Good for Your Community. Psychology Today. As of August 19, 2016, available at:
https://www.psychologytoday.com/blog/overcoming-addiction/201307/why-needle-exchange-is-good-your-community

Centers for Disease Control and Prevention. (2015). Expanding Naloxone use could reduce drug overdose deaths and save lives. As of August 19, 2016, available at:
http://www.cdc.gov/media/releases/2015/p0424-naloxone.html

Centers for Disease Control and Prevention. (2014). Opioid Painkiller Prescribing. As of August 19, 2016, available at:
http://www.cdc.gov/vitalsigns/opioid-prescribing/

Centers for Disease Control and Prevention. (2016). Injury Prevention & Control: Opioid Overdose – Understanding the Epidemic. As of August 19, 2016, available at:
http://www.cdc.gov/drugoverdose/epidemic/index.html

Centers for Disease Control and Prevention. (2015). Today’s Heroin Epidemic. As of August 19, 2016, available at:
 http://www.cdc.gov/vitalsigns/heroin/

Centers for Disease Control and Prevention. (2016). Opioid Data Analysis. As of August 19, 2016, available at:
http://www.cdc.gov/drugoverdose/data/analysis.html

Cullison, Alan, & Dorsey, James M. “Targeting terrorists’ drug money, US puts itself in an awkward situation,” The Wall Street Journal, October 2, 2001, p. 1. As of August 19, 2016, available at:
http://www.wsj.com/articles/SB1001975893873867840

Drug Enforcement Administration. (2015). 2015 National Drug Threat Assessment. As of August 19, 2016, available at:
https://www.dea.gov/docs/2015%20NDTA%20Report.pdf

Drug Enforcement Administration. (2017). Drug Ring Peddling Fentanyl Pills Disguised as Oxycodone, Cocaine and Heroin Dismantled. As of August 15, 2018, available at:
https://www.dea.gov/press-releases/2017/11/16/drug-ring-peddling-fentanyl-pills-disguised-oxycodone-cocaine-and-heroin

Federal Bureau of Investigation. (2016). Raising Awareness of Opioid Addiction. As of August 22, 2016, available at:
https://www.fbi.gov/news/stories/raising-awareness-of-opioid-addiction

Giglio, R.E., Guohua, L., DiMaggio, C.J. (2015). Effectiveness of bystander naloxone administration and overdose education programs: A meta-analysis. Injury Epidemiology, 2:10. As of August 19, 2016, available at:
https://injepijournal.springeropen.com/articles/10.1186/s40621-015-0041-8

Gounder, C. “Who is responsible for the pain-pill epidemic?” The New Yorker; November 8, 2013. As of August 19, 2016, available at:
http://www.newyorker.com/business/currency/who-is-responsible-for-the-pain-pill-epidemic

 

National Institute on Drug Abuse (NIDA). (2014). Prescription Opioid and Heroin Abuse. As of August 19, 2016, available at:
https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/prescription-opioid-heroin-abuse

National Institute on Drug Abuse (NIDA). (2015). Prescription Opioids and Heroin. As of August 19, 2016, available at:
https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-abuse-heroin-use/introduction

Office of National Drug Control Policy. (n.d.). The International Heroin Market. As of August 19, 2016, available at:
https://www.whitehouse.gov/ondcp/global-heroin-market

Partnership for Drug-Free Kids. (2016). Epidemic. As of August 22, 2016, available at: https://www.youtube.com/watch?v=UtMi9ciJN70#action=share

Partnership for Drug-Free Kids. (2016). Heroin and Other Opioids: From Understanding to Action. As of August 19, 2016 at:
http://www.drugfree.org/heroin

Substance Abuse and Mental Health Services Administration. (2016). Naloxone. As of August 19, 2016, available at:
http://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone

U.S. National Library of Medicine. (2016). Opiate and opioid withdrawal. MedlinePlus. As of August 19, 2016, available at:
https://medlineplus.gov/ency/article/000949.htm

These resources may help educators prepare for students’ questions during Project ALERT lessons.

 

National Institute on Drug Abuse (NIDA) for Teachers:  The Brain's Response to Opioids

Everything you always wanted to know about opioid mu receptors!

 

NIDA for Teens:  Prescription Pain Medications (Opioids)

Comprehensive information about prescription painkillers, brain and body effects, and potential for addiction.

 

NIDA:  Drugs, Brains, and Behavior: The Science of Addiction

This gets a little deeper into the weeds, explaining how networks of neurons send signals back and forth to each other and among different parts of the brain, the spinal cord, and nerves in the rest of the body. Great late-night reading!

 

PBS: Transforming Opium Poppies into Heroin

This brief 1998 article profiles Papaver somniferum, the "poppy that makes you sleepy," and its journey from unassuming flower to its fourth stage purification as fluffy white powder heroin.

 

FBI/DEA: Chasing the Dragon: The Life of an Opiate Addict

In a joint effort to combat the growing epidemic of prescription drug and heroin abuse, the FBI and DEA have released this documentary aimed at educating students and young adults about the dangers of addiction.  Not recommended for pre-teens.

 

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