Opiates: History and
Treatment Options
West Virginia University
School of Medicine
Ehab S. Abdallah M.D
General Terms
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Narcotics – A general term technically referring to an
opiate - related or opiate -derived drugs. It is often
mistakenly used to include several other illicit drug
categories as well.
•
Opium – An analgesic and euphoriant drug acquired from
the dried juice of the opium poppy.
•
Opiates – Any ingredients of opium or chemical
derivatives of these ingredients. Opiate generally refer to
opium, morphine, codeine, thebaine and Heroin.
•
Synthetic opiates – Synthetic drugs unrelated to morphine
that produce opiate like effects.
•
Codeine – One of the three active ingredients in opium,
used primarily to treat coughing.
•
Morphine – One of the three major active ingredients in
opium.
•
Thebaine – One of the three major active ingredients in
opium.
•
Heroin – A chemical derivative of morphine. It is
approximately three times as potent as morphine and a
major drug of abuse
Opium
Opiates
Morphine
Opiate
Derivatives
Synthetic
Opiates
Heroin
Methadone
Hydromorphone
(Dilaudid)
Meperidine
(Demerol)
Codeine
Oxymorphine
(Numorphan)
Propoxyphene
(Darvon)
Thebaine
Oxycodone
(Percondan)
LAAM
(Orlaam)
Etorphine
Opium in History

The source is the opium poppy. Known by its
potential name as papaver somniferum (literally
“the poppy that brings sleep.”)
 Opium is harvested by a small shallow incision in
the capsules allowing a milky white juice to ooze
out.
 Opium was first described in specific detail in the
third century B.C. but we can be fairly sure that it
was used for at least a thousand years before that.

Egyptians were knowledgeable about the
medicinal value of opium evidence of this was
found in the Ebers Papyrus writings.
 In the second century A.D., Claudius Galen, the
famous Greek physician and surgeon to Roman
gladiators recommended opium for everything.
 Western Europe was introduced to opium in the
eleventh and twelfth centuries from returning
crusaders who learned of it from the Arabs.
 In 1520, a physician named Paracelsus introduced
a medicinal drink containing opium, wine and an
assortment of spices. He called the mixture
Laudanum (Derived from Latin meaning
“something to be praised”) .

In 1680, the English physician Thomas
Sydenham, considered the father of clinical
medicine, introduced a highly popular
version of an opium drink called
Syndenham’s Laudanum.
 For the next 200 years or so, the acceptable
form of taking opium among Europeans and
Americans would be in the form of a drink,
either Sydenham’s recipe or variations.
The Opium War
•
Sometime in the eighteenth century, China invented a novel form of opium
use, opium smoking, which eventually became synonymous in the Western
mind with China itself.
•
In the eighteenth century the British people had fallen in love with Chinese
tea.
•
British merchants wanted to buy tea and send it home, but what could they sell
to the Chinese in exchange?
•
The problem was that there were few, if any, commodities that China really
wanted from the outside.
•
In Chinese eyes, the rest of the world was populated by “barbarians” with
inferior cultures offering nothing or little the Chinese people needed.
•
The answer was the opium. In 1773 British forces has conquered Bengal
province in India and suddenly had a monopoly on raw opium.
•
It was now easy to introduce opium to China as a major item of trade
•
Opium was successfully smuggled into China through local British and
Portuguese merchants, allowing the British government and its official trade
representative, the East India Company, to carry off the public image of not
being directly involved in opium trade.
•
Opium, flooding into the country from its southern part of Canton, found a
ready market, opium dependence soon became a major Chinese problem.
•
Despite repeated efforts by the Chinese emperor to reduce the use of opium
within China or to cut the supply line from India, the monster flourished.
•
By 1839, the tension had reached a peak. In a historic act of defiance against
the European powers, including Britain, an imperial commissioner appointed
by the Chinese emperor to deal with the opium problem once and for all
confiscated a huge quantity of opium and burned it publicly in Canton.
•
Events escalated shortly after this until open fighting between Chinese and
British soldiers broke out. The opium war had begun.
•
By 1842, British artillery and warships had overwhelmed a nation
unprepared to deal with European firepower. In a humiliating treaty,
China was forced to sign over to Britain the island of Hong Kong and
its harbor (until the distant year of 1997), granting to British merchants
exclusive trading rights in major Chinese ports, and pay a large amount
of money to the British losses during the war.
•
Despite these agreements, fighting broke out again between 1858 and
1860; this time British soldiers were joined by the French and
Americans.
•
Finally in a treaty signed in 1860, China was required to legalize
opium within its borders.
•
The opium war had succeeded in opening up the gates of China, much
against its will, to the rest of the world.
(The Opium War from the Chinese perspective.)
Opium in Britain

The acceptable form of opium use in Victorian
England was opium drinking in the form of
laudanum.
 The Oriental practice of opium smoking was
identified by the British with vice and degradation
and associated with the very lowest fringes of
society.
 Opium in the mid-1800s was the aspirin of its day.
There was no negative public opinion and seldom
any trouble with the police.

Any opium addict, as long as there were no signs
of opium smoking, was considered no worse than
a drunkard.
 Dozens of laudanum based medicines, with
appealing names like


A penny worth of peace
Mrs. Winslow’s Soothing Syrup,
Were used to dull teething pain or colic, or to keep
children quiet.

In 1821, Thomas DeQuincey published his book,
Confessions of an English Opium Eater, that
created a new cultural phenomenon for
recreational opium use.
Opium in the United States

Opium consumption in the U.S. paralleled its
widespread use in Britain.
 Opium poppies were cultivated in Vermont and
New Hampshire, in Florida and Louisiana, and
later in California and Arizona.
 Women outnumbered men in opium use during the
1800s by as much as three to one.
 Alcohol drinking was not an acceptable behavior
for females but laudanum was. The consequence
was that “husbands drank alcohol in the saloons;
wives took opium at home.”

Opium was advertised as a treatment of
alcohol addiction, “white star secret liquor
cure” was designed to be added to a
gentlemen’s after-dinner coffee.
 1850s-1860s
– Thousands of Chinese men and boys were
brought to the West to build the railroads.
– Most of the Chinese workers were recruited
from the Canton area where opium traffic was
particularly intense.
– The practice of opium smoking was well
known to them.

In 1875 San Francisco outlawed opium smoking,
a federal law forbidding opium smoking soon
followed.
 The Harrison Act of 1914 required that physicians
registered with the Internal Revenue Service the
opiate drugs that were being prescribed to their
patients and pay a small fee for the right to
prescribe such drugs.
 In the 1920s, the U.S. Supreme Court interpreted
the Harrison Act more widely. Under the Court’s
new interpretation of the Harrison Act, no
physician was permitted to prescribe opiate drugs
for “non-medical” use.

In 1803, a German clerk named Friedrick
Serturner First isolated a yellowish-white
substance in raw opium turned to be its
primary active ingredient. He called it
morphium, later changed to morphine, in
honor of Morpheus, the Greek god of
dreams.
 In 1898, heroin was introduced into the
market by the Bayer Company in Germany
as a new pain killer. It is the same company
that had been successful in the development
of aspirin.
Symptoms of administering heroin and of withdrawing heroin
Administering
Withdrawing
Lowered body temperature
Elevated body temperature
Decreased blood pressure
Increased blood pressure
Skin flushed and warm
Piloerection (gooseflesh)
Papillary constriction
Tearing, runny nose
Constipation
Diarrhea
Respiratory depression
Yawning, panting, sneezing
Decreased sex drive
Spontaneous ejaculations and orgasms
Muscular relaxation
Nodding, stupor
Restlessness, involuntary twitching and kicking
movements
Insomnia
Analgesia
Pain and irritability
Euphoria
Depression and anxiety
Street names for narcotic drugs
Type of Narcotic
Street Name
Morphine
Big M, Miss Emma, white stuff, M, dope, hocus,
unkie, stuff, morpho
Junk,smack, horse, scag, H, hard stuff, dope, boy,
boot, blow, jolt, spike, slam
Black tar, tootsie roll, chapapote (Spanish for “tar”),
Mexican mud, peanut butter, poison, black jack
Bombitas
White heroin
Brown heroin (from Mexico)
Heroin combined with amphetamines
Heroin combined with cocaine
Heroin combined with marijuana
Heroin combined with cocaine and marijuana
Heroin combined with cocaine and morphine
Codeine combined with Doriden (a nonbarbiturate
sedative-hypnotic)
Dynamite, speedball, whizbang, goofball
Atom bomb, A-bomb
Frisco special, Frisco speedball
Cotton brothers
Loads, four doors, hits
Common Opiate Agents of Abuse
Generic Name
Trade Name(s)
Morphine
Astromorph, PF, Duramorph, Epimorph, Kadian, Infumorph 200&500,
morphitec, M.O.S., MS Contin, MSIR, OMS Concentrate,
Oramorph SR, RMS, Roxanol, Rescudose, Ultraject
--------
Heroin
Codeine
Methadone
Codeine
Dolophine, Methadose
Meperidine
Demerol, Pathadol, Pethidine
Butorphanol
Stadol
Hydromorphone
Dilaudid
Nalbuphine
Nubain
Propoxyphene
Oxycodone
Darvon, Dolene, Novapropoxyn
Oxycodone/Acetaminophen
OxyContin, Oxyfast, Roxicodone, Supeudol
Acetaminophen/Hydrocodone
Percocet, Endocet, Oxycocet, Roxicet, Roxilox, Tylox, OxylR
Oxycodone/Aspirin
Vicodin, Lorcet, Anexsia, Lortab
Percodan, Endodan, Oxycodan, Percodan-Demi, Roxiprin
•
Exogenous opiate drugs act on opiate receptors in the brain.
Researchers theorize that these opiate receptors exist in order
to facilitate the action of the body’s endogenous opiate like
substances known as endorphine and enkaphalin (natural
morphine).
•
Exogenous opiate drugs function as agonist to the brain opiate
receptors, turning on the natural analgesic pathway in the brain
and producing the characteristic analgesia and euphoria
sensation that in susceptible individuals reinforces drugs and
propels the addiction.
•
Habitual opiate use, while turning on the pain-suppression
pathway, causes the normal endogenous opiate system to
decrease the production of endorphin and enkephalin.
•
Repetitive use of exogenous opiates also produces adaptation
of the opiate receptors, rendering them less sensitive to agonist
actions.
•
This “Down-Regulation” of the receptors requires larger
amounts of the drug to produce similar effects, a phenomena
called tolerance, and produces withdrawal symptoms when the
receptors are not under agonist effect.
Treatment Options

Methadone
 Clonidine (Alpha-adrenergic receptor
agonist)
 Ultra rapid detox
 Methadone maintenance
 LAMM (Levo-alpha-acetylmethadol).
Rapid Detox
•
Substance abuse and dependency is a major public health
concern in the United States because of the economic and
human costs.
•
Current drug abuse treatment approaches, developed
primarily during the 1960’s and 1970’s, have changed
very little since their inception. The changes that have
occurred in treatment in the last decade have been
primarily structural and have been propelled by the tide of
managed care reforms rather than the emergency of
treatment models.
•
Managed care and cost-containment polices have affected substance
abuse treatment by decreasing the type and intensity of services,
shifting treatment from in-patient and residential care to out-patient
settings.
•
Eighty-seven percent of patients are now treated in out-patient
programs (substance abuse and Mental Health Services
Administration, 1996).
The Development of New Models of Treatment

Substantive advancements have occurred in our
understanding of the genetic and biochemical basis of
substance abuse and addiction in the last 10 years. Yet little
of this information has been translated into alternative
treatment models for the addicted patient.
•
Abstinence remains the goal of traditional addiction
treatment.
•
Sudden cessation of opioid use causes predictable cascade
of symptoms collectively referred as withdrawal symptoms
as previously mentioned.
•
Medically supervised detoxification treatment has
traditionally been seen as the golden standard and as the
logical starting point of treatment.
•
Traditional detox has involved treatment with prescription
medications, which produces similar physiological
responses, less psycho-activation, and which can be more
precisely regulated and tapered as the patient’s metabolism
readjusts to functioning without the addictive drugs.
•
Traditional detox takes an average of 3 to 15 days,
depending on the abused drug.
•
Medical detox controls but does not eliminate subjectively
uncomfortable withdrawal symptoms.
•
Universally accepted addiction treatment approaches are beginning
to be challenged by the emergence of innovative treatment
approaches based on the new understanding of the neurochemistry
of addiction.
•
Rapid detox has emerged as an alternative that is gaining in both
acceptance and popularity, evidence by recent showcasing in
television episodes of E.R.
•
Rapid detox is an umbrella term that has come to represent new
treatment approaches specifically designed to detox patients
addicted to natural and synthetic opiate drugs within hours rather
than the traditional days and to almost completely eliminate the
subject of discomfort of withdrawal symptoms.
•
Started in Europe in the late 1980’s and brought to the United
States in late 1996.
Common trade names for rapid
detox treatment programs
•
•
•
•
•
•
•
•
Rapid detox (RO)
Neuroregulated detox
Neuro-adaptation treatment
OADUSA (opioid antagonist agent detox under
sedation or anesthesia)
IND (intensive narcotic detox)
UROD (Ultra-rapid opiate detox)
RAND (rapidly accelerated narcotic detox)
KIYSR (kick in your sleep rapid relief)
Rapid Detox
•
•
•
•
Rapid detox procedures has been done by employing two
novel approaches.
First, general anesthesia is to ensure no subjective distress
is felt.
Second, use of large dosages of opiate antagonist in order
to rapidly and completely remove the exogenous opiate
drugs from the opiate receptors in the brain.
Because patient can not feel no subjective distress from
withdrawal, detox can be completed within few hours (4-6)
rather than 3 to 15 days with traditional detox.

It is important to differentiate between:
• Rapid detox, similar to traditional detox strategies,
but patient receives more sedation than usual
during the withdrawal .sedation is accomplished
through the use of benzodiazepines and can
decrease the time of withdrawal by a day or two.
The sedation is done to minimize the subjective
distress of withdrawal symptoms allowing detox
to progress more rapidly.
•
Ultra-rapid detox. An approach using general
anesthesia to induce complete unconsciousness,
thus ensure complete comfort during detox.
Procedures
•
Rapid detox programs require either overnight monitoring
or one day program where individuals checks-in early in
the morning and leaves at the same day.
•
All programs require pre-evaluation entails drug history,
psychological evaluation, medical history and current
health status evaluation.
•
Start I.V. and induce general anesthesia.
•
Ultra-rapid detox (UROD) has become
potent protected treatment name however
literature still refer to it as rapid detox.
•
Most programs offering rapid detox require an
anesthesiologist to be present to monitor the anesthesia and
perform the procedure in the location (hospital) where
emergency services are quickly available should
complication arise.
•
Once general anesthesia has been induced and no
subjective withdrawal discomfort felt by the patient. opiate
receptor blockade is accomplished with the use of opiate
antagonist agents.
•
Three common opiate antagonists exist: Naltrexone,
naloxone and nalmefene. By far naltrexone is the most
widely used opiate antagonist during rapid detox.
Comparison of Opiate Antagonist Agents
Naltrexone
Naloxone
Nalmefene
Trade Names
Revia,
Trexan
Narcan
Revex
Action
Opiate antagonist
Opiate antagonist
Opiate antagonist
Duration
Long-acting (24-72 hr)
Dose-dependent
Short-acting, Too weak and
short-acting for oral use
Short-acting
Common Side
Effects
Hepatotoxia,
Nausea/vomiting,
Headache, Dizziness,
Fatigue, Depression,
Insomnia, Arthralgia,
Suicidal ideation
Hyper/hypotension,
Tachycardia,
Arrhythmia, Insomnia,
Anxiety,
Nausea/vomiting,
Blurred vision, Rashes
Hypertension,
Nausea/vomiting,
Tachycardia, Low-grade
fever, Dizziness,
Arrhythmia, Headache,
Anxiety, Depression
Contraindication/
Caution
Contraindication:
Hepatic Disease
Caution: Use carefully
in in-patients with
cardiovascular disease
Caution: Can raise AST.
•
•
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•
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The opiate antagonists have competitive binding at
opiate receptor level, washing out any exogenous
opiates and assisting the receptors to begin to
reestablish normal sensitivity.
The amount of opiate antagonist required and therefore
the length of time anesthesia must be maintained
depends on patient weights and the duration and
intensity of their addictions.
Procedure average time 4-6 hours.
A short recovery period should follow, including mild
nausea and diarrhea.
The patient is continued on the opiate antagonist agent,
usually Naltrexone, as once a day oral dosage for 6 to
12 months.
Treatment Indications
•
•
•
•
•
•
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Addiction to opiate agents
Motivated for treatment
No co-morbid health condition
Failure of past traditional detox programs
Normal liver function lab values
Normal thyroid function lab values
Limited cardiovascular risk factors.
Treatment contraindications
•
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Poly-substance abuse to primarily non-opiates
Little internal motivation
Medically compromised or unstable
No attempts at detox
Liver disease
Thyroid disease
Cardiovascular disease.
Advantages of ultra-rapid
detox
•
Minimizing the very clinical significant,
subjectively distressing withdrawal symptoms
of opiate addiction.
•
Rapid detox occurs at the neuroreceptor level
and affords the patient an opportunity to start
intensive follow up immediately while feeling
physically capable to engage in ongoing
treatment.
•
Confidentiality can be facilitated when patients
do not require protracted hospitalization,
making treatment more acceptable to some.
•
Continuous use of opiate antagonists post
detox affords the patient a measure of
protection against relapse and decreases
cravings and increases the likelihood of
successful treatment.
Intensive follow up counseling is
required after the rapid detox to
address needed lifestyle
changes, psychological factors
and continued abstinence.
Disadvantages of ultra-rapid
detox
•
Risks related to general anesthesia use the risk of
death associated with general anesthesia is 1 in
250,000 and risk of adverse events rises to 1 in
10,000.
•
Rapid detox accomplishes medical detox or removal
of the physiological effects of the opiate. It does little
to affect the physiological withdrawal syndrome, and
substantial psychological support and counseling are
required for the patient to maintain a drug-free
lifestyle.
•
•
Because rapid detox is considered
experimental, insurance companies do not
cover the cost.
Lack of reliable and valid empirical studies
regarding the efficacy of the treatment.