Table of Contents Purpose and Perspective of the Chapter 1 Cengage Supplements 1 Learning Objectives 2 Complete List of Chapter Activities and Assessments 2 Key Terms 3 What’s New in This Chapter 3 Chapter Outline 3 True or False Questions Answer Key 5 Discussion Questions 6 Appendix 6 Generic Rubrics 6 Standard Discussion Rubric 7

As indicated in previous chapters, psychoactive drugs may have potential for improving the human condition, but also have the potential to cause destruction to individuals and society. No group of drugs captures this paradox more dramatically than the class of drugs we call opiates, which includes opium, morphine, heroin, and related compounds. Opiate drugs have been used for centuries to relieve pain and, when introduced to Europe, were hailed by physicians as a godsend. One of the first European physicians to use opium to relieve pain and suffering in his patients, Thomas Sydenham, wrote in 1680: “Among the remedies which it has pleased Almighty God to give man to relieve his sufferings, none is so universal and so efficacious as opium” (Gay & Way, 1972, p. 47). Even today, opiate drugs remain the most potent painkillers available to physicians, yet we now recognize the ability of opiates to produce severe dependence. Heroin is viewed as the prototypical dependence-producing drug, and illegal use and traffic in heroin are major international problems. Thus, many of the general concerns regarding psychoactive drugs emerge in bold relief in a consideration of opiates. An epidemic of dependence on opiate drugs has swept across the United States in recent years, and opiate overdose is a major crisis today. We will first consider the early history of opiate use and then focus on factors that led to the epidemic.

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The following objectives are addressed in this chapter:

10-1 Discuss the historical patterns of opiate use, including how the Harrison Narcotics Tax Act affects opiate use in the United States

10-2 Evaluate the factors contributing to the current opiate epidemic

10-3 Describe how opiates are absorbed, distributed, metabolized, and excreted from the body

10-4 Explain the mechanisms of action for the opiates

10-5 Discuss how opiates are used to treat acute and chronic pain

10-6 Compare and contrast the acute and chronic effects of opiates

10-7 Evaluate the role of physical and environmental factors associated with heroin dependence

For additional guidance refer to the Teaching Online Guide.

analgesia: Pain relief produced without a loss of consciousness.

heroin: A drug produced by chemically processing morphine. It is more potent than morphine and has become the major opiate drug of harmful use.

naloxone: A short-acting opiate antagonist.

opium: The dried sap produced by the poppy plant.

The following elements are improvements in this chapter from the previous edition:

· Each chapter of the ninth edition has been updated to represent findings from the latest research, as well as to reflect social and legal changes related to drugs. Among the many revisions, we present the latest survey data available at this writing on patterns of drug use in the United States and in other countries worldwide.

· Chapter 10, “Opiates,” provides extensive new coverage of the dramatic increase in use of heroin, prescription opiates, and synthetic opiates. Two new sections are included on the events that led to the opiate epidemic and the current status and impact of the epidemic. The increase in opiate overdose deaths is chronicled, and we add a new box on treating overdose with naloxone.

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I. History of the Opiates

a. Early History

b. Opiate Use in the 19th Century

c. Opiate Use after the Harrison Act

d. The Making of an Epidemic

e. The Opiate Epidemic

f. Knowledge Check 1: History of the Opiates (10.1, PPT Slides #15–16), 5 minutes total, multiple-choice question and answer.

Question: Chronologically, what is the sequence of the discovery and release of the following drugs?

Answer: d. Opium, morphine, heroin. Opium was used thousands of years ago in ancient civilizations, became a serious dependency problem in China by the early 19th century, and became popular in the modern Western world in the 1800s. Morphine was isolated in 1803 and became widely available by the mid-1800s. Heroin was discovered in 1874 and rediscovered in 1898.

II. Pharmacokinetics

a. Absorption

b. Distribution, Metabolism, and Excretion

c. Knowledge Check 2: Pharmacokinetics (10.2, PPT Slides #20–21), 5 minutes total, multiple-choice question and answer.

Question: The opiate ________ passes through the blood-brain barrier more easily than ________; once in the brain, ________ is converted to _______.

Answer: d. heroin; morphine; heroin; morphine. Heroin is more lipid-soluble than morphine and passes through the blood-brain barrier more easily. Once in the brain, heroin is converted to morphine. Thus, heroin more effectively delivers morphine to the brain than morphine itself.

III. Mechanisms of Opiate Action

a. Discovery of Endorphins

b. What Do Endorphins Do?

c. Knowledge Check 3: Mechanisms of Opiate Action (10.3, PPT Slides #24–25), 5 minutes total, multiple-choice question and answer.

Question: What are endorphins?

Answer: a. They are the body’s own natural pain relievers. Opiate antagonists like naloxone are not endorphins; they block endorphin receptors. Endorphins are not placebos, which are medically inactive substances given to research volunteers without their knowledge; if subjects believe these are active drugs and thus expect pain relief, they will experience it, probably through endorphin release.

IV. Medical Use of Opiate Drugs

a. Knowledge Check 4: Medical Use of Opiate Drugs (10.4, PPT Slides #28–29), 5 minutes total, multiple-choice question and answer.

Answer: e. To relieve all of these. Various opiate drugs are used medically to relieve pain, coughs, and heroin withdrawal symptoms, and in maintenance programs to aid ongoing abstinence from heroin use.

V. Acute Psychological and Physiological Effects of Opiates

a. Knowledge Check 5: Acute Psychological and Physiological Effects of Opiates (10.5, PPT Slides #34–35), 5 minutes total, multiple-choice question and answer.

Question: Which of the following is a common acute physiological effect of opiate drugs?

Answer: d. Respiratory depression or failure. Opiates cause respiratory depression. When a high dose of heroin is fatal, the immediate cause is usually respiratory failure. Reduced sex drive, impotence, and impairment in social interactions and cognitive functions are all common acute psychological effects of opiate drugs.

VI. Chronic Effects of Opiates

a. Tolerance

b. Withdrawal and Dependence

c. Knowledge Check 6: Chronic Effects of Opiates (10.6, PPT Slides #41–42), 5 minutes total, multiple-choice question and answer.

Question: Researchers have found that when morphine or heroin was always available, a human and a rhesus monkey did which of the following?

Answer: b. Both increased the dose gradually over time. Neither the human nor the rhesus monkey increased the dose almost immediately or quickly. The similar patterns of self-administration between the human and the monkey illustrate the generality of the emergence of tolerance to the rewarding consequences of opiate drugs.

d. Summary

1. Opium comes from the plant Cannabis sativa.

FALSE. Opium comes from the poppy plant Papaver somniferum.

2. Morphine is one of the active ingredients in opium.

TRUE. Morphine and codeine are chemicals directly derived from opium.

3. Heroin was first made illegal by the 1965 Drug Abuse Control Amendment.

FALSE. All opiates were brought under legal control by the 1914 Harrison Narcotics Tax Act.

4. As of December 2020, not more than 100,000 Americans have died from opiate overdose or dependence.

FALSE. Data from the Centers for Disease Control and Prevention indicate that over 400,000 Americans have died from opiate overdose or dependence as of December 2020.

5. Fentanyl and its analog compounds are less potent than pure heroin.

FALSE. Fentanyl and fentanyl analogs range from ten to hundreds of times more potent than pure heroin. Thus, the risk of overdose is greater.

6. The opiates are among the most powerful analgesic drugs.

TRUE. The principal medical use for opiates is to relieve pain.

7. Heroin enhances sexual desire and activity.

FALSE. Heroin inhibits sexual arousal.

8. Heroin dependence is a factor of physical withdrawal symptoms, lifestyle, and social environment.

TRUE. Heroin dependence is complex. Factors of physical withdrawal symptoms, lifestyle, and

social environment all interact to influence the development and maintenance of heroin

dependence.

9. Heroin withdrawal is much like alcohol withdrawal.

FALSE. Opiate withdrawal does not include delirium tremens but rather is characterized by flu and cold symptoms.

10. Veterans of the Vietnam War had a high rate of heroin dependence and were unable to kick the habit when they returned to the United States.

FALSE. Most veterans were able to quit using heroin when they returned to their home environment.

11. The effects of opiates are synergistic with those of alcohol.

TRUE. Alcohol and other depressant drugs act synergistically with heroin and other opiates, and these combinations are often fatal.

12. The expression “cold turkey” comes from the “goose bumps” seen in those suffering from heroin withdrawal.

TRUE. The resemblance is thought to be the basis for that expression.

You can assign these questions several ways: in a discussion forum in your LMS, as whole-class discussions in person, or as a partner or group activity in class.

1. Discussion: The Opiate Epidemic (p. 270, 10.1, PPT Slide #12) Duration 15 minutes.

a. An essential paradox inherent in opiates is that they are the most effective known painkillers, yet they are also highly addictive.

b. What are some ways that doctors can manage their patients’ pain more effectively, with fewer or no harmful side effects?

i. Answer: Answers will vary. Some students may recall the text’s discussion of physicians’ historical caution in prescribing opiates and say that they should return to those practices, stop overprescribing them, and only allow their short-term use to relieve severe, acute pain. Some students may recommend that researchers work harder to seek alternatives for pain relief that are not addictive. If no students bring these up, remind them of: Research findings of differences in mechanism of action between therapeutic opioids and endorphins, which could inform designing novel, nonaddictive therapeutics, on p. 273; the new (2016) CDC guidelines cited on p. 276; and the Contemporary Issue Box 10.3 on p. 276 about partial opiate agonists like buprenorphine as one safer alternative. Some students may also bring up existing alternative methods of pain relief, such as acupuncture; reinforce this by citing the text’s inclusion of acupuncture in the discussion of endorphins on p. 274.

c. What are some events cited in your text that represent government attempts to address the growing opiate epidemic, and some parallel events that represent a continuing epidemic despite those attempts?

i. Answer: In 2001, the Drug Enforcement Administration (DEA) pressured Purdue Pharma to discontinue the highest dose of OxyContin; however, widespread misuse of this drug did not stop, and even the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) encouraged prescribing opiates (using teaching materials, some developed by Purdue Pharma), suggesting that concerns about addiction and death risks were exaggerated. Also, several U.S. state governments filed lawsuits, and in 2007, Purdue Pharma was fined and paid $634 million for misrepresenting OxyContin’s misuse liability; however, in 2008, deaths from drug overdoses, mostly of opiates, exceeded auto accidents as the United States’ leading cause of death.

Providing students with rubrics helps them understand expectations and components of assignments. Rubrics help students become more aware of their learning process and progress, and they improve students’ work through timely and detailed feedback.

Customize these rubric templates as you wish. The writing rubric indicates 40 points and the discussion rubric indicates 30 points.