The Use of Heroin in Therapeutics

Abstract

The campaign against drug addiction waged under the auspices of the United Nations raises two questions with particular reference to heroin:

Details

Author: Georges Brouet
Pages: 17 to 18
Creation Date: 1953/01/01

The Use of Heroin in Therapeutics

Dr. Georges Brouet
Professor in the Faculty of Medicine, Paris; Practitioner to hospitals

The campaign against drug addiction waged under the auspices of the United Nations raises two questions with particular reference to heroin:

Is the clinical use of heroin essential?

Is the addiction it produces so serious as to justify the drug's removal from the pharmacopoeia ?

This is not the context for discussing why heroin is regarded as a specially dangerous narcotic drug, though it should be noted that observed cases of criminal offences due to its euphoric and mentally exciting effects seem to be rare in France.

Heroin is prescribed for therapeutic purposes essentially because of the pharmaceutical and dynamic properties that are peculiarly its own among the morphine derivatives and related synthetic substances, which are likewise habit-forming.

All pharmacologists agree that the physiological action of morphine is heightened by the acetylation of its two constituents, alcohol and phenol. Its analgesic effect is four to eight times as strong as that of morphine; its depressive effect on breathing is four times as powerful as that of morphine; since the resiration is deeper and stronger and since, as a result, the air cells of the lungs are effectively ventilated, the action of five milligrammes of heroin on the respiration is quantitatively almost equal to that of fifteen milligrammes of morphine; through its inhibiting influence on the central system, it has a well-recognized sedative effect on coughs.

These three properties in which heroin excels morphine and the other derivatives justify its clinical use in certain painful diseases characterized by coughing and difficulty in breathing.

Heroin is administered in pills, but most usually in solution, in liquid form or by subcutaneous injection. French practitioners do not employ intravenous injection. The daily dosage is from five to ten milligrammes (the maximum single dose), the maximum dose in twenty-four hours being twenty milligrammes.

Among the painful diseases only chronic complaints which have reached the terminal stage call for the use of heroin; it is not indicated for recurrent painful spasms. Such serious painful syndromes are essentially those of the painful types of cancer, especially those in which there is an invasion of the nervous system, or metastasis oft the bone which have failed to respond to any other form of therapeutic treatment. Heroin, especially by injection, may be useful as a last resort after the action of other analgesics has been exhausted. Its potent analgesic and tonic action can greatly alleviate the sufferings of the final weeks of a patient afflicted with cancer.

Among the lung diseases the last stages of pulmonary tuberculosis may require the use of heroin. When anti-tuberculosis treatment has met with failure after failure - a contingency which will occur less and less frequently - and when the all too familiar picture of the consumptive who has reached the incurable stage of the disease becomes a reality, the physician should concentrate exclusively on relieving the patient. The advice which Professor Bard put into two words, "opium et mentiri," is an act of charity which the sufferer cannot be denied. During this final stage, heroin, by calming the distressing sensation of asphyxia, soothing the cough and leaving room for hope, can still be used as a valuable medicament which may succeed when all others have ceased to be effective.

Heroin should be used with greater caution, whether in solution or in liquid form, in the case of the curable or chronic types of pulmonary tuberculosis, where we personally advise against its use. It should be prescribed only in exceptional cases, such as infections of the larynx, in which the possibilities of antibiotics have been exhausted. In most cases, properly administered sedatives for the cough can yield equally satisfactory results.

Incurable mediastinal constrictions, whether caused by a cancerous growth, by a pathological condition of the mediastinal reticular lymph or by an aneurism of the aorta causing painful symptoms of asphyxia, may indicate that heroin should be used.

Appreciable use is once more being made of the opiates in the treatment of heart disease, owing to the influence of the work of Vaquez and his collaborators. In periods of asystole the opiates relieve anginal pains, insomnia, extreme distress and difficulty in breathing by their sedative action on the cortical and sympathetic nervous centres. The action of the muscles of the patient's heart is slowed by the resulting sleep and alleviation. Opium, by inducing calm and relaxation, is the last hope of the patient dying of heart disease. Heroin may be used in such circumstances, on the condition, however, that it is only administered after light sedatives have proved ineffective, when the heart failure is acute and lasting, when the action of cardiac stimulants has failed and when it is decided to try something more potent than morphine and its derivatives.

These clinical uses are borne out by the figures for heroin consumption in the Paris hospitals. In the past few years it has been some 200 grammes annually (varying between 144 gr. and 308 gr.), with no regular decrease, whereas ten years ago the figure was approximately a kilogramme. It is remarkable how little heroin is now used; the 200 grammes consumed account for its use in the hospitals of a city of four million people. Half of the annual total is consumed by a large hospital centre for chronic and serious cases of tuberculosis and by anti-cancer centres.

The clinical use of heroin is only admissible on certain conditions:

  1. its use should not be merely routine or customary, but should be justified by the complete or partial ineffectiveness of other drugs;

  2. heroin should, as a rule, be used only for incurables who have not long to live and are in pain, irrespective of whether they are suffering from cancer, pulmonary tuberculosis or heart disease;

  3. the drug should be prescribed more cautiously in private practice than in hospitals, where the physician can control the dose and where it is practically impossible to encourage others to use the drug.

If these conditions are fulfilled, there are hardly any arguments in favour of the removal of heroin from the pharmacopoeia of countries which have clear and well observed legislation on the use of narcotic drugs. These are the conclusions reached by the Commission on Toxic Substances of the National Academy of Medicine in the report submitted by Professor Aubertin on 22 February 1949.

Without encroaching on a field which is not our own, we may express the thought that if morphine continues in current use, heroin is so easy to prepare that there is little point in banning it internationally. If there was any absolute need for prohibiting its use in therapeutics in order to combat addiction, the principle might conceivably be accepted; but if the effect of such prohibition were to be illusory, as we fear it would, it is hard to see why patients who may benefit from it need be deprived of it.

Furthermore, it is common knowledge that most heroin addicts are not recruited from the ranks of patients who have been cured, but from among morphine, cocaine or other addicts, whose addiction has very seldom been produced by the therapeutic use of a narcotic drug.

The rapid advances in modern therapeutics justify the belief that in many cases treatment by sedatives will diminish in scope. Surgical methods to relieve pain have already scored signal successes. Antibiotics now provide the best symptomatic treatment in cases of incurable tuberculosis, both for the cough and for the difficulty in breathing, the use of opiates declining gradually.

With these prospects in view, we feel that heroin should remain one of the therapeutic resources on which the medical profession can draw.