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Background: Heroin is an extremely addictive narcotic drug derived from morphine. Its continued use requires increased amounts of the drug to achieve the same effect, resulting in tolerance and addiction. This study was done in order to determine the prevalence of musculoskeletal pain and forward head posture among heroin users during their withdrawal. Methods: This research was a cross-sectional study that was done on 90 heroin users 83 males, 7 females aged between 20 to 40 years They were selected by simple randomized sampling. Data were collected by a form regarding age, sex, the duration of heroin use, and musculoskeletal pain. Pain was measured by VAS visual analog scale and forward head posture was evaluated by plumb line. Pearson correlation technique and chi-square were used for analyzing the data. Findings: The results revealed that the majority of heroin users suffered from musculoskeletal pain during their withdrawal. At the end of withdrawal Pain in the lower extremities and low back was more common than the upper extremities. The intensity of pain before withdrawal was mild, during withdrawal was moderate, and at the end was sever, but there was no significant correlation between them. The results also showed Conclusion: According to the results, the intensity of pain increased during the withdrawal period; therefore, more attention must be paid to this complication in heroin users for better evaluation and a successful withdrawal. Abstract Background: Heroin is an extremely addictive narcotic drug derived from morphine.

Detection of Heroin and Noscapine in Bile Specimen in a Body Packer

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These drugs mainly comprise opium, heroin, cocaine, 3,4-methylenedioxymethamphetamine ecstasy , amphetamines, and marijuana or hashish. Body packers may also be called swallowers, internal carriers, couriers or mules. Although this practice is not new, its medical complications have always been a matter of concern. Some have reported improved packaging methods to deal with such complications. Body packing is an on-going drug smuggling method and authorities across the world are always on the alert. Case Presentation: It has reported a case of death due to the effects of heroin concealed in a man who was attempting to smuggle the drug within his gastro-intestinal track. According to forensic procedure of sudden unnatural death, the decedent had to accept a series of examination such as CT scan, autopsy and toxicological analysis. He was found dead from acute heroin intoxication due to the rupture of drug packet in the stomach. Discussion: This case illustrates the challenges to forensic diagnosis in forensic medical methods in evaluation of potential drug packers and therefore it needs to consider all methods and finally best method involved in forensic diagnosis. Toxicological analysis of the presence of the drug in body fluids, such as plasma, and in tissue extracts may not be of value when the level of the drug decreases after a period of metabolism. How to cite this article: Najafi N, Montazeri M. Asia Pac J Med Toxicol ; Heroin poisoning occurs when an individual accidentally or intentionally overdoses on the drug or when an ingested heroin packet ruptures in the gastrointestinal GI tract of a 'body packer' or 'body stuffer. Body packers can carry about one kilogram of a drug divided into packets at a time. The packets usually contain life-threatening doses of opium, heroin, and cocaine, or amphetamines and methamphetamine derivatives wrapped in capsules, condoms, balloons, plastic bags, or the fingers of latex gloves Herein, we report a case of a heroin body packer that expired due to respiratory arrest. The deceased was a male height: cm; weight: 73 kg. After illegally entering Iran, he was arrested by the Iranian police and delivered to the camp. His death was announced 30 hours after he was arrested and it was confirmed by an emergency room doctor. The body was moved to the autopsy hall to determine the exact cause of death. While no condensation was seen in the lungs, during the tracheotomy obvious hyperemia and edema were observed, although no consolidation of the tissue or suppuration was found. After carefully and accurately examining the, it was determined that one of the packets had opened and the substance in the packet had been absorbed into the body. Considering this issue, we continued to examine the body and we discovered a total of 61 packets. Each packet was 2. The weight of all 61 packets was grams Figure 2. Although the examiner was unable to obtain a urine specimen from the cadaver, a blood specimen, vitreous, biliary fluid, and viscera samples were collected to conduct toxicology tests. The samples were sent to the legal medicine laboratory for analysis. In the toxicology test results, using the gas chromatography—mass spectrometry GC-MS method, no ethylic alcohol was found in the blood specimen or the vitreous analyses. The results confirmed the presence of morphine and codeine; however, using these two analytical methods no evidence of a drug was found in the viscera specimen. In order to identify the powder contained in the cylindrical packets that were embedded in the body, one cream-colored powder packet was sent to the laboratory for analysis. Using high-performance liquid chromatography HPLC , it was determined that heroin and noscapine were present in the specimens. Heroin diacetylmorphine is a semisynthetic narcotic that was first synthesized in It was originally marketed as a safer, non-addictive substitute for morphine. Soon after its introduction, heroin was realized to be as addictive as morphine. In the United States, heroin remains one of the most frequently abused narcotics. In its pure form, heroin is a white powder with a bitter taste 4, 5. Heroin is a highly addictive semisynthetic opioid that is derived from morphine. When used intravenously, it is times more potent than its parental compound, and it is able to modulate pain perception and cause euphoria. Similar to morphine, heroin and its metabolites have mu, kappa, and delta receptor activity 5. In general, stimulation of the mu receptors results in analgesia, euphoria, central nervous system CNS depression, respiratory depression, and miosis. Stimulation of the delta and kappa receptors also results in analgesia, but the kappa receptors are mostly involved in spinal analgesia 6. Like morphine and other narcotics, heroin reduces the brain's responsiveness to changes in PCO 2 and hypoxia, thus resulting in respiratory depression. It also reduces peripheral vascular resistance resulting in mild hypotension , causes mild vasodilation of the cutaneous blood vessels resulting in flushing , and stimulates histamine release resulting in pruritus. Coma, respiratory depression, and miosis are the hallmarks of opioid overdose 7. Heroin is quickly metabolized to 6-MAM and morphine. Most qualitative toxicological studies only screen for morphine, and they use the presence of morphine in the urine as a surrogate for heroin use. In criminal and legal cases, however, testing for specific compounds is necessary, and, because 6-MAM can only be generated from heroin metabolism, the presence of 6-MAM on a drug screening test is taken as evidence of heroin use The most common scenarios for a significant heroin overdose are the use of a higher dose, the accidental injection of a highly concentrated solution in an unsuspecting user, or the use of heroin after a prolonged period of abstinence. Intentional i. Other scenarios include body packing and body stuffing. As we know, the effects of acute heroin toxicity cannot be medically reversed. The heroin must have been released from one or more of the pellets while he was undergoing the interrogation, which lasted 12 hours prior to his collapsing. This is consistent with pathological findings from similar reported cases of narcotic fatalities The diagnosis of heroin poisoning is usually made clinically with naloxone, but laboratory analysis may be helpful in confirming heroin use. These are indicated if the patient's condition does not respond to naloxone or if the patient's course of treatment is complicated. Resedation occurs when large doses of heroin are used, when continuous absorption from a ruptured transport bag occurs, or if a long-acting narcotic agent is present in the body. The absence of a response to naloxone should prompt a search for another cause of the clinical presentation, such as hypoglycemia. Respiratory support should be instituted early, when necessary 20, Gastric lavage in the setting of an oral heroin overdose is generally not recommended because it has no documented value. Furthermore, gastric lavage is contraindicated in body packers and body stuffers because the procedure may rupture a drug packet. Activated charcoal, which is indicated for orally-ingested narcotics, especially those with large intrahepatic circulation e. Body packers and body stuffers also generally require whole-bowel irrigation, except in the presence of intestinal obstruction or perforation. Admission to the hospital is rarely necessary and is generally limited to complications of heroin overdose and intravenous drug use. Admission to the intensive care unit is also rarely required and is indicated for patients who require respiratory support and those with life-threatening arrhythmias, shock, and recurrent convulsions, as well as those who require continuous naloxone infusions rebound coma, respiratory depression. As noted, because we did not foresee any additional value from the histological findings in this particular case and no specimens were taken for histology X-ray is a method used to identify drug pellets, but the X-ray results may be unclear in strongly suspicious cases 11, 27, Some investigators have reported that urine testing is a reliable method for the identification of drugs in every type of internal concealment, although some investigators have found negative results probably due to the patient's hospitalization 17, Ultrasonography and saliva screening have been found to be unsuitable Once the conversion of heroin to morphine is completed, the measurable detection of the morphine is limited to 12 hours. Thus, even with the most sensitive methods the maximum limit of detection does not exceed 48 hours in plasma Surgery is usually performed without any complications In the present case, the free heroin in the stomach contents probably leaked from one of the pellets in the stomach prior to death before it could be absorbed. In the case presented in this paper, the cause of death was unknown, the pellets were not excreted from the intestines, and the radiology result was unclear so it could not provide accurate documentation. Thus, we performed an autopsy to confirm the toxicology analysis. We recommend that the force-feeding method of achieving drug pellet expulsion from suspected body packers be abandoned and replaced by safer, sensitive methods, and that radiology, if possible, and a toxicology analysis be used to detect the presence of drug packets in the body. Moreover, surgical intervention is indicated for persistent body packers when access to imaging is not an option or when unresponsive toxicology results, gastrointestinal obstruction, or perforation occur in heroin body packers. Najafi, N. Asia Pacific Journal of Medical Toxicology , 6 1 , Nahid Najafi; Mahmoud Montazeri. Asia Pacific Journal of Medical Toxicology , ; 6 1 : Guide for Authors. Submit Manuscript. Contact Us. Full Text. Conflict of interest: None to be declared. Funding and support: None. Figure 1. The risk of body packing: a case of a fatal cocaine overdose. Forensic Sci Int ; Mehrpour O, Sezavar SV. Diagnostic imaging in body packers. Mayo Clin Proc ;e Norfolk GA. The fatal case of a cocaine body-stuffer and a literature review—towards evidence based management. J Forensic Legal Med ; Guide to Psychoactive Drugs. United Kingdom: Routledge; Christie MJ. Cellular neuroadaptations to chronic opioids: tolerance, withdrawal and addiction. Br J Pharmacol ; Basic Pharmacology: How Methadone Works? The Pharmacology of Opioids. Modern pharmacology with clinical application. Lippincott Williams and Wilkins, Philadelphia. J Anal Toxicol ; J Mass Spectrom ; Stability of heroin, 6-monoacetylmorphine, and morphine in biological samples and validation of an LC-MS assay for delayed analyses of pharmacokinetic samples in rats. J Pharm Biomed Anal ; Int J Forensic Sci Pathol ; Fatal heroin intoxication in body packers in northern Thailand during the last decade: two case reports. J Med Assoc Thai ; Sanaei-Zadeh H. Medical Image. Asymptomatic body packer. N Z Med J ; Body packer with opiate toxicity. Intern Med J ; A case report of opium body packer; review of the treatment protocols and mechanisms of poisoning. Toxicol Mech Methods ; Swallowed opium packets: CT diagnosis. Abdom Imaging ; Body packing—the internal concealment of illicit drugs. N Engl J Med ; Establishment of a definitive protocol for the diagnosis and management of body packers drug mules. Emerg Med J ; Addiction ; Sporer KA. Strategies for preventing heroin overdose. Br Med J ; Packers, pushers and stuffers—managing patients with concealed drugs in UK emergency departments: a clinical and medicolegal review. Eur J Surg ; A five-year review of the medical outcome of heroin body stuffers. J Emerg Med ; Morphine to codeine concentration ratio in blood and urine as a marker of illicit heroin use in forensic autopsy samples. Am J Emerg Med ; Surgical treatment in cocaine body packers and body pushers. Int J Colorectal Dis ; Wang L. Forensic Sci Sem ; Am J Pharmacol Toxicol ; Drug addiction as a pathology of staged neuroplasticity. Neuropsychopharmacology ; The bioavailability of morphine applied topically to cutaneous ulcers. J Pain Symptom Manage ; Simultaneous screening and quantification of 25 opioid drugs in post-mortem blood and urine by liquid chromatography—tandem mass spectrometry. Surgical approach to body packing. Dis Colon Rectum ;

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