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N A TIONAL INSTITUTE ON ABUSE ResearchReport S E R I E S Although abuse has tr ended downward during the past couple of years, its prevalence is still higher than in the early 1990s. HHEE RR OO II NN AbuseAbuse andand These relatively high rates of abuse, together with the significant he r oin abuse we are now seeing AAdd dd ii cc tt ii oo nn among school-age youth, the glam- orization of heroin in music and What is heroin? or other poisons. Because heroi n films, changing patterns of drug er oin is an illegal, highly abusers do not know the actual use, and heroin’s increased purity st r ength of the drug or its true and decreased prices, make it addictive drug. It is both imperative that the public have the the most abused and the contents, they are at risk of over- H dose or death. Heroin also poses latest scientific information on this most rapidly acting of the opi- to p i c . ates. Heroin is processed from special problems because of the The National Institute on Drug transmission of HIV and other Abuse (NIDA) has developed this , a naturally occurring substance extracted from the diseases that can occur from publication to provide an overview sharing needles or other injection of the latest res e a r ch findings on seed pod of certain varieties of equipment. he r oin abuse and . plants. It is typically sold He r oin is a highly addictive drug, as a white or brownish powder and its abuse has rep e r cussions that or as the black sticky substance What is the scope extend far beyond the individual known on the streets as “black us e r . The health and social conse- of heroin use in quences of drug abuse–HIV/AIDS, tar heroin.” Although purer hero- the United States? violence, , fetal effe c t s , in is becoming more common, crime, and disruptions in family, most street heroin is “cut” with ccording to the 1998 workplace, and educational other or with substances National Household Survey en v i r onments–have a devastating such as sugar, , powdered on Drug Abuse, which may impact on society and cost billions A milk, or . Street heroi n actually underestimate illicit opi- of dollars each year. Fortunately, the availability can also be cut with strychnine ate (heroin) use, an estimated of treatments to manage 2.4 million peo- addiction and the promise of new ple had used treatments from research provide he r oin at some hope for individuals who suffer time in their from addiction and for those lives, and nearly around them. 130,000 of them We hope this compilation of scientific information on heroin reported using it will help to inform readers about within the month the harmful effects of heroin abuse pr eceding the and addiction and will assist in survey. The sur- pr evention and treatment effo r t s . vey report esti- Alan I. Leshner, Ph.D. mates that there Di re c t o r we r e 81,000 National Institute on Drug Abuse new heroi n

U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s • N a t i o n a l I n s t i t u t e s o f H e a l t h 2NIDA RESEARCH REPORT SERIES

users in 1997. A large prop o r t i o n of these recent new users were , snorting, or sniffi n g he r oin, and most (87 perce n t ) How is heroin used? we r e under age 26. In 1992, er oin is usually injected, ing treatment; however, only 61 percent were younger sn i f fed/snorted, or smoked. researchers have observed a than 26. HTypically, a heroin abuser shift in heroin use patterns, The 1998 Drug Abuse may inject up to four times a day. from injection to sniffing and War ning Network (DAWN), Intravenous injection provides the smoking. In fact, sniffi n g / s n o r t i n g which collects data on drug- gr eatest intensity and most rapid he r oin is now the most widely related hospital emerge n c y onset of (7 to 8 sec- reported means of taking heroi n department (ED) episodes from onds), while intramuscular injec- among users admitted for drug 21 metropolitan areas, estimates tion produces a relatively slow tr eatment in Newark, Chicago, that 14 percent of all drug-rel a t e d onset of euphoria (5 to 8 min- and New York. ED episodes involved heroi n . utes). When heroin is sniffed or With the shift in heroin abuse Even more alarming is the fact smoked, peak effects are usually pa t t e r ns comes an even more that between 1991 and 1996, felt within 10 to 15 minutes. diverse group of users. Older he ro i n - r elated ED episodes more Although smoking and sniffi n g users (over 30) continue to be than doubled (from 35,898 to he r oin do not produce a “” one of the largest user groups in 73,846). Among youths aged as quickly or as intensely as most national data. However, the 12 to 17, heroi n - r elated episodes intravenous injection, NIDA in c r ease continues in new, young nearly quadrupled. researchers have confirmed users across the country who are NIDA’s Community that all three forms of heroin being lured by inexpensive, high- administration are addictive. purity heroin that can be sniffe d Epidemiology Work Grou p Injection continues to be the or smoked instead of injected. (CEWG), which provides infor- pr edominant method of heroi n He r oin has also been appearing mation about the nature and use among addicted users seek- in more affluent communities. pa t t e r ns of drug use in 21 cities, reported in its December 1999 Among publication that heroin was Heroin Treatment Admissions in Selected Areas mentioned most often as the primary drug of abuse in drug Percentage abuse treatment admissions in 100% Ba l t i m o r e, Boston, Los Angeles, 90 Newark, New York, and San 80 Fr a n c i s c o . 70 60 Injecting 50 40

30 Sniffing/ 20 snorting

10 Smoking 0 and other Baltimore Boston L.A. Newark New York St. Louis

Source: Community Epidemiology Work Group, NIDA, December 1999 NIDA RESEARCH REPORT SERIES 3 What are the Act on Many Places in the and Nervous System long-term effects of heroin use? ne of the most detrimental lo n g - t e r m effects of heroi n Ois addiction itself. Addiction is a chronic, rel a p s i n g disease, characterized by compul- sive drug seeking and use, and by ne u r ochemical and molecular changes in the brain. Heroin also Opiates can change the pr oduces profound degrees of tol- limbic system, which erance and , Opiates can which are also powerful motivat- de p r ess brea t h i n g controls emotions, to ing factors for compulsive use and by changing increase feelings of ne u ro c h e m i c a l pleasure. abuse. As with abusers of any activity in addictive drug, heroin abusers the brain Opiates can block gradually spend more and more stem, where messages transmitted time and energy obtaining and automatic by the spinal cord from using the drug. Once they are body the body. addicted, the heroin abusers’ pri- functions mary purpose in life becomes ar e control l e d . seeking and using drugs. The drugs literally change their . Physical dependence develops with higher doses of the drug. brain so rapidly. With heroin, With physical dependence, the What are the the rush is usually accompanied body adapts to the presence of immediate by a warm of the skin, the drug and withdrawal symp- (short-term) effects dry mouth, and a heavy feeling toms occur if use is red u c e d in the extremities, which may abruptly. Withdrawal may occur of heroin use? be accompanied by , within a few hours after the last oon after injection (or inhala- , and severe itching. time the drug is taken. Symptoms tion), heroin crosses the After the initial effects, of withdrawal include res t l e s s - Sblood-brain barrier. In the abusers usually will be drow s y ness, muscle and bone pain, brain, heroin is converted to mor- for several hours. Mental function , , vomiting, cold phine and binds rapidly to is clouded by heroin’s effect on flashes with (“cold receptors. Abusers typically rep o r t the central nervous system. ”), and leg movements. feeling a surge of pleasurable Cardiac function slows. Brea t h i n g Major withdrawal symptoms peak sensation, a “rush.” The intensity is also severely slowed, some- between 24 and 48 hours after the of the rush is a function of how times to the point of death. last dose of heroin and subside much drug is taken and how He r oin overdose is a particular after about a week. However, rapidly the drug enters the brain risk on the street, where the some people have shown persis- and binds to the natural opioid amount and purity of the drug tent withdrawal signs for many receptors. Heroin is particularly cannot be accurately known. months. Heroin withdrawal is addictive because it enters the never fatal to otherwise healthy 4NIDA RESEARCH REPORT SERIES

adults, but it can cause death to losis) may result from the poor reactions to these or other con- the of a pregnant addict. health condition of the abuser as taminants can cause arthritis or At some point during continu- well as from heroin’s depres s i n g other rheumatologic problems. ous heroin use, a person can ef fects on respiration. Many of Of course, sharing of injection become addicted to the drug. the additives in street heroin may equipment or fluids can lead Sometimes addicted individuals include substances that do not to some of the most severe will endure many of the with- readily dissolve and result in consequences of heroin abuse— drawal symptoms to reduce their clogging the blood vessels that infections with B and tolerance for the drug so that lead to the lungs, , kidneys, C, HIV, and a host of other they can again experience the or brain. This can cause infection bl o o d - b o r ne viruses, which drug ru s h . or even death of small patches abusers can then pass on to their Physical dependence and the of cells in vital organs. Immune sexual partners and children . em e r gence of withdrawal symp- toms were once believed to be the key features of heroin addic- Short- and Long-Term Effects of Heroin Abuse tion. We now know this may not be the case entirely, since craving and relapse can occur weeks and S h o rt - Te rm Eff e c t s : L o n g - Te rm Effects: months after withdrawal symp- toms are long gone. We also “ R u s h ” A d d i c t i o n know that patients with chron i c pain who need opiates to func- Depressed Infectious diseases, tion (sometimes over extended periods) have few if any prob - r e s p i r a t i o n for example, lems leaving opiates after their HIV/AIDS and pain is resolved by other means. Clouded mental hepatitis B and C This may be because the patient f u n c t i o n i n g in pain is simply seeking relief of Collapsed veins pain and not the rush sought by Nausea the addict. and vomiting Bacterial i n f e c t i o n s What are Suppression the medical of pain A b s c e s s e s complications of Spontaneous Infection of ch r onic heroin use? a b o r t i o n heart lining edical consequences of and valves ch r onic heroin abuse Minclude scarred and/or Arthritis collapsed veins, bacterial infec- and other tions of the blood vessels and rheumatologic heart valves, (boils) p r o b l e m s and other soft-tissue infections, and liver or disease. Lung complications (including various types of and tubercu - NIDA RESEARCH REPORT SERIES 5

can eliminate drug use, drug- How does Why are related risk behaviors such as he r oin abuse affect heroin users , unsafe sexual pr egnant women? at special risk practices, and, in turn, the risk of ex p o s u r e to HIV/AIDS and other er oin abuse can cause seri- for contracting infectious diseases. Drug abuse ous complications during HIV/AIDS and pr evention and treatment are Hpr egnancy, including mis- highly effective in preventing the carriage and prem a t u r e delivery. hepatitis C? sp r ead of HIV. Ch i l d r en born to addicted moth- er oin addicts are at risk ers are at greater risk of SIDS for contracting HIV, hepa- What are the (sudden infant death syndrom e ) , Htitis C, and other infectious as well. Preg n a n t diseases. Drug abusers may treatments for women should become infected with HIV, heroin addiction? not be hepatitis C, and other blood- variety of effective trea t - de t o x i f i e d bo r ne through shar- ments are available for fr om opiates ing and reuse of he r oin addiction. Trea t m e n t because of and injection parapherna l i a A tends to be more effective when the increa s e d that have been used by risk of spontaneous he r oin abuse is identified early. infected individuals. The treatments that follow vary abortion or prem a t u r e They may also become delivery; rather, trea t - depending on the individual, but infected with HIV and, , a synthetic opiate ment with methadone although less often, to is strongly advised. that blocks the effects of heroi n hepatitis C throu g h and eliminates withdrawal symp- Although infants born un p r otected sexual to mothers taking toms, has a proven record of contact with an success for people addicted to pre s c r i b e d infected person. methadone may he r oin. Other pharma c e u t i c a l Injection drug use ap p r oaches, like LAAM (levo- show signs of physi- has been a factor cal dependence, they alpha-acetyl-methadol) and in an estimated bu p r enorphine, and many be- can be treated easily one-third of all and safely in the nursery. havioral therapies also are used HIV and more for treating heroin addiction. Re s e a r ch has demonstrated than half of all also that the effects of hepatitis C De t o x i f i c a t i o n in utero exposure to cases in the The primary objective of detox- methadone are rel a t i v e l y Na t i o n . ification is to relieve withdrawal be n i g n . NI D A - symptoms while patients adjust to fu n d e d a drug-free state. Not in itself a res e a r ch has tr eatment for addiction, detoxifi- found that cation is a useful step only when drug abusers can it leads into long-term trea t m e n t change the behaviors that is either drug-free (res i d e n t i a l that put them at risk or outpatient) or uses medica- for contracting HIV, tions as part of the treatment. The th r ough drug abuse trea t - best documented drug-free trea t - ment, prevention, and ments are the therapeutic com- community-based out- munity residential prog r a m s reach programs. They lasting at least 3 to 6 months. 6NIDA RESEARCH REPORT SERIES

Methadone prog r a m s can block the Methadone treatment has been ef fects of heroin Treatments for Heroin Addiction used effectively and safely to for up to 72 hours tr eat opioid addiction for more with minimal side than 30 years. Properly pre- ef fects when scribed methadone is not intoxi- taken orally. In cating or sedating, and its effe c t s 1993 the do not interfe r e with ordinary and Drug activities such as driving a car. Ad m i n i s t r a t i o n The medication is taken orally ap p r oved the and it suppresses use of LAAM for withdrawal for 24 to 36 hours. tr eating patients Patients are able to perceive pain addicted to heroi n . and have emotional rea c t i o n s . Its long duration Most important, methadone of action permi t s relieves the craving associated dosing just three with heroin addiction; craving times per week, is a major reason for rel a p s e . th e r eby eliminat- Among methadone patients, it ing the need for has been found that normal stree t daily dosing and doses of heroin are ineffective at take-home doses pr oducing euphoria, thus making for weekends. Methadone the use of heroin more easily LAAM will be ex t i n g u i s h a b l e . in c r easingly avail- programs Methadone’s effects last for able in clinics that about 24 hours—four to six times al r eady dispense as long as those of heroi n — s o methadone. LAAM, , people in treatment need to take and and other medications it only once a day. Also, metha- na l t r exone are done is medically safe even when medications that used continuously for 10 years or also block the Behavioral therapies mo r e. Combined with behavioral ef fects of mor- therapies or counseling and other phine, heroi n , supportive services, methadone and other opiates. enables patients to stop using As antagonists, they are especially may already be available by the he r oin (and other opiates) and useful as antidotes. Naltrex o n e time this Research Report appears. ret u r n to more stable and has long-lasting effects, ranging Bu p r enorphine is a particularly pr oductive lives. fr om 1 to 3 days, depending on attractive treatment because, com- Methadone dosages must be the dose. blocks the pa r ed to other medications, such ca r efully monitored in patients pleasurable effects of heroin and as methadone, it causes weaker who are receiving antiviral thera- is useful in treating some highly opiate effects and is less likely py for HIV infection, to avoid motivated individuals. Naltrex o n e to cause overdose prob l e m s . potential medication interactions. has also been found to be suc- Bu p r enorphine also produces a cessful in preventing relapse by lower level of physical depen- LAAM and other medications fo r mer opiate addicts rel e a s e d dence, so patients who discontin- LAAM, like methadone, is a fr om prison on prob a t i o n . ue the medication generally have synthetic opiate that can be used Another medication to trea t fewer withdrawal symptoms than to treat heroin addiction. LAAM he r oin addiction, bupren o r p h i n e , do those who stop taking NIDA RESEARCH REPORT SERIES 7 methadone. Because of these to brain function and behavior, advantages, buprenorphine may with increased employment rates Where can I get be appropriate for use in a wider and lower risk of HIV and other further scientific variety of treatment settings than diseases and criminal behavior. information about the currently available medica- tions. Several other medications What are the heroin abuse and with potential for treating heroi n addiction? overdose or addiction are opioid analogs and cu r r ently under investigation their dangers? o learn more about heroi n by NIDA. and other drugs of abuse, rug analogs are chemical Tcontact the National Behavioral therapies compounds that are similar Clearinghouse for and Although behavioral and Dto other drugs in their Drug Information (NCADI) at ph a r macologic treatments can ef fects but differ slightly in their 1-800-729-6686. Information be extremely useful when chemical structure. Some analogs specialists are available to assist ar e produced by pharma c e u t i c a l employed alone, science has you in locating needed informa - companies for legitimate medical taught us that integrating both tion and res o u r ces. Informa t i o n reasons. Other analogs, some- can be accessed also through types of treatments will ultimately times ref e r r ed to as “designer” be the most effective approa c h . the NIDA World Wide Web site drugs, can be produced in illegal (www.drugabuse.gov) or the Th e r e are many effective behav- laboratories and are often more NCADI Web site (www.health.org) . ioral treatments available for da n g e r ous and potent than the he r oin addiction. These can original drug. Two of the most include residential and outpatient commonly known opioid analogs ap p r oaches. An important task is ar e and meperidine Access information to match the best trea t m e n t (marketed under the brand name on the Interne t ap p r oach to meet the particular De m e r ol, for example). • Wh a t ’ s new on the needs of the patient. Moreo v e r , Fentanyl was introduced in NIDA Web site several new behavioral therapies, 1968 by a Belgian pharma c e u t i c a l • In f o r mation on drugs such as contingency management company as a synthetic narco t i c of abuse therapy and cognitive-behavioral to be used as an in • Publications and interventions, show particular su r gical proc e d u r es because of communications (including NI D A NO T E S ) pr omise as treatments for heroi n its minimal effects on the heart. • Calendar of events addiction. Contingency manage- Fentanyl is particularly dangerou s ment therapy uses a voucher- because it is 50 times more • Links to NIDA potent than heroin and can or ganizational units based system, where patients rapidly stop respiration. This is • Funding informa t i o n ea r n “points” based on negative not a problem during surgi c a l (including program drug tests, which they can announcements and pro c e d u r es because machines de a d l i n e s ) exchange for items that encour- ar e used to help patients brea t h e . age healthy living. Cognitive- On the street, however, users • In t e r national activities behavioral interventions are have been found dead with the • Links to related Web sites designed to help modify the (access to Web sites of needle used to inject the drug many other orga n i z a t i o n s patient’s thinking, expectancies, still in their arms . in the field) and behaviors and to increa s e skills in coping with various life st r essors. Both behavioral and NIDA Web Sites www.drugabuse.gov NCADI ph a r macological treatments help www.steroidabuse.org to res t o r e a degree of norma l c y Web Site: www.health.org www.clubdrugs.org Phone No.: 1-800-729-6686 8NIDA RESEARCH REPORT SERIES

Gl o s s a r y References National Institute on Drug Abuse. Epidemiologic Trends in Drug Abuse: Vol. 1. Highlights and Executive Ad d i c t i o n : A chronic, relapsing dis- Bowersox, J.A. Buprenorphine may soon be heroin trea t - Su m m a r y, Community Epidemiology Work Grou p . ease, characterized by compulsive ment option. NIDA Notes 10:8-9, 1995. NIH . No. 00-4739. Washington, DC: dr ug seeking and use and by neuro- Bowersox, J.A. Heroin update: smoking, injecting cause Supt. of Docs., U.S. Govt. Print. Off., 2000. chemical and molecular changes in similar effects; usage patterns may be shifting. NIDA National Institute on Drug Abuse. “Heroin.” NIDA Capsule. the brain. No t e s 10:8-9, 1995. NIDA, 1986. Ag o n i s t : A chemical compound that Co o p e r , J.R.; Altman, F.; Brown, B.S.; and Czechowicz, D., National Institute on Drug Abuse. IDUs and infectious mimics the action of a natural neuro- eds. Re s e a r ch in the Treatment of Narcotic Addiction: diseases. NIDA Notes 9:15, 1994. tr a n s m i t t e r . State of the Art. National Institute on Drug Abuse National Institute on Drug Abuse. National Survey An a l o g : A chemical compound that is Monograph, DHHS Pub. # (ADM) 83-1281, 1983. Results on Drug Use From the Monitoring the Fu t u r e Study, 1975-1998, Vol. I: Secondary similar to another drug in its effects but Dole, V.P .; Nyswander, M.E.; and Kreek, M.J. Narcotic di f fers slightly in its chemical stru c t u re . School Students. Washington, DC: Supt. of Docs., blockade. Ar ch Intern Med 118:304-309, 1966. U.S. Govt. Print. Off., 1999. An t a g o n i s t : A drug that counteracts Goldstein, A. Heroin addiction: Neurol o g y , pharma c o l o g y , National Institute on Drug Abuse. National Survey Results or blocks the effects of another drug . and policy. J s 23(2):123-133, on Drug Use From the Monitoring the Future Study, Bu p re n o r p h i n e : A mixed opiate 19 9 1 . 1975-1994, Vol. II: College Students and Young -antagonist medication for the Hughes, P.H., and Rieche, O. Heroin epidemics revisited. Ad u l t s . NIH Pub. No. 96-4027. Washington, DC: tr eatment of heroin addiction. Epidemiol Rev 17(1):63-73, 1995. Supt. of Docs., U.S. Govt. Print. Off., 1995. Novick, D.M.; Richman, B.L.; Friedman, J.M.; Friedman, Cr a v i n g : A powerful, often uncontrol - Ko rn e t s k y , C. Action of opioid on the brain-rew a r d system. J.E.; Fried, C.; Wilson, J.P.; Tow n l e y , A.; and Kreek, lable desire. In: Rapaka, R.S., and Sorer , H., eds. Di s c o v e r y of M.J. The medical status of methadone maintained Novel Opioid Medications. National Institute on Drug De t o x i f i c a t i o n : A process of allowing patients in treatment for 11-18 years. Drug and Abuse Research Monograph 147. NIH Pub. No. 95- the body to rid itself of a drug while Alcohol Depend 33:235-245, 1993. 3887. Washington, DC: Supt. of Docs., U.S. Govt. managing the symptoms of with- Print Off., 1991, pp. 32-52. Of fice of National Drug Control Policy. Dr ugs and Crime drawal; often the first step in a drug Data: Heroin Facts and Figures . Rockville, MD: U.S. tr eatment prog r a m . Kr eek, M.J. Rationale for maintenance pharmacotherapy of De p a r tment of Justice, 1996. opiate dependence. In: O’Brien, C.P., and Jaffe, J.H., Fe n t a n y l : A medically useful opioid Sobel, K. NIDA’s AIDS projects succeed in reaching drug eds. Addictive States. New York: Raven Press, 1992, addicts, changing high-risk behaviors. NIDA Notes analog that is 50 times more potent pp. 205-230. than heroi n . 6:25-27, 1991. Kr eek, M.J. Using methadone effectively: achieving goals by and Mental Health Services Le v o - a l p h a - a c e t y l - m e t h a d o l application of laboratory, clinical, and evaluation Administration. Pre l i m i n a r y Estimates of Drug Related (L A A M ) : An FDA-approved medication res e a r ch and by development of innovative programs. Em e r gency Department Episodes: Advance Report for heroin addiction that patients need to In: Pickens, R.; Leukefeld, C.; and Schuster, C.R., eds. Number 17. Rockville, MD: SAMHSA, 1996. take only three to four times a week. Im p r oving Drug Abuse Trea t m e n t . National Institute Substance Abuse and Mental Health Services Me p e r i d i n e : A medically approved on Drug Abuse Research Monograph 106. Administration. “Prel i m i n a r y Results from the 1996 opioid available under various brand Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., National Household Survey on Drug Abuse.” names (e.g., Demerol ) . 245-266, 1991. SAMHSA, 1997. Me t h a d o n e : A long-acting synthetic Lewis, J.W., and Wal t e r , D. Buprenorphine: background to Swan, N. Research demonstrates long-term benefits of medication shown to be effective in its development as a treatment for opiate depen- methadone treatment. NIDA Notes 9:1, 4-5, 1994. tr eating heroin addiction. dence. In Blaine, J.D., ed. Bu p r enorphine: An Swan, N. Treatment practitioners learn about LAAM. NIDA Al t e r native for Opiate Dependence. National Institute No t e s 9:5, 1994. Physical dependence: An adaptive on Drug Abuse Research Monograph 121. DHSS Pub. physiological state that occurs with No. (ADM) 92-1912. Washington, DC: Supt. of Docs., Woods, J.H.; France, C.P.; and Win g e r , G.D. Behavioral regular drug use and results in a with- U.S. Govt. Print. Off., 1992, pp. 5-11. ph a r macology of buprenorphine: issues relevant to its drawal syndrome when drug use is potential in treating drug abuse. In: Blain, J.D., ed. stopped; usually occurs with tolerance. Mathias, R. NIDA survey provides first national data on Bu p r enorphine: An Alternative for Opiate dr ug abuse during preg n a n c y . NIDA Notes 10:6-7, De p e n d e n c e . National Institute on Drug Abuse Ru s h : A surge of euphoric pleasure that 19 9 5 . Re s e a r ch Monograph 121. DHHS Pub. No. (ADM) rapidly follows administration of a drug . 92-1912. Washington, DC: Supt. of Docs., U.S. Govt. Tol e r a n c e : A condition in which higher Print. Off., 1992, pp. 12-27. doses of a drug are req u i r ed to prod u c e This publication was developed under Contract No. the same effect as during initial use; often NO1DA-4-2205 from the National Institute on leads to physical dependence. Dr ug Abuse. Withdrawal: A variety of symptoms NIH Publication Number 00-4165. that occur after use of an addictive drug Printed October 1997; Reprinted September 2000. is reduced or stopped. Feel free to reprint this publication.