Kratom (Mitrogyna Speciosa) is a tree indigenous to South East Asia, with leaves containing the psychoactive alkaloids mitragynine and 7-Hydroxymitrogynine. It has a long tradition of use by farmers and other manual workers in its native region, who claim it increases productivity. In recent years, the leaves of this plant (usually prepared as a tea) have been gaining popularity internationally, especially in the US. Whilst not under international control (as is often the case with ethnobotanical psychoactives) its legality varies between regions and countries. Little is known about extent of use in Europe, particularly in countries where it is illegal such as the UK, having been controlled under the Psychoactive Substances Act since 2016.

There several types of Kratom, characterised by different colour ‘veins’ in the leaves and sometimes different growing regions, which are said to have impact the plant’s primary indications. Differences in preference for particular types of kratom are not yet well understood. Laboratory analysis has so far detected no significant difference in the major alkaloids in the resulting plant matter, and the plants which produce the different colour veins are not separate ‘strains’ of kratom in the true botanical sense. It is possible that asides from these two well-known alkaloids, there are other compounds within the plant which also produce an effect, either alone or in combination, which may account for these subjective differences.

Kratom is consumed orally. It is usually sold as a dried greenish powder, which can be swallowed neat, chewed, or prepared as a tea or cold beverage. Less frequently, it is sold in capsule or concentrated extract form.

Kratom contains over 40 different alkaloids, plus a number of other compounds. The two which attract the most attention are mitragynine and 7-hydroxymitragynine; alkaloids which act as partial agonists on the opioid receptors, meaning they produce somewhat similar, but milder, effects to opioid-based medications. This is partly due to the low concentrations of psychoactive compounds within the plant matter (usually 1 – 1.5%) meaning relatively large amounts of kratom needs to be consumed before a noticeable psychoactive effect occurs. Bodily effects maybe noticeable at slightly lower doses; some users report the principle (or only) effect as being an absence of fatigue or pain. Interestingly, mitragynine also has a broad affinity with many other receptors in the body, potentially explaining its complex effect on energy and mood.

There is evidence that in smaller quantities, kratom can produce a mild stimulatory effect, hence its traditional use as a aid with hard, physical labour. These stimulatory effects are not generally considered intense enough to attract the interest of those who use ‘party’ or ‘club’ drugs such as amphetamines. In larger doses, it may have an analgesic quality, and also possess sedating and muscle-relaxing effects.

Kratom is not widely used for recreational purposes – it is more commonly used for self-medication. Emerging data suggests that outside of its traditional context, kratom is more frequently used in an attempt to address chronic pain, sleeplessness, and/or to support opioid addiction withdrawal and recovery. More research is needed to scientifically assess its potential therapeutic applications, but the anecdotal evidence for these effects is strong.

Kratom is less likely to cause harm to health than many other illicit drugs and prescription medications, particularly those from the opioid family, of which it mimics some effects.

None the less, there some side-effects of kratom. Similar to opioids, it can produce agitation, tachycardia, constipation, vomiting and nausea. It does not, however, appear produce the respiratory depression which is characteristic of opioid overdoses. There have been a small number (this varies according to the source consulted) of fatalities internationally where kratom was implicated. This was usually because kratom was detected on post-mortem toxicology. However, in almost all cases, a number of different drugs were detected, which may contributed to, or been responsible for, the death. According to the US Center for Disease Control (CDC)  ‘Postmortem toxicology testing detected multiple substances for almost all decedents…Fentanyl and fentanyl analogs were the most frequently identified co-occurring substances.’ It also needs to be considered that as the vast majority of regular kratom users report experiencing chronic pain, or are in recovery from addiction to another substance, they are already at increased risk of death in any given year. Interestingly, no deaths attributed to kratom have been reported in Asia.

People who have impaired liver function, or who are taking prescription medications which may be changed by the liver, may be more at risk of harm, as kratom is believed to temporarily slow down functioning of this organ.

Taking more than one psychoactive drug at a time is always riskier than taking a single substance. Consuming Kratom alongside other opioids (whether illicit drugs or prescribed medications) may be very dangerous, as this likely to potentiate the effects, and the risks of each substance increase. Using alcohol will also raise the likelihood of experiencing negative effects. Little is known about this combination, but in general, central nervous system depressants such as alcohol pose even more risk when combined with either stimulants or sedatives.

There is some evidence that kratom may cause dependence, if taken in sufficient quantities for an extended period of time. Some people report difficulty in stopping or reducing daily use. Withdrawal symptoms are likely to be much milder than those associated with opioids, bearing in mind one of the most common uses of Kratom is to lessen the effects of opioid withdrawal in those with existing issues with addiction. As previously mentioned, the most common mode of use is oral ingestion, which does not lend itself as easily as to addiction, as the onset of effect is longer and milder due to the metabolisation process which accompanies this.

Kratom is a comparatively low-risk substance when taken in small doses. Those who have decided to use kratom are advised to begin with small amounts, as individual tolerance levels will vary. Taking too much kratom can be unpleasant; nausea vomiting and dizziness are common side effects in such instances. Concentrated preparations, such as liquids, are best avoided – accurate dosing is difficult as the strength is often unknown There may be other ingredients present which pose risks of their own – as with any drug purchased in a non-regulated market, there is always the possibility of adulteration. As noted above, kratom can produce mild withdrawal symptoms after regular use, so caution is advised with regards to frequency of consumption.

The US Food and Drug Administration declared kratom to contain ‘opioid agonists’ in 2018, and The CDC states that Kratom is not an opioid. Nonetheless, its action on the Mu-opioid receptors means kratom is sometimes erroneously ‘lumped together’ with opioids such as morphine and heroin. It does not display the same properties, and does not pose the same level of risk of abuse, or in terms of respiratory depression (Opioids such as heroin, suboxone etc can slow breathing down to such an extent that it can cause death – a 2019 review concluded this was not the case with kratom).

In 2016, the Drug Enforcement Administration expressed intent to place both mitragynine and 7-hydroxymitragynine into schedule 1, which would have made possession or sale of kratom illegal across the US. Protesters organised a march and a petition, which garnered over 120,000 signatures to oppose the ban. Of the 23,116 comments which were submitted during the public consultation, 99.1% supported kratom, and included positive accounts from a large number of law enforcement officials, heath care professionals and scientists, who overwhelmingly stressed its potential role in addressing the opioid epidemic currently facing the US.

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Methadone is a prescription only medicine that can be taken orally and is used mainly to treat opioid addiction. Is was initially developed as a painkiller but now it is much more widely used to treat people who have got stuck on heroin or other opioid drugs (such as prescription painkillers). Methadone is a powerful opioid drug, so it has similar effects to drugs like codeine, morphine, and heroin. It lasts much longer in the body than heroin, and therefore it is used to stabilise people currently using heroin (or other opioid drugs) and then help them get off opioid drugs completely.

Methadone should not be confused with mephedrone, they are completely different drugs. Anyone taking methadone when they are looking for mephedrone risks extreme danger.

Methadone usually comes in liquid form that can be swallowed. It is usually a green liquid although there is a blue liquid that is much more concentrated. Methadone also comes as tablets but this preparation is rarely used.

Methadone is used illicitly, there is a street value for methadone that has been diverted from medicinal use. Most people use it illicitly in the same way as prescribed. As methadone is a powerful opioid drug it is very dangerous for people who are not tolerant to opioid drugs.

Methadone is an opioid drug. It mimics the body’s natural pain-killing chemicals, endorphins. Therefore it can relieve pain, cause drowsiness, can cause mild euphoria, slow breathing, slow the bowels causing constipation, and cause other side effects of opioids.

Yes. It is mostly used as a substitute medication for people addicted to opioids such as heroin. It is occasionally prescribed as a pain-killer.

As an opioid, it mimics the body’s natural pain-killing chemicals, endorphins. Therefore it can relieve pain, cause drowsiness, can cause mild euphoria, slow breathing, slow the bowels causing constipation, and other side effects of opioids. As it takes longer to build up in the body and takes longer to come out of the body it causes much less euphoria than heroin. However, most people report being drowsy, mentally slowed, and often a bit sweaty taking methadone every day.

If someone takes an overdose of an opioid drug they can die quickly. This is usually by respiratory depression (slowing the drive and effectiveness of breathing). Anyone not used to opioid drugs would be much more at risk of this. Methadone is often reported as a contributory cause of death in opioid drug related overdoses. It is particular dangerous if mixed with other drugs such as heroin, alcohol, and benzodiazepines.

The risks of death by overdose increase when many substances are taken together for example alcohol and benzodiazepines which also have effects on breathing (respiration). Methadone decreases control and impairs judgment, making the risk of accidents much higher. This means activities like driving under the influence of methadone are potentially very dangerous. If you are prescribed methadone by your doctor you must inform the DVLA and they have to make a decision whether you are still safe to drive.

The risks of depressed breathing caused by methadone may be increased in people with conditions such as muscle weakness (e.g. myasthenia gravis), sleep apnoea, or lung disease/breathing disorders.

Methadone is dangerous if mixed with alcohol, benzodiazepines or heroin. Taking methadone with depressant drugs increases the risk of depressing breathing. Additionally, the effects of methadone may be masked if taken with a stimulant, which can lead to an overdose if a lot of the drug is taken and then the stimulant wears off. Certain medications (e.g. some antidepressants) may also interact with methadone to increase sedative effects.

One-off or occasional use of methadone is very unlikely to result in the development of depend-ence. However, taking methadone regularly over a sustained period can cause serious physical and psychological addiction. People who become dependent on methadone may become tolerant to the drug’s effects and experience withdrawal symptoms without it. Users may crave the drug and feel unable to cope without it. The longer the drug is taken, the higher and more regular the dose and the stronger the methadone, the higher the risk of dependence.

A period of sustained dependence on any drug can be debilitating and prevent people from working and leading an active life. It may also cause mental and physical harm and opioid withdrawal can be very unpleasant.

Acute withdrawal effects from methadone can be intense, although for many they will be milder than those from heroin. Acute withdrawal effects include shivering, yawning, feeling cold and clammy, goose-bumps on the skin, diarrhoea and vomiting, flu-like symptoms, agitation, anxiety, insomnia and sensitivity to sound/light. Opioid withdrawal symptoms are unpleasant but do not endanger life.

Potential effects of long term methadone use include constipation, tiredness, sedation. People often have problems with their teeth as methadone reduces your natural saliva which protects the teeth against dental caries.

Long-term risks of methadone are low if it is used as prescribed.

How much are you taking? How often?

If taken according to prescription then methadone is very safe.

Are you taking it with anything else? Mixing drugs is risky.

Mixing with benzodiazepines and alcohol is potentially very dangerous. Also if other opioid drugs are used, although initially methadone would usually block the effects, eventually you can over-whelm the methadone and accidentally overdose.

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Heroin is the commonly used name for the drug diacetylmorphine (diamorphine). It is a semi-synthetic opiate drug, made by chemically altering morphine, which comes from opium poppies.

All heroin can cause serious harm, but many of the harms from the use of heroin depend on the type and quality, how the user gets it in into their body, and what else is getting in too. The way it is used also affects the chances of getting addicted.

Illicit ‘heroin’ is typically less than 50% pure. The other constituents may include chemicals left over from the manufacturing process, chemicals added to enhance or mimic the effect (other opioids or sedative drugs), and stuff to bulk it up, like paracetamol. Heroin powder may also contain materials that give rise to infections, such as materials that contain spores of the bacteria that lead to anthrax or clostridium infections.

With the variation in purity, the ‘strength’ of any given powder can be hard to know. At times this may lead to overdose when particularly high purity batches are sold on the illicit market.

Brown heroin

Brown powder heroin is the main type of heroin found in Europe. It is an off-white to brown powder or powdery clumps that consists of heroin ‘base’, plus various other potentially harmful substances (see below). Base heroin becomes a vapour when heated and it is often ‘smoked’ (‘chased’) from foil. It can also be snorted although this method of use is uncommon. Base heroin does not dissolve in water so to inject it users need to use an acid (like citric acid) to convert it into the ‘salt’ form.

Heroin hydrochloride

Unusual in Europe, this is the hydrochloride salt form. It dissolves in water and therefore easily prepares for injection. It can also be snorted, but is less suitable for smoking as it does not vapourise easily. Pharmaceutical heroin, diamorphine hydrochloride, is a white odourless powder.

Black tar heroin

Common in the USA, black tar heroin is rarely found in Europe. It is made using a cruder technique, which results in it consisting mainly of drugs that are part-way between heroin and morphine (3-MAM and 6- MAM). It resembles tar- being black or very dark brown, ranging from gooey to crumbly. It can be smoked and injected, though it is considered particularly damaging to inject.

Injecting- (usually into a vein, sometimes under skin or into muscle)

As with the injection of any illicit drugs, injecting heroin poses the greatest risks. These include bacterial, fungal and viral infections, including abscesses at the site of injection, the collapse of veins, and infection with hepatitis HIV and other pathogens.

Injecting, particularly intravenously, results in a strong and addictive rush of euphoria. If someone has regularly injected heroin into their veins, it tends to be very difficult to go back to using one of the less intense methods. Injecting heroin under the skin (subcutaneously) or into muscle (intramuscularly) is possible but gives a less of a ‘rush’. Subcutaneous and intramuscular injections pose a higher risk of bacterial infection at the site of infection.

‘Smoking’ (the drug is actually vaporised rather than burned to produce smoke)

Compared to injecting, there is very much lower risk of overdose when smoking heroin- users have better control over their intake and can feel the effects of the drug very rapidly, regulating or stopping intake as necessary.

Rectally- ‘plugging’ it (squirting it up the rectum with a syringe)

Rectal use avoids injecting harms but has in common with injecting the fact that there is not much you can do if you use too much, which may be a seemingly small amount. Snorting avoids injecting harms, but most European heroin is not ideal for snorting.

Heroin is used recreationally because it produces intense feelings of euphoria and relaxation. Dependent individuals use it to ‘feel normal’ and avoid withdrawal symptoms. It works by affecting brain receptors involved in reward, pleasure and the perception of pain. The chemical modification of the morphine molecule to produce diamorphine has produced a drug that crosses the blood-brain barrier more quickly than morphine- this produces a rapid rise in brain levels of the drug and what users term a ‘rush’.

Heroin is a strong sedative and makes users feel peaceful, cosy and relaxed. Taken in a way that puts it into the bloodstream quickly (injecting mainly, but to a letter extent snorting, smoking, plugging), it will give a ‘rush’ of euphoric pleasure.

Some people experience vomiting and nausea, especially the first few times they use heroin, which introduces a risk of death from choking on inhaled vomit. Heroin also causes significant constipation.

Physical dependence will result after  regular, repeated use. Physical dependence means that the person using will experience withdrawal symptoms if they do not take heroin.

Diamorphine (pharmaceutical heroin) is used medically in many countries. Its primary use is for relief from severe pain. It is used for acute pain, (for example for heart attacks and accidents involving serious injuries) and chronic pain, for example that resulting from terminal cancer.

In some European countries, people with heroin dependencies are given pharmaceutical heroin in specialist clinics where they can inject under supervision. This reduces the harms of using street heroin, and has been shown to prevent almost all overdose deaths, however it remains controversial.

Overdose

Heroin and other opioids cause respiratory depression when used in overdose. This is when the drugs act on the brain and reduce the natural drive of the body to breathe.

Additionally, people can die from becoming unconscious and choking on their vomit. These risks are made greater if heroin is taken with other drugs that cause sedation or make you vomit, such as alcohol.

Overdoses can be caused either by accidentally taking too much, or by taking the same quantity of a purer batch of heroin, which amounts to the same thing. If heroin is injected, overdosing is much easier.

Furthermore, many users have overdosed on an amount of heroin that they have taken many times before. This can happen because of a drop in tolerance. Tolerance  will reduce in a matter of days without heroin and its relatives, or only weak heroin, meaning a previously normal amount could cause overdose. Overdoses are very common when heroin users come out of prison due to little or no tolerance, or users bingeing on freely available drug supplies.

Additionally some tolerance is dependent on the setting and routine in which a person normally takes heroin. Cues such as a particular room, handling injecting equipment or even a smell, will trigger changes in the body in preparation of the drug. This may explain some cases when heroin users have overdosed when taking the usual amount in a new or different environment.

If an overdose is suspected immediate medical attention is required. Symptoms include slow, irregular or shallow breathing, pinpoint pupils, weak pulse, bluish lips and nails, muscle spasms.  A drug called naloxone is the emergency treatment for overdose. There are many urban legends for reviving someone in an overdose situation, but medical treatment with naloxone is the only appropriate course of action in the case of an overdose- failure can act appropriately can result in an avoidable death.

Using illicit heroin long term, and the lifestyle that can accompany it are likely to lead to physical health problems.  Aging drug users have increasing vulnerability to overdose. Overdoses cannot always be seen as just a one-off accident.

The chance of your breathing and heart being dangerously affected by heroin will be increased if you have a heart or breathing condition, or low blood-pressure. Neurological or muscular conditions that could result in breathing being weakened might also increase risks.

Some people are allergic to opiates like heroin, and others can suffer serious allergic reactions to various substances that heroin has been cut with. Life-threatening asthma attacks have been caused by smoking or snorting heroin.

Injecting heroin can spread diseases and also makes wounds that often become infected. Any condition that lowers the immune system will increase the risks.

Many overdoses and fatalities result from the combination of heroin with other drugs. Other sedatives such as alcohol, benzodiazepines (e.g. diazepam- ‘Valium’, and temazepam) and other opiates (e.g. methadone) are frequently involved in accidental overdoses.

Combining heroin with a stimulant could also raise the risk of harm or death, although the evidence is not fully clear. The combination of heroin and cocaine, often called a ‘snowball’ or ‘speedball’, is a well-known example. This seems to be linked to a greater chance of overdose , although there is some evidence that it simultaneously may decrease the chance of that overdose being fatal.

Heroin can be very addictive. There are various aspects to heroin addiction. Firstly people may keep taking the drug because it is very pleasurable. After taking the drug repeatedly tolerance may then develop. Part of the way the brain and body develops tolerance is by producing the opposite effect of the drug, which means that a tolerant person will need the drug to stay at normal levels. Without the drug the person will experience withdrawal effects. Withdrawal effects are in some ways opposite to the effect of the drug. For example, heroin causes constipation, so a person can experience quite extreme diarrhoea in withdrawal.

Many people who become addicted to heroin suffered trauma and/or problems with mental health in their early life, before using heroin. This suggests that some people use it despite the risks as a form of self-medication, which is likely to lead to dependence.

Withdrawal symptoms include: sweating, depression, stomach cramps, diarrhoea, feelings of discomfort and unease, nausea and vomiting, and craving for heroin. Heroin withdrawal is very unpleasant which is a major reason why people addicted to heroin continue to use despite experiencing more and more harms, and less pleasure from use as time goes on.

Heroin’s illegality, its addictiveness and its disruptive influence on employment means that some users can be drawn into making money in ways they otherwise wouldn’t, such as stealing or prostitution, to maintain a heroin addiction. Many heroin dealers are users who sell drugs to fund their own habit. The needs of dependents, such as children of heroin addicts, are often compromised by the time and money needed to  maintain a heroin addiction.

There is also still a significant social stigma over heroin use. People who are dependent on  or have previously been dependent upon heroin may find it hard to be trusted and  employers may discriminate against them.

Injecting heroin carries the risk of infection from viruses or bacteria, especially if people are sharing needles. Repeated injections cause veins to become scarred and collapse.

The harms of heroin are linked to the harms of poverty and unstable lifestyle. Many problems may be caused by neglecting other things necessary for wellbeing in order to maintain the habit.

Street heroin is a drug which always has a high potential for causing harm. However, there is enormous variability in the risks suffered by different users with different habits. When the costs of use can be so high, there is an especially strong reason to make every effort to minimise harms.

Avoiding use, minimising use, avoiding addiction.

Whilst the body does not immediately develop a physical dependency, people will often like the drug and want to repeat the experience from the first use. If you encounter heroin regularly in your social or family life, this constant availability will add to the temptation to repeat an initial experience, as will stresses in life.

If you do use heroin occasionally and do not wish to stop despite the risks, it is important to be vigilant and reactive to signs of dependence. Growing tolerance for heroin (needing more to feel the same effects) is an important warning sign of some of the changes in your brain chemistry that lead to cravings and withdrawal effects when you don’t use.

How are you taking it?

Injecting heroin carries with it more risks than smoking or snorting heroin. Firstly, with heroin injection the total dose is taken in one go, so it is easy to overdose. Judging the amount to use is made more difficult because heroin purity varies. It is therefore much better to take a small amount to see how strong it is before taking a moderate dose. As injecting heroin produces such a big rush it is easier to become addicted to heroin when injecting.

If a user is injecting, they can still do many things to reduce unnecessary harms. Deliberately, or accidentally sharing used needles carry the risk of infection from viruses such as HIV and hepatitis. Using new sterile equipment reduces the risk of  infection. Using lemon juice or vinegar as acids to make brown base heroin is very risky – lemon juice is linked to fungal infections including inside the eyeball. In many countries, advice on safer injection and free equipment can be accessed at needle exchanges.

Are you having anything else? Mixing other drugs with drink can be very risky

Taking heroin with any other drug that can stop breathing (e.g. alcohol or benzodiazepines) increases the risk of overdose. Additionally, taking heroin with stimulants like cocaine and speed (amphetamine) can suppress some of their negative side effects . This is a problem as the effects of cocaine or speed will wear off before heroin does meaning a person could take both drugs and then overdose when the stimulant wears off. Doing this may also be more addictive.

Can heroin dependence happen from one use?

It takes repeated uses over a short space of time to become physically addicted to heroin, so that symptoms appear when you don’t take it. However, heroin is, at least to some people, immediately satisfying and pleasurable (even if it causes vomiting), and some dependent users feel that they ‘fell in love’ with the drug from the first try. Heroin can give a deep feeling of relief and comfort, and having had it once, any time when an individual feels in need of relief and comfort, the temptation to use it may arise.

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Buprenorphine is a prescription-only medicine used mainly to treat opioid addiction. Is was initially used as a pain-killer but now it is much more widely used to treat people who have got stuck on heroin or other opioid drugs (such as prescription pain-killers). Buprenorphine is an opioid drug, so it has similar effects to drugs like codeine, morphine, and heroin. However, it is a partial-agonist at the opioid receptor, that is it only has a partial effect in triggering the opioid receptors in the brain, and therefore its effects are much milder than heroin. It is also much safer than heroin, particularly an overdose.

Buprenorphine usually comes in tablet form. However this must be absorbed over several minutes under the tongue rather than swallowed (it will have very little effect when swallowed due to how it is absorbed and broken down by the body). It also comes as a patch, more often when used as a painkiller. In this case the patch can stay on for several days to give the dose over several days.

Buprenorphine is used illicitly, and there is a street value for buprenorphine diverted from medici-nal use. Most people use it illicitly in the same way although some people crush it up and snort it or inject it. Used in either of these ways it is more dangerous. There is evidence that the effects may be stronger and less easy to judge. Also using by injecting means a person runs the risks associated with intravenous use.

Buprenorphine is an opioid drug. It mimics the body’s natural pain-killing chemicals, endorphins. Therefore it can relieve pain, cause drowsiness, can cause mild euphoria, slow breathing, slow the bowels causing constipation, and other side effects of opioids. However, it is a partial-agonist, that is it only partly causes and effects at the receptor, and therefore produces much less of these effects than full-agonists such as heroin, methadone, and morphine. People report being much less tired and sedated taking buprenorphine rather than heroin or methadone. As it is a partial-agonist if someone is taking it regularly it can block the effects of full-agonist opioid drugs such as heroin. This makes it very useful in the treatment of addiction to heroin.

Yes. It is mostly used as a substitute medication for people addicted to opioids such as heroin. It is also a prescribed pain-killer.

Buprenorphine is an opioid drug. It mimics the body’s natural pain-killing chemicals, endorphins. Therefore it can relieve pain, cause drowsiness, can cause mild euphoria, slow breathing, slow the bowels causing constipation, and other side effects of opioids. However, it is a partial-agonist, that is it only partly causes and effect at the receptor, and therefore produces much less of these effects than full-agonists such as heroin, methadone, and morphine.

If someone takes an overdose of an opioid drug they can die instantly. This is usually by respiratory depression (slowing the drive and effectiveness of breathing). Anyone not used to opioid drugs would be much more at risk of this. However, as buprenorphine is a partial agonist, that is it only has a partial effect at the opioid receptor, it is much less likely at heroin and methadone to cause respiratory depression and therefore death by overdose.

The risks of death by overdose increase when many substances are taken together for example alco-hol and benzodiazepines which also have effects on breathing (respiration). There is evidence that buprenorphine taken with benzodiazepines increases the effects on depressing breathing.

Buprenorphine decreases control and impairs judgment, making the risk of accidents much higher. This means activities like driving under the influence of buprenorphine is potentially very dangerous.

The risks of depressed breathing caused by buprenorphine may be increased in people with condi-tions such as muscle weakness (e.g. myasthenia gravis), sleep apnoea, or lung disease/breathing disorders).

Taking buprenorphine with depressant drugs increases the risk of depressing breathing. Additionally, the effects of buprenorphine may be masked if taken with a stimulant, which can lead to an overdose if a lot of the drug is taken and then the stimulant wears off. Certain medications (e.g. some antidepressants) may also interact with buprenorphine to increase sedative effects.

One-off or occasional use of buprenorphine is very unlikely to result in the development of dependence. However, taking buprenorphine regularly over a sustained period can cause serious physical and psychological addiction. People who become dependent on buprenorphine may become tolerant to the drug’s effects and experience withdrawal symptoms without it. Users may crave the drug and feel unable to cope without it. The longer the drugs are taken, the higher and more regular the dose and the stronger the buprenorphine, the higher the risk of dependence. However, users generally report that it is much easier to come off buprenorphine than heroin or even methadone.

A period of sustained dependence on any drug can be debilitating and prevent people from working and leading an active life. It may also cause mental and physical harm and opioid withdrawal can be very unpleasant.

Acute withdrawal effects for some buprenorphine users can be intense, although for many they will be milder. Acute withdrawal effects include shivering, yawning, feeling cold and clammy, goose-bumps on the skin, diarrhoea and vomiting, flu-like symptoms, agitation, anxiety, insomnia and sensitivity to sound/light. Opioid withdrawal symptoms are unpleasant but do not endanger life.

Potential effects of long term buprenorphine use include constipation, tiredness, sedation.

Long-term risks of buprenorphine are low if they are used as prescribed. Crushing and injecting il-licit buprenorphine puts a person at risk of clots such at DVT (deep vein thrombosis) and PE (Pul-monary Embolus). PE can be life threatening and very dangerous. People can get PE’s from DVT’s in the legs. Other consequences of injecting are also possible such as infections.

How much are you taking? How often?

If taken according to prescription buprenorphine is very safe.

Are you taking buprenorphine with anything else?

Mixing with benzodiazepines and alcohol is potentially very dangerous. If other opioid drugs are used, although the effects are blocked by buprenorphine, eventually you can overwhelm the buprenorphine and accidentally overdose.

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