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The impact of heroin illicit market in the framework of COVID 19 pandemic.

We read with interest the commentary of Tittarelli et al1 on the current diffusion of higher-purity heroin in Italy and related rise of overdose cases1. The author discussed not only recent increasing trend in drug purity, but also on the presence of adulterants rising drug toxicity2-11 and on the possible risk of the presence of new psychoactive substances as even more hazardous adulterants12. In the context of this commentary, some short remarks as to the impact of heroin illicit market in the framework of COVID 19 pandemic can be of interest. Indeed, within the extremely serious health emergency that we have been experiencing since the beginning of 2020, the rules set by the authorities during “lock down” have led to a significant drop in the street sale of psychotropic drugs. A scenario that opens up the hypothesis that drug users are turning to the illicit market present in the “dark web”, to obtain classic drugs such as cocaine, hashish or heroin. It is plausible that in a period of home confinement, habitual consumers of drugs of abuse no longer search for psychoactive substances stimulating socialization in recreational environments such as cocaine, amphetamines or designer drugs, but rather for compounds to be consumed in solitude to ease confinement anxiety such as tranquilizers (e.g. benzodiazepines) or narcotics (e.g. prescription or illicit opioids and heroin). In this concern, the US National Institute on Drug Abuse (NIDA), has also recently addressed the problem COVID-19, publishing on its website a focus on the possible implications for people with drug use disorders, with special attention to heroin users13. NIDA highlighted the determined role of the scientific community and its vigilance on the damage that the pandemic can cause to heroin users, as they are more vulnerable due to the effects that this substance has on the respiratory apparatus. People who consume high doses of heroin and more in general of opioids for therapeutic reasons or because they have an addiction, face a number of problems and threats to their lung health14. Since opioids and specifically heroin act on the brain stem and reduce respiratory rate, their consumption not only puts at risk of a fatal or potentially lethal overdose, but can also cause a dangerous reduction in the blood oxygen levels potentially harmful to the central nervous system: while brain cells can withstand short periods of poor oxygen supply, they can be seriously damaged when the situation persists. Since several established studies demonstrate how chronic lung disease increases the risk of overdose mortality for heroin users, the reduced lung capacity caused by COVID-19 can seriously endanger heroin consumers. Therefore, physicians should be prepared to monitor the possible adverse effects of heroin consumption in the treatment of drug addicts with COVID-19. In conclusion, the rise of heroin consumption, which is reported internationally15, the concomitant increase in its purity, the possible presence of toxic adulterants should be seriously taken into consideration by health professional in charge of treating opiates addicts at risk of contracting COVID-19.