Opioids are a group of chemical substances—some produced naturally by the body, some naturally occurring in plants, some made synthetically as medication—that bind to receptors in the brain to regulate pain and reward. Their capacity to relieve pain makes them particularly subject to misuse and abuse, and opioids are a common source of addiction.
The brain makes its own (endogenous) opioids, most notably endorphins, which circulate throughout the body and induce pain relief and euphoria by regulating the action of neurotransmitters. Exogenous opioids—whether extracted from plants, like morphine and codeine, or made in a laboratory partially or wholly, like oxycodone and fentanyl—are widely prescribed as painkillers. Opioid medications are intended to be used under medical supervision and are frequently prescribed for postsurgical pain relief.
However, they often are obtained and used illicitly. Misuse of prescription painkillers can lead to use of heroin, an opioid derived from morphine and widely available as a “street drug.” Opioid-related disorders associated with the overuse, misuse, and dependence on these drugs include opioid-use disorder, opioid intoxication, and opioid withdrawal.
Opioids are among the most effective drugs for treating pain and can significantly improve the quality of life for individuals with chronic pain or who have just undergone surgery. They also have other medical uses, including acting as cough suppressants and reducing diarrhea. But because the body adapts to some of their effects over time, people may develop a tolerance to opioids and become dependent on them for pain relief.
In addition to pain relief, opioids are associated with a number of potentially negative side effects, such as:
- Nausea and vomiting
- Clouded thinking
- Respiratory problems
- Gradual overdose
- Sexual dysfunction
Given the possibility of tolerance, people can develop symptoms of withdrawal upon abrupt cessation of opioid drugs. Individuals taking prescribed opioid medications should not only do so under appropriate medical supervision; they should also be medically supervised when stopping use to reduce or avoid withdrawal symptoms.
Opioid intoxication is diagnosed when recent exposure to an opioid causes significant problematic behavioral or psychological changes. Psychological symptoms include:
- Initial euphoria followed by apathy
- A strong sense of unease
- Unintentional and purposeless movement (hand wringing, pacing, uncontrolled tongue movement)
- Slowed cognition and movement
- Impaired judgment
Physical symptoms include:
- Constriction or dilation of the pupils
- Slurred speech
- Impairment in attention or memory
- Drowsiness or coma
A large single dose can cause severe or fatal respiratory depression.
When an individual takes opioids for a long time and then suddenly stops or lowers the dosage, they may experience withdrawal. This can manifest as a wide range of aversive symptoms lasting anywhere from a week to several months.
Some of the most common symptoms of withdrawal include:
- Increased sensitivity to pain
- An achy feeling, often found in the back and legs
- A strong sense of unease
- Nausea or vomiting
- Excessive tearfulness
The speed and severity of opioid withdrawal depend on the type of opioid used. Among people who use heroin, withdrawal symptoms begin within 6 to 12 hours after their last dose, while those who take longer-acting drugs, such as methadone, may experience withdrawal symptoms two to four days after their last dose.
Opioid Use Disorder
To be clinically diagnosed with Opioid Use Disorder, an individual must experience a harmful pattern of opioid use that leaves him or her impaired or distressed due to at least two of the following factors within the previous year:
- Taking larger dosages and/or taking opioids for a longer period of time than intended
- Being unable to reduce opioid use despite a strong desire to do so
- Spending a large amount of time procuring, using, or recovering from the effects of opioids
- Experiencing an overwhelming desire or urge to use opioids
- Finding oneself unable, due to opioid use, to meet responsibilities in one's job, school, or home life
- Continuing one's use of opioids in the face of social/interpersonal problems that result from or are made worse by it
- Prioritizing opioid use to such an extent that social, occupational, and recreational activities are either given up completely or are reduced drastically
- Using opioids even in situations where it becomes physically hazardous
- Continuing to use opioids despite knowing that they are causing or exacerbating physical and psychological problems
- Developing tolerance in the form of either of the following:
- Intoxication requires greater amounts of opioid use than it did previously
- The same dose of opioid over the same amount of time results in weaker effects
- Developing withdrawal in the form of either of the following:
- Individuals displays characteristics of Opioid Withdrawal Syndrome
- Symptoms of withdrawal diminish as a result of the use of opioids (or similar substances)
Heavy or prolonged use of opioids causes the body to become physically dependent on the drugs, which in turn causes symptoms of withdrawal that are so distressful that it becomes challenging to stop taking them. When dependence and inability to cease use interferes with the quality of a person's life, it is considered to have developed into Opioid Use Disorder.
Opioid Use Disorder—as well as overdoses and deaths related to opioid use—are at epidemic levels in the United States and other places around the world. This crisis, known as the "opioid epidemic," is considered to have begun in the 1990s, when, due to changing federal regulations and increased marketing by pharmaceutical companies, prescriptions of legal opioids increased rapidly. Today, they are among the most prescribed medications in the U.S.; as of 2017, there were 58 opioid prescriptions for every 100 Americans, according to the CDC.
As opioids are highly addictive, many who are prescribed the medications, often for legitimate pain, become dependent on them. After developing a habit, some who are dependent on opioids may continue their prescriptions for months or years longer than recommended; if a clinician declines to refill a prescription, they may seek other, illegal forms of opioids—such as heroin—to manage chronic pain or opioid dependence. A person with Opioid Use Disorder might purchase opioids on the illegal market or may falsify or exaggerate medical problems to receive prescription opioids from a physician. Health care professionals who have Opioid Use Disorder might write prescriptions for themselves or take opioids from pharmacy supplies.
Though some illegal forms of opioids can be stronger than prescription opioids or may be cross-contaminated with other substances, overdosing on any form of opioid is still very dangerous. In 2017 alone, opioid overdoses were linked to nearly 50,000 deaths in the U.S.
Opioid drugs include:
• Codeine — can relieve milder pain
• Fentanyl (Actiq, Abstral, Duragesic, Fentora) — a powerful synthetic opioid used to treat severe pain, especially after surgery
• Hydrocodone/acetaminophen (Hysingla, Zohydro ER, Lorcet, Lortab, Norco, Vicodin) — taken orally to treat pain; may act as a cough suppressant
• Hydromorphone (Dilaudid, Exalgo) — extended-release medication used to treat long-term, severe pain
• Meperidine (Demerol) — used less frequently because of its severe side effects
• Methadone (Dolophine, Methadose) — used to treat extreme, round-the-clock pain; it may also be prescribed to relieve withdrawal symptoms for those trying to recover from an opiate addiction
• Morphine (Kadian, MS Contin, Morphabond) — frequently prescribed to alleviate severe pain after surgery
• Oxycodone (OxyContin is an oral, controlled-release form of the drug) — used to treat moderate to severe pain for extended periods of time
• Propoxyphene (Darvon) — used to treat mild to moderate pain
People often find it difficult to cut back on opioid use without treating the underlying cause of their pain. When patients with chronic pain are trying to avoid opioid dependency, it helps to have an effective health care team that shares information and agrees on a treatment plan. Non-drug alternatives for treating chronic pain can provide some relief; these may include meditation and relaxation techniques, guided imagery, biofeedback, yoga, and cognitive behavioral therapy. It’s also important to have a medication management plan with the goal of tapering and eventually stopping opioid use.
Substance misuse can weaken the body’s natural defenses against pain, making it so that the person builds up a tolerance to prescription opioids and requires higher doses to achieve the same effects. Different kinds of opiate pain medication may be safer for people who have a history of substance misuse. Physicians may also want to consider long- or extended-release formulations to decrease the risk of abuse for patients with a history of addiction.
Like other substance use disorders, Opioid Use Disorder is treatable. Through treatment that is tailored to individual needs, patients can learn to control their condition. Those in treatment for drug addiction, like those with diabetes or heart disease, learn behavioral changes and often take medication as part of their recovery program.
Behavioral therapies can include counseling, family therapy, psychotherapy, or support groups. Treatment medications help to suppress withdrawal symptoms and drug cravings and to block the effects of drugs. Many patients require other services as well. Patients who stay in treatment for longer than three months usually have better outcomes than those who do not. Patients who go through medically assisted withdrawal without any further treatment perform about the same in terms of their drug use as those who were never treated.
Methadone, a synthetic opioid that eliminates withdrawal symptoms and relieves craving, has been used successfully for more than 30 years to treat people addicted to heroin as well as other opiates. Studies show that treatment for opioid addiction using methadone at an adequate dosage level combined with behavioral therapy reduces death rates and many health problems associated with opioid abuse. Buprenorphine, another synthetic opioid, is a more recently approved medication for treating opioid addiction; it can be prescribed in a physician's office.
Naltrexone is a long-acting opioid receptor blocker that can be employed to help prevent relapse. (This medication can only be used for someone who has already been detoxified, since it can produce severe withdrawal symptoms in a person continuing to abuse opioids.) Naloxone is a short-acting opioid receptor blocker that counteracts the effects of opioids and can be used to treat overdoses.
Types of Treatment Programs
The ultimate goal of treatment is lasting abstinence, but the immediate goals are reduction of drug use, improvement of the patient's ability to function, and diminishing the medical and social complications of drug abuse.
There are several types of drug abuse treatment programs. Short-term methods last less than six months and include residential therapy, medication therapy, and drug-free outpatient therapy. Longer-term treatment may include, for example, methadone maintenance outpatient treatment and residential therapeutic community treatment.
In maintenance treatment for those who are addicted to heroin, patients are given an oral dose of a synthetic opiate, usually methadone hydrochloride or levo-alpha-acetyl methadol (LAAM), administered at a dosage sufficient to block the effects of heroin and yield a stable, non-euphoric state free from craving for opiates. In this stable state, the patient is able to disengage from drug-seeking and (in some cases) related criminal behavior and, with appropriate counseling and social services, re-engage with the community.
Outpatient drug-free treatment encompasses a wide variety of programs for patients who visit a clinic regularly. Most of the programs involve individual or group counseling. Some programs also offer other forms of behavioral treatment, such as:
- Cognitive-behavioral therapy, which seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs
- Multidimensional family therapy, which was developed for adolescents with drug abuse problems as well as their families, addresses a range of influences on drug abuse patterns and is designed to improve overall family functioning
- Motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment
- Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs
Therapeutic communities (TCs) are highly structured programs in which patients stay at a residence, typically for 6 to 12 months, where the focus is on the re-socialization of the patient to a drug-free lifestyle. TCs differ from other treatment approaches principally in their use of the community-treatment staff and those in recovery as key agents of change to influence patient attitudes, perceptions, and behaviors associated with drug use. Patients in TCs include those with relatively long histories of drug dependence, involvement in serious criminal activities, and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children.
Short-term residential programs, commonly referred to as chemical dependency units, are often based on the "Minnesota Model" of treatment for alcoholism. These programs involve a 3- to 6-week inpatient treatment phase followed by extended outpatient therapy or participation in 12-step self-help groups, such as Narcotics Anonymous (NA).
Drug treatment programs in prisons can succeed in preventing a return to criminal behavior, particularly if the patient is involved in a community-based program that continues treatment after he or she has left prison. For example, the Delaware Model, an ongoing study of comprehensive treatment of prison inmates who struggle with drug addiction, shows that prison-based treatment including a therapeutic community setting, a work release therapeutic community, and community-based aftercare reduces the probability of re-arrest by 57 percent and reduces the likelihood of returning to drug use by 37 percent.
About 10.1 million people (aged 12 and up) misused opiates in 2019, according to a Substance Abuse and Mental Health Services Administration (SAMHSA) survey. The opioids prescribed to help manage pain are generally done so out of necessity and with good intentions. However, there are insufficient resources in place to help most patients stop using opioids. Patients who are prescribed opioids, particularly at high doses, would benefit from a long-term management plan, counseling on appropriate use, and an exit strategy that takes into account potential withdrawal. We can also address the opioid problem by better educating physicians on long-term pain management, including best practices in tapering opioid use.
The U.S. government, for instance, has passed guidelines for doctors to limit the type and quantity of opioids they prescribe patients, as well as the duration of treatment. By extension, they reason, they can limit both legal and illegal access to opioids. The American government has also improved opioid education and increased the availability of Naloxone, a medication designed to rapidly treat an opioid overdose, which could save lives in an emergency. Cooperation on the local and federal levels is necessary to fight back against the opioid epidemic.