Opioids are chemicals that bind to receptors in the brain and body that are associated with pain, reward, and addictive behaviors. Common opioids include “street drugs,” like heroin, and legal narcotics, such as oxycodone, buprenorphine, morphine, codeine, methadone, and fentanyl. Opioid medications are intended to be used under the supervision of health care providers to relieve pain that cannot be treated with less powerful drugs, but improper prescription or use can easily lead to addiction. Opioid-related disorders are associated with the overuse, misuse, and dependence on these drugs; these include opioid-use disorder, opioid intoxication, and opioid withdrawal.
Morphine is frequently prescribed to alleviate severe pain after surgery; fentanyl can also be prescribed for similar reasons. Codeine can relieve milder pain, as can oxycodone (OxyContin is an oral, controlled-release form of the drug), propoxyphene (Darvon), hydrocodone (Vicodin), hydromorphone (Dilaudid), and meperidine (Demerol), which is used less often because of its side effects. Diphenoxylate or Lomotil can also relieve severe diarrhea, and codeine can ease severe coughs.
Other drugs may be given with pain medication for increased effectiveness. These include corticosteroids, anticonvulsants, antidepressants, local anesthetics, and stimulants. Opioids are only safe to use with other drugs under a physician's supervision. They should not be used in conjunction with alcohol, barbiturates, antihistamines, or benzodiazepines. These drugs may slow down breathing, and the combined effects can result in life-threatening respiratory depression.
Symptoms of Use
Common side effects of opioid use include:
- Nausea and vomiting
- Clouded thinking
- Respiratory problems
- Gradual overdose
- Sexual dysfunction
Patients should talk to their doctor if side effects become troubling.
Repeated exposure to opioids causes the body to adapt, sometimes resulting in tolerance and in symptoms of withdrawal upon abrupt cessation of drug use. Thus, 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.
People experiencing withdrawal may display:
- 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. People who use heroin begin to have withdrawal symptoms within 6 to 12 hours after their last dose, while people who take longer-acting drugs, such as methadone, may experience withdrawal symptoms two to four days after their last dose.
Opioid Use Disorder
Strong cravings for opioids, an inability to function without opioids in spite of physical, emotional and financial side effects, and loss of control over their use are signs of Opioid Use Disorder. To be clinically diagnosed with the disorder, an individual must experience a pattern of opioid use that leaves him or her impaired or distressed due to at least two of the following within the previous year:
- Taking larger dosages and/or taking opioids for a longer period of time than intended
- Wanting or desiring to reduce opioid use, or making unsuccessful efforts to reduce use
- Spending a large amount of time procuring, using, or recovering from the effects of opioids
- An overwhelming desire or urge to use opioids
- The inability, due to opioid use, to meet responsibilities in one's job, school, or home life
- Continued use of opioids in the face of social/interpersonal problems that result from, or are made worse by, the use of opioids
- 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
- Opioid use continues even when the individual knows that the opioid use causes or exacerbates physical and psychological problems
- Tolerance develops 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
- Withdrawal develops 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)
What factors contribute to the opioid epidemic?
A combination of pressure from manufacturers and pharmaceutical companies as well as patients may persuade a doctor to prescribe opioids. However, there is a high risk of patients building up a tolerance or getting hyperalgesia, which is increased sensitivity to pain after the long-term use of opioids. As a result, individuals may require higher doses of opioid medications to get relief, thus building up a dependency that often isn’t easy to break. Putting an end to the opioid epidemic may require better education and greater awareness.
Why are older adults at increased risk of misusing opioids?
Older adults are one of the demographics most likely to experience daily pain and be prescribed opioids. Opioid prescriptions are particularly common in nursing home settings, and older adults face unique challenges in the opioid crisis. Due to age-related changes in their bodies and their greater likelihood of being on multiple medications, older adults are also at increased risk of having adverse side effects to opioids. Opioid-related hospitalizations and overdose deaths are more common for older adults as well. Traditional programs and support groups for people who misuse opioids are rarely tailored to meet the needs of older adults, making recovery more difficult.
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.
How can people avoid opioid dependency?
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.
Is it safe for people with a history of addiction to use opioids for pain management?
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.
How can we make prescription opioid use more responsible?
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.
What is being done about the opioid epidemic?
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.