Opioids

Opioids are chemicals that bind to receptors in the brain and body associated with pain, reward, and addictive behaviors. Opioid medications are used by healthcare providers to relieve pain that cannot be treated with less powerful drugs. Common opioids include heroin and narcotic medications such as oxycodone, buprenorphine, morphine, codeine, methadone, and fentanyl. Opioid-related disorders are associated with overuse, misuse, and dependence on these drugs, and they include opioid-use disorder, opioid intoxication, and opioid withdrawal. 

Definition

Opioids are a class of controlled pain-management drugs that contain natural or synthetic chemicals based on morphine, the active component of opium. These narcotics effectively mimic pain-relieving chemicals that the body produces naturally. Opioids are the most often prescribed pain-relievers because they are so effective. Many studies have shown that opioid analgesic drugs are safe and rarely cause clinical addiction or compulsive usage if taken as directed.

Morphine, heroin, codeine and related drugs are among the opioids. Morphine is frequently prescribed to alleviate severe pain after surgery (fentanyl also can be prescribed for similar reasons). Codeine can be helpful in soothing milder pain, as are oxycodone (OxyContin, 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.

Opioid pain medication may be taken in a variety of ways. The preferred method is by mouth, since medication taken orally is convenient and usually inexpensive. When this method cannot be utilized, medication may be taken rectally or through patches placed on the skin. Intravenous methods are used only when easier and cheaper methods are not available. Patient-controlled analgesia (PCA) pumps are sometimes used to allow a patient to deliver the drug into veins, skin, or the spine. Intraspinal administration is especially helpful for patients who do not respond to pain medication delivered via the other methods or who experience extreme side effects.

Common side effects of opioids include constipation, sleepiness, nausea and vomiting, clouded thinking, respiratory problems, gradual overdose, sexual dysfunction. Some of the milder side effects may be avoided by adjusting the time when doses are taken, such as after a meal or at bedtime if a person is experiencing nausea or sleepiness. Constipation may be lessened by drinking more fluids, eating high-fiber foods, or taking a laxative (which should be approved or prescribed by the patient's doctor). Patients should talk to their doctor if side effects become too troubling.

Patients may find that they develop a tolerance to opioid pain medications and need to have their doses increased to be effective. Repeated exposure to opioids causes the body to adapt, sometimes resulting in tolerance (that is, more of the drug is needed to achieve the desired effect compared with when it was first prescribed) 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, but they should also be medically supervised when stopping use to reduce or avoid withdrawal symptoms, which can include muscle and bone pain, insomnia, vomiting, cold flashes with goose bumps, involuntary leg movements, diarrhea, and restlessness.

Adjuvant Drugs: Other drugs may be given with the 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 slow down breathing, and their combined effects can result in life-threatening respiratory depression.

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, and impaired judgment. Other symptoms include constriction or dilation of the pupils, drowsiness or coma, slurred speech, and impairment in attention or memory. 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 an addiction. A large single dose can cause severe or fatal respiratory depression.

The symptoms of opioid withdrawal are opposite to the effect of opioids. People experiencing withdrawal may display anxiety, restlessness, irritability, increased sensitivity to pain, and have an “achy feeling” that is often found in the back and legs. Other symptoms include a strong sense of unease, nausea or vomiting, muscle aches, excessive tearfulness, and runny nose. The speed and severity of opioid withdrawal depends 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.

To be clinically diagnosed with opioid use 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 (Mild 2-3 symptoms; Moderate 4-5 symptoms; Severe 6 or more symptoms): 

  • The amount of opioids taken is a larger dosage and/or is taken for a longer period of time than intended
  • The want or desire to reduce opioid use exists, or efforts were taken to reduce opioid use
  • A large amount of time goes into procuring, using, or recovering from the effects of opioids
  • An overwhelming desire, urge, or craving to use opioids
  • The inability, due to opioid use, to maintain obligations to 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
  • Opioid use becomes prioritized to such an extent that social, occupational, and recreational activities are either given up completely, or are reduced drastically 
  • The use of opioids occurs even in situations where it becomes physically hazardous for the individual
  • Continued use of opioids even when the individual knows that the opioid use causes or exacerbates physical and psychological problems
  • Tolerance develops according to one of the following:
    • Intoxication requires greater amounts of opioid use than previously
    • The same dose of opioid over the same amount of time results in weaker effects 
  • Withdrawal due to one 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)

Causes

Opioid-use disorder may be diagnosed when a person shows compulsive, prolonged use of opioids for no legitimate medical purpose or in larger doses than are needed for medical treatment. 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. Healthcare professionals who have opioid use disorder might write prescriptions for themselves or take opioids from pharmacy supplies. Heavy or prolonged use causes the body to become physically dependent on opioids, which in turn causes symptoms of withdrawal that are so distressful that it becomes difficult to stop taking them. When that dependence and inability to cease use interferes with the quality of a person's life, it is considered an addiction.

Treatments

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 and live normal, productive lives. 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. Results tend to be improved when more treatment is given. Many patients require other services as well, such as medical and mental health services and HIV prevention services. Patients who stay in treatment longer than three months usually have better outcomes than those who stay less time. 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.

Medication

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 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 addiction to heroin and other opiates. 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. It is not widely used, however, because of poor compliance, except by highly motivated individuals (e.g., physicians at risk of losing their medical license). It should be noted that 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 for opiate addicts and residential therapeutic community treatment.

In maintenance treatment for heroin addicts, 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, noneuphoric state free from physiological craving for opiates. In this stable state, the patient is able to disengage from drug-seeking and related criminal behavior and, with appropriate counseling and social services, become a productive member of his or her 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 their 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 crime-free, drug-free lifestyle. TCs differ from other treatment approaches principally in their use of the community-treatment staff and those in recovery—as a key agent 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, often 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 or Cocaine Anonymous. Chemical dependency programs for drug abuse arose in the private sector in the mid-1980s with insured alcohol/cocaine abusers as their primary patients. Today, as private provider benefits decline, more programs are extending their services to publicly funded patients.

Methadone maintenance programs are usually more successful at retaining clients with opiate dependence than are therapeutic communities, which tend to have greater success than outpatient programs that provide psychotherapy and counseling. Within various methadone programs, those that provide higher doses of methadone (usually a minimum of 60 mg) have better retention rates. Those that provide other services, such as counseling and medical care, along with methadone, generally achieve better results than the programs that provide minimal services.

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. Some of the more successful programs have reduced the re-arrest rate by one-fourth to one-half. For example, the Delaware Model, an ongoing study of comprehensive treatment of drug-addicted prison inmates, 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.

Drug abuse has a high economic impact on society, costing an estimated $67 billion per year. This figure includes costs related to crime, medical care, treatment programs, social welfare programs, and time lost from work. Treatment of drug abuse can reduce those costs. It costs approximately $3,600 per month to leave a drug abuser untreated, and incarceration costs approximately $3,300 per month. In contrast, methadone maintenance therapy costs about $290 per month. Overall, studies have shown that $4 to $7 is saved for every dollar spent on treatment.

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References

  • National Cancer Institute National Institutes of Health
  • U.S. Department of Health and Human Services National Institute on Drug Abuse
  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Last reviewed 02/01/2018