Opioid addiction is a disease that entails a physical and psychological dependence on opioids. Given the way our brain chemistry responds to them, some people have a route to addiction. Specialized treatment is highly recommended and may prove to be the only form of recovery for addiction symptoms. Addiction is a chronic illness that may be treated, but not cured.
What Are Opioids?
Simply stated, the term opioid refers to any substance, natural or synthetic, that binds to opioid receptors in the brain. Although it is common for the terms opioids and opiates to be used interchangeably, there are some notable differences. Opiates refer to natural opioids such as heroin, morphine, and codeine while opioids refer to all natural, semisynthetic, and synthetic opioid compounds.1
Opioids interact with one’s natural physiology through the opioid system. This system is primarily responsible for pain, reward, and addictive behaviors. Here, opioids bind with opioid receptors in the brain, which include mu, delta, and kappa receptors.2 Given that opioids interact with perhaps one of our most vulnerable brain systems, the potential for physiological dependence and addiction is high. Therefore, use must be regulated with caution.
The following list provides the names of common opioids from the least to most potent:
Of important note is that heroin ranks tenth out of sixteen opioids from weakest to strongest, and is about two to five times stronger than morphine. As such, many of the prescribed opioids are significantly stronger than those produced for recreational use on the streets.
When Are Opioids Prescribed?
Opioids are generally prescribed as a means of treating pain. The kind and dose prescribed will vary according to the treatment provided and likely intensity of pain. For instance, codeine may be prescribed to assist with a severe cough or chest cold. A stronger opioid, such as hydrocodone, may be prescribed after highly invasive and painful dental work, such as multiple root canals. Even stronger opioids, such as fentanyl, are sometimes used to assist during labor in the form of an epidural or given to patients who just completed a major surgery.
Time and time again, people believe that thought, “If my doctor prescribed it or me, then it must be okay.” Because individual pain thresholds vary, as do prescribing physicians, there is no exact science to prescribing the specific kind and dose in every case. Physicians are oftentimes unaware of any underlying mental health or addiction issues. Accordingly, physicians do their best to figure out the best prescription based on the pain level currently experienced and/or anticipated.
Opioid Addiction vs Drug Tolerance vs Drug Dependence
Opioid addiction varies from drug tolerance. It is important to note the differences in order to spot an actual addiction.
Opioid Addiction vs Drug Tolerance
While not everyone who takes opioids will become addicted, it is important to note that for all those who use them (even as recommended), that tolerance will happen as it is a physiological response. As repeated use of an opioid is introduced to the body, it will develop tolerance to the medication. For this reason, it is important to consult with a physician and ensure that a plan is in place to safely discontinue consumption. Tolerance is not a sign of addiction.
Opioid Addiction vs Drug Dependence
Many people use the word addiction and dependence interchangeably, but this is not correct. Dependence is a medical term that describes the body changing as it creates an adaption to having medication, or an opioid, within it. When someone is dependent on an opioid, if they stop taking the drug suddenly, they will show withdrawal symptoms due to the body’s created adaptations.
Addiction, on the other hand, is when the dependence has become an overwhelming or uncontrollable urge to use a medication, and the person is even willing to sacrifice one’s wellbeing or put oneself in harm’s way to take a drug.
Common Co-occurring Disorders
It is important to consider how mental health disorders impact substance use disorders and vice versa. Those with mental health disorders may cope by using, which reinforces continued use. For those who have progressed into opioid addiction, it is also likely that they may experience a substance-induced mental health disorder.
Common co-occurring disorders include anxiety disorder, major depressive disorder, post-traumatic stress disorder (PTSD), bipolar depression, and schizophrenia spectrum. In such cases it is critical that both the addiction and mental health disorder are treated concurrently.
Signs of Opioid Addiction: What It Looks Like
Opioid addiction is a serious problem in the United States. From 1999 to 2017, the United States alone witnessed a 300% increase in the sales of opioid pain prescriptions.4 Accordingly, during this same timeframe, it has been reported that 399,230 Americans lost their lives to opioid overdose4 with more recent numbers in 2017 alone indicating more than 47,000 lives lost.5
Opioid addiction is similar to any other addiction in the respect that it has no demographic boundaries. Essentially, anyone with access to opioids at any time in life who is not careful may be at risk. According to Vowles et al., approximately 21-29% of those prescribed opioids for chronic pain misuse them with around 8-12% developing a diagnosable opioid use disorder.5 For those with addictive tendencies, mental health disorders, chronic pain, and/or any other combination of factors; there is an increased risk that may be significant in nature.
Spotting an individual struggling with opioid use is not easy. Many are quite functional and may appear completely normal. Signs of opioid addiction become more readily apparent when individuals stop using (or go into withdrawal). Individuals with opioid addiction are mothers, fathers, grandparents, siblings, co-workers, police officers, physicians and nurses, lawyers, activists, and so on.
It’s also important to note that many people with chronic painful conditions, such as cancer, need long term pain control with opioids and develop tolerance and physiological dependence, but never sacrifice their wellbeing and become an addict.
Use of opioids in adolescence can begin with availability or with peer pressure. For some teenagers, they may have been prescribed opioids after a medical procedure and have an undiagnosed mental health condition. It’s important to talk to teenagers in your life about pain treatment and management, especially if they are prescribed opioids. Their relatively short life experience and incomplete brain development put them at particular high risk for addiction.
Adults with mental health disorders such as major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are also at increased risk. Opioids not only kill pain but serve as a powerful relaxant.2
Symptoms of Opioid Addiction
Symptoms of opioid addiction vary in intensity according to potency and kind, dose, frequency of use, and physiological tolerance. It is important, however, to decipher the difference between those abusing opioids and those prescribed them as a form of pain management (e.g., cancer patients). Although individuals prescribed opioids for pain management will also experience similar increases in tolerance and the like, their use is medically managed. In such cases it is still important to watch for signs and symptoms of addiction, as research has indicated nearly a quarter of those prescribed opioids for pain management do abuse them.5
For those who abuse opioids and/or use them recreationally, an experienced user with high tolerance may find taking many pills per day. Due to this increased volume of pill consumption, users may ultimately switch to something more powerful. For instance, an individual may find similar satisfaction taking one oxycodone versus five or more hydrocodone. To this effect research has found that nearly 5% of those with an opioid addiction will try heroin.4 while 77% of people who use heroin began by misusing other opioids.6
As with any other substance use disorder, opioid use disorder is diagnosed on a continuum from mild to moderate to severe based off the number of the following symptoms present:
- Taking opioids in larger amounts or for longer than prescribed
- Wanting to cut down or stop using opioids but being unable to do so
- Spending an excessive amount of time getting, using, and/or recovering from opioid use
- Cravings and urges to use opioids
- Not managing to fulfill daily life obligations at work, home, school, and elsewhere due to use
- Continuing to use despite it causing issues in relationships
- Giving up important social, occupational, or recreational activities due to use.
- Using opioids repeatedly even when they pose a safety risk
- Continuing to use, even when one is aware of having a physical and/or mental condition that could have been caused by or made worse by opioid use
- Needing more opioids that the prescribed dose to feel the desired effect (oftentimes referred to as “chasing the dragon”)
- Development of withdrawal symptoms, which may be relieved by taking more of the substance7
More specific to opioids, other symptoms of opioid use may include constipation, small pupils, nausea, reduced sex drive, sensitivity to pain, shallow breathing, and/or slurred speech.8
Symptoms of An Overdose
Overdose occurs when an individual consumes more opioids than their body can tolerate. Individuals who relapse after an abstinent recovery effort, detox, and incarceration are at particularly high risk, as their bodies no longer have the tolerance to doses they did at last use. Though great strides have been made to prevent overdose from becoming deadly, still, almost 70% of the more than 67,000 drug overdose deaths in 2018 involved an opioid.9 To prevent an overdose from becoming deadly, it is important to recognize the warning signs.
According to MedlinePlus, “[Opioids] may also cause slowed breathing, which can lead to overdose deaths.” If someone has signs of an overdose, call 911:
- The person’s face is extremely pale and/or feels clammy to the touch
- Their body goes limp
- Their fingernails or lips have a purple or blue color
- They start vomiting or making gurgling noises
- They cannot be awakened or are unable to speak
- Their breathing or heartbeat slows or stops10
Narcan (naloxone) has become increasingly used as a means of reversing an opioid overdose. If you or anyone you know does engage in regular opioid use, it is recommended to acquire and learn how to use a kit, which is offered free or low cost at many clinics.
Risk Factors for Opioid Abuse
If you are concerned that you will become addicted to opioids after receiving a prescription from your doctor, it is important to discuss your concerns with your doctor. You should also make sure to follow your doctor’s directions carefully about how to take your medications in order to reduce your risk of abuse and keep your prescription out of the reach of children and teenagers.
Risk Factors may include:
- Genetic vulnerability (Mice models have shown that genetic vulnerability may cause one to become addicted before someone else, but more research is needed to draw a definitive conclusion)12
- Family history of use
- Peers who use
- Ease of access
- Chronic pain
- Intense acute pain
- Struggling with a major loss
- Having undergone trauma
- Casual recreational use having become out of control
- A diagnosable mental health disorder or condition
- Addictive personality8
These are only examples of some of the most common risk factors, not an all inclusive list. If you are concerned that you might be at risk, talk to your doctor about options for reducing your risk for abuse or changing your prescription.
Treatment of Opioid Addiction
The best treatment of opioid addiction must be tailored to the individual and be holistic. The intensity and duration of treatment will depend on the severity of the addiction. Further, for the most successful prognosis, a significant life change effort should be made.
Medication Assisted Treatment
Given the intense cravings and withdrawal symptoms individuals with opioid addiction experience, there are many cases where medication assisted treatment (MAT) is recommended. MAT combines medication with treatment toward a holistic recovery approach. Generally, medication curbs cravings and reduces withdrawal symptoms to reduce the desire to use. This way patients may focus on lifestyle changes without experiencing as much physical agony.
Three commonly used medications with MAT include methadone, buprenorphine, and naltrexone.
Methadone is a synthetic opioid agonist and has been the primary form of MAT since the 1960s.11 To conceptualize its function as an opioid agonist, consider how morphine or heroin activate the brain’s opioid system; however, in this case, the individual experiences a reduction in cravings and withdrawal symptoms without experiencing the euphoric high.
Methadone is recommended for more severe cases of opioid use disorder, including intravenous heroin use. Side effects of methadone may vary as well and should be used with discretion and as prescribed.
Buprenorphine is classified as a partial opioid agonist, which activates the same brain receptors as methadone but to a lesser degree.11 As explained by Hazelden Betty Ford Foundation, “At a certain level, buprenorphine provides comfort but reaches a plateau in terms of increasing intoxication. This ceiling effect helps protect against addictive euphoria and reduces the risk of misuse, dangerous side effects and overdose.”11 Buprenorphine is generally used with moderate to severe cases of opioid addiction.
Unlike methadone and buprenorphine, naltrexone is an opioid antagonist. Its function is to prevent the high experienced from opioid use. Naltrexone is an attractive form of MAT in that it is generally given in extended-release form as a once monthly injection. Further, “it has been shown to decrease opioid cravings, reduce the risk of relapse and overdose, and help people stay engaged in addiction treatment programming.”12 Though more convenient in that patients need not worry about taking something daily, the cost is generally more than the aforementioned forms of MAT.
Therapy is highly recommended for anyone suffering from opioid addiction. For anyone who decides to partake in MAT, sessions with a therapist are legally mandated by the federal government. The intensity of therapy does depend on the severity of the addiction.
Common Types of Therapy
As with most addictive disorders, cognitive behavior therapy (CBT) remains a preferred method of therapy. CBT considers how one’s cognitions (thoughts) based upon personal beliefs and values impact one’s emotions to lead toward a particular behavioral outcome. The therapy also focuses on automatic negative thoughts (ANTs). These thoughts are those that lead toward illogical thinking and irrational behavior. Generally, ANTs contribute toward opioid use and relapse.
Dialectical behavioral therapy (DBT) is similar to CBT but includes an element of mindfulness, which helps keep individuals focused on the present and aware of their internal and external environment. This is particularly helpful when one experiences a craving and may utilize mindfulness to recognize that it soon will pass.
A holistic recovery effort requires substantial change. Accordingly, many substance use professionals tell patients that they must change their persons, places, and things, for recovery to be possible. Individuals are encouraged to distance themselves from anything and everything that may trigger use while engaging those that will promote recovery. Without doing this, it is increasingly likely that individuals will resort back to using thoughts and behaviors, which ultimately continue the cycle.
Inpatient vs Outpatient Treatment for Opioid Addiction
Inpatient treatment entails living in a recovery environment. This may include inpatient hospitalization as well as sober living communities. These environments provide 24/7 monitoring and support. Outpatient therapy may prove ideal for mild to moderate cases. It is also the next step after inpatient treatment.
Such therapy may include outpatient counseling visits (comprised of 30-, 45-, or 60-minute appointments); intensive outpatient therapy (IOP, which requires multiple weekly sessions lasting at a minimum of several hours each); and partial hospitalization (which mimics residential treatment, but extends additional freedoms for individuals to work during the day, sleep at home at home at night, etc.).
Intended Treatment Outcome & Timeline
Recovery from opioid use disorder is possible, but it must be understood that it is not a curable disease. Research has shown that about 72-88% of individuals who have attained opioid detoxification for a period 12-36 months experience a relapse.12,13 As a general rule of thumb, it is recommended that individuals consistently engage in treatment for the same duration of time they were actively using. So long as abstinence and a healthy lifestyle have been maintained, one may then progress into aftercare.
How to Get Help for Opioid Addiction
Getting help for opioid addiction entails an initial awareness of the problem. Second, it is important to be knowledgeable of resources available for treatment. Given the severity and frequency of occurrences throughout the nation and beyond, there are many resources available, although these vary from one region to another. An excellent place to begin is the SAMHSA Locator, which is a government-sponsored website that helps individuals find nearby treatment locations.
How to Get Help for a Loved One
Being as supportive as possible when attempting to help a loved one is of vital importance. It is expected that the individual struggling with opioid addiction will be in denial or resistant to treatment. This is a symptom of the disorder. Knowing this, it is important to use supportive, concerned language while avoiding becoming defensive or giving up. It is just as important to be as involved in the recovery process as possible. This may include attending counseling sessions, going to support groups, and making personal lifestyle changes as well, especially if you are struggling with addiction also.
How to Get Help for a Teen
Being supportive and involved in the recovery process is also recommended for helping teens. Unlike with adults, parents and guardians may involuntarily commit teens to treatment. It is important to consider the most appropriate form of treatment here as well, as something not invasive enough may allow for continued use, while something too invasive may actually backfire.
Family counseling is also recommended, as an addictive disorder for one member of the family creates toxicity within the entire family dynamic. The family must learn new coping skills, boundaries, emotional expression, and so on to restore or perhaps for the first time attain a healthy familial relationship.
Opioid Addiction Statistics
With the 21st Century came a wave of opioid addiction that has been regarded as an epidemic. The numbers of opioid related diagnoses, overdoses, and deaths has indicated a need to take the matter seriously and switch to a more proactive than reactive response.
In addition to those dispersed throughout this article, statistics shared from the National Institute on Drug Abuse revealed the following:
- In 2018, 46,802 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid.8
- That same year, an estimated 1.7 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers, and 526,000 suffered from a heroin use disorder (not mutually exclusive).16
- Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them.17
- Between 8 and 12 percent develop an opioid use disorder.17
- An estimated 4 to 6 percent who misuse prescription opioids transition to heroin.18,19,20
- About 80 percent of people who use heroin first misused prescription opioids.18
- Update: Among 38 states with prescription opioid overdose death data, 17 states saw a decline between 2017-2018; none experienced a significant increase.9,14
Living with Opioid Addiction: Coping & Managing Symptoms
For those who have met success with recovery and progressed into maintenance, it should be known that you have attained a major accomplishment. Recovery is an intentional process that is ongoing for the duration of one’s life.
Common techniques for coping and managing symptoms include:
- Discussing a plan with a physician to manage opioid use
- Regularly attending support groups (e.g., Heroin Anonymous, SMART Recovery)
- Having a sponsor or being a sponsor
- Engaging in healthy and enjoyable activities
- Acquiring and engaging in a hobby
- Distancing from “drug buddies” and other toxic relationships
- Keeping one’s space clear of drugs and paraphernalia
- Working toward and achieving a goal
- Exploring one’s life meaning
- Getting in touch with one’s spiritual and/or religious side
- Speaking to someone when experiencing cravings or emotional disturbance
- Refraining from going to places where one regularly used opioids
- Having an optimistic perception of recovery.
History of Opioid Use
Opioids are derived from the opium poppy plant. Historically, the cultivation of the opium poppy dates back to 3400 B.C. in lower Mesopotamia. The Sumerians referred to the plan as Hul Gil, the “joy plant.” As knowledge of the plant’s euphoric effects continued to spread, so did its use. It is important to note, however, that the opium used in 3400 B.C. is significantly different than many of the versions used today, which may be highly synthesized and modified to various levels of potency and methods of use.