What Is An Opioid?
Opioids are drugs, either natural or synthetic, that are derived from opium or are manufactured to mimic the effects of opium derivatives. The word “opioid” used to refer only to synthetic or semi-synthetic drugs that simulated opiates, but now encompasses the entire family of opiates.
Natural opiates include morphine, codeine, heroin and opium. Heroin sometimes is classified as a semi-synthetic opioid, being derived from morphine. Some widely used synthetic and semi-synthetic opioids include:
- Oxycodone, which includes brands names such as OxyContin, Percocet and
- Hydrocodone, including Lorcet, Lortab and Vicodin
- Meperidine, such as Demerol
- Hydromorphone, including Dilaudid
Opioids are used medically, almost exclusively, for pain relief. Some opioids, especially methadone, are used in the treatment of drug addiction, particularly heroin addiction. Not only are opiates extremely effective in controlling and alleviating pain, they’re also very cheap. Morphine has been used as a pain reliever since the mid-1800s, gaining widespread use during the Civil War, and is still used extensively today.
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All opiates produce some type of “high,” and the faster acting the drug, typically the more intense the euphoric feeling. Heroin is a very fast-acting opiate and thus produces an intense feeling of euphoria; heroin’s half-life is two to six minutes, while morphine can take four to six hours to metabolize.
In 2012, approximately 2.1 Americans suffered from prescription opioid pain-reliever abuse, compared with an estimated 467,000 who were addicted to heroin, according to the National Institutes of Health (NIH). Additionally, overdose deaths involving opioids quadrupled from 1999 through 2015, according to the Centers for Disease Control and Prevention (CDC).
Effects Of Opioids
Opioids cause the release of dopamine in the brain, creating pleasurable feelings while reinforcing the need for continued behavior—such as continued and ingestion and increasing amounts of the opioids being used.
Short-term effects and side effects of opioid use include:
- Euphoric feelings
- Decrease or cessation of pain
- Drowsiness and sedation
- Lethargic feelings
- Decrease in respiratory rate
Longer-term results of opioid use include:
- Increased tolerance
- Dependence and addiction
- Itching and sweating
- Persistent constipation, nausea and vomiting
- Abdominal pain and bloating
- Increased sensitivity to pain
- Liver damage
- Brain damage, often due to hypoxia (from lack of oxygen caused by decreased respiration)
Who Uses Prescription Opioids And Why?
Opioid medications are prescribed to relieve pain. They also produce a sense pleasure, euphoria, and well-being due to the effect on the brain’s opioid receptors. It’s estimated that more than 100 million Americans deal with chronic pain, and many rely on opioid medications for pain relief.
Prescription opioids mimic the effects of heroin and morphine, thus posing a high risk of abuse and addiction (especially when used for recreational purposes). Addiction risks increase greatly when people ingest opioids through means such as crushing tablets and snorting or injecting the product. Combining prescription pills with alcohol or other drugs also increases health and addiction risks.
The Opioid Epidemic In The U.S.
The CDC estimates that 20 percent of patients who complain of non-cancer pain symptoms are prescribed opioids. Health-care providers prescribed opioid pain medications 259 million times in 2012 alone, “enough for every adult in the United States to have a bottle of pills.” Prescriptions for opioid pain medications increased, per capita, 7.3 percent between 2007 and 2012.
Prescription opioids are the largest factor in what most health and medical experts refer to as an “epidemic.” The CDC reports a quadrupling of both the number of prescription opioids dispensed and the number of prescription opioid deaths since 1999—despite no corresponding change in the amount of pain reported by Americans.
Between 1999 and 2015, more than 500,000 Americans died from overdoses of all drugs, with more than six out of ten of all U.S. drug overdoses involving opioids. Ninety-one U.S. residents die daily from an opioid-involved overdose. Abuse rates in North America—the United States, Mexico and Canada—are nearly five times the global average. North America has a 3.7 percent opioid abuse rate versus 0.7 percent for the rest of the world. Overdose deaths involving opioids containing oxycodone, hydrocodone and methadone outnumber heroin and cocaine overdose deaths combined.
Because hydrocodone isn’t widely available outside the United States, America accounts for more than 99 percent of worldwide hydrocodone consumption. But even oxycodone, which is much more readily available globally, is consumed by Americans at 84 percent of the world’s supply. The number of opioid prescriptions for hydrocodone and oxycodone drugs increased from about 76 million in 1991 to 207 million in 2013.
Improved opioid prescription practices is recommended by the CDC as a prime remedy to the opioid epidemic. The CDC Guideline for Prescribing Opioids for Chronic Pain provides guidelines for opioid prescription pain medication, focusing on opioid use in the treatment of chronic pain (not including cancer treatment and terminal-illness care).
The NIH suggests that the dramatic increase in opioid use and abuse can be attributed to a general “environmental availability” of prescription medications and opioid analgesics—pain relievers—in particular. This, in turn, has led to a greater social acceptability regarding prescription drugs and the resulting drastic increase in the number of prescriptions written. Aggressive marketing by pharmaceutical companies also is cited by the NIH as a contributing factor in the opioid epidemic.
Hospitalization And Death
The opioid epidemic has seen an accompanying increase in hospitalizations and deaths. The increase has been drastic, as reported by the NIH. Emergency room visits for non-medical opioid use skyrocketed from an estimated 144,600 in 2004 to more than 305,000 in 2008. Admissions for opioids (not including heroin) went from 1 percent of all admission to more than 5 percent in 2007—almost all involving oxycodone and hydrocodone products. Overdose deaths more than tripled over the 20 years leading up to 2010 to a total of 16,651. In 2002, deaths listing opioid pain-reliever poisoning as the primary cause outnumbered deaths from heroin and cocaine for the first time. That trend continued through 2014, with opioid drug overdose deaths in the U.S. reaching 28,647—or nearly 61 percent of all reported drug overdose deaths.
The Heroin Epidemic In The U.S.
While prescription opioids have overtaken heroin as the primary drugs of use and abuse, heroin use has nonetheless also increased dramatically in the United States. The increase has been seen among both men and women, within almost all age groups, and within all income levels. Also disturbing is that some of the largest increases have occurred among demographic groups which have traditionally been somewhat immune to heroin use: women, privately insured people, suburban and rural residents, and those in higher income brackets.
Between 2002 and 2013, the heroin overdose death rate increased by nearly four times, from 0.7 deaths per 100,000 to 2.7 deaths per 100,000. More than 8,200 people died in 2013. Also in 2013, approximately 517,000 people reported past-year heroin abuse or dependence, signifying a 150 percent increase since 2007.
First-time heroin use in 2002-2011was highest among men age 18 to 25 years, among non-Hispanic whites, and among people with a yearly of less than $20,000 (although first-time user rates increased across most demographic groups). The NIH also reports that the majority of heroin users report a history of non-medical prescription opioid use. The increase in heroin overdose rates and overdose death rates corresponds to the overall opioid epidemic. Hospitalizations between 1993 and 2009 showed that increases in opioid pain reliever hospitalizations not only correlated with heroin hospitalizations, but also predicted an increase in heroin overdose emergency room visits and hospital admissions.
More encouraging is the decrease in heroin use among young people. According to a December 2016 NIH report, teens have been bucking the overall opioid use and overdose trend of American adults. Abuse of opioids decreased over the past five years among high school seniors by an astounding 45 percent—from 8.7 percent to 4.8 percent. Heroin use was particularly low, with only 0.3 percent of students in all grades reporting having used heroin.
The CDC lists the following groups as the most at risk for heroin addiction:
- Non-Hispanic whites
- People 18 to 25 years old
- Those addicted to prescription opioid painkillers
- People who are addicted to marijuana and alcohol
- People addicted to cocaine
- People with no health insurance or those enrolled in Medicaid
- People in urban areas
Despite these indicators, there also was a drastic increase—100 percent—among women. While poor people are most likely to use heroin, the biggest financial demographic change was among those earning $20,000 to $50,000 a year (a 77 percent jump), compared to a 60 percent jump among those making less the $20,000 annually. Privately insured users increased by 63 percent.
Heroin Effects And Signs
Heroin use and abuse typically is accompanied by short- and long-term effects and symptoms, both physically and behaviorally.
Short-term heroin use can cause:
- Lethargy, sleepiness and drowsiness
- Shortness of breath and decreased heart rate
- Dry mouth
- Constricted pupils
- Sudden changes in behavior or actions
- Confusion and loss of memory
- Periods of increased alertness followed by sleepiness
- Stumbling or loss of motor-skill function
Longer-term indications may include:
- Weight loss
- Jaundiced appearance or bluish coloring
- Runny nose and eyes
- Needle marks
- Infections or abscesses, usually occurring at needle injection sites
- Decrease in blood flow or loss of menstrual cycles in women
- Cuts, bruises, scabs and other skin anomolies
People using heroin also usually manifest behavioral changes, including:
- Increased sleep
- Slurred and incoherent speech
- Lying and other deceptive behavior
- Drop-off in work or school performance
- Lack of interest in sex and/or inability to perform
- Lack of hygiene
- Avoidance of family and friends
- Hostility toward family and friends
- Withdrawal from interests, activities and hobbies
- Avoiding eye contact
- Theft or pawning and selling material items
People who use heroin often also simultaneously use other drugs or alcohol, increasing the risk of an overdose. Although heroin typically is injected intravenously, it is also smoked and snorted. When injected, heroin users are at risk of life-threatening, long-term infections like HIV, Hepatitis C and Hepatitis B, and bacterial infections of the skin, bloodstream, lungs, liver, kidneys and heart.
Heroin Addiction: A Slippery Slope
The CDC reports that nearly all heroin users also use at least one other drug, with most using at least three other drugs (including alcohol) simultaneously. People addicted to alcohol are twice as likely to be addicted to heroin; marijuana users are three times as likely to be addicted to heroin; for cocaine users, the likelihood for heroin addiction is 15 times greater; and opioid pain-reliever users are 40 times as likely to be addicted to heroin.
Another danger with heroin use is the ever-present possibility that the heroin being used is mixed with dangerous additives. Fentanyl, a synthetic opioid pain reliever, is 50 to 100 times more potent than morphine and often is used in place of, in combination with, or as an additive to, heroin. There has been an increase in fentanyl use, abuse, overdoses and deaths in recent years. Most cases of fentanyl-related overdoses and deaths in the United States are the result of illegally manufactured fentanyl, sold for its heroin-like effects. Fentanyl sometimes is mixed with heroin or cocaine to increase the euphoric effects of all the drugs.
Commonly Abused Prescription Opioids
Some of most commonly abused prescription opioids, including generic and brand names, include:
Codeine is most often found in prescription cough syrups. When used with alcohol, the sedative effects of both drugs is enhanced, increasing the risks of overdose. Codeine also often is abused by being mixed with soft drinks, ice and sometimes candies like Jolly Ranchers to produce “Purple Drank.” The codeine typically is found in the form of a cold medication and contains promethazine, which is an antihistamine.
In hospitals, morphine typically is injected directly following surgery. Brand-name tablets and oral compounds that contain morphine include MS Contin, Morphine Sulfate ER, Roxanol, Kadian, Duramorph, Filnarine, Morphgesic, MST Continus, MXL, Oramorph, Sevredol and Zomorph. Abusers often crush pills in order to snort or inject the powder.
Traditionally used in the treatment of heroin addiction, methadone is itself highly addictive. Brand names include Methadose and Dolophine.
Fentanyl is a wholly synthetic pain medication with a rapid onset and a very short duration. As mentioned, it often is used s as heroin substitute or in conjunction with heroin. Known on the street as Apache, China girl, dance fever, friend, jackpot, murder 8, TNT, Tango and Cash, and Goodfella, Fentanyl can be found in the brand-name drugs Actiq, Duragesic and Sublima.
Sometimes referred to as “hillbilly heroin” on the street, oxycodone can be found in Tylox, Oxycontin, Percodan and Percocet.
Hydrocodone is found in Vicodin, Lortab and Lorcet.
Oxymorphone is a powerful semi-synthetic painkiller with a rapid onset of pain relief. It’s sold under the brand names Dilaudid, Opana, Numorphan and Numorphone.
Meperidine hydrochloride is found in Demerol. It’s used to treat acute and short-term pain, and is not to be used for long-term pain treatment due to the risk of accumulated toxicity.
Used to treat moderate pain, propoxyphene is found as a single ingredient in Darvon and in combination with acetaminophen in Darvocet.
Medication-Assisted Treatment For Heroin And Opioid Addictions
Medication-assisted treatment is becoming one of the most common ways to treat an addiction to heroin or prescription opioids. Several drugs are used in the treatment of opioid addiction. Some, like methadone, are classified as “agonists,” meaning that the drugs activate opioid receptors in the brain. Heroin and opium, as well as opioid prescription drugs like those listed above, are “full agonist opioids” that provide a full opioid effect. Methadone is particularly effective in managing heroin withdrawal symptoms.
Other opioid-treatment drugs are partial opioid agonists; they produce a milder effect than full opioid agonists. Buprenorphine is one such drug. Brand names containing buprenorphine include Suboxone and Subutex.
Finally, “antagonist” drugs actually block opioids. They attach to opioid receptors in the brain without stimulating them. Antagonists provide no opioid effect, and include the drugs naltrexone and naloxone.
Methadone Maintenance Treatment
As mentioned, methadone binds to a person’s opioid receptors in the brain, filling the receptors and relieving the need and urge for other drugs. Although addictive when abused, methadone doesn’t provide a “high.” It’s this characteristic that helps methadone unshackle opioid abusers from dependence.
After beginning a methadone regimen, a single dose will provide patients with withdrawal relief for 24 to 36 hours, eliminating the need to consume opioids every few hours. A consistent regimen of methadone treatment can protect patients from emotional highs and lows, and from the dangers of relapse of addictive opioid drugs.
Methadone maintenance programs can only be administered through certified opioid replacement clinics, of which more than 1,000 exist in the U.S. and Canada. The administering of methadone is only one component of a comprehensive program that typically includes acute medical care, preventive care, drug and health education, school and job counseling, and other life-skills coaching. Methadone maintenance programs begin as inpatient treatment, followed by closely supervised outpatient treatment. Prescriptions for methadone can only be written by physicians associated with certified methadone treatment programs.
The U.S. Drug Addiction Treatment Act of 2000, combined with approval in October 2002 by the Food and Drug Administration, provided treatment alternatives for those addicted to opioids. Unlike methadone, which still can be administered only under the auspices of doctors affiliated with certified methadone treatment programs and registered under the Drug Enforcement Agency’s Narcotic Treatment Program, buprenorphine can be prescribed by any qualified physician who has undergone specialized training and certification from the Center for Substance Abuse Treatment.
Buprenorphine, an opioid partial agonist, produces effects similar to opioids such as euphoria and decreased respiration, but at a much lower level. The opioid effects of buprenorphine gradually increase until, at moderate doses, they plateau—even as the dosage increases. This minimization of opioid effects reduces the risks of dependency, abuse and other associated side effects. Buprenorphine also is very log-lasting, meaning that it may not have to be administered on a daily basis.
Suboxone And Subutex Treatment
Suboxone is a brand-name drug for buprenorphine that’s combined with naloxone (an opioid antagonist).
Suboxone was developed in, in part, in response the abuse of buprenorphine by people who injected or snorted buprenorphine to get high. Naloxone, which blocks the brain’s opioid receptors, was included to eliminate the opioid effects of the drug if Suboxone was injected or snorted. If users ingest other opioids while taking Suboxone, the drugs are blocked from the brain’s receptors by preventing the effects and the high that normally provided by these opioids. The naloxone in Suboxone will not block opioid effects when taken orally. Other buprenorphine/naloxone brand-name drugs include Zubsolv and Bunavail.
Subutex was the forerunner of Suboxone; it was a brand-name buprenorphine product minus naloxone, administered in pill form. When taken as prescribed, Subutex generates a much lower level of euphoria, drowsiness and other effects provided by street and prescription opioids. Subutex often is administered in inpatient settings as the initial drug to combat withdrawal symptoms; it’s typically used for acute detoxification. Patients often are then transitioned to Suboxone.
By crushing Subutex pills and snorting or injecting the resulting product, abusers could achieve a more powerful opioid effect. In large doses, the Subutex can suppress respiration, causing dizziness, drowsiness, confusion, unconsciousness, coma and even death.
Naloxone And Naltrexone
Aside from being used in combination with buprenorphine in the brand-name drug Suboxone, naloxone is used alone as an emergency treatment for opioid overdoses. As an opioid antagonist, naloxone binds to the brain’s opioid receptors and blocks, and even reverses, the effects of opioids—respiratory distress, decreased breathing rates and drowsiness.
Naltrexone is an opioid antagonist that blocks the brain’s opioid receptors, making it a good alternative if a person is beyond the opioid withdrawal stage and is dedicated to long-term recovery. Naltrexone also may be used for patients in the early stages of addiction. It may not stop cravings, and is administered in pill form under the brand names ReVia and Depade (as well as in generic forms). An extended-release, injectable variation is available under the brand name Vivitrol, and is administered monthly.
Opioid Detox and Inpatient Rehab Programs
Determining which drug or drugs are used in opioid-addiction treatment must be determined by qualified health-care professionals, and this can usually be done only through a long-term, residential program. Detoxification usually is the first step and, again, this can be accomplished only via an inpatient setting.
Detoxification by itself, however, doesn’t address other issues such as behavioral problems, family dynamics, work and social issues, physical problems, and mental-health needs. Detoxification needs to be followed by medical and psychological assessments, and a comprehensive treatment program must be developed.
A typical long-term residential program is a 24-hours-a-day regimen. Although some programs are hospital-based, most are not. The most traditional current therapies include the therapeutic community (TC) and cognitive remediation therapy (CRT), which often are used in combination. A typical stay for opioid-addiction treatment is six to 12 months. When medications are combined with behavioral counseling and other support services, the approach is known as Medication Assisted Treatment, or MAT.
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Because addiction is seen in the context of a person’s social, medical and psychological issues, treatment centers around accountability and responsibility. This highly structured approach includes activities developed to assist residents in addressing negative beliefs and destructive behaviors, and usually includes training and support services dealing with employment, family relationships, education and reintegration into society.
Opioid-addiction treatment in the U.S. is overseen by the Certification of Opioid Treatment Programs, 42 Code of Federal Regulations (CFR) 8, which created an accreditation system to govern and certify opioid treatment programs, or OTPs.
Get Help Today For An Addiction To Opioids
If you or a loved one is experiencing opioid abuse or addiction, we can help. Many people begin the path of opioid addiction through no fault of their own; they may develop problems due to a medical condition that legitimately required pain medication. Withdrawal can be difficult and painful; sobriety can be very difficult if not addressed by medical professionals.