Opioids are a class of drugs known colloquially as "painkillers" and include a vast array of similar chemical compounds. The CDC defines opioids as natural, synthetic, or semi-synthetic chemicals that interact with opioid receptors on nerve cells in the body and brain and reduce the intensity of pain signals and feelings of pain. This class of drugs includes heroin, synthetic opioids such as Fentanyl, and pain medications available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, and many others.
There can be some confusion when the term "opiate" is also used since it is not always interchangeable with "opioid." Opiates are only those opioids that are natural, such as Morphine or codeine.
This has also been loosely extended to heroin and other opioids that are not entirely synthetic and derived from natural opiates. But the term "opioids" is more inclusive and refers to ALL drugs of the above definition, including natural opiates.
Opioids work by activating opioid receptors on nerve cells that exist throughout the body. These receptors serve to diminish the signals of pain by blocking them. They also are responsible for some sensations of pleasure and enjoyment. While the term "opioid receptor" is a bit of a misnomer, it is commonly accepted and used to describe this system. As with much of science, opioid receptors were discovered after opioids, and so their naming occurred in reverse order. This is similar to the discovery of the endorphin, or the native particle which opioids mimic. Yet despite this relationship, the word endorphin is a coined term that derives from the morphing of the words "endogenous" and "morphine," quite literally meaning "the morphine within."
The History of Opioids
As is the case with virtually every drug, the story of opioids begins with a natural life form, plants. In this case, the poppy is the plant, a rather delicate and beautiful flower that grows wild around the world. According to many reports, the first records of poppies being cultivated were the Sumerians in Mesopotamia, circa 3,400 BC. The poppy wound up in every major civilization across Asia and Europe because of its narcotic qualities. Farmers learned to extract a gummy substance from the flowers, which, when dried, is known as opium, the base of all opiate drugs. This substance was usually smoked to induce pleasure as well as relief from pain and other medical conditions. But unfortunately, the unregulated use of opium led to addiction, war, and the famed opium dens that populated China and eventually America in the mid-1800s. These incidents and the apparent potential for addiction and destruction prompted efforts to restrict use to medical purposes.
In 1803, Morphine was first isolated from opium resin by extraction. This achievement marked a new age in medicine and gave birth to one of the most widely used drugs in modern medicine. Morphine was then touted as a "miracle drug," due to it being ten times stronger than opium by weight. It allowed pain management that was unprecedented at the time and is a drug that is still commonly used today. Morphine is still so effective that it is considered the gold standard against which every new opioid medication is measured today.
Another notorious opioid is heroin. Heroin was first created in 1874 by placing Morphine through a chemical reaction process. The resulting product, diacetylmorphine, or "heroin," was first introduced into medical use by Bayer Company of Germany and was initially promoted as more effective and less addictive than Morphine. This claim turned out to be false. The drug was eventually restricted from medical uses but not before it could cause severe damage through misuse and its relative ease of reproduction. This ability to mass-produce the drug from raw opium with little technology or relative cost is still a contributing reason that the drug is available as one of the significant illicit substances of abuse across the world. And, of course, its incredible potency of being two to four times stronger than Morphine.
What Do Opioids Look Like?
HEROIN AND FENTANYL PILLS
Effects of Opioids
Opioids are known as a central nervous system depressant. This means that their primary mechanism of action consists of slowing down the major functions of the body. These include involuntary functions such as breathing, heart rate, and digestion, to name a few. Depressants are the opposite of stimulant drugs like methamphetamine that increase activity across the system.
They include many categories, such as sleeping pills and alcohol.
Many depressants also produce euphoria and other pleasant sensations and mood elevation, which is why they are so readily abused. Opioids do this very effectively and reduce pain and leave the user feeling pleasantly numb and content. Sleepiness is a common effect in high doses, as well as itchiness and irritability. "Nodding out" is a common phenomenon among opioid users, where the person is so intoxicated that they continually fall asleep or lose consciousness in otherwise inappropriate settings such as while standing up or sitting briefly at work or during a meal.
It appears that the person cannot stay awake because they are so high. Other side effects of opioid use include nausea and constipation.
Opioids can be consumed in a variety of manners, but perhaps the most notorious is injection. This is a direct, intravenous administration of the drug, which results in a near-immediate "rush" from the massive, sudden onset of the drug. Injecting opioids is a common form of ingestion, especially for potent drugs like heroin. This is because their concentration and relative purity make injection possible. But these drugs can also be consumed in any other way possible since they are water-soluble compounds. Smoking, eating, and transdermal application are just a few ways that opioids can be consumed.
The list of long-term effects of opioid use is extensive. Perhaps the most troubling in the medical field is the phenomenon of rebound pain and lowered pain threshold. When used to treat pain, they ultimately make a person more sensitive to pain. This is because of the diminished endorphin production but also appears to be a psychological result. Regardless of the cause, people with chronic pain who use opioids long-term to treat it end up having more pain collectively. While at first, the medications may give the appearance of helping, the pain comes back worse when the drugs wear off, and the person's ability to endure it is diminished. This leads them to depend on opioids and eventually become addicted even if they do not abuse them recreationally.
There is a near full-system collapse when opioids are taken chronically. Gastrointestinal issues develop rapidly since the drug heavily impacts digestion and causes constipation. Respiratory problems develop due to the reduced efficacy of the lungs and breathing rates, which is most notable in the form of sleep-disorder breathing conditions such as apnea. Chronic opioid use is associated with a 77% increased risk of cardiovascular events like heart failure. The person becomes more accident-prone due to opioid neurotoxicity, so they may fall or make careless mistakes more easily. They are also much more likely to suffer skeletal fractures and other musculoskeletal injuries.
We also see hormonal issues in both sexes and a lowered immune response.
These health risks pertain to all opioids but do not include specific health risks that come with the ingestion of specific drugs. For example, intravenous opioid users incur additional circulatory and cardiovascular risks, as well as lesions and abscesses. Those who smoke opioids, be it crushed pills or heroin, are at much greater risk for pulmonary damage and conditions like COPD. Snorting opioids presents its own risks as well, again depending upon the opioid substance.
An often-overlooked toll from opioid use is nutritional. Opioids curb appetite, leading the user to consume less food as the addiction progresses. Additionally, they chemically deplete vitamins and minerals from the body, specifically calcium. This can lead to premature tooth decay, malnourishment, and other health conditions that can stem directly from vitamin and mineral deficiencies.
There are many health effects of consuming opioids, both long and short term. The most immediate and deadly is overdose. Drug overdose has become one of the country's preeminent public health threats, with opioids being the leading cause.
This is a multifaceted problem, with the country's drug epidemic being just a part of it. In addition to the nation's increasing appetite for drugs and opioids, issues like pharmaceutical lobbying and advertising have resulted in a system that directly profits from addiction. In other words, the more people that are hooked on opioids, the more money can be made. These same companies now even sell drugs to reverse an opioid overdose and drugs to treat addiction caused by their opioids.
Drug overdose rates have increased astronomically since the 1990s. According to the CDC's drug overdose report, nearly 450,000 people have collectively died from an opioid overdose from 1999 to 2018. This is mainly due to the issue above but is also a result of technological advancements and shared knowledge. Synthetic drugs like Fentanyl are created in clandestine laboratories to feed the nation's addiction and profit, only illegally. "Synthetic" means that the drug is made entirely artificially and is not derived or extracted from opium. These synthetic drugs are first developed by pharmaceutical companies and used until it becomes clear that they are incredibly addictive and deadly, at which point they become restricted. But by then, the drug has been reverse-engineered and is being illicitly mass-produced.
The genie cannot now be put back in the bottle, so we have a drug like Carfentanil, which is 10,000 times stronger than Morphine. It was first synthesized in 1974 by Janssen Pharmaceutical company and now has no medical uses in humans. But it has been copied and is now used as both a deadly agent to add to heroin and a chemical weapon which can be aerosolized and used on large groups of people such as the 2012 Moscow Theater Hostage Crisis. This trend is continuing today despite public awareness of how the pharmaceutical industry drove the nation's opioid epidemic.
In just November of 2018, the FDA approved the use of a new drug, Dsuvia, which is ten times stronger than Fentanyl.
It was created by AcelRX Pharmaceuticals, in collaboration with the United States Department of Defense.
Opioid overdoses occur from respiratory failure. When a person consumes opioids, their respirations slow involuntarily. This is why opium and its derivatives have been used for centuries as a cough suppressant. Extremely high doses of opioids flood receptors to the degree that breathing will slow and ultimately stop. The person overdosing on opioids suffocates. They lose consciousness well-before this occurs, so they can do nothing to save themselves or avoid this fate once the deadly dose has been administered. They may feel very good for a short period before becoming unconscious and ultimately dying without intervention.
If discovered, their life can be saved with medical attention. A drug called "Narcan" has been found to reverse an opioid overdose and effectively bring someone back to consciousness overdosing on opioids.
It does this by literally kicking opioid molecules out of the receptor sites and blocking their further adhesion.
This isn't entirely foolproof since the receptors can be so flooded with opioids that enough Narcan cannot be gotten into the receptor sites before it's too late, and the body shuts down. But thankfully, Narcan has given those who struggle with opioid addiction many more chances at life and is becoming more widely used and accessible.
The person who uses opioids and avoids overdose still must contend with the inevitable consequences of long-term addiction. Addiction can begin in as many different ways as there are unique individuals and situations. But there are some common themes.
Addiction begins as a solution to a problem. This could be anything from physical pain to mental or emotional distress. Approximately 80% of people who use heroin misused prescription opioids first, so pain pills are often a starting point. This doesn't mean that all people who take prescription opioids for pain are necessarily addicted, but pain can be a major catalyst to opioid use disorder. If the opioids didn't make something better for the person initially, they would not continue to use them until physical dependence and, eventually, addiction occurred.
Regardless of the reason taken, opioids develop tolerance rapidly, where the person requires more and more of the drug to achieve the same effects. This is why best-practice guidelines recommend only using them for short periods at the lowest dose possible for pain. But when people have chronic pain, opioids can be used as a long-term solution, making addiction almost inevitable. Those who are taken off painkillers when their prescription is finished sometimes continue pursuing the drug and the relief they found from it. Between 8 and 12% of patients prescribed opioids for chronic pain develop an opioid use disorder.
To feed the addiction, many who are addicted to opioids begin manipulating the medical system that introduced them to the drug in the first place. "Doctor shopping" is a common term used to describe a behavior pattern in addiction where the patient sees multiple doctors to get more opioids.
This can either be simultaneously or through seeing one after the other until each no longer gives them drugs.
Many patients will malinger or manufacture fictitious medical complaints to get opioids.
Because the drug is so widely used in the medical field and used to treat the subjective phenomenon of pain, doctor shopping can be difficult to stop. Shared information systems and computers have aided in preventing this practice, but it still occurs regularly as people adapt. Once they reach the end of the road medically, most people resort to using illicit opioids. Because heroin is the most readily available, cheap, and potent opioid on the black market, it is where most people land. Illegal opioids are obtained from drug dealers or other people's legitimate prescriptions that have been stolen or sold. It has been determined 4 to 6% of people who misuse prescription opioids transition to heroin. Overdose becomes a near certainty at some point unless the person gets help.
Aside from the physical degradation of the person, there is a behavioral and potentially spiritual decline that occurs in addiction. At first, the person believes that they are in control and can quit whenever they like. But the drug gives them relief from an unbearable existence, so they continue to use and keep this hidden from those around them. Anyone who would try to get them to stop is viewed as an enemy, so they will lie and go to extreme lengths to protect their developing addiction. These lies and other transgressions compound and form a mental burden, which causes the person to withdraw further. They will even begin to blame those around them for their issues in an attempt to justify and rationalize why they are behaving in a way that they know is wrong deep down. This cycle of addiction causes the person to feel worse and consume more and more drugs to mask the mounting problems in their life.
Physically, withdrawal syndrome is perhaps the most notable immediate consequence of opioid addiction. When the person does not consume the drug regularly, they will begin to feel extremely ill. Withdrawal symptoms from any drug always include the opposite effects the drug produced, both physically and mentally. So, with opioids, withdrawal is a harrowing experience. The body is no longer producing endorphins because they are being "supplemented" from the outside by consuming heroin. When the heroin in discontinued, the body "expects" more and will not begin to produce its own endorphins again for a few days while it "waits" for more heroin. This period and its accompanying symptoms are known as withdrawal, or "kicking." The most notable symptoms of opioid withdrawal are insomnia, pain, nausea and vomiting, diarrhea, chills, sweating, anxiety, depression, restlessness, and intense cravings for the drug. Most people do not sleep for several days and eventually succumb to exhaustion and cravings and relapse. If they are not given any more opioids for several days, their body will adjust and begin to produce endorphins normally again. They will start to feel better and sleep, and within a week or so, they will start to feel normal again without needing to take a substance. But that period may be so excruciating as to be unbearable for many people, which is why opioid addiction can be so gripping and deadly.
How to help a loved one addicted to opioids
If someone you know is addicted to opioids, time is of the essence. Do not wait for them to come to you and ask for help, as they could die at any time. While this may seem scary, it is a stark reality backed up by statistics.
A common myth when it comes to opioid addiction is that the person will never be able to live a drug-free life. This is false, as evidence by the many people who have completely recovered from opioid addiction and now live a life free of chemicals. This means no replacement drugs or psychiatric medications. It is entirely possible, and though not promoted heavily for some reason, is the only way to be completely rehabilitated.
Newer models that push pharmacological intervention often sell the idea that there is no other way and that the person “will never feel normal again” unless they continue to take pharmaceutical opioids. Sadly, this approach backfires frequently. Instead of saving lives and reducing harm, these shock-tactics can cause people to decide to stay on drugs. Why bother getting clean if they will still be dependent on opioids?
Though it may take some time, the body will completely recover from opioid dependence. Chemistry will eventually regulate, and the person will begin to feel normal without taking the drug. But it is vital the person undergo the withdrawal process to get off the drugs completely. How long this will take is dependent on each individual’s unique biochemistry, but also other major factors like the length of opioid use and what specific drug is being consumed. Drugs like heroin may be extremely uncomfortable to withdraw from, but it is a relatively fast process of a few days when compared to some of the opioid replacement drugs which people are placed on long term. These drugs may take weeks of months to recover from, with certain symptoms like interrupted sleep patterns persisting for even longer. Therefore, many are beginning to only suggest Medication-Assisted Treatment as a last resort.
When approaching your loved one about their suspected drug use, assume that your suspicions are true. Most family members are far too dismissive of their own instincts and give their loved one the benefit of the doubt. If you think they are on drugs, they probably are.
Rather than ask them, tell them your concern and that you are here to help them and listen without judgment. Never become angry with them, or they will not be honest with you. The reason they are hiding it in the first place is that they know you don’t approve. Do not belabor this point.
If they become angry or defensive, they are likely lying. This is a normal human defense mechanism. Do not react to this and just keep listening and acknowledging what they have to say. It may not make sense, but that’s probably from the drugs. Just be patient and they may break down and tell you what’s really going on.
If they do not, you should drop the conversation before it becomes too detrimental. Move on to getting some help with finding treatment and intervention services. You can always call the number on this page for assistance. But do not just wait for them to be ready. That day may never come before it is too late.
Treatment for opioid addiction has changed surprisingly little since the inception of modern drug and alcohol rehabilitation. Like most drugs that aren't alcohol, the only solution to treating addiction has been to apply the twelve steps of Alcoholics Anonymous. And along with alcoholism, drug addiction was initially viewed as a moral shortcoming. Opioid addiction may have even more stigma due to its extensively controversial history and ability to ruin lives fastidiously. The term "junkie" came about from such stigma and, sadly, is still used today to describe people who use heroin and other opioids.
Only recently have we begun to see drastic changes in the way opioid addiction is treated. This is likely due to both technological and medical advances and an urgency driven by the raging opioid epidemic. Some responses have drawn criticism as being desperate or extreme, such as drug replacement therapy and other harm reduction methods. Yet, given the unprecedented rate of drug overdose, prevailing practices have been aimed at preventing life loss rather than rehabilitating the individual to a completely drug-free state.
The use of medications like Suboxone and Methadone comprise the core of Medication-Assisted Therapy.
This form of treatment for opioid addiction presupposes that the individual cannot remain abstinent once becoming addicted to opioids. So, it aims to end the cycle of addictive behavior that surrounds drug use and makes it safe. Suboxone and Methadone are both opioid drugs themselves but have unique properties that cause them to have a longer duration and block the effects of other opioids like heroin. The person has been prescribed these drugs as medications, and they take them daily to maintain the levels of opioids in their system. The goal is to help the person return to a semblance of normalcy, allowing them to hold a job and function where they otherwise couldn't while always pursuing illicit opioids.
A less controversial approach to utilizing these medications is for the process of medical detoxification.
Often called med detox for short, it is the process of using Suboxone or Methadone to wean the person off illicit drugs like heroin comfortably. This can alleviate withdrawal symptoms and allow someone to confront the withdrawal process, where they otherwise may have balked at treatment and continued using.
The person is weaned off these medications completely rather than placed on a maintenance dose for life, and upon discharge from detox, should enter a rehabilitation program. Rehabs that don't utilize medications are few and far between and are known as holistic treatment programs.
Because of the alternative nature of these programs, many of them are not covered by insurance providers. This can make them expensive and difficult to access for everyone, despite being incredibly effective at addressing severe addiction. Though they may take longer than traditional rehabs, holistic treatment programs can return the person to the condition they were in before drug use began.
When selecting the right program for you, make sure that you are completely honest about your drug use with the intake specialist assisting you. This will ensure that you receive the right level of care for your needs.
Also, ensure that you are assertive and clear about which type of treatment you want so that you aren't forced into a modality that you don't agree with or isn't right for you.
Statistics for Opioids
Opioid overdoses accounted for more than 42,000 deaths in 2016, more than any previous year on record. An estimated 40% of opioid overdose deaths involved a prescription opioid.
The U.S. opioid epidemic is continuing. Drug overdose deaths nearly tripled during 1999–2014. In 2014, among 47,055 drug overdose deaths, 61% involved an opioid. During 2013–2014, deaths associated with the most commonly prescribed opioids (natural/semisynthetic opioids) continued to increase slightly; however, the rapid increase in deaths appears to be driven by heroin and synthetic opioids other than methadone.
From 2014 to 2015, the death rate from synthetic opioids other than methadone, which includes fentanyl, increased by 72.2%, and heroin death rates increased by 20.6%. Rates of death involving heroin and synthetic opioids other than methadone increased across all demographic groups, regions, and in numerous states. Natural/semisynthetic opioid death rates increased by 2.6%, whereas methadone death rates decreased by 9.1%.
Drug overdose is the leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. There were 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015.
From 1999 to 2008, overdose death rates, sales, and substance use disorder treatment admissions related to prescription pain relievers increased in parallel. The overdose death rate in 2008 was nearly four times the 1999 rate; sales of prescription pain relievers in 2010 were four times those in 1999, and the substance use disorder treatment admission rate in 2009 was six times the 1999 rate.
In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills. 80% of new heroin users started out misusing prescription painkillers, and 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain.” In 2015, 122,000 adolescents (age 12-17) were addicted to prescription pain relievers that we know of.
The prescribing rates for prescription opioids among adolescents and young adults nearly doubled from 1994 to 2007. Women are more likely to have chronic pain, be prescribed prescription pain relievers, be given higher doses, and use them for longer time periods than men. 48,000 women died of prescription pain reliever overdoses between 1999 and 2010. Prescription pain reliever overdose deaths among women increased more than 400% from 1999 to 2010, compared to 237% among men. From 2010 through 2013, female heroin overdoses increased from 0.4 to 1.2 per 100,000.
Key Word List for Opioids
|Opioid addiction (Opioid use disorder (OUD))||occurs when attempts to cut down or control use are unsuccessful or when use results in social problems and a failure to fulfill obligations at work, school, and home. Opioid addiction often comes after the person has developed opioid tolerance and dependence, making it physically challenging to stop opioid use and increasing withdrawal risk.|
|Fentanyl||Pharmaceutical fentanyl is a synthetic opioid, approved for treating severe pain, typically advanced cancer pain. It is 50 to 100 times more potent than Morphine. However, illegally made Fentanyl is sold through illicit drug markets for its heroin-like effect. It is often mixed with heroin or other drugs, such as cocaine, or pressed into counterfeit prescription pills.|
|Illicit drugs||These are drugs that are prohibited by law. These drugs can include amphetamine-type stimulants, marijuana, cocaine, heroin, other opioids, and synthetic drugs, such as illicitly manufactured Fentanyl (IMF) and ecstasy (MDMA).|
|Narcotic Drugs||These originally referred to any substance that dulled the senses and relieved pain. Some people use the term to refer to all illegal drugs, but technically, it refers only to opioids. Opioid is now the preferred term to avoid confusion.|
|Opioid tolerance||This is an occurrence where the person using opioids begins to experience a reduced response to medication, requiring more opioids to achieve the same effect.|
|Opioid dependence||A condition where the body adjusts its normal functioning around regular opioid use. Unpleasant physical symptoms occur when medication is stopped.|
|Methadone||A synthetic opioid prescribed for pain reduction or use in MAT for opioid use disorder (OUD). For MAT, Methadone is used under the direct supervision of a healthcare provider.|
|Suboxone||A synthetic opioid comprised of two compounds, Buprenorphine and Naloxone. Buprenorphine acts as Morphine or other opioids do, causing pain relief and relief of opioid withdrawal symptoms. Naloxone, also known as Narcan, acts as a blocker. The preparation allows for lower abuse potential and assists in abstaining from illicit drug use while taking it. It is used in MAT and medical detox applications primarily.|
|Naltrexone||A synthetic opioid, similar to Narcan, which blocks opiate receptors in the nervous system and is used chiefly in heroin addiction treatment.|