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How Addictive Are Prescription Opioids?

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The various prescription opioids—including oxycodone, hydrocodone, and fentanyl are indicated for the management of significant pain.1,2 They are safe and effective when taken as prescribed for a short period of time. Longer-term use may result in the development of physiological dependence, in which the person grows to need the opioid to function optimally. Many people divert these drugs and abuse them merely for their euphoric properties, a dangerous practice that can quickly lead to addiction and increase one’s risk of negative health consequences.

Many of the commonly used prescription opioids are Schedule II controlled substances, meaning that they have a high potential for abuse. Additionally, chronic opioid abuse can lead to addiction, a progressive condition characterized by compulsive opioid use regardless of adverse effects.

Opioid Crisis

In the 1990s pain was added to the list of vital signs physicians are required to assess during a standard check-up.17 Prior to that addition, the 4 vital signs tested in medical check-ups were:17

  • Blood pressure.
  • Heart rate.
  • Respiratory rate.
  • Temperature.

Medical practitioners and those in training were paying increasing attention to the phenomenon of inadequately managed pain and its potentially deleterious role in health outcomes. The addition of a “5th vital sign” to the standard patient evaluations reflected this change and soon was paralleled by a spike in opioid painkiller prescribing practices, one factor which may have influenced the rise in opioid diversion and abuse.

In 2014, 10.3 million people reported using prescription opioids recreationally (non-medically) and more than 14,000 people in the U.S. died from prescription opioid overdose.1,5 Between 2000 and 2014, the rates of death from prescription opioid overdose nearly quadrupled.5 On average, 91 Americans die every day due to an opioid overdose (this includes heroin).6

Studies have revealed that people who abuse opioids often transition to heroin. In 2014, 914,000 people reported heroin use, which is a 145% jump since 2007. Additionally, 39%-70% of heroin users reported that they had abused prescription opioids before transitioning to heroin use.5 Difficulty in obtaining prescriptions due to tighter mandates aimed at curtailing the inappropriate prescribing of opioids could be one possibility for users transitioning to heroin; however, this is still somewhat unclear.Additionally, wider availability, lower cost, and the increased potency of heroin in the U.S. are possible factors involved in the transition to heroin use.5

Opioid Painkiller Abuse

Prescription opioids attach to and activate opioid receptors in the brain, a molecular interaction that is accompanied by a rewarding, dopamine-mediated surge of euphoria or elation—one main reason these drugs are so heavily abused. Research shows that people often start with oral use (pills) and then, as tolerance grows, move to methods of administration that may result in a faster-onset of and/or more powerfully experienced drug effect, such as smoking, snorting, and injecting.5 It is also common for users to mix prescription opioids with alcohol or other drugs to further enhance the high.

Eventually, if opioid use is dramatically reduced or discontinued, the user is likely to experience unpleasant withdrawal symptoms; they may continue using to relieve these symptoms, thus continuing the cycle of opioid abuse.10

Compulsive opioid use can harm a user’s physical and psychological health and can give rise to numerous side effects, including:11

  • Tolerance, the need to take more of the medication for the desired drug effect(s).
  • Physical dependence and the accompanying onset of an acute withdrawal syndrome when the medication is stopped.
  • Drowsiness and dizziness.
  • Confusion.
  • Depression.
  • Increased sensitivity to pain.
  • Reduced levels of testosterone, resulting in decreased strength, energy, and sex drive.
  • Excessive sweating, runny nose, watering eyes, and itching.
  • Nausea, vomiting, and dry mouth.
  • Constipation.

A classic sign of drug abuse is secrecy: hiding the amount and frequency of use. It is also not uncommon for opioid abusers to procure multiple prescriptions at one time, as the user will usually take more than prescribed or run out of the prescription before the refill date.

The Addictive Potential

After opioids are used, certain brain processes are activated that play a key role in the development of addiction. Opioids stimulate brain cells within an area known as the mesolimbic reward center. The reward center contains a group of dopamine-containing neurons, which are stimulated to release this dopamine throughout targets such as the nucleus accumbens—one of the brain’s pleasure centers.13 When dopamine is released, other areas of the brain form an imprint, logging the memory and associating it with positive situations that promote survival.13 Opioid substances bind to at least 3 types of opioid receptors, including:10

  • Mu.
  • Delta.
  • Kappa.

Each of these 3 receptor subtypes has a different function. For example, mu receptors are responsible for opioids’ pleasurable effects and pain reduction.10 The user begins to crave more of the same desirable effects, possibly resulting in tolerance, dependence, and eventually, addiction. Addiction is extremely common amongst opioid users; in 2014, nearly 2 million Americans met the criteria for opioid painkiller addiction based on their past-year use.9

That being said, not everyone who abuses opioids becomes addicted. Both genetic and environmental influences determine if a particular person who uses opioid drugs will become addicted.13

Some common signs of opioid addiction include:18

  • Mounting negative health consequences.
  • Inability to fulfill roles at work, home, or school.
  • Inability to control or cut down on use.
  • Lack of interest in social activities.
  • Use in dangerous situations, such as while driving.
  • Depression and suicidal thoughts or attempts.
  • Preoccupation with taking the drug.
  • Financial hardship and stress.

Regardless of how severe someone’s opioid addiction is, it’s never too late to seek professional detox and substance abuse treatment. These programs help to manage painful withdrawal and promote long-lasting recovery.

How Common is Relapse?

Relapse is a common part of the recovery process for drug users. Addiction is a chronic condition which has similar relapse rates to medical illnesses, such as asthma, diabetes, and hypertension.19 Research indicates that between 40% and 60% of users in recovery relapse at some point.19 These rates do not mean that recovery isn’t possible; it simply means that treatment may need to be re-instated. Ongoing support, such as support groups and counseling, can also be a factor in preventing relapse.

One of the reasons that relapse is common is opioid withdrawal symptoms, which can be extremely distressing. Users may relapse while trying to detox in attempts to alleviate these symptoms.

Opioid withdrawal symptoms may include:14

  • Anxiety.
  • Irritability.
  • Insomnia.
  • Restlessness.
  • Muscle aches or twitching.
  • Tremors.
  • Nausea or vomiting.
  • Abdominal cramps.
  • Diarrhea.
  • A runny nose.
  • Fever.
  • Sweating.
  • Hot/cold flashes.
  • Yawning.

Because cravings and withdrawal symptoms can be so intense, users may repeatedly relapse. An important thing to be aware of is that tolerance decreases when a person is detoxing from opioids. Often, they will stop using and then relapse, thinking they can use their previously used dose, which increases the risk of overdose. Opioid overdose is a medical emergency and may result in death if left untreated.

Call 911 immediately if a person displays any of the following signs:15

  • Their heartbeat or breathing slows or stops
  • They begin vomiting or make gurgling sounds
  • Their face is clammy or very pale
  • Their lips or fingers have a blue color
  • They are unable to speak or cannot be awakened

Recovering From Opioid Addiction

Prescription opioids are highly addictive, but options for treatment are available. The first step in recovery from opioid addiction is detox, which ideally is then followed by a comprehensive inpatient or outpatient treatment program.

Detoxification consists of 3 stages:16

  1. Evaluation: Assessing the patient and administering diagnostic tests.
  2. Stabilization: Managing withdrawal and achieving a stable, drug-free state.
  3. Fostering patient readiness and entry into a treatment program: Preparing the patient for inpatient/outpatient rehabilitation and educating them on why follow-up treatment is so important.

Detox for opioids is likely to include medications, such as methadone or Suboxone, which can help to alleviate withdrawal symptoms and reduce opioid cravings.16 These medications are then gradually tapered off to create a more comfortable and smoother withdrawal experience for the patient.

After completing detox, patients may transition to inpatient treatment, which ranges from 30–90 days or longer, depending on the individual. These programs require that you live at the facility for the duration of the substance abuse treatment program; many people find this beneficial since they’re separated from their old, using environment. Patients receive around-the-clock supervision and treatment. Most professional treatment approaches will utilize a combination of therapeutic interventions including individual therapy, group counseling, family therapy, medication-assisted treatment (MAT), medical care, and support group meetings.

Patients may also transition into an outpatient treatment program, which allows them to attend treatment during the day but still return home at night. This type of treatment is best suited for those who have a strong, sober support system. Outpatient programs range in intensity, frequency, and duration. Some programs meet a couple hours per day for 1-2 days per week while others meet for 6-8 hours, 5 days a week.

Other recovery options utilized by people both in and out of treatment include community support groups, such as Narcotics Anonymous (NA) or Pills Anonymous (PA), which are free and widely accessible support groups. Members of these programs benefit from the encouragement and support of fellow members and sponsors.

Sources

  1. U.S. Department of Health & Human Services. (2016). About the Epidemic.
  2. National Institute on Drug Abuse. (2016). Opioids.
  3. U.S. Drug Enforcement Administration. (N.D.). Drug Scheduling.
  4. National Institute on Drug Abuse for Teachers. (2017). How Does Someone Become Addicted to Opioids?
  5. Compton, W., Jones, C., & Baldwin, G. (2016). Relationship Between Nonmedical Prescription-Opioid Use and Heroin Use. The New England Journal of Medicine, 374(2), 154–163.
  6. Center for Disease Control and Prevention. (2017). Understanding the Epidemic.
  7. Zimmerman, B., Lindberg, C., & Plsek, P. (1998). Edgeware: Lessons From Complexity Science for Health Care Leaders. Irving, TX: VHA.
  8. Rowitz, L. (2014). Public Health Leadership: Putting Principles Into Practice(3rd ed.). Burlington, MA: Jones & Bartlett.
  9. Substance Abuse and Mental Health Services Administration. (2016). Opioids.
  10. National Institute on Drug Abuse for Teachers. (2017). Mind Over Matter: Prescription Pain Medications (Opioids).
  11. Centers for Disease Control and Prevention. (2017). Prescription Opioids.
  12. Coscarelli, J. and Kovaleski, S. (2017). How Prince Concealed His Addiction: Aspirin Bottles of Opiates.
  13. Kosten, T. &George, T. (2002). The Neurobiology of Opioid Dependence: Implications for Treatment. Scientific Practices and Perspective, 1(1), 13–20.
  14. Wesson, D. (2003). The Clinical Opiate Withdrawal Scale (COWS). The Jouranl of Psychoactive Drugs, 35(2), 253–259.
  15. Substance Abuse and Mental Health Services Administration. (2016). Opioid Overdose.
  16. Substance Abuse and Mental Health Services Administration (2013). Detoxification and Substance Abuse Treatment: A Treatment Improvement Protocol (TIP 45).
  17. Pain News Network. (2016). AMA Drops Pain as Vital Sign.
  18. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  19. National Institute on Drug Abuse. (2014). Addiction and Health.

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