An Overview of Opiate (Opioid) Addiction and Treatment

The opioid crisis currently claims 115 lives every day to overdose and leaves countless families devastated in its wake. According to the Centers for Disease Control, opioid abuse is the number-one cause of preventable death among 18- to 35-year-olds today.

It’s estimated that over 2.5 million Americans are in need of opiate addiction treatment. Here is everything you need to know about opiate addiction, including how it develops and how it’s successfully treated.

What Are Opiates?

Opiates are drugs that are synthesized from morphine, which is found in some varieties of the poppy plant.

Opiates produce intense euphoria and slow down respiratory function by activating certain opioid receptors in the central nervous system, including in the Pons, where respiratory rhythms are generated. High doses of opioids can quickly lead to respiratory depression and death.

Two classes of opiates are heroin and prescription painkillers.

Heroin

Heroin is an illegal opiate that’s listed on Schedule I of the Controlled Substances Act, which means that it has no medical value and a high potential for abuse. Heroin can be injected, smoked or snorted.

According to the National Institute on Drug Abuse (NIDA,) around 156,000 people used heroin for the first time in 2006, and by 2012, that number had doubled. Between 2002 and 2011, heroin use among the 18- to 25-year-old crowd increased by 109 percent. Nearly 600,000 people are currently addicted to heroin.

Around 86 percent of people who are addicted to heroin first used prescription painkillers, according to NIDA. One reason why so many people have moved from painkillers to heroin is the advent of abuse-resistant formulations for opiate painkillers that make them harder to abuse. These abuse-deterrent strategies include:

  • Adding naloxone, which reverses the effects of opioids if the drug is misused
  • Technologies that make it impossible to crush pills for snorting
  • Technologies that turn a dissolved tablet into a gelatinous substance that can’t be injected
  • Agents that cause nasal discomfort if a tablet is crushed and snorted

Heroin is typically cheaper than prescription opioids, it’s easier to find and its temporary euphoric effects are stronger than those of prescription painkillers. Some people turn to heroin to keep withdrawal at bay when they can’t find prescription painkillers. But since it’s impossible to know the purity and strength of a batch of heroin, the risk of overdose is always high.

Prescription Painkillers

Opiate painkillers are used to treat mild, moderate and severe pain. They work by reducing the intensity of pain signals that travel to the brain. The most commonly used painkillers are oxycodone (Percocet, OxyContin) and hydrocodone (Vicodin, Lortab.) Opiate painkillers are listed under Schedule II of the Controlled Substances Act. This means that while they have medical value, painkillers have a high potential for abuse.

America accounts for just five percent of the world’s population, but we consume 75 percent of all prescription drugs. The United States accounts for 81 percent of the world’s market for oxycodone and 100 percent of the market for hydrocodone. Around two million Americans are currently addicted to opiate painkillers.

Opioid Overdose: A Real and Present Danger

Naloxone and Opiate Treatment

Opiate overdose deaths quadrupled between 2000 and 2013, and today, opiate overdose is the leading cause of accidental death in the U.S., according to the American Society of Addiction Medicine.

Overdose deaths continue to rise. Between July 2016 and September 2017, opioid overdoses increased by 30 percent in 45 states. In the Midwest, they increased by 70 percent in that same time period. It is now recommended that anyone who uses opioids, family members, and friends of people who use them should carry naloxone with them.

Naloxone is known as the opiate overdose reversal drug. An opioid antagonist, naloxone knocks opioids out of the receptors to reverse their depressive effects and restore breathing. Naloxone is available over the counter in most states under the trade name Narcan, a nasal spray that delivers naloxone to an unconscious overdose victim.

Arrival

Opiates arrived in the New World in 1620, brought by Sam Fuller in the form of laudanum, a solution of opium and alcohol that was later used to treat soldiers on the battlefields of the American Revolution.

In the 19th century, opium dens were found all over the country, and over-the-counter medications included opium-laced infant sleep aids, teething powders and elixirs for a range of aches, pains and other conditions.

Harrison Narcotic Tax Act

In the early 1900s, the Harrison Narcotic Tax Act was passed to address the increasing opiate addiction problem. This law levied a tax on anyone importing, manufacturing, selling or distributing opiates. Because addiction at that time was considered a moral failing, physicians were barred from prescribing opiates to treat dependence, leaving many to a fate of lifelong addiction.

After World War II, opioids like hydrocodone and oxycodone were synthesized from morphine to treat pain. However, because of the high risk of addiction and dependence, few physicians prescribed these medications.

Treating Pain

Then, in the 1970s, a misunderstanding in the treatment of pain began, leading pharmaceutical companies to convince doctors that they were under-treating pain. By the late 1970s, opiate painkillers were widely prescribed for all types of pain.

By 1991, 76 million prescriptions for opiates were written each year. In 2015, 240 million opioid prescriptions were written-nearly one prescription for every American adult-even though research shows that Americans’ perception of pain changed very little since the 1970s.

Why Opiate Abuse Happens

Opiates produce a keen sense of euphoria and well-being. Some people abuse opiates to get high and relax, while others get addicted by increasing their doses without the approval of their physician in order to better control their pain.

People who become addicted to opiates typically have underlying risk factors for addiction.

Four of the most common underlying causes of opiate addiction are pain, chronic stress, a history of trauma, and co-occurring mental illnesses.

Pain

An estimated 25.3 million American adults are living with chronic pain at any given time, according to the National Center for Complementary and Integrative Health. Many others suffer from acute pain related to surgery or injury. According to the 2012 National Health Survey, two-thirds of people who abused opioids-which is defined as taking them other than as prescribed-did so to reduce their pain. Just 10 percent of respondents reported abusing them to get high.

According to a study published in JAMA, 5.9 to 6.5 percent of people who are prescribed painkillers after surgery become new and persistent painkiller users.

Trauma

Trauma changes the brain by elevating activity in the amygdala, the brain region responsible for the stress response, including fear and anxiety. Trauma can cause symptoms of post-traumatic stress disorder, or PTSD, which include nightmares, insomnia, anger, fear, and flashbacks. Many people with a history of trauma or who suffer from PTSD use opiates to numb their emotional pain, dampen negative emotions, stave off nightmares, and cope with fear and anger.

Chronic Stress

Chronic stress often comes from life situations like poverty or abuse. It simmers below the surface, characterized by elevated stress hormone levels that keep the body in a perpetual stress response state. This can cause serious medical problems, including high blood pressure, heart disease, addiction, and dependence.

Some people who abuse opiates use them to relax and reduce stress. But opiates reduce the body’s ability to effectively cope with high-stress levels, leading to worsened stress in the long run. Additionally, opiates cause numerous life problems that end up increasing stress.

Mental Illness

When mental illnesses like anxiety or depression co-occur with addiction, it’s known as a dual diagnosis. Around half of all people who abuse drugs or alcohol also suffer from a co-occurring mental health issue. It’s common for people with a mental illness to abuse drugs or alcohol to self-medicate their symptoms. Ultimately, substance abuse almost always worsens symptoms of mental illness down the road, and it can even cause the onset of a mental illness that didn’t previously exist.

How Opiate Addiction Develops

Opiates are highly addictive. Around 23 percent of people who abuse heroin become addicted to it, according to the National Institute on Drug Abuse. By contrast, around 15 percent of people who use alcohol develop an addiction to it.

Tolerance

One reason opiates are so addictive is that they produce intense euphoria that many people want to experience again and again. Another reason is that opiates produce a high level of tolerance very quickly, leading to dependence.

Dopamine

Dopamine, the neurotransmitter responsible for feelings of pleasure, plays a key role in the learning, memory, motivation and reward processes of the brain. Dopamine is designed to keep the species thriving by making us want to do pleasurable activities, like eat, exercise, and help others, all of which produce a dopamine release in the brain. However, the brain carefully regulates the amount of dopamine released.

Opioids produce a dopamine release that’s nearly ten times greater than what occurs with normal, everyday pleasures. This produces intense euphoria.

Changes in the Brain

Opiate addiction is characterized by compulsive heroin or prescription painkiller use despite the negative consequences it causes. It’s marked by changes in the brain’s physical structures and chemical functions. Opiates cause addiction by hijacking the brain’s reward circuit.

Environmental Cues

When you use opiates, the brain records a memory of the experience, including environmental cues that are present when you use, such as the people you use with, the places you use and your emotional state before using. These environmental cues trigger intense cravings once an addiction develops.

Repeated exposure to opiates causes nerve cells in the brain’s reward center to begin communicating with those in the brain region responsible for planning and executing tasks. Your brain begins to equate liking opiates with wanting them. The result is intense opiate cravings that drive compulsive use. Even as life changes negatively because of use, the risk remains that you’ll continue using opiates once you’ve developed an addiction.

Dependence
Dependence is different from addiction. Dependence is characterized by the occurrence of withdrawal symptoms that occur when you stop using opiates. It develops as the brain changes its chemical function in order to compensate for the presence of the drug of abuse. For example, opiates produce a large dopamine release, so the brain reduces the activity of the dopamine system by producing less of it or shutting down some of the opioid receptors in the body.
Tolerance
Dependence leads to tolerance, which means that it takes increasingly larger doses of opiates to get the drug’s effects. As you increase the doses, the brain continues to change the way it operates in an attempt to maintain normal functioning. At some point, brain function may shift so that it operates more comfortably when opiates are present. Then, when use is stopped, normal brain function rebounds leading to physical withdrawal symptoms.
Diagnosis
Opiate abuse, addiction, and dependence are diagnosed under the umbrella of opioid use disorder, or OUD, in the Diagnostic and Statistical Manual, Fifth Edition, or the DSM-V. Eleven criteria are used to determine whether you have an OUD, which will be classified as mild, moderate or severe, depending on how many criteria apply.

The diagnosis covers past-year use. If two or three of the below criteria apply, the OUD will be classified as mild. A moderate OUD is indicated if four or five apply. More than five criteria denotes a severe OUD.

Criteria
The criteria for diagnosing an opioid use disorder are:

  • Using more opiates or using them for a longer time than you intended
  • Wanting or trying to stop using but finding you can’t
  • Spending excessive amounts of time seeking, using and recovering from using opiates
  • Experiencing intense cravings that make it difficult to think about anything else
  • Continuing to use opiates even though doing so is causing problems at work, home or school
  • Continuing to use even though it’s causing problems in your relationships
  • Losing interest in activities you once enjoyed
  • Repeatedly finding yourself in dangerous situations due to your opiate use
  • Continuing to use even though it’s causing new or worsened symptoms of medical or mental illness
  • Developing a tolerance so that you need increasingly larger doses of opiates to get the same effects a smaller amount once produced
  • Experiencing withdrawal symptoms that set in when you stop using opiates

Additional signs that someone you love may be abusing opiates include:

  • The presence of paraphernalia, such as burnt spoons, glass pipes, syringes and the small baggies or balloons that heroin is sold in
  • Needle marks on the arms, legs, hands or feet, including between the toes and fingers
  • Dilated pupils or droopy eyelids
  • Nodding off to sleep at inappropriate times
  • Flushed skin
  • A runny nose
  • Slowed breathing
  • Increased neglect of personal hygiene
  • A loss of appetite

Medication-Assisted Treatment for Opiate Use Disorders

According to the Substance Abuse and Mental Health Services Administration, medication-assisted treatment, or MAT, is the gold standard for treating opiate addiction. MAT is a combination of medication and counseling that offers the best outcomes for opiate addiction.

It’s Not Just a New Addiction

Despite the proven success of MAT for treating opiate addiction, many people -including some in the medical community- regard MAT as simply replacing one addiction with another. But this simply isn’t true. Just as other chronic diseases like diabetes and heart disease require a combination of medication and lifestyle changes to manage them, opiate addiction can also be managed with this combination of therapies.

Focus on Recovery

The medications used with MAT prevent withdrawal and reduce cravings so that addicted individuals can focus on learning essential coping skills and addressing a variety of other issues.

MAT helps to restore brain function and reduce cognitive problems associated with opiate addiction, including problems with concentration, memory, and decision-making. This makes it easier for people in recovery to focus on treatment. It enables them to find and maintain employment or return to school.

Three medications are approved for treating opiate addiction.

Methadone

Methadone is a synthetic opiate that has been used to treat opiate addiction for many decades. Methadone is an opioid agonist, which means that it acts on the same receptors that painkillers and heroin act on. However, its effects are more gradual and less intense than those produced by other opiates.

Still, methadone has a high potential for abuse, so treatment requires a daily visit to a clinic or doctor’s office that’s certified by the Substance Abuse and Mental Health Services Administration and registered with the Drug Enforcement Agency. For this reason, it can be difficult for some people to stay on methadone. If they skip a dose, many people will turn back to painkillers or heroin if only to prevent withdrawal from setting in.

Buprenorphine

Buprenorphine is a semi-synthetic opiate approved in 2002 for medication-assisted treatment. It reduces cravings and helps restore normal brain function.

A partial opioid agonist, buprenorphine will produce the same effects as full-agonist opiates, but the effects are far weaker. Buprenorphine has a ceiling effect wherein larger doses won’t increase its effects. Therefore, it can be prescribed and taken at home, which increases compliance with MAT.

Suboxone is a brand of buprenorphine commonly used with MAT. Suboxone is a combination of buprenorphine and naloxone, the overdose reversal drug. If Suboxone is taken in higher doses than prescribed, or it’s crushed and snorted, the naloxone will prevent the buprenorphine’s psychoactive effects and send the user into withdrawal.

Naltrexone

Naltrexone was approved by the FDA in 2010 for MAT. Naltrexone is an opioid antagonist, which means it blocks the euphoric effects of opioids and reduces cravings. It can be taken daily in pill form or as a monthly injection.

While methadone and buprenorphine can be taken at any time in the recovery process, naltrexone can only be taken once all traces of opiates are out of your system. Medical detox helps individuals through the withdrawal process before they start on naltrexone.

The medication component of MAT can be used for as long as it’s needed. Some people stay on medication for a few months, while others stay on it for a few years. Some will stay on it for the rest of their lives.

Medical Detox for Opiate Dependence

Medical detox is the first step in opiate addiction treatment for those who decide against medication-assisted treatment with buprenorphine or methadone. During detox, opiates are withheld so that all traces can leave the body and brain function can begin to return to normal.

During medical detox, a variety of medications are used to reduce the severity of withdrawal symptoms and reduce the time it takes to detox. Not everyone will experience all of the possible symptoms of opioid withdrawal, and symptoms can range from mild to severe. While opiate withdrawal isn’t particularly dangerous, it can be excruciating.

Withdrawal can last anywhere from a few days to a few weeks or longer, depending on factors like your age, biology, general state of physical and mental health, and how much of the drug is in your system at the time of detox.

Symptoms of opiate withdrawal include:

  • Runny nose
  • Fever
  • Anxiety or agitation
  • Hot and cold chills
  • Nausea and vomiting
  • Abdominal cramps and diarrhea
  • Muscle aches
  • Intense cravings

During medical detox, a variety of assessments are given to identify the multiple needs and issues of the client. Information gained helps providers develop an individualized treatment plan that addresses needs and issues.

Another focus of medical detox is attempting to bring the client to a state of readiness for change. Providers in medical detox work to engage clients in addiction treatment, which is essential for successful recovery.

Treating an Opiate Addiction

On their own, detox and medication do very little to treat an opiate addiction, which is far more complex than dependence. According to a study published in the Irish Medical Journal, 91 percent of patients in a detox program relapsed after detox –59 percent of them within a week. Those who participated in a treatment program after detox either didn’t relapse or the relapse was significantly delayed. However, in the study, the treatment program only lasted for six weeks.

According to the National Institute on Drug Abuse, staying in rehab for an adequate period of time is essential for the best possible treatment outcomes. Anything less than 90 days of treatment is of limited effectiveness, according to NIDA. That’s because treating an addiction is as complex as the addiction itself.

Successful treatment requires addressing the many dimensions of addiction, including:

  • Its underlying causes
  • The changes in thought and behavior patterns it brings
  • Unhealthy lifestyle choices that perpetuate it
  • The life problems that resulted from it
  • The relationship problems it led to
  • A lack of purpose and meaning in life
  • Missing coping and life skills required for successful recovery

Just as it takes time to develop an addiction, it takes time to re-learn healthy thought and behavior patterns and address the underlying causes of the addiction. It takes time to develop the healthy lifestyle habits that promote successful long-term recovery. All of this occurs through a variety of therapies, services, and interventions during treatment.

Traditional Therapies Used in Treatment

A holistic approach to treatment that addresses issues of body, mind, and spirit offers the best treatment outcomes, according to the Substance Abuse and Mental Health Services Administration. A holistic treatment program will offer both traditional and complementary therapies to help clients work through issues and develop the skills needed for successful recovery.

Traditional treatment therapies are those that have been shown through research to be effective for treating addiction. Some of the traditional therapies commonly used in treatment include:

  • Motivational interviewing, which helps increase engagement in treatment and leads individuals to identify their own intrinsic motivation for wanting to recover.
  • Cognitive-behavioral therapy, or CBT, which helps individuals identify and change self-destructive thought and behavior patterns. CBT helps clients develop the coping skills they need to deal with cravings, stress, negative emotions, and other relapse triggers.
  • Family therapy, which helps to restore function to the family system. Family members learn healthy communication skills and begin to repair damaged relationships and restore trust.
  • Mindfulness-based therapies like acceptance and commitment therapy, or ACT, and dialectical behavior therapy, or DBT. These therapies help trauma survivors and others develop emotional coping skills, regulate their emotions and maintain a high level of mindfulness in recovery.

Complementary Therapies Used in Treatment

Complementary therapies are those that have been shown through research to be effective for treating addiction when they’re used along with traditional therapies. Some complementary therapies commonly used in treatment include:

  • Art or music therapy, which increases self-awareness, reduces stress and helps individuals work through difficult emotions and experiences.
  • Equine therapy, which involves working with horses. Equine therapy promotes self-confidence, setting healthy boundaries, and developing social and communication skills.
  • Yoga, which reduces stress, increases mindfulness and promotes physical and psychological flexibility, endurance, and strength.
  • Meditation, which reduces stress, improves self-awareness and increases mindfulness.
  • Biofeedback, during which participants learn stress reduction techniques as their vital functions are displayed on a monitor so that they can see them improve in real-time.
  • Nutritional therapy, which helps repair damage done to the body by the addiction and identifies any nutritional deficiencies.

Other Therapies, Services, and Interventions Used in Treatment

The overarching goal of treatment is to address an individual’s multiple needs. Traditional and complementary therapies address a wide range of problems and issues, but other, more practical help is often needed to repair and restore other aspects of an individual’s life.

Psychoeducational classes provide education on a wide range of topics related to substance abuse, including addiction and dependence, stress, relapse prevention, mental illness, and medications used in treatment.

Life skills classes help clients develop the essential life skills they need to be fully independent and participate in society. These may include domestic, financial, self-care, and relationship skills.

Vocational or educational assistance helps clients through the process of finding employment or returning to school.

Medical or psychiatric care helps people with a medical or mental illness get the condition under control, which is central to successful recovery.

Legal assistance helps individuals with legal issues navigate the court system. Legal problems cause a great deal of stress, which can interfere with successful recovery.

Housing assistance helps clients find a safe and stable place to live after treatment. Housing arrangements may include time in a sober living home, which offers some independence along with a high level of support from sober peers.

Why Some People Resist Treatment

Fewer than ten percent of people who have an addiction of any kind seek the help they need to recover for the long-term.

These are common fears, and they’re not unreasonable. But the alternative is a progression of the addiction, which can only lead to more devastating problems down the road.

There is Hope

The Substance Abuse and Mental Health Services Administration cites hope as the foundation of recovery. Overcoming an opiate addiction may seem like an insurmountable task, but recovery is possible with professional help and hope for a better future, even if you have a severe opiate addiction.

Recovery isn’t easy, but neither is being addicted to opiates. If you’re ready, treatment can help guide you through each step of the recovery process with a high level of support and encouragement along the way.