Opioids

Opioids are among the most effective drugs for treating pain and can significantly improve the quality of life for individuals with chronic pain or who have just undergone surgery. They also have other medical uses, including acting as cough suppressants and reducing diarrhea. But because the body adapts to some of their effects over time, people may develop a tolerance to opioids and become dependent on them for pain relief.

In addition to pain relief, opioids are associated with a number of potentially negative side effects, such as:

• Constipation
• Sleepiness
• Nausea and vomiting
• Clouded thinking
• Respiratory problems
• Gradual overdose
• Sexual dysfunction

Given the possibility of tolerance, people can develop symptoms of withdrawal upon abrupt cessation of opioid drugs. Individuals taking prescribed opioid medications should not only do so under appropriate medical supervision; they should also be medically supervised when stopping use to reduce or avoid withdrawal symptoms.

Opioid Intoxication

Opioid intoxication is diagnosed when recent exposure to an opioid causes significant problematic behavioral or psychological changes. Psychological symptoms include:

• Initial euphoria followed by apathy
• A strong sense of unease
• Unintentional and purposeless movement (hand wringing, pacing, uncontrolled tongue movement)
• Slowed cognition and movement
• Impaired judgment

Physical symptoms include:

• Constriction or dilation of the pupils
• Slurred speech
• Impairment in attention or memory
• Drowsiness or coma

A large single dose can cause severe or fatal respiratory depression.

Opioid Withdrawal

When an individual takes opioids for a long time and then suddenly stops or lowers the dosage, they may experience withdrawal. This can manifest as a wide range of aversive symptoms lasting anywhere from a week to several months.

Some of the most common symptoms of withdrawal include:

• Anxiety
• Restlessness
• Irritability
• Increased sensitivity to pain
• An achy feeling, often found in the back and legs
• A strong sense of unease
• Nausea or vomiting
• Excessive tearfulness

The speed and severity of opioid withdrawal depend on the type of opioid used. Among people who use heroin, withdrawal symptoms begin within 6 to 12 hours after their last dose, while those who take longer-acting drugs, such as methadone, may experience withdrawal symptoms two to four days after their last dose.

Opioid Use Disorder

To be clinically diagnosed with Opioid Use Disorder, an individual must experience a harmful pattern of opioid use that leaves him or her impaired or distressed due to at least two of the following factors within the previous year:

• Taking larger dosages and/or taking opioids for a longer period of time than intended
• Being unable to reduce opioid use despite a strong desire to do so
• Spending a large amount of time procuring, using, or recovering from the effects of opioids
• Experiencing an overwhelming desire or urge to use opioids
• Finding oneself unable, due to opioid use, to meet responsibilities in one's job, school, or home life
• Continuing one's use of opioids in the face of social/interpersonal problems that result from or are made worse by it
• Prioritizing opioid use to such an extent that social, occupational, and recreational activities are either given up completely or are reduced drastically
• Using opioids even in situations where it becomes physically hazardous
• Continuing to use opioids despite knowing that they are causing or exacerbating physical and psychological problems
• Developing tolerance in the form of either of the following:
  • Intoxication requires greater amounts of opioid use than it did previously
  • The same dose of opioid over the same amount of time results in weaker effects
• Developing withdrawal in the form of either of the following:
  • Individuals displays characteristics of Opioid Withdrawal Syndrome
  • Symptoms of withdrawal diminish as a result of the use of opioids (or similar substances)

Heavy or prolonged use of opioids causes the body to become physically dependent on the drugs, which in turn causes symptoms of withdrawal that are so distressful that it becomes challenging to stop taking them. When dependence and inability to cease use interferes with the quality of a person's life, it is considered to have developed into Opioid Use Disorder.

Opioid Use Disorder—as well as overdoses and deaths related to opioid use—are at epidemic levels in the United States and other places around the world. This crisis, known as the "opioid epidemic," is considered to have begun in the 1990s, when, due to changing federal regulations and increased marketing by pharmaceutical companies, prescriptions of legal opioids increased rapidly. Today, they are among the most prescribed medications in the U.S.; as of 2017, there were 58 opioid prescriptions for every 100 Americans, according to the CDC.

As opioids are highly addictive, many who are prescribed the medications, often for legitimate pain, become dependent on them. After developing a habit, some who are dependent on opioids may continue their prescriptions for months or years longer than recommended; if a clinician declines to refill a prescription, they may seek other, illegal forms of opioids—such as heroin—to manage chronic pain or opioid dependence. A person with Opioid Use Disorder might purchase opioids on the illegal market or may falsify or exaggerate medical problems to receive prescription opioids from a physician. Health care professionals who have Opioid Use Disorder might write prescriptions for themselves or take opioids from pharmacy supplies.

Though some illegal forms of opioids can be stronger than prescription opioids or may be cross-contaminated with other substances, overdosing on any form of opioid is still very dangerous. In 2017 alone, opioid overdoses were linked to nearly 50,000 deaths in the U.S.

Like other substance use disorders, Opioid Use Disorder is treatable. Through treatment that is tailored to individual needs, patients can learn to control their condition. Those in treatment for drug addiction, like those with diabetes or heart disease, learn behavioral changes and often take medication as part of their recovery program.

Behavioral therapies can include counseling, family therapy, psychotherapy, or support groups. Treatment medications help to suppress withdrawal symptoms and drug cravings and to block the effects of drugs. Many patients require other services as well. Patients who stay in treatment for longer than three months usually have better outcomes than those who do not. Patients who go through medically assisted withdrawal without any further treatment perform about the same in terms of their drug use as those who were never treated.

Medication

Methadone, a synthetic opioid that eliminates withdrawal symptoms and relieves craving, has been used successfully for more than 30 years to treat people addicted to heroin as well as other opiates. Studies show that treatment for opioid addiction using methadone at an adequate dosage level combined with behavioral therapy reduces death rates and many health problems associated with opioid abuse. Buprenorphine, another synthetic opioid, is a more recently approved medication for treating opioid addiction; it can be prescribed in a physician's office.

Naltrexone is a long-acting opioid receptor blocker that can be employed to help prevent relapse. (This medication can only be used for someone who has already been detoxified, since it can produce severe withdrawal symptoms in a person continuing to abuse opioids.) Naloxone is a short-acting opioid receptor blocker that counteracts the effects of opioids and can be used to treat overdoses.

Types of Treatment Programs

The ultimate goal of treatment is lasting abstinence, but the immediate goals are reduction of drug use, improvement of the patient's ability to function, and diminishing the medical and social complications of drug abuse.

There are several types of drug abuse treatment programs. Short-term methods last less than six months and include residential therapy, medication therapy, and drug-free outpatient therapy. Longer-term treatment may include, for example, methadone maintenance outpatient treatment and residential therapeutic community treatment.

In maintenance treatment for those who are addicted to heroin, patients are given an oral dose of a synthetic opiate, usually methadone hydrochloride or levo-alpha-acetyl methadol (LAAM), administered at a dosage sufficient to block the effects of heroin and yield a stable, non-euphoric state free from craving for opiates. In this stable state, the patient is able to disengage from drug-seeking and (in some cases) related criminal behavior and, with appropriate counseling and social services, re-engage with the community.

Outpatient drug-free treatment encompasses a wide variety of programs for patients who visit a clinic regularly. Most of the programs involve individual or group counseling. Some programs also offer other forms of behavioral treatment, such as:

• Cognitive-behavioral therapy, which seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs
• Multidimensional family therapy, which was developed for adolescents with drug abuse problems as well as their families, addresses a range of influences on drug abuse patterns and is designed to improve overall family functioning
• Motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment
• Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs

Therapeutic communities (TCs) are highly structured programs in which patients stay at a residence, typically for 6 to 12 months, where the focus is on the re-socialization of the patient to a drug-free lifestyle. TCs differ from other treatment approaches principally in their use of the community-treatment staff and those in recovery as key agents of change to influence patient attitudes, perceptions, and behaviors associated with drug use. Patients in TCs include those with relatively long histories of drug dependence, involvement in serious criminal activities, and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children.

Short-term residential programs, commonly referred to as chemical dependency units, are often based on the "Minnesota Model" of treatment for alcoholism. These programs involve a 3- to 6-week inpatient treatment phase followed by extended outpatient therapy or participation in 12-step self-help groups, such as Narcotics Anonymous (NA).

Drug treatment programs in prisons can succeed in preventing a return to criminal behavior, particularly if the patient is involved in a community-based program that continues treatment after he or she has left prison. For example, the Delaware Model, an ongoing study of comprehensive treatment of prison inmates who struggle with drug addiction, shows that prison-based treatment including a therapeutic community setting, a work release therapeutic community, and community-based aftercare reduces the probability of re-arrest by 57 percent and reduces the likelihood of returning to drug use by 37 percent.

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