Opioids and related disorders
Opioids are a class of drugs that include both natural and synthetic substances. The natural opioids (referred to as opiates) include opium and morphine. Heroin, the most abused opioid, is synthesized from opium. Other synthetics (only made in laboratories) and commonly prescribed for pain, such as cough suppressants, or as anti-diarrhea agents, include codeine, oxycodone (OxyContin), meperidine (Demerol), fentanyl (Sublimaze), hydromorphone (Dilaudid), methadone , and propoxyphene (Darvon). Heroin is usually injected, either intravenously (into a vein) or subcutaneously (under the skin), but can be smoked or used intranasally (i.e., "snorted"). Other opioids are either injected or taken orally.
The manual that is used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders . The latest edition of this manual was published in 2000, and is also known as the DSM-IV-TR . DSM-IV-TR lists opioid dependence and opioid abuse as substance use disorders. In addition, the opioid-induced disorders of opioid intoxication and opioid withdrawal are listed in the substancerelated disorders section as well.
Opioid dependence, or addiction , is essentially a syndrome in which a person continues to use opioids in spite of significant problems caused by or made worse by the use of opioids. Typically individuals with opioid dependence are physically dependent on the drug as evidenced by tolerance and/or withdrawal.
Opioid abuse is less severe than opioid dependence and typically does not involve physical dependence on the drug. Opioid abuse is essentially repeated significant negative consequences of using opioids recurrently.
When an individual uses a sufficient amount of an opioid, they will get "high" from the drug. Some people, however, have negative experiences when they use an opioid. When too much of an opioid is taken, an individual can overdose.
Individuals who use opioids on a regular basis, even if only for a few days, may develop a tolerance to the drug and experience physiological and psychological symptoms when they stop using the drug. The "abstinence syndrome" related to opioids is very similar to a bad case of influenza (or the "flu").
Dependence on opioids involves significant physiological and psychological changes, which make it extremely difficult for an individual to stop using the opioids. Recurrent use of opioids causes actual changes in how the brain functions. An individual who is addicted to opioids cannot simply just stop using, despite significant negative consequences related to their use. Marital difficulties, including divorce, unemployment, and drug-related legal problems are often associated with opioid dependence. People dependent on opioids often plan their day around obtaining and using opioids.
People who abuse opioids typically use them less frequently than those who are dependent on opioids. However, despite less frequent use, an individual with opioid abuse suffers negative consequences. For example, while intoxicated on opioids, an individual may get arrested for their behavior.
An individual who uses opioids typically experiences drowsiness ("nodding off"), mood changes, a feeling of heaviness, dry mouth, itching, and slurred speech. Individuals who use heroin intravenously describe an intense euphoria (or "rush"), a floating feeling, and total indifference to pain. Symptoms of intoxication usually last several hours. Severe intoxication from an overdose of opioids is life-threatening because breathing may stop.
Tolerance to opioids occurs quickly. Regular users of opioids take doses that would kill someone who has never used before. After regular use, the human body adapts to the regular presence of the drug and the person only feels "normal" when they have opioids in their system. Therefore, when an opioid-dependent individual stops using opioids abruptly, he or she will experience withdrawal symptoms. Withdrawal symptoms from heroin usually begin six to eight hours after last use and peak after two days. Acute withdrawal typically lasts no more than seven to ten days, but some symptoms of withdrawal (such as craving, insomnia , anxiety, lack of interest) can last six months or longer. Although withdrawal is very uncomfortable, it is not life-threatening unless there is an underlying medical condition, such as heart disease. In addition to physical withdrawal, "psychological withdrawal" often occurs. The individual who is dependent on opioids has difficulty imagining living without the drug, since they were dependent on it to function. This is similar to how someone addicted to nicotine may feel after giving up cigarettes.
Causes and symptoms
There are no clear-cut causes of drug use other than the initial choice to use the drug. This decision to use may be highly influenced by peer group. Typically, the age of first use of heroin is about 16 years old, but this age has been dropping in recent years.
Certain social and behavioral characteristics, however, are more commonly seen among individuals who become dependent on opioids than those who do not. For instance, many heroin users come from families in which one or more family members use alcohol or drugs excessively or have mental disorders (such as antisocial personality disorder ). Often heroin users have had health problems early in life, behavioral problems beginning in childhood, low self-confidence, and anti-authoritarian views.
Among opioid-dependent adolescents, a "heroin behavior syndrome" has sometimes been described. This syndrome consists of depression (often with anxiety symptoms), impulsiveness, fear of failure, low self-esteem, low frustration tolerance, limited coping skills, and relationships based primarily on mutual drug use.
OPIOID DEPENDENCE. The DSM-IV-TR specifies that three or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid dependence:
- Tolerance: The individual either has to use increasingly higher amounts of the drug over time in order to achieve the same drug effect or finds that the same amount of the drug has much less of an effect over time than before.
- Withdrawal: The individual either experiences the characteristic abstinence syndrome (i.e., opioid-specific withdrawal) or the individual uses opioids or similar-acting drugs in order to avoid or relieve withdrawal symptoms.
- Loss of control: The individual either repeatedly uses more opioids than planned or uses the opioids over longer periods of time than planned.
- Inability to stop using: The individual has either unsuccessfully attempted to cut down or stop using the opioids or has a persistent desire to stop using.
- Time: The individual spends a lot of time obtaining opioids, getting money to buy opioids, using opioids, being under the influence of opioids, and recovering from the effects of opioids.
- Interference with activities: The individual either gives up or reduces the amount of time involved in recreational activities, social activities, and/or occupational activities.
- Harm to self: The individual continues to use opioids despite having either a physical or psychological problem (depression, for example) that is caused or made worse by the opioid use.
OPIOID ABUSE. The DSM-IV-TR specifies that one or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid abuse:
- Interference with role fulfillment: The individual's use of opioids repeatedly interferes with the ability to fulfill obligations at work, home, or school.
- Danger to self: The individual repeatedly uses opioids in situations in which it may be physically hazardous (while driving a car, for example).
- Legal problems: The individual has recurrent opioidrelated legal problems (such as arrests for possession of narcotics).
- Social problems: The individual continues to use opioids despite repeated interpersonal or relationship problems caused by or made worse by the use of opioids.
OPIOID INTOXICATION. The DSM-IV-TR specifies that the following symptoms must be present in order to meet diagnostic criteria for opioid intoxication:
- Use: The individual recently used an opioid.
- Changes: The individual experiences significant behavioral or psychological changes during, or shortly after, use of an opioid. These changes may include euphoria initially, followed by slowed movements or agitation, impaired judgment, apathy ("don't care attitude"), dysphoric mood (depression, for example), or impaired functioning socially or at work.
- Opioid-specific intoxication syndrome: The pupils in the eyes get smaller. In addition, drowsiness or coma, slurred speech, and/or impaired memory or attention during, or shortly after, opioid use occur.
OPIOID WITHDRAWAL. The DSM-IV-TR specifies that the following symptoms must be present in order to meet diagnostic criteria for opioid withdrawal:
- Abstinence: Either the individual has stopped using (or has reduced the amount of) opioids, or an opioid antagonist (i.e., a drug, such as naloxone, that blocks the action of opioids) has been administered.
- Opioid-specific withdrawal syndrome: Three or more symptoms develop after abstinence. These symptoms include dysphoric (negative) mood, nausea or vomiting, muscle aches, runny nose or watery eyes, dilated pupils, goosebumps, or sweating, diarrhea, yawning, fever, and insomnia.
- Impairment or distress: The withdrawal symptoms must cause significant distress to the individual or impairment in functioning (socially, at work, or any other important area).
- Not due to other disorder: The withdrawal symptoms cannot be due to a medical condition or other mental disorder.
There are at least 600,000 individuals with opioid dependence living in the United States. It has been estimated that almost 1% of the population has met criteria for opioid dependence or abuse at some time in their lives.
In the late 1800s and early 1900s, individuals who were dependent on opioids were primarily white and from middle socioeconomic groups. However, since the 1920s, minorities and those from lower socioeconomic groups have been overrepresented among those with opioid dependence. It appears that availability of opioids and subcultural factors are key in opioid use. Therefore, medical professionals (who have access to opioids) are at higher risk for developing opioid-related disorders.
Males are more commonly affected by opioid disorders than females—males are three to four times more likely to be dependent on opioids than females. Age also is a factor in opioid dependence. There is a tendency for rates of dependence to decrease beginning at 40 years of age. Problems associated with opioid use are usually first seen in the teens and 20s.
Diagnosis of opioid-related disorders are based on patient interview and observations of symptoms, including signs of withdrawal such as dilated pupils, watery eyes, frequent yawning, and anxiety, among others.
Other mental disorders are common among individuals with opioid dependence. It has been estimated that 90% of those with opioid dependence have one or more other mental disorders. Depression (usually either major depression or substance-induced mood disorder) is the most common disorder. Opioid-dependent individuals frequently report suicidal ideation (thoughts) and insomnia. Other substance use disorders (such as alcoholism), anxiety disorders, antisocial personality disorder, post-traumatic stress disorder , and a history of conduct disorder are also fairly common.
Intoxication on other substances, such as alcohol, sedatives, hypnotics, and anxiolytics, can resemble intoxication on opioids. Furthermore, dilated pupils can be seen in hallucinogen intoxication, amphetamine intoxication, and cocaine intoxication.
The restlessness and anxiety seen in opioid withdrawal is also seen in withdrawal from sedatives, hypnotics, and anxiolytics.
Because opioid-related disorders are complex, multiple treatment approaches are often necessary. Generally, the more treatment (a combination of medication, individual therapy, and self-help groups , for example) and longer the treatment (i.e., at least three months), the better the outcomes. There are a wide variety of treatment options, both inpatient or residential and outpatient:
- Methadone maintenance treatment. Methadone is a long-acting opioid that is generally administered in an outpatient setting (a methadone maintenance clinic). The methadone prevents the individual from experiencing opioid withdrawal, reduces opioid craving, and enables the individual to have access to other services (such as individual counseling, medical services, and HIV-prevention education). A proper dose of methadone also prevents the individual from getting "high" from heroin. Methadone maintenance therapy can decrease criminal activity, decrease HIV-risk behaviors, and increase stability of employment. Low-dose methadone maintenance treatment is preferable for pregnant individuals who would otherwise use illicit opioids. A longer-acting alternative to methadone is LAAM (levo-alphacetylmethadol). Individuals receiving the proper doses of LAAM only need to take it three times per week, instead of every day as with methadone.
- Opioid antagonist treatment. An opioid antagonist is a medication that blocks the effects of opioids. Treatment with an antagonist, usually naltrexone (Trexan), typically takes place on an outpatient basis following an inpatient medical detoxification from opioids. The effects of taking any opioids are blocked by the naltrexone and prevent the individual from getting "high," thereby discouraging individuals from seeking opioids. By itself, this treatment is suitable for individuals highly motivated to discontinue opioid use. However, antagonists can be used in addition to other treatment modalities or with individuals who have been abstinent for some time but fear a relapse.
- Opioid agonist-antagonist treatment. An opioid agonist is a drug that has a similar action to morphine. Buprenorphine (Buprenex) is an example of an opioid agonist-antagonist, which means it acts as both an agonist (having some morphine-like action) and antagonist (it blocks the effects of additional opioids). Buprenorphine has been shown to effectively reduce opioid use. It is also being studied for opioid detoxification.
- Outpatient drug-free treatment. These are outpatient treatment approaches that do not include medications. There are a number of different types of programs ranging from simple drug education to intensive outpatient programs that offer most of the services of an inpatient setting. Some programs may specialize in treating specific groups of people who are opioid-dependent (those with co-occurring mental disorders, for example).
- Residential or inpatient treatment. These include inpatient rehabilitation programs (usually seven to 30 days in length) and long-term residential programs (such as therapeutic communities). Rehabilitation programs provide an inpatient atmosphere following detoxification and usually offer individual and group counseling as well as medical services. Therapeutic communities are designed to be more than six months long and are highly structured. The primary focus is on resocializing the individual to a drug-free and crime-free lifestyle.
- Individualized drug counseling. Individual counseling is often a part of a methadone maintenance program or inpatient rehabilitation program. The primary focus is on helping the individual learn strategies to reduce or stop their opioid use and learn coping mechanisms to maintain abstinence. Twelve-step participation is encouraged and referrals for medical, psychiatric, employment, or other services are made as necessary.
- Supportive-expressive psychotherapy . This type of individual psychotherapy may be a part of a methadone maintenance program or offered alone. The focus of this type of therapy is to help individuals feel comfort able talking about themselves, work on relationship issues, and solve problems without resorting to opioids or other drugs.
- Self-help groups. Narcotics Anonymous (NA) is a twelve-step group based on the same model as Alcoholics Anonymous. This self-help group can provide social support to an individual in the process of reducing or stopping opioid use. Participation in NA is often encouraged or is a required component of other types of treatment for opioid dependence. Nar-Anon is a group for family members and friends of opioid-dependent individuals.
- Alternative therapies. Hypnosis, guided imagery, biofeedback , massage, and acupuncture have all been studied as adjunctive treatments for opioid dependence, but none have been proven to be effective.
Most of the treatments for opioid dependence would be appropriate for opioid abuse except methadone main tenance and opioid antagonist treatment.
An opioid antagonist, naloxone (Narcan), can be administered to reverse the effects of acute intoxication or overdose on most opioids.
Opioid withdrawal can be treated either on an inpatient basis (detoxification) or on an outpatient basis (methadone detoxification):
- Inpatient detoxification program. Typically, this would be from three to seven days. The withdrawal can be medically managed. Clonidine may be administered to help reduce some symptoms of withdrawal.
- Outpatient methadone detoxification. Methadone would be substituted for the illicit opioid and the dose would be gradually reduced. Detoxification from methadone is easier (i.e., the symptoms are less severe) than from heroin. However, the withdrawal or abstinence syndrome also lasts longer. Clonidine may also be administered during the methadone detoxification to help reduce withdrawal symptoms.
Recovering from opioid dependence is a long, difficult process. Typically, multiple treatment attempts are required. Relapsing, or returning to opioids, is not uncommon even after many years of abstinence. Brief periods of abstinence are common.
Inpatient detoxification from opioids alone, without additional treatment, does not appear to have any effect on opioid use. However, other treatments have been shown to reduce opioid use, decrease illegal activity, decrease rates of HIV-infection, reduce rates of death, and increase rates of employment. Benefits are greatest for those who remain in treatment longer and participate in many different types of treatment (individual and group counseling in addition to methadone maintenance, for example).
Very little is known about the course of opioid abuse.
The best single thing an individual can do to prevent opioid-related disorders is never to use illicit opioids such as heroin. Opioids are powerfully addicting, especially if used intravenously. The risk of becoming dependent on appropriately prescribed opioids, however, is generally low except for individuals who already have a substance use disorder.
On a larger scale, comprehensive prevention programs that utilize family, schools, communities, and the media can be effective in reducing substance abuse. The recurring theme in these programs is not to use drugs in the first place.
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Jennifer Hahn, Ph.D.