All About Opioids

All About Opioids

Opioid addiction is a chronic medical condition. It can create long-term changes to your brain. Luckily, early treatment intervention can help you avoid some of the long-term health conditions associated with addiction to opioids. It takes much more than willpower to break free of prescription drug abuse, but you can escape the cycle of detox and relapse. It may be a long-term process, but medications and counseling can improve your chances of success. Heroin is also an opioid and addiction to it is treated similarly to prescription drug addiction. 

Physical Dependence and Detox

Opioid addiction leads to changes in certain areas of your brain. Prescription drug addiction alters the circuits that handle mood and reward behavior.  In addition, long-term prescription drug abuse affects almost all of your body’s systems. When you cut off the opioid supply, you’re likely to get withdrawal symptoms such as:

  • Craving for drugs
  • Diarrhea
  • Large pupils
  • Yawning
  • Belly pain
  • Chills and goosebumps (the origin of the phrase “cold turkey”)
  • Nausea and vomiting
  • Body aches
  • Agitation and severe bad moods

If you have an opioid (also called a narcotic) addiction, you know that a list of these symptoms doesn’t capture the agony of going through them. It’s very unpleasant, and you’ll do almost anything to avoid it. Opioid withdrawal lasts hours to days — and sometimes weeks. It depends on which drug you were taking, how long you were taking it, and how much. After the intense initial symptoms subside, some physical and mental discomfort may linger for weeks.

Medication for Opioid Addiction

The symptoms of withdrawal are a major reason for relapse and further prescription drug abuse. But medications can help you through opioid withdrawal and prevent symptoms. After the initial detox, you’re at risk for relapse. Experts say psychological and social factors are the main drivers that could push you back to using. Stress and situations that remind your brain of the pleasure the drug can bring are common triggers. Successful, lifelong therapy to stay opioid-free usually involves long-term medication as well as counseling or talk therapy programs. One of the most frequent reasons people go to the doctor is for pain relief. There are a number of different drugs that can ease pain; most commonly prescribed are opioids.   These pain relievers are made from opium, which comes from the poppy plant. Morphine and codeine are the two natural products of opium.

Lab-made versions of morphine produce these other opioids:

  • Fentanyl (Duragesic)
  • Heroin, a street drug
  • Hydrocodone with acetaminophen (Lorcet, Lortab, Vicodin)
  • Hydrocodone (Hysingla ER, Zohydro ER)
  • Hydromorphone (Dilaudid, Exalgo)
  • Methadone
  • Meperidine (Demerol)
  • Oxycodone (OxyContin)
  • Oxycodone with acetaminophen (Percocet)
  • Oxycodone with aspirin (Percodan)

Misuse

These drugs are generally safe when you take them for a short time as prescribed by your doctor. But in addition to helping you manage the pain, they can also give you a feeling of well-being or euphoria.

Abuse occurs when opioids are:

  • Take a higher dose than prescribed
  • Take someone else’s prescription, even for a legitimate problem, like pain
  • Take it to get high
  • Find yourself preoccupied with the drug and when you’re next scheduled to take it

In 2017, approximately 2 million Americans had substance abuse disorders related to opioid medications.

Opioid Use Disorder Symptoms

Opioids produce high levels of positive reinforcement, increasing the odds that people will continue using them despite negative resulting consequences. Opioid use disorder is a chronic lifelong disorder, with serious potential consequences including disability, relapses, and death.  The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition describes opioid use disorder as a problematic pattern of opioid use leading to problems or distress, with at least two of the following occurring within a 12-month period:

  • Taking larger amounts or taking drugs over a longer period than intended.
  • Persistent desire or unsuccessful efforts to cut down or control opioid use.
  • Spending a great deal of time obtaining or using the opioid or recovering from its effects.
  • Craving, or a strong desire or urge to use opioids
  • Problems fulfilling obligations at work, school or home.
  • Continued opioid use despite having recurring social or interpersonal problems.
  • Giving up or reducing activities because of opioid use.
  • Using opioids in physically hazardous situations.
  • Continued opioid use despite ongoing physical or psychological problem likely to have been caused or worsened by opioids.
  • Tolerance (i.e., need for increased amounts or diminished effect with continued use of the same amount)
  • Experiencing withdrawal (opioid withdrawal syndrome) or taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.
  • While opioid use disorder is similar to other substance use disorders in many respects, it has several unique features. Opioids can lead to physical dependence within a short time, as little as 4-8 weeks. In chronic users, abruptly stopping the use of opioids leads to severe symptoms, including
    • generalized pain
    • chills
    • cramps
    • diarrhea
    • dilated pupils
    • restlessness
    • anxiety
    • nausea,
    • vomiting
    • insomnia, and
    • very intense cravings.  Because these symptoms are severe it creates significant motivation to continue using opioids to prevent withdrawal.

As with other addictions, both genetic factors and environmental factors, such as ease of access, contribute to the risk of opioid use disorder. Access to prescription opioids and to heroin have contributed to the current opioid epidemic. According to the American Medical Association (AMA), an estimated 3 to 19 percent of people who take prescription pain medications develop an addiction to them. People misusing opioids may try to switch from prescription painkillers to heroin when it is more easily available. About 45 percent of people who use heroin started with an addiction to prescription opioids, according to the AMA.

More than half of people misusing opioid medications report 

  • Obtaining them for free or stealing them from a friend or family member
  • Going to multiple doctors to get additional prescriptions
  • Filling prescriptions at different pharmacies so that no one will notice how many pills they get each month

Treatment

Effective treatments are available, however, only about one in four people with opioid use disorder receive specialty treatment.

Medication-assisted treatment (MAT) is an effective treatment for individuals with an opioid use disorder. It involves use of medication along with counseling and behavioral therapies. Brain chemistry may contribute to an individual’s mental illness as well as to their treatment. For this reason, medications might be prescribed to help modify one’s brain chemistry. Medications are also used to relieve cravings, relieve withdrawal symptoms and block the euphoric effects of opioids. Treatment typically involves cognitive behavioral approaches, such as encouraging motivation to change and education about treatment and relapse prevention. It often includes participation in self-help programs, such as Narcotics Anonymous. MAT has been shown to help people stay in treatment, and to reduce opioid use, opioid overdoses and risks associated with opioid use disorder.

FDA-approved medications are commonly used to treat opioid addiction:

  • Methadone – Prevents withdrawal symptoms and reduces cravings in people addicted to opioids. It does not cause a euphoric feeling once patients become tolerant to its effects. It is available only in specially regulated clinics.
  • Buprenorphine – Blocks the effects of other opioids, reduces or eliminates withdrawal symptoms and reduces cravings. Buprenorphine treatment (detoxification or maintenance) is provided by specially trained and qualified physicians, nurse practitioners and physician assistants (having received a waiver from the Drug Enforcement Administration) in office-based settings.
  • Naltrexone – Blocks the effects of other opioids preventing the feeling of euphoria. It is available from office-based providers in pill form or monthly injection.

The National Institute on Drug Abuse (NIDA) emphasizes that these medications do not substitute one addiction for another. The dosage of medication used in treatment does not get a person high—it helps reduce opioid cravings and withdrawal. It helps restore balance to the brain circuits affected by addiction. Different levels of treatment may be needed by different individuals or at different times – outpatient counseling, intensive outpatient treatment, inpatient treatment, or long-term therapeutic communities.

Continuing Care

Opioid use disorder often requires continuing care to be effective. Evidence-based care for opioid use disorder involves several components, including:

  • Personalized diagnosis and treatment planning tailored to the individual and family
  • Long-term management – Addiction is a chronic condition with the potential for both recovery and recurrence. Long-term outpatient care is important.
  • Access to FDA-approved medications
  • Effective behavioral interventions delivered by trained professionals
  • Coordinated care for addiction and other conditions
  • Recovery support services, such as mutual aid groups, peer support specialists, and community services
  • Prevention and Public Health
  • Preventing overdose

Naloxone (Narcan, Evzio) is a potentially life-saving medication used to quickly reverse an opioid overdose. It can reverse and block the effects of other opioids and return normal breathing to someone whose breathing has slowed or stopped because of an opioid overdose. It is available as a pre-filled auto-injection device, as a nasal spray and as an injectable. In April 2018, U.S. Surgeon General Jerome M. Adams, M.D., M.P.H., released a public health advisory to urge more Americans to carry naloxone. Naloxone can be obtained from most local pharmacies and harm reduction clinics at little to no cost for family members and active opioid users.

Avoiding opioids

If you or a family member is seeking treatment for acute or chronic pain seeking treatment, the AMA recommends talking with your physician about pain medications or treatments that are not opioids to avoid bringing opioids into your home. In addition, any person who has struggled with addiction of any kind should inform their doctors before any type of other medical treatment and request non-narcotic pain relievers in the event of an injury or procedure. Get more information from the CDC on non-opioid treatments for chronic pain and download a guide for managing pain for people in recovery from mental illness or substance use from the Substance Abuse and Mental Health Services Administration.

Preventing overdose

Naloxone (Narcan, Evzio) is a potentially life-saving medication used to quickly reverse an opioid overdose. It can reverse and block the effects of other opioids and return normal breathing to someone whose breathing has slowed or stopped because of an opioid overdose. It is available as a prefilled auto-injection device, as a nasal spray and as an injectable. In April 2018, U.S. Surgeon General Jerome M. Adams, M.D., M.P.H., released a public health advisory to urge more Americans to carry naloxone. Naloxone can be obtained from most local pharmacies and harm reduction clinics at little to no cost for family members and active opioid users.  Most pharmacy outlets such as Rite-Aide offer theses at little or no cost with few questions.  Harm Reduction clinics also provide these kits and include a brief training on the use.  Please note:  Always call 9-1-1 in the event of a suspected overdose prior to administering the medication.  Naloxone is not a cure-it may need to be administered more than once, but it does buy time while waiting for trained professionals and saves lives.

Addiction versus Physical Dependence-Pain Management

Addiction is defined by the American Society of Addiction Medicine as: 

“A chronic, relapsing disorder characterized by 

  • compulsive drug seeking
  • continued use despite harmful consequences, and
  • long-lasting changes in the brain. 

It is considered both a complex brain disorder and a mental illness.

Physical dependence means, in part, that an individual experiences symptoms and signs of withdrawal when abruptly lowering his or her dose of a medication.  People can also become physically dependent on antidepressants, blood pressure medications, and so forth, but this does not mean they have a substance use disorder or are “addicted” to these substances, at least from a formal medical understanding.

Tolerance can also be a sign of physical dependence. Tolerance occurs when a medication no longer seems to have the same effect on the person’s symptoms, and as a result, higher doses are required to achieve similar benefits.

A diagnosis of an Opioid Use Disorder should be conducted by a medical professional who is trained and ASAM Certified in determining pain management treatment protocol changes. 

Stigmas often prevent those involved from realizing or accepting that OUD is a formal medical diagnosis with confirmed genetic and common risk factors. Substance use disorders have a clear process of how a medical condition develops and progresses compared to most diseases. 

Furthermore, there are validated effective medical treatments for opioid use disorder.

Proper Evaluation Can Ensure Proper Treatment

The Centers for Disease Control (CDC), estimates as many as one in four adults will develop an opioid use disorder as a result of taking prescribed opioids for chronic pain  

This estimate is in comparison to the commonly cited (among clinicians) 98% of adults who may develop physical dependence during long-term use of opioids.

Understanding the distinct differences between having an OUD and being physically dependent on opioids is important not only in terms of discussions held between a patient and his/her doctor, but also paves the way for receiving proper care when using or tapering prescribed opioids.

Tapering

Tapering is a specific process prescribed by a doctor to slowly decrease, over time, a patient’s use of prescribed opioids until they are no longer taking them. 

Tapers, which help to reduce withdrawal symptoms, may be conducted for a variety of reasons, including 

  • addiction and physical dependence
  • undesired side effects, a pending surgical procedure
  • The medication’s effect on secondary medical conditions, such as anxiety or depression. 

In some cases, tapers involve taking another, weaker opioid medication.

There are simple questionnaires that help to make these determinations: 

  • Current Opioid Misuse Measure
  •  Rapid Opiate Risk Tool

If your doctor determines that you may have an OUD or another substance use disorder (SUD) they may refer you to an addiction specialist for professional confirmation and treatment.

 Alcohol use disorders are quite common in the population at large and perhaps even more so in patients with complex pain issues. For those patients at high risk, ongoing monitoring will likely be folded into the treatment plan.

How often a doctor conducts formal evaluation checks for an opioid use disorder will be based on the patient’s specific clinical contextual factors. For example, if an individual is not able to adhere to standard agreements related to opioid use, or findings on urine drug screens become problematic, the physician may request a re-evaluation sooner than later. On the other hand, if an individual has a terminal illness, other objectives in the treatment plan are likely to take precedence.

Chronic Opioid Agonist Therapy

Individuals who are taking prescribed opioids to manage chronic pain that lasts more than 3 months are said to be on “chronic opioid agonist therapy,” or COAT for short. 

Opioid agonist therapy (OAT) is an effective treatment for addiction to opioid drugs such as heroin, oxycodone, hydromorphone (Dilaudid), fentanyl and Percocet. The therapy involves taking the opioid agonists methadone (Methadose) or buprenorphine (Suboxone). 

These medications work to prevent withdrawal and reduce cravings for opioid drugs. People who are addicted to opioid drugs can take COAT to help stabilize their lives and to reduce the harms related to their drug use. 

Agonist medications by definition create an action, causing the medication to bind to the receptors in your brain in a similar manner to the natural opioid-like substances that every brain produces. These substances can help limit pain and anxiety.  Antagonist therapy, on the other hand, can be used to block the brain’s opioid receptors and interfere with the effects of opioids.

If one is diagnosed with an OUD, there is commonly experienced disbelief or fear. While the diagnosis should be taken seriously, there are safe and effective treatments that promote positive outcomes. 

Standard first-line care includes medication-assisted treatment (MAT), which is particularly helpful for those living with chronic pain conditions. There is a lot of overlap between the brain circuits that manage addictions, sleep, mood, pain, and even anxiety. If one does not effectively manage the OUD, therefore, chronic pain management and the care of other underlying conditions may be compromised.

The basics and nature of MAT can be explored online. SAMSHA, the US Substance Abuse and Mental Health Services Administration, is a reliable source for pertinent patient information on medication-assisted-treatment and on medications for OUD.

Physical Dependence Without An OUD Diagnosis 

The decision to taper off of opioids will likely be the prescribed path. Tapering  is a complex medical decision and is often individualized for the specific patient’s situation based on his or her medical history, any secondary or underlying conditions, the reason for the taper, and more. 

The most important issue is for you and your doctor to establish the goal of therapy together – most often, this is to improve quality and duration of life.

Effective interventions, including alternative therapies and even surgical options, may be presented to help manage your chronic pain while reducing or discontinuing opioids. Be sure to ask your doctor for a clear plan, including timeframes, benefits, and risks. It is essential that contingencies be made available if the taper is not successful or consistent with common goals.

Points to Remember

  • Patients who are on chronic opioid agonist therapy (COAT) for pain management need to be monitored and occasionally screened for possibly having an opioid use disorder, even when there are no overt symptoms or signs. 
  • Skilled physicians can taper opioids safely and often the results are quite good. If opioids are to be continued, regular evaluations and discussions with your doctor can limit unnecessary complications.
  • If a physician makes the recommendation for screening or monitoring services, one can hopefully avoid feeling resentful based on societal stigmas associated with having a substance use disorder. 
  • Regular evaluations, as in all areas of medicine, provide measures to better assure that each and every patient receives the safest and most effective care.

 

 

**CDC Guideline for Prescribing Opioids for Chronic Pain

https://www.practicalpainmanagement.com/patient/treatments/tapering/tapering-how-safely-transition-opioid-pain-medications

https://www.camh.ca/-/media/files/oat-info-for-clients.pdf

https://www.webmd.com/mental-health/addiction/painkillers-and-addiction-narcotic-abusehttps://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder