Opioid Addiction

Definition of Opioid Use Disorder

According to the American Society of Addiction Medicine, addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.  Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

This chronic illness has a biological basis and does not indicate a moral failing or lifestyle choice.

According to the DSM-5 the diagnosis of Opioid Use Disorder can be applied to someone who uses opioid drugs and has at least two of the following symptoms within a 12 month period: 

1. Taking more opioid drugs than intended 
2. Wanting or trying to control opioid drug use without success
3. Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs     
4. Cravings opioids
5. Failing to carry out important roles at home, work or school because of opioid use 
6. Continuing to use opioids, despite use of the drug causing relationship or social problems 
7. Giving up or reducing other activities because of opioid use 
8. Using opioids even when it is physically unsafe 
9. Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway 
10. Tolerance for opioids
11. Withdrawal symptoms when opioids are not taken

Opioid tolerance, dependence, and addiction are all manifestations of brain changes resulting from chronic opioid abuse. The opioid abuser’s struggle for recovery is in great part a struggle to overcome the effects of these changes. Medications such as methadone and buprenorphine act on the same brain structures and processes as addictive opioids, but with protective or normalizing effects. Despite the effectiveness of medications, they must be used in conjunction with appropriate behavioral health therapies.

  
We recognize both the biological basis of addiction and each person’s unique sociocultural situation, and work to individualize treatment to each person. Our goal is to deliver compassionate, evidence-based care that improves quality of life and daily life functioning.

Pleasure derived from opioids’ activation of the brain’s natural reward system promotes continued drug use during the initial stages of opioid addiction. Subsequently, repeated exposure to opioid drugs induces the brain mechanisms of dependence, which leads to daily drug use to avert the unpleasant symptoms of drug withdrawal. Further prolonged use produces more long-lasting changes in the brain that may underlie the compulsive drug-seeking behavior and related adverse consequences that are the hallmarks of addiction.
Three important classes of opioid receptors:

  1.  μ receptor or Mu receptors:Three subtypes: μ1, μ2 and μ3 receptors. Present in the brainstem and the thalamus, activation of these receptors can result in pain relief, sedation and euphoria as well as respiratory depression, constipation and physical dependence.

2.  κ receptor or kappa receptor:Present in the limbic system.  Activation of this receptor causes pain relief, sedation, loss of breath and dependence.

3.  δ receptor or delta:Widely distributed in the brain and also present in the spinal cord and digestive tract. Stimulation of this receptor leads to analgesic as well as antidepressant effects but may also cause respiratory depression.

Opioids target the brain's reward system by flooding the circuit with dopamine. Dopamine is a neurotransmitter present in regions of the brain that regulate movement, emotion, cognition, motivation, and feelings of pleasure. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects sought by people who misuse drugs and teaches them to repeat the behavior. Our brains are wired to ensure that we will repeat life-sustaining activities by associating those activities with pleasure or reward. Whenever this reward circuit is activated, the brain notes that something important is happening that needs to be remembered, and teaches us to do it again and again, without thinking about it. Because drugs of abuse stimulate the same circuit, we learn to abuse drugs in the same way. 

One of the most widely prescribed medications, opiates and opioids (Oxycodone, Lortab, Percocet, and OxyContin) are opioid-based pain medications. Opiates are a derivative of opium which is also used to manufacture heroin and morphine and opioid are synthetic opiates. Opiates/opioids are successful in diminishing pain but are highly addictive, and the withdrawal symptoms of opioid addiction are very similar to the pain it was relieving. Opioids are some of the most commonly abused prescription pain medications today. 

Opioid Epidemic Statistics

• The majority of drug overdose deaths (at least 60%) involve an opioid
• From 2000 to 2015 more than half a million people died from drug overdoses
• Since 1999, the amount of prescription opioids sold in the U.S. nearly quadrupled, yet no overall change in the amount of pain that Americans report
• Among new heroin users, approximately 75% report abusing prescription opioids prior to using heroin
• Heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015
•  Opioids killed more than 33,000 people in 2015, more than any year on record. Nearly half of all opioid overdose deaths involve a prescription opioid. 

• Prescription drug monitoring programs
• State prescription drug laws
• Insurance strategies such as prior authorization, quantity limits, and drug utilization review
• Quality improvement programs in health care systems to increase implementation of recommended prescribing practices
• Youth substance abuse prevention, such as intensive family or school-based programs
• Patient education on the safe storage and disposal of prescription opioids
• Patient discussions with providers regarding the risks and treatment options before taking opioid medication

Opioid overdose continues to be a major public health problem in the United States. It has contributed significantly to accidental deaths among those who use or misuse illicit and prescription opioids. 
According to Centers for Disease Control and Prevention, health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills. 

A variety of effects can occur after a person takes opioids, ranging from pleasure to nausea, vomiting, severe allergic reactions (anaphylaxis), and overdose, in which breathing and heartbeat slow or even stop.  Opioid overdose can occur when a patient deliberately misuses a prescription opioid or an illicit drug such as heroin. It can also occur when a patient takes an opioid as directed, but the prescriber miscalculated the opioid dose or an error was made by the dispensing pharmacist or the patient misunderstood the directions for use.  Also at risk are individuals who misuse opioids and combine them with sedative hypnotic agents resulting in sedation and respiratory depression. 

Signs of OVERDOSE, which often results in death if not treated, include:  

• Extreme sleepiness, inability to awaken verbally or upon sternal rub.    
• Breathing problems that can range from slow to shallow breathing in a patient that cannot be awakened.  
• Fingernails or lips turning blue/purple.  
• Extremely small “pinpoint” pupils.  
• Slow heartbeat and/or low blood pressure.    

Signs of OVERMEDICATION, which may progress to overdose, include: 

• Unusual sleepiness, drowsiness, or difficulty staying awake despite  loud verbal stimulus or vigorous sternal rub.  
• Mental confusion, slurred speech, intoxicated behavior.  
• Slow or shallow breathing.  
• Extremely small “pinpoint” pupils, although normal size pupils do not  exclude opioid overdose.  
• Slow heartbeat, low blood pressure.  
• Difficulty waking the person from sleep.    

• Anyone who uses opioids for long-term management of chronic cancer or non-cancer pain is at risk for opioid overdose.
• Individuals who use heroin.  
• Receiving rotating opioid medication regimens (and thus are at risk for incomplete cross-tolerance). 
• Discharged from emergency medical care following opioid intoxication or poisoning. 
• At high risk for overdose because of a legitimate medical need for analgesia, coupled with a suspected or confirmed substance use disorder, or non-medical use of prescription or illicit opioids. 
• Completing mandatory opioid detoxification or abstinent for a period of time (and presumably with reduced opioid tolerance and high risk of relapse to opioid use). 
• Recently released from incarceration and who have a history of opioid use disorder (and presumably have reduced opioid tolerance and high risk of relapse to opioid use). 
• Certain medical conditions including liver and kidney dysfunction. 
• Unsecured opioid medications in the household.    

Ali, M., Dowd, W., Classen, T., Mutter, R. and Novak, S. (2016, June). Prescription drug monitoring programs, nonmedical use of prescription drugs, and heroin use: Evidence from the National Survey of Drug Use and Health. Addictive Behaviors, 69, 65-77. doi: org/10.1016/j.addbeh.2017.01.011 

Centers for Disease Control and Prevention (CDC). (2016). Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics. Retrieved from http://wonder.cdc.gov  

Centers for Disease Control and Prevention (CDC). (2016). Understanding the Epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html 

Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. (2016, December). MMWR Morb Mortal Wkly. DOI: 10.15585/mmwr.mm6550e1.