Opioids

The Truth: Opioid Addiction

Originating in southwest Asia, opioids are powerful chemical substances derived from the opium poppy plant. Opioids are available in many forms, and often prescribed by physicians after accidents, injuries or surgeries to mitigate and manage pain.

As a member of the analgesic drug class, opioids relieve pain and produce euphoric effects. Opioids may also be used in combination with other medications to suppress a cough.

According to the Centers for Disease Control and Prevention (CDC), prescription opioids are responsible for more overdose-related deaths than any other drug. Opioids are misused when individuals consume an unprescribed dose to feel euphoric effects.

When taken for non-medical use, prescription painkillers can become severely addicting. Opioid side effects are debilitating and dangerous. Overdose-related deaths are increasing, and the CDC reports more than three out of five deaths involve an opioid.

Common Addiction Terms from the CDC 

Opioid use disorder - A problematic pattern of opioid use that causes clinically significant impairment or distress. A diagnosis is based on specific criteria, such as unsuccessful efforts to cut down or control use, as well as social problems and a failure to fulfill obligations at work, school, or home. Opioid use disorder has also been referred to as “opioid abuse or dependence” or “opioid addiction.”

Physical dependence - Adapting to a drug that produces symptoms of withdrawal when the drug is stopped.

Tolerance - Reduced response to a drug with repeated use.

Drug misuse - The use of prescription drugs without a prescription, or in a manner other than as directed by the prescriber.

Overdose - Injury to the body that occurs when excessive amounts of a drug are consumed. An overdose can be fatal or nonfatal.

Medication-assisted treatment (MAT) - Treatment for opioid use disorder combining the use of medications (methadone, buprenorphine, or naltrexone) with counseling and behavioral therapies.

Studies + Science

Opioids come in various forms and doses, including capsules, tablets, patches, liquids, and powders. Opioids can be taken intravenously, topically or orally.

Prescription opioids may be formulated in combination with different active ingredients and in extended-release variations. There are three categories of opioids, though heroin is often placed within a separate classification.

How Opioids Work

When consumed, opioids move through the bloodstream to the brain. Opioids then bind to brain receptors to send pain-relieving signals to the body. The analgesic effects decrease the feelings of pain while increasing tolerance to pain. Opioids also work with the spinal cord to reduce pain.

Opioid use creates changes in the brain to trigger a biochemical reward system. Feelings of euphoria and pleasure make users dependent on the drug, which leads to misuse, dependence, and addiction. Some individuals may have a genetic predisposition to addiction, with abnormal brain pathways making the individual more likely to develop a dependence.

Common Opioid Side Effects

• Sedation
• Dizziness
• Nausea
• Vomiting
• Constipation
• Respiratory depression
• Shallow breathing
• Slurred speech

Less Common Opioid Side Effects

• Delayed gastric emptying
• Hyperalgesia
• Immune and hormone dysfunction
• Muscle rigidity
• Myoclonus

Abuse, Dependence + Addiction

According to the National Institute on Drug Abuse, the number of people abusing opioids is estimated at 2.1 million in America and between 26.4 and 36 million globally. Abuse can lead to tolerance, dependence, addiction, and overdose.

Chronic use of opioids creates abnormal brain structures that lead to compulsions and cravings. When opioid medications are used for an extended period, the body grows accustomed to the effect. Over time, the body builds a tolerance and requires more of the drug to achieve euphoric feelings. Tolerance can increase the risk of accidental overdose.

Opioid addiction, built on a growing dependence the effect, is when psychological cravings are paired with symptoms of physical withdrawal. The body experiences symptoms of withdrawal when opioid use is discontinued.

During withdrawal, opioid side effects may worsen after the first few days. The detoxing process may sometimes be mistaken for the flu because withdrawal puts stress on the body, and if left unmonitored, it could become life-threatening. Symptoms of opioid withdrawal include, but are not limited to:

• Craving
• Sweating
• Euphoria or general discontent
• Chronic constipation
• Abdominal pain
• Diarrhea
• Small or dilated pupils
• Nausea and vomiting
• Reduced sex drive
• Sensitivity to pain
• Muscle aches
• Restlessness
• High blood pressure
• Anxiety
• Blurry vision
• Teary eyes
• Runny nose
• Inability to sleep
• Goosebumps
• Rapid heartbeat

Treatment + Recovery

Because addiction creates serious physical and psychological side effects, people often need professional treatment to recover. Recovery is a long process that requires cognitive and biological healing. The first step in treating an individual with opioid use disorder is detoxification, which may take weeks or days after their last use.

Individuals addicted to opioids must receive treatment to overcome abnormal brain structures that create cravings and lead to withdrawal symptoms. Certain medications, like Clonidine, Naloxone or Suboxone, are used to help with withdrawal.

Recovery requires medication monitoring, in-patient treatment, group therapy, and support from family and friends. It is common for those in recovery to relapse during the rehabilitation period. Programs like Narcotics Anonymous have been successful in helping some patients transition. People may choose to reside in sober living after in-patient treatment is complete.

Regardless of successful program completion or a stay in sober living, recovered individuals may start using when faced with stressful psychological or environmental challenges.

Neonatal Opiate Withdrawal Syndrome (NOWS)

Neonatal opiate withdrawal syndrome (NOWS), a subset of neonatal abstinence syndrome (NAS), occurs when a pregnant woman abuses opioids. The mother’s addiction is passed through to the child by blood infused with opiates via the placenta, which creates a dependence in the child that begins before birth and grows with the mother's use.

NOWS occurs when the child is severed suddenly from its source of opioids, the placenta, during birth. NOWS is the infant going into withdrawal during the first hours of its life.

Although NOWS is not often fatal, it causes significant illness in the newborn and often results in prolonged hospital stays. The symptoms of NOWS vary by the affected organ system.

Common symptoms may include:

• Central Nervous System Effects
• High-pitched crying
• Irritability
• Exaggerated reflexes
• Tremors and tight muscles
• Sleep disturbances
• Autonomic Nervous System Effects
• Sweating
• Fever
• Yawning
• Sneezing
• Gastrointestinal Effects
• Poor feeding
• Vomiting
• Loose stools
• Respiratory Effects
• Nasal stuffiness
• Rapid breathing

Although the best method of preventing NOWS is to abstain from opioid use while pregnant, if the mother does use opioids while pregnant, a detox can be highly dangerous to the infant.

It is instead recommended that addicted individuals undergo medication-assisted treatment, such as methadone, in order to ensure the health of the infant through birth. Though medication-assisted treatment will prevent opiate-born NOWS, methadone does allow the possibility of NAS.

Even though methadone and buprenorphine offer longer treatment times, there is often less risk of serious symptoms and complications when compared to the use of prescription opioids, such as Oxycontin. There is no cure for NOWS or NAS, but medical attention and surveillance can help improve the child’s odds of going home healthy.

Regulation Recap

Opium, heroin, and prescription painkillers have a long and complex history. The Food and Drug Administration (FDA) has been working to better regulate opioid medications for decades.

As the epidemic grows, safe use of prescription opioids becomes more difficult.

History of Opioids

Healers have used opium-derived substances for centuries. Since the passing of the Heroin Act in 1924, the importation, manufacture, and possession of heroin have been illegal--even for medicinal use.

However, medical variations, such as codeine, morphine and oxycodone, were still available. The FDA approved Percodan, an oxycodone-aspirin combination, in 1950. The use of oxycodone started to grow, expanding in the 1960s.

Later, in the 1970s, the Controlled Substances Act was passed. The act regulated opioid drugs into schedule categories based on medicinal benefit, harmfulness, and potential for abuse or addiction. Heroin remains a schedule I drug, whereas other drugs are Schedule II and III.

In 1978, German pharmaceutical company Knoll released Vicodin, a combination of hydrocodone and acetaminophen. While President Nixon called for the War on Drugs, people suffering from cancer and other chronically painful illnesses lobbied to increase access to these medications. Despite a number of serious opioid side effects, patients with chronic pain demanded the medications for their care.

In the 1990s and 2000s, the FDA expanded the uses of opioid-derived drugs. The market subsequently grew, and so did the abuse. From 1998 to 2008, the misuse of OxyContin, Vicodin, Percocet, and Lortab doubled.

Today, the FDA works to regulate opioids, releasing a number of safety alerts, labeling changes and prescribing guidelines. The agency is in the process carrying out the following actions:

• Expand use of advisory committees
• Develop warnings and safety information for immediate-release (IR) opioid labeling
• Strengthen postmarket requirements
• Update Risk Evaluation and Mitigation Strategy (REMS) Program
• Expand access to abuse-deterrent formulations (ADFs) to discourage abuse
• Support better treatment
• Reassess the risk-benefit approval framework for opioid use

Who is at fault for the opioid crisis?

The Sackler Family

Many Americans who learn about the opioid crisis wonder how government agencies and health professionals allowed the epidemic to become so widespread. America’s struggle with opiate addiction may be directly related to the greed and inaction from key members of pharmaceutical companies, such as the Sackler family and their primary subsidiary, Purdue Pharma.

The Sackler family was a renowned humanitarian and philanthropic group best known for their contributions to the Louvre Museum and other iconic art establishments. As the opioid crisis began to overtake America, the family’s image changed as their corporation came under legal fire.

The Sackler family founded Purdue Pharma in 1892. It was a successful pharmaceutical company throughout the 19th and 20th centuries. In 1996, however, Purdue Pharma released their major contribution to the opioid crisis: Oxycontin.

Now known as “heroin in a pill,” Oxycontin was immensely profitable for the Sackler family. While the Sacklers claim that they have done no wrong as they control only 1.7% of the opioid market, that statistic is misleading.

Purdue Pharma owns 1.7% of the share of opioids produced, but the Sackler family also owns a smaller off-brand opioid manufacturer called Rhodes Pharma. Together these two manufacturing giants give the Sackler family 6% of the opioid market, the seventh largest share of opiates in the United States.

Founded only four months after a scandal rocked the upper echelons of Purdue Pharma, Rhodes Pharma peddles mostly opioids and has little available information or associated press. The Sackler family maintains their stance of innocence despite weathering nearly two decades of successful lawsuits against their companies for their role in the opiate epidemic.

Despite losing that lawsuit, and others, the Sackler family have pleaded innocence. According to The Guardian, they were continuing to fund anti-regulatory lobbying for opioids and continuing to produce Oxycontin.

Purdue Pharma

Since 2004, Purdue has been fighting lawsuits since over mislabeled products. The company has been accused of intentionally suppressing addiction information about oxycontin, their most valuable asset.

Originally patented in 1996, Purdue Pharma pushed Oxycontin as “non-addictive” and more effective than non-opioid based painkillers. Through a practice of aggressively marketing to doctors and instructing for doses to be made stronger, not more frequent, Purdue quickly found itself riding a tidal wave of profits that continues through to the present.

OxyContin has brought in over $35 billion in revenue since its release in 1996 despite being muddled in controversy since before its release. The first major blow to the unstoppable Oxycontin was a lawsuit in 2007 that revealed that Purdue Pharma was not only lying about the addictive possibilities of its product, but that key executives knew the risks since before the product released and actively hid the information — even from their own staff.

By 2010, it also came to light that Purdue was moving bulk inventory to dubious “clinic” locations without looking into illegal resale risk. One lawsuit even cited locations that included a derelict vehicle whose “patients” were the local homeless.

This pattern of neglect and apathy in pursuit of profits led to an explosion of opioid abuse and allowed hundreds of thousands of patients seeking pain-relief to become opioid addicts. Despite growing allegations that Purdue was perpetuating the sale of opioids to disreputable establishments, they denied all knowledge and claimed to be practicing with ethics and integrity.

On July 2nd, 2018, 26 states filed lawsuits against Purdue Pharma, in addition to Puerto Rico and several tribes of Native Americans, for overstating the benefits and downplaying the risks of addiction and abuse associated with Oxycontin. The lawsuit outlined the hundreds of thousands of addicts who had gone on to become dependent on Oxycontin, users of illicit substances, and victims of overdose.

Other culprits for the skyrocketing opioid deaths are the makers of Narcan and Evzio, manufactured by Adapt Pharma and Kaléo Pharma, respectively. According to a study by the New England Journal of Medicine, Narcan can cost over $150 for a single, life-saving dose, and a two-pack of nasally applied Evzio has increased in price by over 500% in two years from $690 to $4,500.

To put this into perspective, a single tablet of Oxycontin can cost between $1.25 to $6.00 per tablet legally. For off-brand labels, the product may be even cheaper. The cost means that an overdose can be bought for as little as $20 (3+ tablets in 12 hours), yet comparatively, it can cost eight times the amount to treat and survive it.

It’s no wonder that 50,000 fatal opioid overdoses occur annually in the United States.

The Next Steps

According to the CDC, 62,029 people died from opioid overdoses. This number is actually down 2.9% from 2018 and will hopefully continue to decrease as more people become aware of how to recognize and stop opioid symptoms. The opioid problem in the United States continues to gain increased attention from health care, politics, and news organizations and is very much ongoing more than a decade after it began.

Types of Addiction Treatments

Opioid addiction recovery takes many forms. Some drugs help by standing in for opioid fixes, allowing addicts to recover and resume a normal life. Others can provide a life-saving aid in the event of an overdose.

The primary drugs used to treat opioid addiction are naloxone and methadone. Each drug helps manage the opiate epidemic in America in different ways.

Naloxone

Naloxone is a drug that has recently found its way into the hands of many, courtesy of state and local governments. Naloxone, commonly prescribed as Narcan, is a life-saving drug that stops overdoses in their tracks. By binding to opioid receptors in the brain, Narcan helps stop overdoses, even after they've begun.

While effectiveness hinges on the time between administration and overdose, it’s a miraculous step towards decreasing the 50,000 annual opioid deaths in America. Unfortunately, because addicts chase a high close to overdose, Naloxone is not able to save the lives of an individual taking opioids on their own. Additionally, many opioid addicts are reticent to administer Naloxone to someone else—but with awareness and education, that's starting to change.

Once an addict is “Narcanned” they not only stop experiencing opioid stimulation, they go into immediate withdrawal and aren’t to get high again until the Narcan unbinds days later.

Naloxone is controversial in its effectiveness. According to a 2018 study, abusers will go right back to opioids or heroin once naloxone immunity wears off to counteract the immediate withdrawal naloxone causes, meaning it is not the best choice for recovery from opioid addiction.

Methadone

Methadone is a common “stand-in” drug used to help treat opioid addiction and get addicts back on track without fears of opioid withdrawal. Methadone clinics have consistently treated over 245,000 people since 2010 and are the most common form of Medication Assisted Treatment (MAT) next to its sister drug, buprenorphine.

Methadone doesn’t cure opioid addiction. Methadone and buprenorphine act as opioid substitutes, filling in the opioid receptors without creating a high in order to prevent the addict from going into withdrawal. Methadone therapy is used to control relapse so the addict can return to society.

However, there's a hitch. Just as an addict can build up a tolerance to opioids, clinic patients build up an immunity to methadone. Additionally, methadone users often depend on their daily dose at the clinic as much as, if not more, than their opiate fix.

Methadone clinics rarely allow patients to have at-home supply, so many addicts become“Methadone Prisoners.” While Methadone does satisfy opioid cravings, most addicts trade one drug for another.

According to American Addiction Centers, 25% of methadone clinic patients will be weaned off of methadone while most will remain either addicted to methadone or trapped in an alternating cycle of opioid relapse and methadone addiction.

Most opioid treatment is a combined assault of therapy, detox and MAT. Unfortunately, because of the potent nature of opioids, many patients require two options of treatments to balance the long-lasting, effective and non-addictive elements.

An example of opioid treatment trade-off is the FDA approval of non-opioid Lucemyra (lofexidine hydrochloride) in May of this year. Lucemyra is a non-addictive withdrawal blocker, but it only lasts 14 days before succumbing to immunity.

The last treatment option discovered was buprenorphine in 2003, but even this drug carries the same addiction risk as methadone, which was first used in 1930. Many doctors and addicts are fighting to cure an ever-evolving issue with therapy and treatment trapped in 15 years of stagnation.

If you're struggling with side effects from prescription opioids, you may be able to access helpful resources. Advocates are standing by.