Opioids: Addiction, Withdrawal and Recovery

A List of Common Opioids in Increasing Strength

These are some of the common opioids and their generic names. They are listed in order of increasing strength.

• Codeine
• Hydrocodone (Vicodin, Hycodan)
• Morphine (MS Contin, Kadian)
• Oxycodone (Oxycontin, Percoset)
• Hydromorphone (Dilaudid)
• Fentanyl (Duragesic)

What are Opioids?

Opioids are a group of drugs that are used for treating pain. They are derived from opium which comes from the poppy plant.

Opioid vs Opiate vs Narcotic

The term opiates refers to natural or slightly modified components of opium such as codeine, morphine and heroin. The term opioids was originally used for synthetic opiates such as Oxycontin and Fentanyl. But now is used for the entire class of drugs. Narcotics is an older name originally referring to any mind-altering compound with sleep-inducing properties.

Opioids Addiction

Opioids produce a sense of wellbeing or euphoria that can be addictive to some people. Opioids are legitimately used for treating pain. When used for pain relief, many people develop tolerance, meaning they need more and more to get the same effect. Some people go on to develop an addiction to opioids. They begin to obsessively think about getting more opiates and in some cases engage in illegal activities such as double doctoring.

A high dose of opioids can cause death from cardiac or respiratory arrest. Tolerance to the euphoric effect of opioids develops faster than tolerance to the dangerous effects. Therefore people often overdose by mistake because they are trying to get a higher high and take too much.

Opioid overdose can be reversed in hospital with intravenous naltrexone. Please contact emergency services if you feel you are in danger of an overdose.

Do You Have an Opioid Addiction?

• Has your use of opioids increased over time?
• Do you experience withdrawal symptoms when you stop using?
• Do you use more than you would like, or more than is prescribed?
• Have you experienced negative consequences to your using?
• Have you put off doing things because of your drug use?
• Do you find yourself thinking obsessively about getting or using your drug?
• Have you made unsuccessful attempts at cutting down your drug use?

If you answered yes to at least three of those questions, then you are addicted to opioids. (Look here for a more detailed addiction self-assessment quiz.)

Opioid Withdrawal

Opioid withdrawal can be extremely uncomfortable. The important thing to remember is that opioid withdrawal is not life threatening if you are withdrawing only from opioids and not a combination of drugs. (Withdrawal is different for each drug. Alcohol withdrawal and benzodiazepine withdrawal are potentially dangerous)

Opioid Withdrawal Symptoms Include:

• Low energy, Irritability, Anxiety, Agitation, Insomnia
• Runny nose, Teary eyes
• Hot and cold sweats, Goose bumps
• Yawning
• Muscle aches and pains
• Abdominal cramping, Nausea, Vomiting, Diarrhea

Stages of Opioid Withdrawal

Opioid withdrawal symptoms can last anywhere from one week to one month. The first phase (acute withdrawal) begins about 12 hours after your last opioid use. It peaks at around 3 - 5 days, and lasts for approximately 1 - 4 weeks. The second phase (post-acute withdrawal) can last up to two years. The symptoms include mood swings, anxiety, variable energy, low enthusiasm, variable concentration, and disturbed sleep.

The acute stage has mostly physical symptoms, and the post-acute stage has mostly emotional symptoms. The symptoms of post-acute withdrawal are less severe but last longer.

The Opioid Crisis (Epidemic)

The opioid crisis (epidemic) began in the 1990s with over-prescription of powerful opioid pain relievers. They quickly became the most prescribed class of medications in the United States, exceeding antibiotics and heart medication.

In the late 1990s, pharmaceutical companies reassured the medical community that "patients would not become addicted to prescription opioid pain relievers.” [1]

But the facts are that 20 to 30 percent of patients who are prescribed opioids for chronic pain will misuse them. [2]

About 80 percent of people who use heroin began by first misusing prescription opioids.[3]

Drug overdose is the leading cause of accidental death in the United States. There are more drug overdose deaths in America every year than deaths due to guns and car accidents combined. In 2016 there were more than 64,000 drug overdose deaths. Most of those deaths were due to opioid use. The opioid “fentanyl” was involved in more than 20,000 of those fatalities.

Fentanyl

Fentanyl is so strong that it can easily cause an accidental overdose. It is 50 to 100 times more potent than morphine. About two milligrams of fentanyl – equivalent to six or seven grains of salt – is a lethal dose.

There are many chilling statistics about fentanyl. Here is just one of them. In one-third of fentanyl overdoses, the individual died within seconds of taking fentanyl. They died so quickly that their body didn’t have enough time to begin to metabolize the drug, and no metabolites of fentanyl were found in the autopsy. [4]

How did fentanyl become such a big part of the opioid epidemic? Around 2010, heroin became so abundant that it suddenly became cheaper than many other drugs, and addicts started to switch from other drugs to heroin. In one survey, 94% of people in treatment for opioid addiction said they used heroin because prescription opioids were more expensive and harder to obtain. [5]

Next, drug cartels discovered how to make fentanyl cheaply. Heroin cannot be created entirely in a lab. It must first start as morphine. Huge quantities of fentanyl from China started flooding the market. Because fentanyl is easier to make and more powerful than heroin, drug dealers began to lace their heroin with fentanyl.

People taking fentanyl-laced heroin are more likely to overdose because they do not know they are taking a more powerful drug. Which brings us to the opioid epidemic and the crisis of opioid overdoses.

Fentanyl is now starting to find its way into prescription pills. Fentanyl pills are pressed and dyed to look like oxycodone. If you are using oxycodone and take fentanyl not knowing it is fentanyl, you will almost certainly overdose.

A new variation of fentanyl is finding its way into the drug trade. Carfentanil is 100 times stronger than fenatanyl, which makes it 10,000 times more potent than morphine.

Naloxone

Naloxone is used to rescue individuals from opioid overdose. Naloxone is an opioid antagonist, meaning it binds to opioid receptors but does not produce the high or the dangerous side effects. What makes naloxone useful is that it binds to opioid receptors more strongly than heroin or any prescription opioids.

If someone is overdosing on heroin or any other opioid and naloxone is administered, it will replace the opioid drug in the person's receptors, and reverse the high and side effects of the opioid. The person can go from comatose one moment to awake and moving the next.

Naloxone is carried by many EMS services, and can be administered either in intravenous form or as a nasal spray.

Opioid Treatment Recovery Plan

• Break the cycle of guilt and shame. Do your recovery with other people who are going through the same thing. This is the benefit of going to 12-step meetings such as Narcotics Anonymous NA or Alcoholics Anonymous AA.
• Ask for help. Have a strong support system.
• Be honest, and practice sharing how you feel.
• Avoid high risk situations.
• Learn relapse prevention strategies.
• Do your recovery one day at a time.

What is Suboxone - Buprenorphine?

IMPORTANT: This is general medical information, and is not tailored to the needs of a specific individual. This material is NOT complete. It does not cover all possible precautions, side effects, or interactions. You should always consult your physician when making decisions about your health.

Suboxone is a medication used for withdrawing and detoxing from opioids. It is a combination of buprenorphine a mild opiate, and naloxone a medication that reverses the effects of opiates if taken intravenously.

Buprenorphine is unlike other opioids in that it does not lead to a greater high the more you take. It is a partial opioid agonist, meaning that it produces a mild high at most. Therefore it is sometimes used to get people off more addictive drugs such as Oxycontin or heroin.

The reason for combining buprenorphine and naloxone is that it reduces the risk of intravenous use. Suboxone is supposed to be taken as a tablet and held under the tongue. But if Suboxone is dissolved and taken intravenously, the naloxone reverses the effects of the buprenorphine, which blocks the high. Therefore there is less danger of diversion.

Patients do not have to go to special clinics to get their Suboxone as they do with methadone. Physicians with proper training and certification can prescribe Suboxone in their offices, and patients can take it home.

The Effects, Side Effect and Dangers of Suboxone

• Suboxone is potentially addictive.
• You will probably experience withdrawal symptoms as you come off Suboxone.
• If you take Suboxone too soon after another opioid, you may experience withdrawal symptoms.
• Suboxone can increase the drowsiness due to other drugs or alcohol.
• Suboxone overdose can cause slow breathing, seizures, confusion, loss of consciousness, coma, and death.

Suboxone Withdrawal

Suboxone causes withdrawal symptoms, similar to other opioids, if stopped too quickly: low energy, irritability, anxiety, hot and cold sweats, muscle aches and pains, abdominal cramping, nausea, diarrhea. Some people feel that the withdrawal from Suboxone is just as difficult as the withdrawal from methadone.

Medications to Treat Opioid Withdrawal

• Suboxone, Subutex (buprenorphine) helps shorten reduce the withdrawal period and lessen symptoms.
• Methadone helps relieve withdrawal symptoms and make detoxification easier.

Medications to Treat Opioid Addiction

• Suboxone, Subutex (buprenorphine) a partial opioid agonist that can be an opioid replacement.
• Methadone used for opioid replacement therapy.
• Revia (naltrexone) Used to reduce opioid cravings and prevent an opioid high.

References

1. https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis
2. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576.
3. Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.
4. Overdose Deaths Related to Fentanyl and Its Analogs — Ohio, January–February 2017. Morbidity and Mortality Weekly Report (MMWR)/ September 1, 2017 / 66(34);904–908
5. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826.]