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What are Opioids and how are they Used?

By Dr. Karl Benzio MD

Page Overview

Opioids are all chemicals with a morphine-like effect related to those derived from the opium poppy plant. Their primary action is changing the way the brain and the nervous system react to pain, while also having an impact on other areas of the brain affecting emotions and thinking.
  1. Opiates are found naturally in the opium poppy plant. The main psychoactive compounds include morphine, codeine, and thebaine. Opioids are compared to morphine to determine pain-relieving strength.
  2. Semi-synthetic Opioids are man-made manipulations of the naturally occurring opiates from the poppy plant and are chemically synthesized in a laboratory setting. These include heroin, oxycodone (Oxycontin), hydrocodone (Vicodin), oxymorphone (Opana), and hydromorphone (Dilaudid).
  3. Synthetic Opioids are not derived from opiates at all as they are totally created in a laboratory. These include methadone, fentanyl, and buprenorphine.

Legally, opioids can be awesome medications when used as prescribed as they provide much needed pain relief. Unfortunately, they often give the users a feeling of euphoria which some start to crave. Because of powerful highs, dissociation, or occasional hallucinations, these medications carry a high abuse potential and illegal opioids are also readily available. Compounding the problem, when taking an opioid, physical dependence is highly probable, and for many, this leads to an addiction.

Common Prescribed Opiates

No other class of pain medications is used, or more abused, than opiates. This class includes prescription medications such as:

  • Hydrocodone/Acetominophen (Vicodin, Lorcet, Lortab)
  • Hydromorphone (Dilaudid)
  • Codeine (Tylenol 3)
  • Morphine (MS Contin)
  • Tramadol
  • Methadone
  • Meperidine (Demerol)
  • Oxycodone /Acetominophen (Percocet)
  • Oxycodone (Oxycontin, Roxicodone)
  • Fentanyl Patch (Duragesic)
  • Dextromethorphan (the DM in cough suppressants)

Beneficial Uses of Opiates

As medications, opiates provide powerful and lasting pain relief to millions. They are commonly used to manage moderate to severe pain, not relieved by other pain meds, associated with sports injuries, medical procedures or surgeries, arthritis, chronic pain from diseases, accidents, injuries, and age related wear and tear. Examples are cancer patients, moms-to-be, surgical/dental procedures, and those who have been in an accident. When used correctly, individuals with debilitating discomfort can often go on to lead normal lives, thanks to the relief opiate medications give them.

Opioids have two other major medicinal uses. They are very helpful as cough suppressants and are added to prescription strength or extra strength cough medicine. They are also very beneficial for diarrhea and are used in antidiarrheal agents when over the counter options are not enough and dehydration or malnutrition is a concern from the significant diarrhea.

Destructive Opiate Uses

Opiates can easily be abused (not taken as prescribed) however, and destructive opiate use can lead to a life of addiction, overdose, and death. In fact, a couple years ago for the first time, overdoses on prescription medications outnumbered overdoses on illegal drugs.

Overuse

Prescription medications can be overused or not used as directed. Because of the significant pain relief opioids deliver, one often feels more is better. More could be more pills than what was ordered at the prescribed time, or taking them more frequently than prescribed. Also, the euphoria, high, or escape also tempts the patient to either take more or take it more frequently than prescribed. Opiates are highly addictive, and by taking them carelessly, a person puts themselves in danger of a stronger dependence and addiction. These medications are like dynamite – use them responsibly and they are a great help; use them irresponsibly and they are very destructive.

Getting High

Another way opiates are used destructively is when the person uses them specifically to get high, cope, escape, or dissociate. Drug seekers often overuse their own prescription opioids, use a friend’s opioids, or buy prescription medications illegally. They are often used in combination with other drugs or alcohol to achieve a different kind of high. Drug addicts also use street opiates, such as heroin, for the sole purpose of getting high, coping with life, escaping, or avoiding withdrawal symptoms.

Over-Prescribing

It is the responsibility of everyone involved (patient, doctor, pharmacist) to follow protocols and treat opiate medication responsibly in order to prevent abuse and addiction. Doctors sometimes over-prescribe these medications because a patient fakes or lies about an injury or symptoms. Some doctors overprescribe because they compassionately want to help soothe their patient’s pain. Sadly, a very small percentage of doctors are actually being the drug dealer and selling medications they know will be abused just for their own profit. These pill mills have contributed to the sudden increase in destructive opiate usage in America today.

Doctor Shopping

More often it is the patient who tries to play the system and actively seeks more prescription opioids. These individuals doctor shop, or visit multiple doctors to get an excessive amount of medications for the same real, or fabricated, pain. Doctor shopping is a sign of opiate addiction, and states are working to curb this type of drug abuse by implementing prescription drug databases to help identify individuals who doctor shop and are filling multiple prescriptions in a small amount of time.

Opiates can easily be abused (not taken as prescribed) however, and destructive opiate use can lead to a life of addiction, overdose, and death. In fact, a couple years ago for the first time, overdoses on prescription medications outnumbered overdoses on illegal drugs. Dr. Karl Benzio

How are Different Types of Opioids Used?

Oral

The most common types of prescription opioids are oral tablets taken by mouth such as oxycodone, hydrocodone, hydromorphone, tramadol and codeine. Opioid pills are often prescribed for patients after surgery or an injury, to be taken at home for a short period of time. These should only be taken as prescribed by a doctor, because overuse can lead to both dependence and addiction. Oral opioid abuse is common, as individuals take more pills than directed, crush and snort the powder, or dissolve and inject the drugs.

Transdermal Patches

Medications like Fentanyl and Buprenorphine patches provide long lasting pain relief throughout the day. The patch is applied to the skin every 72 hours or so and provides a smoother and more consistent round the clock dosing and relief than oral dosing. Just as with all types of opioids, this type of medication can be harmful and cause dependence if not used correctly.

Intravenous (IV)

Some opiates are given in a medical setting directly into the bloodstream, or vein, called intravenously. IV opiates such as Morphine and Dilaudid are fast-acting and are usually reserved for severe acute pain, such as during or after surgery, emergency visits, and for end-stage cancer patients.

Subcutaneous

For patients unable to swallow or after surgery have their pain medications injected under the skin by a very small needle connected by a catheter to a pump. The pump is controlled by the patient with certain limits built in. This method is slower acting than IV but usually longer lasting.

Rectally

For patients who are unable to swallow or keep pills down or have minimal vein access, most oral opioid medications also are made as suppositories and are inserted into the anus. This is usually only a short-term solution until swallowing is normal or nausea/vomiting is over.

Intramuscular (IM)

On rare occasions, a shot for pain is given in the thigh or deltoid of the upper arm. This is not ideal but used when the other options are not available.

Intraspinal (Epidural or Intrathecal)

Intraspinal administration describes infusing liquid opioid (usually fentanyl or morphine) directly into the space around the spinal cord, similar to a spinal tap, also called a lumbar puncture (LP). This is obviously very risky and used for significant pain when other options haven’t worked or for surgical procedures and post-op.

Snorting

When in powder form, or when pills are crushed, snorting them through the nose delivers a quicker and more potent high than ingesting them orally. With the quicker and more powerful effects come an increased danger of overdose. Snorting is never used medicinally, rather it is a common form of recreational abuse of opioids.

Opioid Dependence Vs. Opioid Addiction

  • Dependence is when the body becomes physically dependent on a chemical, and when the chemical is taken away or not available, the body’s functioning is disrupted producing withdrawal symptoms. Dependence is common if a person is taking it regular (daily or more), at moderate doses, for a consistent period of time (a month or more). But dependence does not mean the person is addicted to it.

People who developed dependence on their pain meds, but are not addicted, are able to stop or taper off the medication when the med is no longer needed, upon the recommendation of their doctor, or of their own volition. They usually haven’t experienced significant harm or consequences from their pain medication use, nor do they abuse or overuse their pain medication.]

  • Addiction is when a person continues to use a substance despite harm and consequences and is unable to stop on their own. Dependence and withdrawal are 2 of the 11 criteria we use to diagnose the level of abuse/addiction, but are not required for the diagnosis as one only needs any 4 of the 11 criteria to qualify as being addicted. 

People who are addicted to opioids are most often also physically dependent on the opioid and will experience withdrawal if they stop using. They have also experienced many other consequences from their opioid use, while their functioning has been compromised and the distress in their lives has increased. Unlike the person who is only dependent on opioids, the addicted patient is no longer able to stop on their own and has lost power over the medication and it now controls them.

How Long is Opioid Withdrawal?

The acute symptoms of opiate withdrawal typically last a few days to a week or two. This is all dependent on the type of opiates the person is using, how much and how frequently they used it, the method of getting it into the body, the person’s drug use history, their age, and their overall health and body’s ability to recover.

Most opiate withdrawals follow the same pattern, with symptoms beginning in the first day and lasting up to a week and a half. Because of the way they work in the body, different opiates have different withdrawal timelines. Slow release opiates take longer for withdrawal symptoms to begin, and the withdrawal symptoms often last longer. In general:

Percocet: Withdrawal begins within 8 hours of last use, and can last a few days

OxyContin: Withdrawal begins within 24 hours and lasts 5 to 7 days

Morphine: Withdrawal begins within 6 hours and lasts 3 to 5 days

Codeine: Withdrawal begins within a few hours and lasts up to a week

Heroin: Withdrawal begins within 6-12 hours, peaks in 2 to 3 days, and lasts 5 – 10 days

Acute Opioid Withdrawal

Depending on whether a person was using a short acting or long acting opioid, early stages of opioid withdrawal usually begin 6 to 24 hours after the last time the chemical was taken, end in 5-10 days, and peak around 72-96 hours. Prior to the peak is the most difficult period of withdrawal because of the uncomfortable physical symptoms as well as the draining psychological effects. (For a Clinical Opiate Withdrawal Scale, click here.)

Physical Symptoms:

  • Nausea
  • Vomiting
  • Diarrhea
  • Sweating
  • Runny nose
  • Muscle cramping
  • Muscle twitching
  • Loss of appetite
  • Insomnia
  • High blood pressure
  • Rapid respiration
  • Goosebumps
  • Yawning
  • Dilated pupils
  • Excessive tear production
  • Irregular heart rate
  • Extreme fatigue

Psychological Symptoms:

  • Anxiety
  • Irritation
  • Agitation
  • Anger
  • Mood Swings
  • Depression
  • Trouble concentrating
  • Depression
  • Cravings

Post Acute Withdrawal Syndrome (PAWS) from Opioids

For a small group of opioid addicts, opiate withdrawal symptoms either continue on for months after their acute withdrawal is over or they restart several months after the last use. These symptoms are not as severe as initial withdrawal symptoms and are much more manageable, but can become an annoyance and even a distraction to the person’s recovery. These symptoms should be addressed by a treatment professional.

Physical Symptoms:

  • Insomnia
  • Fatigue
  • Reduced appetite

Psychological Symptoms:

  • Anxiety
  • Reduced ability to deal with stress
  • Mood swings
  • Depression
  • Trouble concentrating and thinking clearly
  • Fear of social settings
  • Drug cravings
  • Apathy

Types of Detox Available

Home detox: Is it dangerous to detox at home?
Opiate withdrawal is rarely medically dangerous, as physical symptoms are generally no more serious than the severe flu, but it is always recommended to seek the help of a medical professional. With diarrhea, vomiting, and lack of appetite, the person can become dehydrated, can experience respiratory distress or irregular heartbeat, and the detox can take a serious toll on the person’s major organ functions. The emotional rollercoaster can also lead to some impulsive or destructive decisions to themselves or those around them.

The person going through opiate detox can quickly become discouraged and upset. Being at home, unlike being in a medical or supervised detox setting, makes it easier to find and take their drug to stop the withdrawal process. Because of the physical side effects and the psychological distress, home detox is often unsuccessful.

Supervised detox: A good detox option is medically supervised detox in a rehab facility that is equipped to provide around-the-clock supportive nursing care and therapy. Individuals in this type of detox will benefit from having trained staff nearby to support, encourage, pray with, instill hope, and provide healthy meals, plenty of fluids, and medications to minimize or stop some of the withdrawal symptoms.

Medical monitored detox: A step up from basic supervised detox is medical detox. This is also called Harm Reduction therapy as the goal is to reduce the harm of withdrawal so the patient can complete the withdrawal and get on to the more psychologically and spiritually intensive part of treatment. During this type of detox physicians and staff are available to intervene when necessary and provide acute medical treatment. Medications are used to ease withdrawal symptoms, make detox go faster, and make the patient more comfortable overall.

Medications Used During Medical Opiate Detox:

  • Analgesics (acetaminophen, ibuprofen, aspirin): used to treat fever and pain
  • Loperamide: helps with diarrhea
  • Hydroxyzine: eases nausea
  • Clonidine: reduces intensity of withdrawal symptoms such as anxiety, muscle aches, blood pressure, and restlessness
  • Benxodiazepines (klonopin, valium): eases anxiety, insomnia, and poor appetite
  • Opioids (methadone, Suboxone, naltrexone): Partial opioid agonists, these medications help reduce cravings and shorten the detox time. These medications are designed to produce little to no high that other opiates cause, and are not as addicting or as easy to abuse. Still, there are risks to taking these medications as they can still cause dependence and high in some, and it is important for anyone recovering from opiate addiction to use these with caution, and only for a short period of time.

Rapid detox: Some facilities offer another option for detox: rapid detox. The patient is put under general anesthesia while the body is put into a fast withdrawal with IV opiate-blocking drugs. The patient is hospitalized for a day during detox and then another day to recover. Those who support the idea of rapid detox say it is faster, easier, and less painful on the patient. However, there are risks involved with making the body go through withdrawal so quickly, as well as risks of general anesthesia itself. This is also a very expensive form of treatment with few qualified physicians to provide it. Most importantly, those who go through rapid detox often try to shorten the psychological and spiritual treatment process or minimize the importance of it. But rapid detox plus a good intensive psychological and spiritual rehab for 30-90 days can be very effective.

Treatment after Detox

It is important to consider the transition to long-term care when selecting an opiate detox program. Detox is not the end of recovery, but is just the first of many steps in the treatment and transformation process. After detox, the physical body doesn’t need the opioid anymore, but psychologically and spiritually, the addict still has trouble functioning without their primary coping mechanism of using opioids.

A person must go through some intensive therapy to uncover why they were looking to opioids to cope with life, heal that inner problem, and then develop better psychological, emotional, relational, and spiritual skills to engage and thrive in life to bring the joy, peace, and fulfillment they are longing for. This should happen in a licensed facility with skilled therapists who can provide the tools necessary to renew one’s life and achieve their God-given potential away from addicting substances and all other life-interfering behaviors and thoughts.

While looking for an opiate detox program, make sure you are able to transition directly into rehab after detox, in order to continue the treatment process. Many put in the hard work and experience the discomfort and pain of withdrawal, think they have their opioid addiction licked, skip rehab, and then relapse within a week and have to go through the detox and withdrawal all over again.