Opioid Dependence

Definition

Opioids are a class of drugs that include both natural and synthetic substances. The natural opioids (referred to as opiates) include opium and morphine. Heroin, the most abused opioid, is synthesized from opium. Other synthetics (only made in laboratories) and commonly prescribed for pain, such as cough suppressants, or as anti-diarrhea agents, include codeine, oxycodone (OxyContin), meperidine (Demerol), fentanyl (Sublimaze), hydromorphone (Dilaudid), methadone, and propoxyphene (Darvon). Heroin is usually injected, either intravenously (into a vein) or subcutaneously (under the skin), but can be smoked or used intranasally (i.e., "snorted"). Other opioids are either injected or taken orally.

The manual that is used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders. The latest edition of this manual was published in 2000, and is also known as the DSM-IV-TR. DSM-IV-TRlists opioid dependence and opioid abuse as substance use disorders. In addition, the opioid-induced disorders of opioid intoxication and opioid withdrawal are listed in the substancerelated disorders section as well.

Opioid dependence

Recovering from opioid dependence is a long, difficult process. Typically, multiple treatment attempts are required. Relapsing, or returning to opioids, is not uncommon even after many years of abstinence. Brief periods of abstinence are common.

Inpatient detoxification from opioids alone, without additional treatment, does not appear to have any effect on opioid use. However, other treatments have been shown to reduce opioid use, decrease illegal activity, decrease rates of HIV-infection, reduce rates of death, and increase rates of employment. Benefits are greatest for those who remain in treatment longer and participate in many different types of treatment (individual and group counseling in addition to methadone maintenance, for example).

Opioid abuse

Very little is known about the course of opioid abuse.

Opioid intoxication

An opioid antagonist, naloxone (Narcan), can be administered to reverse the effects of acute intoxication or overdose on most opioids.

Opioid withdrawal

Opioid withdrawal can be treated either on an inpatient basis (detoxification) or on an outpatient basis (methadone detoxification):

  • Inpatient detoxification program. Typically, this would be from three to seven days. The withdrawal can be medically managed. Clonidinemay be administered to help reduce some symptoms of withdrawal.
  • Outpatient methadone detoxification. Methadone would be substituted for the illicit opioid and the dose would be gradually reduced. Detoxification from methadone is easier (i.e., the symptoms are less severe) than from heroin. However, the withdrawal or abstinence syndrome also lasts longer. Clonidine may also be administered during the methadone detoxification to help reduce withdrawal symptoms.

Causes

There are no clear-cut causes of drug use other than the initial choice to use the drug. This decision to use may be highly influenced by peer group. Typically, the age of first use of heroin is about 16 years old, but this age has been dropping in recent years.

Certain social and behavioral characteristics, however, are more commonly seen among individuals who become dependent on opioids than those who do not. For instance, many heroin users come from families in which one or more family members use alcohol or drugs excessively or have mental disorders (such as antisocial personality disorder). Often heroin users have had health problems early in life, behavioral problems beginning in childhood, low self-confidence, and anti-authoritarian views.

Among opioid-dependent adolescents, a "heroin behavior syndrome" has sometimes been described. This syndrome consists of depression (often with anxiety symptoms), impulsiveness, fear of failure, low self-esteem, low frustration tolerance, limited coping skills, and relationships based primarily on mutual drug use.

Symptoms

OPIOID DEPENDENCE.The DSM-IV-TRspecifies that three or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid dependence:

  • Tolerance: The individual either has to use increasingly higher amounts of the drug over time in order to achieve the same drug effect or finds that the same amount of the drug has much less of an effect over time than before.
  • Withdrawal: The individual either experiences the characteristic abstinence syndrome (i.e., opioid-specific withdrawal) or the individual uses opioids or similar-acting drugs in order to avoid or relieve withdrawal symptoms.
  • Loss of control: The individual either repeatedly uses more opioids than planned or uses the opioids over longer periods of time than planned.
  • Inability to stop using: The individual has either unsuccessfully attempted to cut down or stop using the opioids or has a persistent desire to stop using.
  • Time: The individual spends a lot of time obtaining opioids, getting money to buy opioids, using opioids, being under the influence of opioids, and recovering from the effects of opioids.
  • Interference with activities: The individual either gives up or reduces the amount of time involved in recreational activities, social activities, and/or occupational activities.
  • Harm to self: The individual continues to use opioids despite having either a physical or psychological problem (depression, for example) that is caused or made worse by the opioid use.

OPIOID ABUSE.The DSM-IV-TRspecifies that one or more of the following symptoms must occur at any time during a 12-month period (and cause significant impairment or distress) in order to meet diagnostic criteria for opioid abuse:

  • Interference with role fulfillment: The individual's use of opioids repeatedly interferes with the ability to fulfill obligations at work, home, or school.
  • Danger to self: The individual repeatedly uses opioids in situations in which it may be physically hazardous (while driving a car, for example).
  • Legal problems: The individual has recurrent opioidrelated legal problems (such as arrests for possession of narcotics).
  • Social problems: The individual continues to use opioids despite repeated interpersonal or relationship problems caused by or made worse by the use of opioids.

OPIOID INTOXICATION.The DSM-IV-TRspecifies that the following symptoms must be present in order to meet diagnostic criteria for opioid intoxication:

  • Use: The individual recently used an opioid.
  • Changes: The individual experiences significant behavioral or psychological changes during, or shortly after, use of an opioid. These changes may include euphoria initially, followed by slowed movements or agitation, impaired judgment, apathy("don't care attitude"), dysphoric mood (depression, for example), or impaired functioning socially or at work.
  • Opioid-specific intoxication syndrome: The pupils in the eyes get smaller. In addition, drowsiness or coma, slurred speech, and/or impaired memory or attention during, or shortly after, opioid use occur.

OPIOID WITHDRAWAL.The DSM-IV-TRspecifies that the following symptoms must be present in order to meet diagnostic criteria for opioid withdrawal:

  • Abstinence: Either the individual has stopped using (or has reduced the amount of) opioids, or an opioid antagonist (i.e., a drug, such as naloxone, that blocks the action of opioids) has been administered.
  • Opioid-specific withdrawal syndrome: Three or more symptoms develop after abstinence. These symptoms include dysphoric (negative) mood, nausea or vomiting, muscle aches, runny nose or watery eyes, dilated pupils, goosebumps, or sweating, diarrhea, yawning, fever, and insomnia.
  • Impairment or distress: The withdrawal symptoms must cause significant distress to the individual or impairment in functioning (socially, at work, or any other important area).
  • Not due to other disorder: The withdrawal symptoms cannot be due to a medical condition or other mental disorder.

Demographics

There are at least 600,000 individuals with opioid dependence living in the United States. It has been estimated that almost 1% of the population has met criteria for opioid dependence or abuse at some time in their lives.

In the late 1800s and early 1900s, individuals who were dependent on opioids were primarily white and from middle socioeconomic groups. However, since the 1920s, minorities and those from lower socioeconomic groups have been overrepresented among those with opioid dependence. It appears that availability of opioids and subcultural factors are key in opioid use. Therefore, medical professionals (who have access to opioids) are at higher risk for developing opioid-related disorders.

Males are more commonly affected by opioid disorders than females—males are three to four times more likely to be dependent on opioids than females. Age also is a factor in opioid dependence. There is a tendency for rates of dependence to decrease beginning at 40 years of age. Problems associated with opioid use are usually first seen in the teens and 20s.

Diagnosis

Diagnosisof opioid-related disorders are based on patient interview and observations of symptoms, including signs of withdrawal such as dilated pupils, watery eyes, frequent yawning, and anxiety, among others.

Prevention

The best single thing an individual can do to prevent opioid-related disorders is never to use illicit opioids such as heroin. Opioids are powerfully addicting, especially if used intravenously. The risk of becoming dependent on appropriately prescribed opioids, however, is generally low except for individuals who already have a substance use disorder.

On a larger scale, comprehensive prevention programs that utilize family, schools, communities, and the media can be effective in reducing substance abuse. The recurring theme in these programs is not to use drugs in the first place.

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

Jenkins, Susan C., Joyce A. Tinsley, and Jon A. van Loon. A Pocket Reference for Psychiatrists.3rd edition. Washington, DC: American Psychiatric Press, 2001.

Kaplan, Harold I., M.D., and Benjamin J. Sadock, M.D. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry.8th edition. Baltimore: Williams and Wilkins.

ORGANIZATIONS

American Psychiatric Association. 1400 K Street, Washington, DC 20005. (202) 682-6000. <http://www.psych.org>.

American Psychological Association. 750 First Street, NE, Washington, DC 20002-4242. (800) 374-2721. <http://www.apa.org>.

National Institute of Mental Health, 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov>.

National Institute on Drug Abuse. 5600 Fishers Lane, Room 10-05, Rockville, MD 20857. Nationwide Helpline: (800) 662-HELP. <http://www.nida.nih.gov>.

National Library of Medicine. 8600 Rockville Pike, Bethesda, MD 20894. <http://www.nlm.nih.gov/medlineplus/drugabuse.html>.

Jennifer Hahn, Ph.D.