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.
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).
Very little is known about the course of opioid abuse.
An opioid antagonist, naloxone (Narcan), can be administered to reverse the effects of acute intoxication or overdose on most opioids.
Opioid withdrawal can be treated either on an inpatient basis (detoxification) or on an outpatient basis (methadone detoxification):
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.
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:
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:
OPIOID INTOXICATION.The DSM-IV-TRspecifies that the following symptoms must be present in order to meet diagnostic criteria for opioid intoxication:
OPIOID WITHDRAWAL.The DSM-IV-TRspecifies that the following symptoms must be present in order to meet diagnostic criteria for opioid withdrawal:
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.
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.
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.
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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.