Addiction and Substance Use Disorders

Opioid Use Disorder

In 2017, more than 72,000 Americans died from drug overdoses, including illicit drugs and prescription opioids, a 2-fold increase in a decade.

The sharpest increase involved synthetic opioids, primarily fentanyl and fentanyl analogs (similar compounds), with nearly 30,000 overdose deaths, according to the Centers for Disease Control and Prevention (CDC).1 Heroin was involved in nearly 16,000 deaths and prescription painkillers were involved in nearly 15,000 deaths.

From 2002 to 2017, there was a 22-fold increase in the total number of deaths involving fentanyl and other synthetic opioids (not including methadone) and more than a 7-fold increase in the number of deaths involving heroin. Emergency department visits for suspected opioid overdoses rose by 30 percent in the U.S. from July 2016 to Sept. 2017.

The opioid crisis was declared a nationwide Public Health Emergency on Oct. 27, 2017.

Opioids

Opioids are natural or synthetic (made in laboratories to mimic the properties of natural opioids) chemicals that interact with opioid receptors on the nerve cells in the body and brain and reduce feelings of pain. They are a class of drugs that include prescription pain relivers, synthetic opioids and heroin. Prescription opioids are meant to be used to treat acute pain (such as recovering from injury or post-surgery), chronic pain, active-phase cancer treatment, palliative care and end-of-life care. Many people rely on prescription opioids to help manage their conditions under the care of a physician.

Opioids reduce the perception of pain, but can also cause drowsiness, mental confusion, euphoria, nausea and constipation. At high doses they can depress respiration. Prescription pain relivers include oxycodone (OxyContin®) hydrocodone (Vicodin®), codeine, morphine, and others. Synthetic opioids include fentanyl, methadone, pethidine, tramadol and carfentanil.

Fentanyl is 50 times more potent than heroin and 100 times more potent than morphine. Carfentanil, an extremely potent fentanyl analog, is estimated to be 10,000 times more potent than morphine. Pharmaceutical fentanyl is prescribed to manage severe pain. Illegally manufactured fentanyl is available in counterfeit pills or mixed with heroin and/or cocaine.4 According to the Drug Enforcement Administration, "Fentanyl is the most prevalent and the most significant synthetic opioid threat to the United States." (May 2018) Overdoses related to use of synthetic marijuana laced with fentanyl have also been reported recently.

Opioid Use Disorder Symptoms

Opioids produce high levels of positive reinforcement, increasing the odds that people will continue using them despite negative resulting consequences. Opioid use disorder is a chronic lifelong disorder, with serious potential consequences including disability, relapses, and death. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition describes opioid use disorder as a problematic pattern of opioid use leading to problems or distress, with at least two of the following occurring within a 12-month period:

  1. Taking larger amounts or taking drugs over a longer period than intended.
  2. Persistent desire or unsuccessful efforts to cut down or control opioid use.
  3. Spending a great deal of time obtaining or using the opioid or recovering from its effects.
  4. Craving, or a strong desire or urge to use opioids
  5. Problems fulfilling obligations at work, school or home.
  6. Continued opioid use despite having recurring social or interpersonal problems.
  7. Giving up or reducing activities because of opioid use.
  8. Using opioids in physically hazardous situations.
  9. Continued opioid use despite ongoing physical or psychological problem likely to have been caused or worsened by opioids.
  10. Tolerance (i.e., need for increased amounts or diminished effect with continued use of the same amount)
  11. Experiencing withdrawal (opioid withdrawal syndrome) or taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.

While opioid use disorder is similar to other substance use disorders in many respects, it has several unique features. Opioids can lead to physical dependence within a short time, as little as 4-8 weeks.2 In chronic users, the abruptly stopping use of opioids leads to severe symptoms, including generalized pain, chills, cramps, diarrhea, dilated pupils, restlessness, anxiety, nausea, vomiting, insomnia, and very intense cravings. Because these symptoms are severe it creates significant motivation to continue using opioids to prevent withdrawal.

As with other addictions, both genetic factors and environmental factors, such as ease of access, contribute to the risk of opioid use disorder. Access to prescription opioids and to heroin have contributed to the current opioid epidemic.2

According to the American Medical Association (AMA), an estimated 3 to 19 percent of people who take prescription pain medications develop an addiction to them.3 People misusing opioids may try to switch from prescription pain killers to heroin when it is more easily available. About 45 percent of people who use heroin started with an addiction to prescription opioids, according to the AMA.

More than half of people misusing opioid medications report 3

  • Obtaining them for free or stealing them from a friend or family member
  • Going to multiple doctors to get additional prescriptions
  • Filing prescriptions at different pharmacies so that no one will notice how many pills they get each month

Treatment

Effective treatments are available, however, only about one in four people with opioid use disorder receive specialty treatment. Medication-assisted treatment (MAT) is an effective treatment for individuals with an opioid use disorder. It involves use of medication along with counseling and behavioral therapies. Brain chemistry may contribute to an individual’s mental illness as well as to their treatment. For this reason, medications might be prescribed to help modify one’s brain chemistry. Medications are also used to relieve cravings, relieve withdrawal symptoms and block the euphoric effects of opioids.

Treatment typically involves cognitive behavioral approaches, such as encouraging motivation to change and education about treatment and relapse prevention. It often includes participation in self-help programs, such as Narcotics Anonymous. MAT has been shown to help people stay in treatment, and to reduce opioid use, opioid overdoses and risks associated with opioid use disorder.

Three FDA-approved medications are commonly used to treat opioid addiction:

  • Methadone – Prevents withdrawal symptoms and reduces cravings in people addicted to opioids. It does not cause a euphoric feeling once patients become tolerant to its effects. It is available only in specially regulated clinics.
  • Buprenorphine – Blocks the effects of other opioids, reduces or eliminates withdrawal symptoms and reduces cravings. Buprenorphine treatment (detoxification or maintenance) is provided by specially trained and qualified physicians, nurse practitioners and physician assistants (having received a waiver from the Drug Enforcement Administration) in office-based settings.
  • Naltrexone – Blocks the effects of other opioids preventing the feeling of euphoria. It is available from office-based providers in pill form or monthly injection.

The National Institute on Drug Abuse (NIDA) emphasizes that these medications do not substitute one addiction for another. The dosage of medication used in treatment does not get a person high—it helps reduce opioid cravings and withdrawal. It helps restore balance to the brain circuits affected by addiction.

Different levels of treatment may be needed by different individual or at different times – outpatient counseling, intensive outpatient treatment, inpatient treatment, or long-term therapeutic communities. Opioid use disorder often requires continuing care to be effective. Evidence-based care for opioid use disorder involves several components, including:

  • Personalized diagnosis and treatment planning tailored to the individual and family
  • Long-term management – Addiction is a chronic condition with the potential for both recovery and recurrence. Long-term outpatient care is important.
  • Access to FDA-approved medications
  • Effective behavioral interventions delivered by trained professionals
  • Coordinated care for addiction and other conditions
  • Recovery support services, such as mutual aid groups, peer support specialists, and community services

Prevention and Public Health

Preventing overdose

Naloxone (Narcan, Evzio) is a potentially life-saving medication used to quickly reverse an opioid overdose. It can reverse and block the effects of other opioids and return normal breathing to someone whose breathing has slowed or stopped because of an opioid overdose. It is available as a prefilled auto-injection device, as a nasal spray and as an injectable.

In April 2018, U.S. Surgeon General Jerome M. Adams, M.D., M.P.H., released a public health advisory to urge more Americans to carry naloxone. More information from NIDA on Naloxone can be found here.

Avoiding opioids

If you or a family member is seeking treatment for acute or chronic pain seeking treatment, the AMA recommends talking with your physician about pain medications or treatments that are not opioids to avoid bringing opioids into your home.

Get more information from the CDC on non-opioid treatments for chronic pain and download a guide for managing pain for people in recovery from mental illness or substance use from the Substance Abuse and Mental Health Services Administration.

Resources

SAMHSA/HHS

National Institute on Drug Abuse

Centers for Disease Control and Prevention

Drug Enforcement Administration

APA

References

  1. Centers for Disease Control and Prevention. WONDER and Overdose statistics
  2. Sharma, B, et al. Opioid Use Disorders. Child Adolesc Psychiatr Clin N Am. 2016 Jul; 25(3): 473–487. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920977/
  3. AMA Alliance. Prescription Opioid Epidemic: Know the Facts
  4. Centers for Disease Control and Prevention. Synthetic Opioid Overdose Data.
  5. Substance Abuse and Mental Health Services Administration. 2018. Facing Addiction in America: The Surgeon General’s Spotlight on Opioids

Physician Reviewed

Andrew Saxon, M.D, chair, APA Council on Addiction Psychiatry

Members of the Council's Opioid Task Force:

  • John Renner, M.D.
  • Shelly Greenfield, M.D., M.P.H.
  • Elie G. Aoun, M.D.

November 2018

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