It starts out innocently enough. A bout of back pain leads to a prescription for a oxycodone or some other opioid pain reliever. The back gets better halfway through the bottle. You finish it anyway because you feel good taking it. When your prescription runs out, you ask the doctor for another—just in case you need pain relief again. She refuses your request for a refill.
You remember that your dad took painkillers after his hip replacement. You visit your parents’ home with an eye to the medicine cabinet. Dad offers them to you since he’s feeling fine. So you take them (with permission you weren’t going to ask for anyway).
When dad’s supply runs out, you decide to find a new physician and start again—with a new pharmacy, too, while you’re at it. Maybe you even go to the gym and purposefully hurt your back—just enough to convince a new doctor you’re in real pain. When you go to the appointment, you bring some extra cash because you’re getting so desperate that you’ll buy a script if you can.
Eventually, the supply chain tightens up. Bad timing, too, because now you’re so dependent on opioids that you can’t stop or function without them. You’ll do anything to avoid the sickness that descends when you run out of medication.
With all other options exhausted, you start searching for heroin because it’s cheap, potent, and available—danger be damned.
It’s become a common American narrative. In 2014 alone, a version of this story played out in more than 10 million lives—people using prescription opioids without a prescription. Not for medical reasons, but for the abject necessity of the high. The users aren’t morally bankrupt or incurable thrill-seekers. They have an Opioid Use Disorder (OUD).
Causes and risk factors
The chronic pain pandemic
For more than a hundred million Americans, controlling pain is an everyday struggle. That means for drug manufacturers, prescription pain relief is one big business. Retail pharmacies filled 245 million scripts for opioid analgesics in 2014, making them the most commonly prescribed drug in the U.S. So widespread is the problem that the Institutes of Medicine have identified chronic pain a disease in itself and its management a moral imperative. Unfortunately, long term opioid use can change how the brain perceives pain and cause hyperalgesia, a paradoxical hypersensitivity to pain.
The distance between misuse of opioids and OUD is often traveled by the most vulnerable among us: the mentally ill, the pain-intolerant, and those with other substance use disorders. Frequently along for the ride are a host of people suffering mood, anxiety, personality, and post-traumatic stress disorders.
A false sense of security
Contrary to popular belief, just because a drug has a brand name and a doctor’s note doesn’t mean it’s safe to use or distribute to others. Your brain marinates in heroin the same way it soaks up legal drugs such as Vicodin and OxyContin – by binding to the receptors that control feelings of pain, pleasure, and processes that keep you alive, such as blood pressure, arousal, and breathing.
A traumatic childhood
Childhood abuse has a long-established relationship with Post Traumatic Stress Disorder (PTSD) and the personality trait impulsivity, both of which, in turn, put patients at risk for substance use disorders. Emotional abuse especially causes people to internalize their emotions and damages their ability to manage negative feelings. These people then reach out substances, including opiates, to help regulate their moods.
Diagnosing Opioid Use Disorder
The clinical criteria
Think back over the past year. Just two of these symptoms is enough to confirm an OUD diagnosis. Four or five symptoms qualify as a moderate case; it’s a severe case if there’s six symptoms or more.
Suspect OUD in someone who:
- Takes large doses of opioids, or takes them beyond the time prescribed
- Wants or tries to cut down, but can’t
- Makes a full-time job out of finding, using and recovering from opiates
- Craves opioids or fights strong impulses to use them
- Shirks responsibilities at home, work or school
- Suffers socially and in relationships because of their opioid use
- Abandons once-important social, career, or leisure activities
- Risks life and limb under the influence of opioids, such as when driving a car or operating machinery
- Doesn’t care that their opioid use is harming their physical or mental health
- Needs increasingly large doses to achieve the desired effect (and can’t get it on a lesser dose)
- Undergoes withdrawal (sweating, body aches, nausea, vomiting, diarrhea, yawning) when they stop using opiates, or uses just to avoid the symptoms of it
A person is in early remission if they have been absent of symptoms (except cravings, #4 above) for at least three months but fewer than 12 months. Sustained remission is marked by symptom absence for over 12 months.
Treating Opioid Use Disorder
Opioid use is a big-tent disorder. In 2014, it covered nearly 600,000 heroin users and 2 million people dependent on prescription pain relievers. Here’s how modern addiction medicine can help.
Think of detoxification as poison control for opioid users—that critical washout period between using drugs and the start of recovery. It’s the necessary first step for longer-term treatment of dependence.
The goal of a detox program is to separate users from their demonizing drug with minimum pain and maximum mercy. For all the best intentions, it’s still a messy breakup. Although detox from opioids isn’t life-threatening, it can sure feel that way because the patient must undergo withdrawal. That’s like volunteering to contract a raging bout of influenza. Common symptoms of opiate withdrawal include runny nose, sneezing, watery eyes, stomach and leg cramps, nausea, vomiting, diarrhea, chills, sweating, insomnia, and (quite understandably) irritability and anxiety. Between the misery of the symptoms and the intensity of the cravings, many people have a tough time getting past this stage.
Although detox is never easy, the right medication-assisted therapy (MAT) can make it feel a lot less hard. Options include:
The abrupt approach
Call this the express lane to detox—cold turkey, often with a side of clonidine or lofexidine to take the edge off. These two medications suppress the brutality of withdrawal symptoms, which increases the odds that the patient will see therapy through to the end. Patients who stick with the program for more than three months tend to have better outcomes, studies suggest. This brand of detox requires a short stay in either a hospital or specialized detox unit.
The tapered approach
Don’t want to take the screeching-halt route to detox? Try pumping the brakes instead. Tapering slowly backs users away from opioid dependence by supplanting the drug of abuse with a controlled, prescribed stand-in.
The oldest of the tapering drugs is methadone, most well known from so-called “methadone maintenance clinics”, while a slightly different, more recent option is buprenorphine.
Methadone can only be administered at government-regulated clinics on a daily basis; patients cannot take it home. The side effects include breathing difficulty (if overdose or mixed with alcohol or sedatives), heart electrical abnormalities, sexual dysfunction, interactions with HIV/AIDS medications, and weight gain. One major benefit it has over buprenorphine is that it is safe in pregnancy.
Subutex (buprenorphine) comes in tabs that dissolve under the tongue and can be prescribed for a month at a time so that patients do not need to go to a clinic every day. It blocks the effects of other opiates and has a lower maximum effect than methadone, reducing the risk of overdose. Buprenorphine is usually combined with naloxone, an opioid blocker, to form the brand-name drug Suboxone. If patients try to abuse it by injection, the naloxone kicks in and blocks the high.
This approach is based on the idea that if patients get regular, controlled doses of opioids from a physician or clinic, it will reduce cravings, help prevent relapse, lower risk of overdoses, minimize drug-related criminal behavior, and guard against intravenous drug use related infections, like HIV and viral hepatitis. Buprenorphine and methadone are the most common maintenance medications. The major downside is that patients remain physically dependent on the medications and are subject to their side effects. Furthermore, though harm-reduction therapy can be lifesaving for those who have repeatedly failed abstinence therapy, it is difficult to implement when it would interfere with the patients’ professions, such as with pilots and physicians.
Abstinence-based therapy requires completely stopping the use of opioids and other drugs. Abstinence is reached initially either by a detox program or by a taper. These can be followed with a prescription for Naltrexone, an opiate blocker given either daily or monthly, which offers additional protection against relapse. Abstinence has its roots in 12-Step programs such as Narcotics Anonymous, which is a crucial source of peer support during recovery. Patients also often couple 12 Step-type programs with additional individual psychotherapy.
This involves the treatment of acute overdoses. The main method for reversing the effects of opioids is a drug called Naloxone. Education about the dangers of combining opioids with other drugs such as alcohol and sedatives as well as prescriptions for take-home Naloxone can decrease fatality rates.
Managing Opioid Use Disorder
Choosing the path to recovery
The U.S. Department of Health and Human Services has created an online tool for people who want to stop using opioids called Decisions in Recovery. It provides additional information about the process and treatments from treatment providers and from patients.
Dancing with disease (and death)
Intravenous use of opiates can lead to vein destruction (track marks on the forearms are a common sign), Hepatitis C, HIV, cellulitis, and heart valve infections. Overdose by any method can cause respiratory depression, heart rhythm abnormalities, and death.
Stop the delusion
Think you can quit any time you want? Maybe, but maybe not. It’s true enough that some people can use opioids just once or twice a year without incident. For too many others, though, daily opioid use becomes a life-ruining (and sometimes life-ending) compulsion. Don’t kid yourself into rationalizing that your habit is under control.
Fess up and face it
The first step in treating Opioid Use Disorder is admitting the problem and demonstrating a willingness to change. To begin, some frank discourse about the ghosts of substance abuse (past and present) are in order. These conversations allow clinicians to meet patients where they are along a five-step continuum (precontemplation, contemplation, preparation, action, or maintenance) and tailor recovery programs accordingly.
Go through hell to find help
Before you pack your bags for the clinic, know that maintenance and other rehabilitation programs may require proof of a detox attempt before they will admit a user as a patient. Often times the best way into a rehabilitation program is via a referral after completing detox inside a special unit.
Use, then lose
You can’t abuse what you don’t have. Disposing of unused opioids when you no longer need them keeps them from falling into the wrong hands (or mouths, like your child’s) or toilets, where they’ll end up contaminating public water supplies downstream. Not sure what to do with the extras? Check to see if your pharmacy offers a buyback program, or if your community has set up dropoff locations. In any case, always be sure to keep tabs on expiration dates—those pills you’re so hesitant to part with may be well past their prime.