Opiate and Opioid Drug Abuse

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Opiate and Opioid Drug Abuse

Opiates are substances created from opium that act to depress or slow the action of the central nervous system. Opium is the dried juice of the opium poppy (Papaver somniferum), a plant grown since ancient times. The term "opiates" is generally used to refer to morphine, heroin, and codeine. Opioids, a larger category, refers to opiates and synthetic (artificially produced) substances that have morphine-like effects. When used for medical reasons, opioids are unlikely to result in dependence . However, as drugs of abuse, opioids lead to the same conditions of dependence and addiction as opiate drugs—conditions from which it is extremely difficult to recover.

Chemical Background

The juice of the seed pod of the opium poppy is a sticky brown sap. The sap contains 7 to 15 percent morphine, the main active ingredient. The name morphine is derived from the Greek god Morpheus, the god of dreams and sleep. In 1803 morphine was first isolated from opium. Morphine is a crystal alkaloid (an organic compound containing nitrogen). In 1874 a chemist discovered that morphine could be bonded to a common industrial acid, acetic anhydride. The result was a potent opiate, diacetylmorphine, that could be used as a painkiller. This opiate was introduced to the market in 1898 as heroin. Another active ingredient in opium is codeine. Opium poppy sap usually contains less than 2 percent codeine. Codeine is used as a painkiller, cough suppressant, and for treating diarrhea.

The History of Opiate and Opioid Use

Archaeological records indicate that the earliest use of opium poppies as medicine started more than 5,000 years ago. The first recorded use of opium was in Mesopotamia (an area in modern-day Iraq). The ancient Egyptians grew opium poppies and used parts of the plant as medicines. Through trade, opium made its way into ancient Greece and Rome. Opium and poppies are often mentioned in the myths and epic tales from that time. Opium was usually taken by eating parts of the plant, taking the dried juices in elixirs (liquid mixtures), or smoking.

During the seventh century, opium spread throughout the Middle East and western Asia. Opium was used as a trade good. The use of opium potions that were either eaten or drunk for the treatment of minor ailments was widespread. By the eleventh century, doctors had noted that the more opium people took, the more opium they needed to have the same effect. By the fourteenth century, doctors had observed that long-term use of opium by a person degenerates, corrupts, and weakens the mind.

In 1803 morphine was isolated from opium. Morphine was seen as a powerful painkiller, and within twenty years it changed medicine. The effects of morphine are strongest when put directly into the bloodstream. This led to the invention and refinement in the 1840s and 1850s of the hypodermic syringe. The advancements in medicine also increased the strength of opium. By 1906 there were more than 50,000 patented medicines that contained opiates.

In the past 150 years, scientists have attempted to change the chemical makeup of morphine and codeine to eliminate unpleasant side effects that caused health problems. One of the first attempts (in the 1890s) produced an agent known as heroin. Unfortunately, heroin is not an improvement when it comes to the problems of tolerance , dependence, or abuse. Ironically, it was originally marketed as a cure for opium addiction and alcoholism; yet it led directly to heroin addiction. In fact, since about 1950, heroin has become the principal drug of opioid abusers.

In the United States federal and state laws control the production and distribution of opioid drugs. Opioid users must get their drugs from illicit sources, and opioid dependence has become closely connected to many kinds of crime. Because illicit opioid drugs are expensive, their users often turn to illegal activities—such as theft, fraud, prostitution, and illicit drug traffic—to make money to pay for their drugs.

Opioids as Pain Medication

Opioid analgesics (painkillers) are extremely useful in controlling both acute and chronic pain. Morphine is routinely used to combat severe pain. The patient is given a small dose, and patients with severe pain rarely experience the euphoria effect that drug abusers seek. When taken under medical supervision, opioid drugs are unlikely to be toxic . The most common side effects of opioids prescribed for pain include nausea, drowsiness, and constipation. In addition to relief of pain, doctors may prescribe opioid drugs to suppress coughing and to stop diarrhea (the drugs decrease activity in the intestines). The most commonly used opioids in medicine for pain relief include:

morphine sulfate (Duramorph, MS Contin, Roxanol)
meperidine (Demerol)
hydromorphone (Dilaudid)
oxymorphone (Numorphan)
methadone
codeine phosphate and codeine sulfate
oxycodone (Percocet, Percodan)
hydrocodone (Hycodan, Vicodin)

Opioids are also, however, among the most common drugs of abuse. Health-care providers are very cautious when prescribing opioid drugs because of the risks of dependence and tolerance. Doctors are also concerned about the sale of these drugs to illegal markets. For years, concerns about patients becoming addicted led to pain being under treated and the unnecessary suffering of many patients. In the 1990s the federal government and a number of state organizations undertook initiatives with the aim of setting policy on how to appropriately treat pain. These pain initiatives worked to educate the medical community about how to adequately treat pain, when to worry about potential addiction in a patient, and when not to worry about such addiction.

Addiction to Opioids

Addiction to opioids is both a psychological and physical addiction. Heroin is especially addictive. When the body is exposed to heroin, the brain tells the body that heroin is needed to survive. With limited or one-time use, the effects of addiction are mild and usually not noticed. With extended use, tolerance builds and more opiates are needed. The increased use of opiates intensifies the effects of withdrawal and the user becomes more addicted.

With continued daily use and dependence, the user's life becomes an uncontrolled cycle of seeking the drug, getting high, coming down, and trying to secure more drugs. Young people who become dependent during high school often drop out and never develop regular work habits or job skills. Users may manage to stop taking drugs for extended periods (sometimes because they are in prison), but almost all return to taking drugs within six months.

Complications of Opioid Abuse

Many of the complications of opiate use are related to the unsanitary conditions associated with drug use. Sharing needles often leads to diseases such as hepatitis (a liver disease) and AIDS. Opiate abusers often have other risky behaviors such as unprotected sex with multiple partners, which leads to sexually transmitted diseases. Long-term users often also have scarred veins, cutaneous abscesses (localized areas of pus under the skin), and phlebitis (inflamed veins).

The death rate of opioid users is about three times the rate expected for non-drug-abusers. Many of the deaths are due to overdose, homicide, suicide, accidents, and liver disease. In the 1980s AIDS appeared as an additional hazard for injecting drug users.

Physical Complications. People who take opioids without a prescription often do so to achieve a feeling of relaxation and euphoria, a state of intense well-being. Instead, they sometimes experience the opposite effect, dysphoria . Once a person becomes dependent, opioid abuse and addiction can produce a range of physical problems. Abuse of pure forms of opioid drugs can have the following effects:

respiratory depression (loss of the ability to breathe automatically)
lung infections (a danger to users who inject drugs)
viral hepatitis (a liver disease; a danger to users who inject drugs)
osteomyelitis (inflammation of bone and the bone marrow caused by bacterial infection; users who inject drugs are prone to this infection)
swelling of veins and skin irritations caused by repeated injections
constriction of pupils
sweating
nausea and vomiting
constipation
itching
convulsions (especially with high doses of Demerol and Darvon)

Heroin sold on the street is typically impure. It is diluted by the seller with powdered materials and injected by the user in an unhygienic manner. The size of the dose is also difficult to measure. Heroin use of this kind results in extremely dangerous complications, including:

strokes (damage to an area of the brain caused by interruption of oxygen delivery to that area)
inflammation of brain blood vessels (which can cause brain damage by depriving areas of the brain of oxygen)
bacterial meningitis (a bacterial infection of the membranes that cover the brain and spinal cord)
aneurysms (weakness in the walls of arteries, which puts them at risk of bursting)
brain abscesses (walled-off areas of infection within the brain)
damage to the spinal cord that could lead to paralysis
widespread injury to muscle tissue (due to infections and blood vessel problems after years of injections)
death from overdoses

Treatment of Opioid Dependence

The modern treatment of opioid dependence is often called detoxification. Drug withdrawal is done as an inpatient or outpatient procedure. The patient may live in a treatment center as an inpatient, or live at home, receiving treatment as an outpatient. Self-help groups such as Narcotics Anonymous are available, as well as special religious programs for drug users. Because the addiction is both physical and psychological, the most effective treatment programs use counseling and group therapy in addition to treatment with drugs.

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

In another treatment, known as methadone maintenance, a heroin user is given methadone, a legally prescribed opioid drug, as a substitute. Once on methadone, the user does not suffer from symptoms of the withdrawal syndrome. This treatment helps chronic heroin users to return to normal activities. Once they stop using heroin, they can also end the criminal activities needed to obtain it. Ending opioid use entirely is a possible, though distant, goal. To become drug free, the user must also gradually end methadone maintenance. Most opioid abusers find it very difficult to maintain abstinence from either illegal opioids or methadone maintenance programs.

Successful treatment of opioid dependence is extremely difficult. Users usually suffer from chronic emotional distress, so that ending drug use is especially challenging. If opioids are easily available, the user typically cannot control his use. The only way the user finds relief from withdrawal symptoms, which persist for six months or longer after the last dose, is to take more of the drug. Finally, in opioid users, drug seeking, and the criminal behavior necessary to obtain drugs, become part of a person's lifestyle. The individual's only friends are likely to be users themselves. The person comes to see himself as a user, with no chance for change. Studies show that only a minority of opioid users remain abstinent for long periods.

Withdrawal

Within a day or two of stopping morphine or heroin, a person experiences the following withdrawal symptoms: restlessness, weakness, chills, body and joint pains, muscle spasms, twitching, gastrointestinal cramps, loss of appetite, nausea, vomiting, diarrhea, tearing eyes, runny nose, gooseflesh, rapid breathing, dilated pupils, hypertension (high blood pressure), and tachycardia (rapid heart beat). After a person has been off drugs for several weeks, she enters a long-term phase of withdrawal, lasting at least six months. The symptoms include: hypotension (low blood pressure), bradycardia (low heart rate), hypothermia (lower than normal body temperature). The pupils become small and constricted. Other signs of long-term abstinence may include an inability to concentrate and a decrease in fine-motor control. Patients who stop taking methadone after becoming dependent on it feel tired and weak. They often withdraw from society, with feelings of inefficiency, decreased popularity and competitiveness, and loss of self-control. Patients who withdraw from methadone also have a higher chance of developing schizophrenia .

Conclusion

Opioid use in the United States is related to family breakdown, poverty, lack of education, unemployment, and crime. Anything that reduces these problems would likely reduce illicit opioid use. Easy solutions seem unlikely.