Opioid Misuse

Opioid misuse includes use of the illegal drug heroin and misuse of opioid prescription medications. It affects diverse groups of people across the nation—from a middle-aged woman who becomes addicted to an opioid pain reliever originally prescribed for a sports injury to a young person who is using illegal opioids to get high. Opioid misuse is a complex problem that requires comprehensive, coordinated, evidence-based solutions.

What are opioids?                                              

The term opioid designates a class of drugs that includes the following:

  • Natural opiates obtained from the opium poppy plant
  • Semi-synthetic opioids synthesized or derived from a natural opiate
  • Opioids manufactured synthetically to have a chemical structure similar to that of an opiate

Thus, opioid is a broad term that encompasses both natural opiates and chemicals synthesized to resemble an opiate.

Types of Opioids and Examples

What is opioid misuse?

We use the term opioid misuse to encompass the use of illegal opioid drugs (e.g., heroin) and the misuse of prescription opioid medications (e.g., OxyContin).

In Massachusetts, the nonmedical use of prescription drugs is defined as “use [of a prescription drug] without a prescription of the individual’s own or simply for the experience or feeling the drugs caused”.1 However, the misuse of prescription drugs may be defined in different ways.

Misuse, abuse, or nonmedical use of prescription drugs includes the following:

  • Taking a medication without a prescription (whether purchased illegally from drug dealers or stolen from a friend or family member’s medicine cabinet)
  • Taking a prescribed medication in a way that differs from the doctor’s instructions (e.g., taking a higher dose than prescribed; crushing or otherwise tampering with the medication to increase its effect)
  • Taking a prescribed medication for a purpose other than what the drug was prescribed for, usually to elicit a particular experience or feeling1,14
  • Double doctoring (also commonly referred to as “doctor shopping” or Multiple Provider Episodes (MPEs) in academic literature)—obtaining a prescription from more than one doctor without telling the prescribing doctor about other prescriptions received in the past 30 days

Using prescription medication in any of these ways is considered misuse even if it does not lead to harmful consequences.15

Federal laws regulate the possession and distribution of all opioids. Use of prescription opioids is legal when prescribed by a licensed medical practitioner and used by the person to whom the opioids are prescribed. Penalties for the illegal possession and distribution of prescription opioids include fines, imprisonment, or both.

What are the effects of opioids?
Because opioids are depressants, they slow down the central nervous system. The chemicals attach to specific receptors in the brain, spinal cord, and gastrointestinal tract, and block the transmission of pain messages. Other effects may include drowsiness, mental confusion, nausea, and constipation.16 At high levels, opioids reduce consciousness and decrease breathing, which could lead to overdose and death.

As opioids affect the brain regions involved in reward, some people may experience euphoria during use. In fact, most opioid prescription drugs are used to treat pain. Other opioid medications may be used to control coughs or diarrhea.

Most of these drugs are in the form of pills. People who misuse opioids sometimes crush the pills into powder and snort or inject the drug, causing it to enter the bloodstream and brain very quickly. This may increase the risk of addiction and overdose.

Dependence vs. addiction16
Physical dependence occurs because of normal adaptations to chronic exposure to a drug. Dependence is often accompanied by tolerance, or the need to take higher doses of a medication to get the same effect.

Addiction is when a drug becomes central to a person’s thoughts, emotions, and activities, and he or she feels a craving or compulsion to continue using the drug. It may or may not include physical dependence.

Someone who is physically dependent on an opioid will experience withdrawal symptoms when use of the drug is abruptly reduced or stopped. These symptoms can include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes with goosebumps, and involuntary leg movements. The symptoms can be mild or severe, depending on the drug, and can usually be managed medically by using a slow drug taper.

Who is at risk of opioid misuse?

Opioid misuse affects men and women of different ages, race/ethnicities, socioeconomic status, and other characteristics. Different pathways may lead to opioid misuse. In some cases, a person who is prescribed an opioid painkiller for an injury may become addicted and begin to misuse the drug. Others may start using opioids and other drugs to become high or intoxicated. And some users may begin by misusing prescription opioid pills and eventually progress to using heroin, depending on factors such as price and availability.

Findings from a recent study17 suggest that efforts to simply restrict access to opioid medications or to make a prescription opioid more tamper-resistant, thereby making it harder to inhale or inject, could increase the use of heroin—a more dangerous and illegal drug. This highlights the importance of implementing primary prevention activities (strategies to prevent the misuse of opioids) in conjunction with harm-reduction strategies aimed at preventing and reducing unintentional deaths and nonfatal hospital events associated with opioid poisonings. Injecting heroin is particularly dangerous because it can lead to transmission of infectious diseases, such as HIV and hepatitis.

Opioid misuse prevention strategies range from health promotion to prevention of use to prevention of overdose, and may target various populations. For example:

  • Strategies aimed at preventing first use of heroin may target a broad population, such as all high school students. This is consistent with the universal approach to prevention,20 whose goal is to reach the entire population.
  • Strategies may seek to reduce opioid-related overdoses by targeting a specific group identified as being at risk for opioid misuse, such as teens with behavioral issues in a school setting. This is referred to as a selected approach to prevention, targeted to at-risk subgroups of the general population.
  • Particular strategies may be used to address opioid misuse among individuals who have been hospitalized for an opioid overdose. This approach, known as indicated, targets high-risk individuals.

What is an opioid overdose?
An overdose occurs when the body has more drugs in its system than it can handle, leading to a potentially life-threatening condition. During an opioid overdose, the person may become unresponsive to stimulation and/or have difficulty breathing, and the person’s lips and fingers may turn blue from lack of oxygen. The lack of oxygen eventually affects other vital organs, including the heart and brain, which may lead to unconsciousness, coma, and death.

Lack of oxygen is the greatest risk during an opioid overdose. Fortunately, death from overdose is rarely instantaneous. Most deaths from a heroin overdose have been estimated to occur from one to three hours after injection,18 and there is usually time to intervene before the person dies. Furthermore, not all overdoses are fatal. Without any intervention, some people who overdose may become unresponsive and their breathing may slow, but they may still take in enough oxygen to survive.

What affects the risk of an overdose?
Opioids differ in both strength and how long they remain active in a person’s body. Several factors may affect the risk of an overdose:

  • Type of formulation: Prescription opioids come in short-acting and long-acting formulations. For example, oral methadone usually stays in the body for more than 24 hours and can contribute to overdose risk over a long period of time, whereas intravenous fentanyl only stays in the body for a few minutes.
  • Tampering: Tampering with an opioid medication can change the effects of a long-acting, less potent drug. For example, if an extended-release tablet is crushed, the medication becomes fast-acting and more potent.
  • Delivery method: The faster the opioid is delivered, the more intense the high and the greater the risk of an overdose. Rapid delivery methods include injection, which delivers opioid to the brain faster than sniffing, and smoking. However, no delivery method completely protects an opioid user from overdose.
  • Co-ingestion (or concomitant use): Opioid misuse may be combined with the use of other legal and illegal drugs, such as alcohol and benzodiazepines (“benzos”)—sedative drugs commonly used to treat anxiety, sold under brand names such as Xanax and Valium. Combining opioids with other drugs could increase the risk of an overdose.
  • Tolerance: Opioid users who develop a tolerance to the feeling that the drug creates may begin to take larger doses, thereby increasing the risk of an overdose. Individuals who previously developed a high tolerance but have been off the drug for some time (e.g., while in prison or in treatment) may be at an increased risk of an overdose because they make take a higher dose than their bodies can currently tolerate.
  • Purity: As heroin is an illegal drug, its production is not regulated. Quality and purity may vary, which could increase the risk of an overdose.

What are the consequences of opioid misuse?

Opioid misuse is linked to many short- and long-term consequences:21

  • Increased risk of overdose, injury, and death
  • Short- and long-term health problems: Side effects from opioid use may range from mild symptoms to severe reactions, including death. Abruptly reducing or ending use can lead to withdrawal symptoms. Long-term use may lead to hormonal and immune system effects, physiological dependence, increased sensitivity to pain, and an increase in physical disability related to subsequent medical conditions.22
  • Psychiatric conditions: Opioid use is associated with an increased risk of developing psychiatric and other medical conditions, including depression, anxiety, attention deficit hyperactivity disorder, and mania.23,24
  • Cognitive changes: Findings from a small study that used Magnetic Resonance Imaging suggest that prescription opioid dependence may be associated with structural and functional changes to the brain.25 The brain regions affected included those involved in the regulation of affect and impulse control, and in reward and motivation functions.

The misuse of opioids is also associated with other consequences, including problems related to the illegal sale of opioids (e.g., opioid-related crimes and arrests) and in overburdening the health care system with issues related to opioid-related hospitalizations and treatment.