Opioid Drug Abuse

How opioids work and why they are addictive

Opioids attach to opioid receptors in the brain, spinal cord and gut. They relieve pain, cause pleasure and calm, and slow breathing. With repeated use:

• Tolerance develops, so more is needed for the same effect.
• Physical dependence develops, so stopping causes withdrawal.
• Addiction can develop: compulsive use and craving despite harm, driven by changes in the brain's reward and stress systems.

Dependence alone can occur in people taking opioids as prescribed for pain. Addiction is a separate, treatable medical condition, diagnosed as opioid use disorder.

Signs of opioid misuse

Physical signs

• drowsiness, nodding off, slurred speech
• pinpoint pupils
• constipation, nausea
• itching and flushing
• needle marks, wearing long sleeves in warm weather
• weight loss, poor self-care

Behavioral signs

• running out of prescriptions early, "losing" prescriptions, or seeing several prescribers
• taking pills from others or buying them
• switching from pills to heroin or fentanyl
• withdrawing from family and activities
• money problems, secrecy, legal trouble
• mood swings and anxiety between doses

Opioid overdose

Overdose happens when opioids suppress breathing. Risk is highest:

• with illicit fentanyl, which is extremely potent and often mixed into heroin, counterfeit pills and other drugs
• when opioids are combined with alcohol, benzodiazepines or other sedatives
• after a period of not using (prison release, detox, hospital stay), when tolerance is lower
• when using alone

What to do

1. Call 911. Many states have Good Samaritan laws protecting people who call for help.
2. Give naloxone. Spray into one nostril. If no response in 2 to 3 minutes, give a second dose.
3. Support breathing. Give rescue breaths or CPR if trained.
4. Place in the recovery position if breathing, and stay with the person. Naloxone wears off in 30 to 90 minutes and the overdose can return.

Naloxone nasal spray is sold over the counter in the US. Anyone who uses opioids, or has family members who do, should carry it.

Opioid withdrawal

Withdrawal from short-acting opioids starts within 8 to 24 hours of the last dose, peaks at 1 to 3 days and mostly settles within a week. With methadone it starts later and lasts longer. Fentanyl withdrawal can be unpredictable.

Symptoms:

• aching muscles and bones, restlessness
• sweating, chills, goosebumps, yawning, runny nose and watery eyes
• nausea, vomiting, abdominal cramps and diarrhea
• anxiety, irritability, insomnia
• dilated pupils
• strong cravings

Withdrawal is rarely fatal itself, but dehydration can be dangerous, and loss of tolerance after withdrawal sharply raises the risk of fatal overdose if use restarts.

Health risks of opioid misuse

• fatal and non-fatal overdose
• infections from injecting: hepatitis C, HIV, skin abscesses, and endocarditis (heart valve infection)
• severe constipation and hormone changes
• depression and anxiety
• neonatal opioid withdrawal in babies exposed during pregnancy
• job, family, financial and legal problems

Treatment

Medications for opioid use disorder

These are the most effective treatments and reduce overdose deaths substantially:

• Buprenorphine (often combined with naloxone): a partial opioid agonist that eases cravings and withdrawal with a lower overdose risk. Can be prescribed in clinics and primary care.
• Methadone: a full agonist given daily through specialized opioid treatment programs.
• Extended-release naltrexone: a monthly injection that blocks opioids, started after full withdrawal.

Treatment is often long term. Stopping medication early increases relapse and overdose risk.

Withdrawal management

Medically supervised withdrawal, using buprenorphine or methadone tapers, or clonidine or lofexidine to ease symptoms. Withdrawal management alone, without ongoing treatment, has high relapse rates.

Counseling and support

• cognitive behavioral therapy and contingency management
• peer support groups and recovery coaching
• treatment for co-existing depression, anxiety, trauma or chronic pain
• help with housing, employment and legal issues

Harm reduction

Naloxone, fentanyl test strips, never using alone, and syringe services reduce deaths and infections while people work toward recovery.

Preventing opioid misuse

• Use prescribed opioids only as directed, for the shortest time possible.
• Ask about non-opioid pain options.
• Store opioids locked and out of reach, and dispose of unused pills at take-back sites.
• Never share prescription opioids.

Frequently asked questions

What are the signs of opioid addiction?

Signs include taking more than prescribed, running out early, seeking pills from others, cravings, withdrawal symptoms between doses, drowsiness, pinpoint pupils, mood changes, withdrawal from family and activities, and continuing to use despite problems.

What are the signs of an opioid overdose?

Signs include being unresponsive or very hard to wake, slow, shallow or stopped breathing, gurgling or snoring sounds, blue or gray lips and fingertips, and tiny pupils. Call 911 and give naloxone immediately.

How long does opioid withdrawal last?

For short-acting opioids like heroin or oxycodone, symptoms start within about a day, peak at 1 to 3 days, and mostly fade within a week. Methadone withdrawal lasts longer. Cravings and poor sleep can persist for weeks to months.

What is the best treatment for opioid addiction?

Medications for opioid use disorder, buprenorphine, methadone or extended-release naltrexone, combined with counseling and support, are the most effective treatments. They reduce cravings, relapse and the risk of fatal overdose.

Where can I get naloxone?

In the US, naloxone nasal spray is available over the counter at pharmacies and often free from health departments and community programs. Keep it where you and others can find it quickly.