In a 2014 address to the Senate Caucus on International Narcotics Control, Dr. Nora D. Volkow of the National Institute on Drug Abuse noted that in 2012, over two million people in the U.S. suffered from a substance use disorder related to prescription opiate pain relievers, and nearly half a million people were addicted to heroin.
She went on to cite statistics concerning the increase in the number of people abusing opiates, including the fact that unintentional overdose deaths from prescription opiate painkillers have more than quadrupled since 1999.
One of the factors that has led to the high prevalence of prescription opiate abuse is an alarming increase in the number of prescriptions being written for these medications, which has risen from 76 million in 1991 to nearly 207 million in 2013. Americans comprise nearly 100 percent of the world’s consumers of hydrocodone and 81 percent of its consumers of oxycodone.
A 2011 study published in the medical journal Pain Medicine estimated that the total societal cost of opiate abuse, dependence, and addiction in America exceeded $55 billion in 2007, with health care costs accounting for nearly half of that total.
Societal costs aside, the personal consequences of an addiction to opiates include a wide range of social, legal, and financial problems as well as devastating physical and mental health complications and an overall low quality of life. But the good news is that addiction is a treatable disease, and educating yourself about the mechanics of an opiate addiction and its consequences on your physical and mental health and wellbeing is the first step to overcoming a reluctance to seek help.
What Exactly Are Opiates?
Opiates are drugs that are derived from opium, which is extracted from certain varieties of the poppy plant.
Opiates bind to opioid receptors in the body and reduce the intensity of pain signals, and they fall into four general classes, according to The National Alliance of Advocates for Buprenorphine Treatment:
- Those that are naturally produced in the body.
- Opium alkaloids, which are organic compounds and include morphine and codeine.
- Semi-synthetic opiates, which include heroin and oxycodone.
- Fully synthetic opiates, which include methadone.
Opiates are prescribed by physicians to treat pain. According to the National Institute on Drug Abuse, the most commonly prescribed opiates are:
- Hydrocodone (Vicodin), which is typically prescribed for a range of painful conditions, including medical and dental pain.
- Oxycodone (OxyContin), which is also prescribed for various types of pain but carries different side effects than hydrocodone.
- Morphine (Avinza), which is prescribed for severe pain, such as that due to surgery.
- Codeine, which is prescribed for mild pain and is often used to relieve severe diarrhea and coughs as well.
Opiates are considered extremely addictive, which is why prescription opiates appear on Schedule II of the Controlled Substances Act. Schedule II drugs carry a very high risk of developing a dependence on these drugs, but they have some medical value. Heroin, on the other hand, is a Schedule I drug, which means that there’s a high risk of developing a dependence on it, but there is no medical value in using it.
The Difference Between Dependence and Addiction
Dependence and addiction are not the same thing. Dependence, as defined by the National Institute on Drug Abuse, occurs when the body develops a tolerance to a drug and requires increasingly higher doses to get the same effects, which will eventually result in the onset of withdrawal symptoms when the drug is withheld. Withdrawal symptoms are an indication that the body has become dependent on the drug.
Addiction, by contrast, is defined as the compulsive use of a drug despite negative consequences, and it’s characterized by being unable to stop using the drug even though you want to or have tried. Dependence doesn’t necessarily indicate an addiction, and an addiction doesn’t necessarily indicate that a dependence has developed, but the two often occur together, particularly with opiates.
How Opiates Do Their Job: Opiates and Opioid Receptors
Your body produces its own opiate-like substances that attach to opioid receptors located around the body, including in the brain, spinal cord, and gastrointestinal tract. The three types of opioid receptors are mu, delta, and kappa receptors, and depending on the type of opiate and which receptors it binds to, different effects are produced.
When opiates bind to delta receptors, they relieve pain in the peripheral nervous system, and when they bind to kappa receptors, they relieve pain in the spine. When they bind to mu receptors, they relieve pain in the central nervous system and cause drowsiness and respiratory depression. Here, they also reduce the amount of the neurotransmitter GABA, which controls the amount of the feel-good brain chemical dopamine that’s released into the body.
The suppression of GABA and the resulting flood of dopamine causes a keen sense of well-being and marked euphoria.
According to the National Institute for Drug Abuse, when opiates act on any of the receptors in the limbic system, which controls emotions, they produce feelings of relaxation, contentment, and pleasure. When they act on the receptors in the brainstem, which controls involuntary actions of the body, they produce respiratory depression, and it’s here that they can ease a bad cough and reduce pain.
The side effects of an opiate drug depends on its type, how much is taken, and how frequently. Side effects may include drowsiness, euphoria, confusion, constipation, and nausea. But perhaps the most serious side effect is physical dependence and addiction.
How Opiates Cause Dependence and Addiction
An article published in the journal Science & Practice Perspectives explains that an addiction develops when opiates attach to mu opioid receptors, and the reward center of the brain is activated.
The user feels pleasure, and the brain creates a memory that associates this pleasure with the act of using the drug. Called “conditioned associations,” these memories lead to cravings that send the user on a search for more of the drug, despite the obstacles of obtaining it and despite the consequences taking the drug may cause. Repeated recreational use of the drug often leads to addiction, even if dependence hasn’t yet set in.
Over time, the compulsive use of opiates alters the way the brain operates. The brain cells that contain opioid receptors will gradually become less sensitive to the opiates, and the user will need to take higher doses to activate them. This leads to tolerance, and the user will need increasingly larger doses in order to get the desired effects.
Eventually, the brain begins to function somewhat more “normally” when the drugs are present than when they’re not. When the drug aren’t present, the “abnormal” functioning is characterized by withdrawal symptoms, indicating that a physical dependence has developed.
Withdrawal symptoms are caused by changes that occur in another area of the brain known as the locus ceruleus, or LC, which contains neurons that produce noradrenaline, a chemical that’s distributed to other parts of the brain to induce functions like breathing, regulating blood pressure, and stimulating wakefulness and alertness. When opiates attach to the mu receptors in the LC, the production of noradrenaline is suppressed, causing the typical effects of an opiate high–drowsiness, reduced respiration rate, lower blood pressure.
With repeated exposure to opiates, the neurons compensate for the suppressing effects of the drug by increasing their level of activity so that when the drug is present, the person feels relatively normal. But when opiates are withheld, the neurons continue to release abnormally high levels of noradrenaline, and the user experiences withdrawal symptoms, which include increased anxiety and restlessness, muscle cramps, and diarrhea.
Additional brain areas are also affected by the continual presence of opiates, including the mesolimbic reward system, which may change and prevent the user from getting pleasure from activities that were once enjoyable, such as eating, sex, and former hobbies.
Other changes in brain function and structures that occur over time include changes in the shape of the brain cells, the size and shape of particular neurons, and the way synapses work. These and other changes combine to affect the user’s behaviors and perceptions.
Long-Term Effects of Opiates on the Brain
Research shows that the depressed respiration caused by taking opiates can reduce the amount of oxygen that reaches the brain, a condition known as hypoxia, which can cause permanent psychological and neurological damage as well as induce a coma.
Long-term heroin abuse has been shown to cause deterioration of the white matter in the brain, which may lead to prolonged or permanent problems with decision making abilities as well as affect the ability to regulate behavior and respond appropriately to stressful situations.
A study published in the Primary Care Companion to the Journal of Clinical Psychiatry found that chronic opiate users have a much higher risk than non-users of developing depression, anxiety disorders, and bipolar disorder, and they’re over 10 times more likely to require inpatient mental health services.
Long-Term Effects of Opiates on the Body
Opiate abuse, dependence, and addiction also cause a number of physical health problems across a number of organ systems. In general, people who chronically abuse opiates have a lower quality of life related to their health, and their healthcare costs are considerably higher than non-users’. Overall, people who engage in long-term opiate abuse have an 87 percent higher mortality than non-users across all causes.
Due to the prevalence of mu opioid receptors in the gastrointestinal tract, chronic abusers of opiates may experience opioid-induced bowel dysfunction, or OBD, which causes constipation, abdominal cramping, spasms, and bloating as well as a higher prevalence of hemorrhoids, fecal impaction, and diverticular disease. OBD occurs when opiates inhibit the release of neurotransmitters, reducing mucosal secretions and affecting the ability of the gastrointestinal system to coordinate the rhythmic contractions required for bowel movements.
Up to 63 percent of chronic opiate users experience constipation related to OBD, which in general may affect up to 80 percent of chronic users, according to a study published in the International Journal of Clinical Practice.
Narcotic Bowel Syndrome, or NBS, is a common subset of OBD, according to research published in the medical journal Clinical Gastroenterology and Hepatology. NBS is characterized by chronic abdominal pain that gets worse with continued opiate use, and it can cause nausea and vomiting, abdominal distention, and bloating, all of which worsen with eating. This condition can last long enough to cause dramatic weight loss and malnutrition.
According to a study published in The Primary Care Companion to The Journal of Clinical Psychiatry, up to one-third of those with chronic constipation due to OBD or NBS experience a significant reduction in their quality of life and economic status as well as an increase in symptoms of depression.
Recent research shows a relationship between chronic opiate use and sleep-disordered breathing, including:
- Sleep apnea, during which breathing stops and starts periodically throughout the night.
- Ataxic breathing, which is characterized by an irregular breathing pattern and periods of apnea. Ataxic breathing causes damage to the medulla oblongata, the portion of the brain that controls heart and lung function.
- Hypercapnia, or carbon dioxide retention, which increases the heart rate and blood pressure and in severe cases may cause arrhythmia, convulsions, unconsciousness, and even death.
- Hypoxemia, or low blood oxygen, which can cause right-sided heart failure and respiratory failure.
Opiate abuse is associated with a 77 percent higher risk of cardiovascular events like an abnormal heart rate, heart failure, and heart attack. Injecting opiates may lead to collapsed veins and bacterial infections of the heart valves and blood vessels.
Endocrine System Problems
Opiates affect the release of all of the hormones that originate in the anterior pituitary gland, including:
- Prolactin, which plays a role in reproduction, metabolism, behavior, and the regulation of the body’s fluids and immune system.
- Thyroid-stimulating hormone, which regulates the thyroid and affects nearly every other function in the body, including metabolism and brain function.
- Adrenocorticotropic hormone, which helps govern how we respond to stressful stimuli.
- Lutein-stimulating hormone, which stimulates the production of testosterone in men and plays a major role in the female reproductive system.
Specifically, the hormonal shifts due to chronic opiate abuse cause problems including sexual dysfunction, fatigue, and infertility as well as increase the risk of developing metabolic syndrome and insulin resistance, which can lead to diabetes.
Immune System Problems
Chronic opiate abuse, particularly related to morphine and fentanyl, have notable immunosuppressive effects. Recently, scientists funded by the National Institute on Drug Abuse identified a biochemical trigger caused by opiate abuse that inhibits an immune cell critical for fighting cancer and viruses. Additionally, opiates suppress the activity of three different types of white blood cells:
- B lymphocytes, or B-cells, which make antibodies that identify and neutralize pathogens in the body.
- T lymphocytes, or T-cells, which scan the body for foreign invaders, kill cells infected with bacteria or viruses, destroy cancer cells, and help the B-cells make antibodies.
- Natural killer cells, or NK cells, which are critical for causing the body to reject tumors and cells infected with viruses.
Long-term opiate abuse leads to a broad range of viral and bacterial illnesses and other conditions due to the suppression of the cells used by the immune system to fend them off.
A fine line exists between an opiate dose that produces the intended effects and one that results in a dangerous or fatal overdose. According to the World Health Organization, 19,687 Americans died of an opiate overdose in 2010, with more than three-quarters of them due to prescription painkillers.
The risk of overdosing on opiates is high, mainly due to the effects of they have on the part of the brain that regulates respiratory function, but the risk is far higher when alcohol or sedative drugs are used at the same time.
Getting Help for an Opiate Addiction
The sooner you beat an opiate dependence or addiction, the better the prognosis for your mental and physical health.
In many cases, brain abnormalities that characterize opiate dependence resolve in the days and weeks after detox, which can take place through an inpatient treatment facility or an outpatient program and should ideally include the administration of medications to help alleviate the unpleasant symptoms of withdrawal.
But for those who are addicted to opiates as well as dependent on them, it takes more than detox to help ensure long-term recovery. During opiate addiction treatment, various therapies will be utilized to help you identify and work through the underlying issues that led to the abuse that in turn led to the addiction.
One of several highly effective therapies used in addiction treatment is cognitive-behavioral therapy, or CBT, which takes place in individual, group, and family settings. CBT helps those in recovery identify self-destructive thoughts, attitudes, and behaviors and replace them with healthier ways of thinking and behaving.
An opiate addiction may seem to be an insurmountable problem from where you’re standing, but through an intensive treatment program, you will gradually develop the skills and techniques you need to eliminate or withstand cravings, cope with stress, and identify and either avoid or cope with triggers.
Recovery is a lot of work, and it isn’t always easy. But successful long-term recovery is possible, and it leads to an immeasurably better quality of life for both you and the people who love you.
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