DE: Substance Abuse, Chemical Depence, and Drug DiversionPage 6 of 12

4. A Closer Look at Addiction

Health Risks of Opioids

Health effects related to opioid misuse and abuse include pain relief, drowsiness, nausea, constipation, and euphoria. An acute effect, when taken in ways other than prescribed, is life-threatening respiratory depression leading to coma and death. Long-term effects include drug tolerance and addiction. In combination with alcohol, opioid use can cause life-threatening slowing of the heart rate and respiration with potential coma and/or death.

Certain populations have additional health risks. Youth often think that prescription drugs are safer to use than illegal drugs because they are prescribed by a physician and manufactured by legitimate pharmaceutical companies. But according to a 2013 SAMHSA study, ED visits for youth aged 12 to 17 on a typical day include 174 prescription drug-related incidents, with 74 for prescription or nonprescription pain relievers (SAMHSA CBHSQ Report, 2013).

Pregnant women who use opioids nonmedically can have spontaneous abortions and low-birth-weight babies. Older adults are at greater risk for severe health consequences due to accidental misuse or abuse of opioids because of age-related changes in metabolism, alcohol use, or drug interactions with multiple prescriptions (NIDA, 2012a). Addiction and accidental overdose occurs in all populations.

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is often characterized by behaviors that include one or more of the following:

  • Impaired control over use
  • Compulsive use
  • Continued use despite harm
  • Craving

Addiction medicine is a specialty field in the mechanism and treatment of addiction. In August 2011 the American Society of Addiction Medicine released a new definition of addiction, Public Policy Statement: Definition of Addiction. Its shortened revised definition:

Addiction is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. (ASAM, 2011)

How Addicting Are Opioids?

Opioids are a class of drugs that broadly includes heroin, hydrocodone, oxycodone, and other morphine-derived drugs. Brain abnormalities can result from chronic use of such drugs and they cause dependence (the need to keep taking drugs to avoid withdrawal syndrome) and addiction. Dependence can resolve after detoxification. Addiction, however, has complex and long-lasting effects, involving craving that can lead to relapse long after the patient’s dependence resolves (Kosten & George, 2002).

The opiate travels through the bloodstream to the brain, where chemicals attach to proteins called mu opioid receptors on the surfaces of opiate-sensitive neurons. When the chemicals link with the receptors, a biochemical process of the release of dopamine into the nucleus accumbens rewards the individual with feelings of pleasure, in the same manner as when they experience sex and food. Although the opioid may be prescribed to relieve pain, the pleasure reward process is activated, building motivation for repeated use of the drug for pleasure.

The brain creates lasting associations of the feelings of pleasure with the circumstances and environment in which they occur, further cementing the motivation to continue taking the opioid, despite the risks and obstacles.

Although taking drugs for pleasure is the first stage of drug abuse, the behavior becomes compulsive, which leads to tolerance and dependence. Repeated doses of opioids alter the brain. It begins to function normally when the drugs are present and abnormally when they are not. Higher dosages are needed to achieve the surge of dopamine for the same pleasurable effect; this is known as tolerance. The brain’s opioid receptors gradually become less responsive to the opioid. The dopamine rush has a diminished impact on the reward circuit, which means the drug user experiences a reduced ability to enjoy not only the drug but also other pleasurable life experiences.

Drug dependence is the condition of being so accustomed to the drug that withdrawal symptoms occur if the drug is not used. Another brain change in the locus ceruleus from use of opioids results in withdrawal symptoms of jitters, anxiety, muscle cramps, and diarrhea because excessive levels of noradrenaline are produced. Dependence leads to daily drug use to avoid unpleasant symptoms of withdrawal (Kosten & George, 2002).

Symptoms of drug withdrawal from opioids include:

  • Anxiety
  • Irritability
  • Craving for the drug
  • Rapid breathing
  • Yawning
  • Runny nose
  • Salivation
  • Gooseflesh
  • Nasal stuffiness
  • Muscle aches
  • Vomiting
  • Abdominal cramping
  • Diarrhea
  • Sweating
  • Confusion
  • Enlarged pupils
  • Tremors
  • Loss

According to the National Institute on Drug Abuse (2012b):

Long-term abuse causes changes in other brain chemical systems and circuits as well. Glutamate is a neurotransmitter that influences the reward circuit and the ability to learn. When the optimal concentration of glutamate is altered by drug abuse, the brain attempts to compensate, which can impair cognitive function. Brain imaging studies of drug-addicted individuals show changes in areas of the brain that are critical to judgment, decision making, learning and memory, and behavior control.

It is important to understand the opioid dependence and addiction are chronic medical disorders. Although initially people may voluntarily take a drug to treat pain or to feel pleasure, the brain changes that result from opioid use can create a physiologic and psychological need that is difficult to resist (Kosten & George, 2002).

Best Practices of Pain Management and Addiction Medicine

The Physicians Advisory Committee for Controlled Substances of the Medical Society of Delaware issued guidelines and

recognizes that the use of opioid analgesics for other than legitimate medical purposes can pose a threat to the individual and society and that the inappropriate prescribing of controlled substances, including opioid analgesics, may lead to drug diversion and abuse by individuals who seek them for other than legitimate medical use. Accordingly, these guidelines mandate that licensed practitioners incorporate safeguards into their practices to minimize the potential for the abuse and diversion of controlled substances. (MSD, 2013)

A comprehensive approach is necessary to achieve safe pain management and optimal patient functioning (physical, psychosocial, social, and work-related) while guarding against misuse, abuse, addiction, and overdose. The Delaware approach aligns with the 2011 Prescription Drug Abuse Prevention Plan, which outlines actions in four major areas to reduce prescription drug abuse:

  • Education for parents, youth, and patients about the dangers of abusing prescription drugs, and for prescribers on the appropriate and safe use and proper storage and disposal of prescription drugs.
  • Monitoring via Prescription Drug Monitoring Programs (PDMPs) in every state to reduce doctor shopping and diversion, and enhance PDMPs to make sure data is available across states and used by healthcare providers.
  • Proper medication disposal in convenient and environmentally responsible programs to help decrease the supply of unused prescription drugs in the home.
  • Law Enforcement tools to eliminate improper prescribing practices and stop pill mills. (ONDCP, 2011a)

It is not enough merely to diagnose and treat patients’ pain. It is incumbent on clinicians to understand the treatment of pain, alternatives to opioids, and medical indications for using opioids in the treatment of chronic pain, including the drugs’ general characteristics, toxicities, and drug interactions.

Delaware clinicians can reference the Delaware Pain Initiative (, which aims to educate the public and healthcare providers regarding the assessment and treatment of pain, reduce the barriers to effective pain management, and serve as a resource for state-of-the-art pain information.

Of use to all healthcare providers is the Opioid Overdose Prevention Toolkit. It aims to educate healthcare providers, patients, and family members about the risks of opioid analgesic misuse, abuse, and overdose, the risks associated with such drugs, how to identify overdose, how to treat it, how to appropriately prescribe and monitor the use of opioids (SAMHSA, 2014d).

In brief, the best practices approved by the Medical Society of Delaware and SAMHSA include the following:

  • Evaluation
  • Treatment plan
  • Informed consent
  • Agreement for treatment
  • Periodic review
  • Consultation
  • Medical records
  • Compliance with controlled substance laws and regulations (MSD, 2013)

These best practice recommendations are echoed in publications by the Federation of State Medical Boards (2013) and the American Society of Addiction Medicine. We will discuss each of these safeguards in more depth.