What are opioids, exactly? Why are they so hard to kick and what makes them so lethal? In the midst of our nation's opioid epidemic, it's more important than ever to understand the neurobiological mechanics and psychosocial effects of opioid addiction and identify the most promising treatment protocols. The revealing, first-person story shared below by David D., a health care professional in recovery from opiate addiction, also provides a telling personal account of the grip of opioid addiction and the path to recovery. What Are Opioids? “Opioids” is an umbrella term for all the natural and synthetic painkillers that are derived from or based on the poppy plant Papaver somiferum. (The related term “opiate” applies only to those medications that use natural opium poppy products. The drug heroin is an opiate.) Physicians often prescribe opioids to relieve acute pain—from injuries, surgeries, toothaches or other medical and dental procedures—or alleviate chronic pain. Some well-known opioid drugs include: Morphine Codeine Diacetylmorphine (heroin) Hydromorphone (Dilaudid) Hydrocodone (Vicodin) Oxycodone (OxyContin) Meperidine (Demerol) Fentanyl (Sublimaze, Actiq) How Do Opioids Work? When opioid molecules travel through the bloodstream into the brain, they attach to receptors, specialized proteins on the surface of certain brain cells. The binding of these molecules with their target receptors triggers the same chemical response in the brain’s reward center that occurs with anything that causes intense pleasure or is intended to be reinforcing to survival itself. This is the part of the brain that ensures our survival—by reinforcing acts such as eating, drinking fluids, caring for our babies and having sex (for survival of the species). All rewarding and survival-based activities result in release of dopamine in the brain’s reward center. But opioids, like all drugs of abuse, trigger the release of dopamine in excess amounts, far beyond what is needed to provide pleasure or keep us alive. The brain has been signaled: Something extremely important has taken place, and it needs to be repeated. Everyone exposed to prescription opioids experience excess dopamine release in the reward center of the brain. However, most people do not become addicted after such exposure. Although experts are not entirely sure why this is so, it may be related to altered function of dopamine receptors in individuals predisposed to addiction. David D.'s Story: “I got home from having my wisdom teeth removed and I was miserable. My face was swollen, and I was in a lot of pain. I took some ibuprofen, and that didn’t seem to do anything, so I took a Percocet . . . I can remember exactly where I was standing in the room of my fourth-year medical school student apartment, the angle of the sun through the windows, where the TV and couch were located. My mind said, ‘I don’t know what you did, but let’s do that again.’” Opioid Dependence Prolonged use of increasingly higher doses of opiates changes the brain so that it functions more or less normally when the drug is present and abnormally when the drug is removed. This alteration in the brain results in tolerance (the need to take higher and higher doses to achieve the same effect; “chasing the dragon”) and opioid dependence (susceptibility to withdrawal symptoms). Euphoria is the effect that most opioid users seek, but it’s also the effect most likely to diminish with regular use of the drug. The opioid receptors have changed at a cellular level, trying to protect against overstimulation. An opioid addict takes his or her drug of (no) choice in order to feel “normal,” a concept that can be difficult to grasp. Many people assume addicts enjoy their daily drug use, but most people with opiate addiction cannot recall the last time their drug use was enjoyable. After a certain point, daily use becomes drudgery and its own form of torture. This cycle of drug abuse has formidable consequences when a user tries to stop. David D.'s Story: "Within six weeks, I was avoiding the sickness of opioid withdrawal, the emotional, mental and physical sequelae of withdrawal. It gets its proverbial fingernails into you, and you feel like you end up in a situation that you can’t escape. I knew that I shouldn’t be using the medications, and I knew that I wanted to get off of them. But I couldn’t. If I tried to endure the symptoms of withdrawal, questions would come up: Why do you look sick? Why are you not coming to work? Why are you sleeping all the time? Why are you making mistakes? Some of that comes off as depression. And some people interpret it that way.” Opiate Withdrawal and Relapse Attempting to avoid the agony of opiate withdrawal symptoms is one of the more powerful factors driving dependence and addictive behaviors. "For most patients, going through opioid withdrawal feels like a terrible case of the flu," explains nurse Susan Munson, RN, CARN from Hazelden in Plymouth, Minnesota. Nausea, body aches, abdominal cramping, fever, runny nose and fatigue are common opiate withdrawal symptoms, along with: Agitation Anxiety Itching Irritability Insomnia Goose bumps Rapid heart rate Mild hypertension Vomiting Diarrhea At the peak of opiate withdrawal, intense anxiety, tremors, shakes, muscle cramps and joint and deep bone pain begin to manifest. Down the road are more serious, long-term consequences of opiate withdrawal. Anxiety, depression and craving for the drug can continue for months, even years after being free of use. Addicts in recovery also have an increased sensitivity to real or imagined pain and are more vulnerable to stressful events. The desire to feel “normal” again, to escape this seemingly permanent state of dysphoria, puts addicts at a high risk of relapse, and, even more tragically, at a high risk of accidental overdose and death. A user who returns to the same dosage after losing his or her tolerance to that drug risks respiratory suppression and death. David D.'s Story: “I started to seek help from psychiatrists under the guise of having major depression disorder when actually it was depression as a result of drug use. That feeling trapped: Knowing my desire to be a good physician, a good person, a good son, and a good citizen. Knowing that I shouldn’t be doing these things and that I shouldn’t be addicted to opiates. But then also knowing that I can’t get off of them. It’s an awful situation to be in. Hopeless, actually.” Treatment for Opioid Addiction Because of the unique challenges in addressing opiate addiction, and because of the addict’s vulnerability to relapse and accidental death, the Hazelden Betty Ford Foundation developed enhanced opioid addiction treatment protocols that include the use of certain medications, extended continuing care and close monitoring of medication use. These addiction treatment protocols are known as the Comprehensive Opioid Response with Twelve Steps (COR-12™). The approach is designed to provide addicts with a sufficiently long enough time in recovery to begin forming new relationships and taking in new information essential to addiction recovery. Treatment is delivered within the context of Twelve Step Facilitation and other evidence-based therapies, with abstinence from drugs as the ultimate goal. As part of the COR-12 addiction treatment protocol, physicians work with each patient to determine the treatment course that best fits his or her clinical needs. Patients may receive Suboxone®, a combination of buprenorphine and naloxone, for detox to ease withdrawal. Some patients may receive a recommendation for a monthly, extended-release injection of Vivitrol®, also known as naltrexone, to ease cravings. This medication works to block cravings and help prevent relapse. (Although methadone is commonly used to ease opioid/opiate withdrawal, the Hazelden Betty Ford Foundation provides buprenorphine instead, for a number of important reasons. Buprenorphine has been deemed a better medication for the Hazelden Betty Ford Foundation's patient population, in keeping with the goal of transitional use of medication-assisted treatment versus long-term medication maintenance. Learn more about methadone vs suboxone for treatment of opiate addiction and withdrawal.) Learn more about the Hazelden Betty Ford Foundation opioid treatment program. David D.'s Story: “If someone clearly has been struggling with multiple relapses and having difficulty engaging in recovery and achieving longer term sobriety and abstinence, we need to look at that, we need to adjust how we treat that—as we would any disease . . . because of the Twelve Steps, I have a choice today. Because I have put some energy into recovery and health, and because I have had time for those executive functioning areas of my brain to regenerate, I can make healthier decisions today, especially the choice for freedom—on a daily basis.” You may also be interested in Prescription Painkillers: History, Pharmacology, and Treatment by Marvin D. Seppala, MD (Hazelden Publishing, 2010). Partially excerpted from Prescription Painkillers by Marvin D. Seppala, MD, chief medical officer of the Hazelden Betty Ford Foundation.