As declared by the National Institute on Drug Abuse and the Centers for Disease Control and Prevention, the U.S. is in the midst of an opioid epidemic. Individuals, families and communities all across the country are impacted by this crisis, which is why it's more important than ever to understand the potential dangers of opioid use, including: How prescription opioid painkillers, heroin and other opiate drugs work Why opioid dependence (or heroin addiction) can develop before you realize it When opioid overdose risk is greatest Which treatment approaches for opioid use disorder are most effective Let's start with some basic definitions. What Are Opioids? "Opioids" is an umbrella term for natural and synthetic painkiller drugs derived from or based on the poppy plant. The related term "opiate" applies only to medications that use natural opium poppy products. For example, the illicit drug, heroin, is classified as an opiate because it is derived from the poppy plant. Physicians often prescribe opioid medications to relieve acute pain—from injuries, surgeries, toothaches, or other medical and dental procedures—or to alleviate chronic pain. However, studies show that long-term opioid use for chronic pain can be ineffective—and comes with the risk of addiction. You might recognize some of the more well-known opioid drugs prescribed for pain, including: Morphine Codeine Diacetylmorphine Hydromorphone (Dilaudid) Hydrocodone (Vicodin, Lortab) Isotonitazene Opium Oxycodone (OxyContin, Percocet) Oxymorphone Meperidine (Demerol) Methadone Fentanyl (Sublimaze, Actiq) Tramadol What Are the Differences in These Various Opioids? The form of the drug—such as powder, pill, liquid or tar—is one of the biggest differences. Opioids may also vary in potency, how long they affect the brain and the risk or potential for addiction. Some are classified as a "controlled substance" which means the drug is regulated and therefore produced in a standardized manner. Others are illegally produced and distributed, which factors into the heightened risk for overdose. Whether regulated or unregulated, prescription or illicit, all of these drugs have the potential for misuse, dependence and addiction. Also, when used in combination with cocaine or other drugs, such as prescription medications, different reactions and effects are produced. Potency, cost and accessibility are considerations that affect the popularity and recreational use of these substances. Most recently, an opioid known as Isotonitazene—commonly referred to as "iso"—has been linked to an increase in overdose-related deaths. A synthetic opioid more powerful than fentanyl, iso is actually legal across most of the United States. Like other "designer drugs," iso has been developed to differ enough chemically from its outlawed version while still producing similar effects on the brain. What's the Connection between Prescription Painkillers and Heroin? The nation's epidemic level of addiction to prescription opioid medications (painkillers) has given rise to the use of heroin as a less expensive, more readily accessible substitute. Heroin, a highly addictive illegal drug typically used for its euphoric effect, comes in the form of a black tar substance or a white or brown powder. Street names include "horse," "smack," "brown sugar" and "junk." In the U.S., heroin use and heroin addiction are at an all-time high. Heroin can be smoked or snorted, but the drug is more typically injected into a vein in order to achieve the quickest high. Injection causes the greatest risk to users because heroin overdose can more easily occur, and because disease and infections can be spread by dirty needles. How Do Opioids Work, and Why Are They So Addictive? When opioid molecules travel through the bloodstream and into the brain, they attach to opioid receptors on the surface of certain cells. The chemical response triggered in the brain's reward center is the same as the reaction to intense pleasure and reinforces acts such as eating, drinking fluids, caring for babies and having sex—all necessary for survival of the species. These rewarding and survival-based activities result in the release of dopamine in the brain's reward center. But opioid use, like use of any drug of abuse, triggers the release of dopamine in excess amounts, far beyond what is needed to provide pleasure or keep us alive. In the process, the brain has been signaled: something extremely important has taken place, and it needs to be repeated. Opioid medications can also induce euphoria, an effect that can be intensified when the drug is administered by routes other than those prescribed or recommended. For example, although the prescription painkiller OxyContin is prescribed in pill form, the medication can be snorted or injected to enhance the euphoric effects. Unintended consequences of misusing opioid drugs in this way can include serious medical problems, even opioid overdose. Addiction is defined as the compulsive and uncontrollable use of alcohol or other drugs despite adverse consequences. Dependence occurs when the body adapts to the presence of the drug, causing withdrawal symptoms when use is reduced or discontinued. Prolonged and increasingly higher doses of opioids change 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 brain function results in drug tolerance (the need to take higher and higher amounts to achieve the same effect; "chasing the dragon") and opioid dependence (or heroin addiction) as signaled, in part, by susceptibility to withdrawal symptoms. Euphoria is the sensation most opioid users seek, but it's also the effect most likely to diminish with prolonged use. That's why it's said a person with opioid addiction uses the drug in order to feel "normal." And while you might assume an opioid or heroin addict takes pleasure in using, most people who develop opioid dependence cannot recall the last time their drug use was enjoyable. After a certain point, substance abuse and dependence become drudgery, and the addictive cycle becomes its own form of torture. What Are the Signs, Symptoms and Side Effects of Opioid Addiction? Every person's situation is different, but in general, opioid use disorder is a condition that involves both physical and psychological processes. Progression of the disease can be so incremental that it's not recognized as such until a crisis occurs. Here are eight potential warning signs of opioid or heroin abuse: Taking the drug in larger amounts or over a longer period than intended or prescribed A persistent desire or unsuccessful efforts to cut down or control drug use An excessive amount of time and effort spent getting, using and recovering from the effects of use Intense cravings or a strong desire or urge to use Failure to fulfill obligations at work, school or home due to drug abuse Continued use despite persistent or recurrent social or personal problems caused by usage Continued use despite situations that could be physically hazardous, including overdose risk Continued use despite awareness of potential physical or mental health problems As with all types of drug or alcohol addiction, having a family history of substance abuse increases your risk of developing dependence. Other signs, symptoms or side effects of prescription opioid abuse or heroin use include: Problematic mental health, behavioral or psychological changes such as agitation, poor judgement or apathy Drowsiness or coma Impaired mental functioning Slurred speech Constricted pupils Euphoria Slowed down respiration Dry mouth Nausea Constipation Abdominal cramping Skin rashes and infections Weight gain Menstrual problems Depression Headaches Bad dreams Loss of libido, sexual dysfunction Mood swings Collapsed veins Risk of HIV, hepatitis B or C Miscarriage Infections of the heart lining and valves What Are the Warning Signs of Opioid Overdose? Taking a large, single dose of heroin or any opioid drug can cause severe respiratory depression with the potential for accidental drug overdose and death. Opioid abuse is also associated with a higher risk of suicide. Signs of overdose may include: Shallow breathing Pinpoint pupils Convulsions Coma Nervous system changes Decreased vital signs Cold or clammy skin, or bluish lips The strength of heroin is unpredictable because other drugs, such as fentanyl, are sometimes added to increase volume or enhance potency. Heroin is one of the substances most frequently reported by medical examiners in drug abuse deaths. What Is Opioid Withdrawal? Opioid withdrawal occurs as the body adjusts to a decrease or discontinuance in drug use. The withdrawal effects can be especially challenging and, in fact, prevent some people with addiction from seeking the help they need and deserve. Opioid withdrawal symptoms include: Restlessness Muscle aches, pain, stiffness, spasms and bone pain Insomnia Diarrhea Vomiting Cold flashes with goose bumps ("cold turkey") Involuntary leg movements Agitation Anxiety, panic Itching Irritability Rapid heart rate Mild hypertension Runny nose Sweating, shaking Flu-like symptoms, fever Yawning Seizures Sleep difficulties Fear, paranoia At the height of opiate withdrawal, symptoms typically include intense anxiety, tremors, shakes and muscle cramps. Joint ache and deep bone pain often manifest, as well. The long-term consequences of opiate withdrawal, including anxiety, depression and cravings, can continue for months, even years after being free of use. Recovering addicts may also have an increased sensitivity to real or imagined pain, and greater vulnerability to stressful events. The desire to feel "normal" again, to escape the seemingly permanent state of dysphoria, puts recovering opioid addicts at a high risk of relapse and, even more tragically, at a high risk of accidental overdose, respiratory suppression and death. When people with opioid dependence stop using—for weeks or months or years—and then pick up again, their tolerance for the drug changes so that an amount they could previously tolerate can become a lethal dose. What Is the Most-Effective Treatment for Opioid Addiction? Given the unique treatment and recovery challenges associated with heroin addiction, including challenging withdrawal symptoms and an increased vulnerability to relapse and accidental death, clinicians at the Hazelden Betty Ford Foundation developed an evidence-based opioid addiction treatment protocol that includes the use of certain medications, an extensive level of continuing care and close monitoring of medication use. Known as Comprehensive Opioid Response with Twelve Steps (COR-12™), the approach is designed to provide patients with a sufficiently long enough time in treatment programming to begin forming healthy new practices and taking in new information essential to recovery. Treatment programming is delivered within the context of Twelve Step Facilitation and other evidence-based therapies (including integrated care for co-occurring disorders, as appropriate), with abstinence from drug use as the ultimate goal. As part of the COR-12 treatment protocol, physicians work with the patient to determine the treatment course that best fits his or her clinical needs. Patients may receive Suboxone®, a combination of buprenorphine and naloxone, during detox to ease withdrawal symptoms. Some patients may receive a recommendation for a monthly, extended-release injection of the medication Vivitrol®, also known as naltrexone, to block cravings and help prevent relapse. Although methadone is commonly used to ease opioid and heroin withdrawal, Hazelden Betty Ford provides buprenorphine instead, for a number of important reasons. Buprenorphine has been deemed a better medication for Hazelden Betty Ford'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 (buprenorphine with naloxone) for treatment of opiate addiction and withdrawal. Learn more about our medication-assisted treatment program for opioid use disorder. You may also be interested in Prescription Painkillers: History, Pharmacology, and Treatment by Marvin D. Seppala, MD (Hazelden Publishing, 2010).