When we say “opioid,” we are talking about chemicals, both natural and synthetic, that, when taken correctly, mimic the pain dampening ability of opium. The word opioid is derived from the name opium, the concentrated juice of the poppy Papaver somniferum, which can aid in sleep, pain relief, and relaxation and from which morphine, codeine, and several other alkaloids used as or in prescription medication are taken.
Table 1: Opioids
- Oxymorphone (contains Thebaine)
- Hydrocodone (contains Codeine)
- Oxycodone (contains Thebaine)
- Hydromorphone (contains Morphine)
Semisynthetic opiates are molecules that contain some natural opiates and a mix of synthetic chemicals.
Opium, and to a greater or lesser extent, all of the “opioids” can enter the brain, stimulating chemical receptor sites conveniently known as opioid receptors located in the brain, bowels, and spinal cord. When an opioid is present, the activated receptors slow or block pain signal transmission to the brain, slow bowel function, and in general produce a warmly euphoric feeling in both the limbic areas of the brain that house the “reward” response and the frontal cortex which helps to mediate pleasure.4 An increase in natural endorphins, pain-relieving chemicals produced naturally by the body, accompanies opioid use, boosting feelings of wellbeing, and further suppressing the perception of pain.5 The longer opioids are used, fewer and fewer endorphins are manufactured by the body, leaving natural pain fighting abilities handicapped and at a loss to function normally.
Prescription opioids are an invaluable asset for the legitimate control of moderate to severe pain.
Abuse of opioids varies. For some, the relief from stress, the warmth, the feeling of “at ease with life” that accompanies an opioid’s lowering of heart rate, widening of blood vessels, and gentle sedation is the goal. Then there are those reaching for the intense pleasure high levels of the neurotransmitter dopamine; a chemical increased by opioids can help produce.
Dopamine Makes Good Feelings
As the National Institute on Drug Abuse puts it in materials designed to aid teachers in helping youth make good decisions, “Dopamine is sometimes called the pleasure neurotransmitter because it helps you feel good.” “When something pleasurable happens, certain axons release lots of dopamine. The dopamine attaches to receptors on dendrites of neighboring neurons and passes on the pleasure message”.6
In part, according to the National Institute of Health, it is the good job opioids do managing pain and helping us to feel better that is contributing to the overuse/ misuse problem with some 21 to 29 percent of those with chronic pain using them outside of their health providers instructions. Sadly, some 8 to 12 percent of chronic pain patients develop what is referred to as an opioid use disorder, which includes both substance dependence and addiction, with about 4 to 6 percent of those chronic pain sufferers who misuse opioid prescription medicines moving on to use the opioid street drug heroin. Conversely, reports indicate that around 80 percent of those who use the illegal street drug heroin has a history of first misusing prescription opioids.5
Coming to TERMS with: Opioid – Opiate – Narcotic4
Terminology can be confusing. The term opiate is meant to indicate a natural or only slightly modified derivative of opium, such as morphine, codeine, and heroin. The favored term currently, opioid, technically should be used for only the synthetic and semisynthetic opium facsimiles such as Oxycontin or Fentanyl. Opioid is now used, however, for the entire family of opium-like drugs. The term narcotic is also seen applied to opioids, be wary, however, in its use, as narcotic technically can indicate any mind-altering chemical possessing sleep-inducing properties.
Relief from pain accompanied by feelings of well-being and even a touch of euphoria are the hallmarks of pain relief prescription opioids, giving them a high risk for addiction. When used for pain for more than two to three days, many people begin to develop a physiological tolerance. This means that a more rapid break down of the opioid chemicals by the body is occurring along with greater resistance to the opioid effects. Therefore, it takes a larger and larger amount of the medication to get the same result as before. Some begin to think obsessively about how to get more opioids and even begin hoarding them so as not to run out. Others succumb to the temptation of illegal activities, such as “double doctoring,” or seeking additional medication from illicit or illegal sources.
Dependence on opioids affects an estimated 5 million adults in the United States and led to around 42,000 deaths in 2016.5 Surprisingly half of the deaths from drug overdose are attributed to the use or misuse of prescription medications, with overdose fatalities raising, according to the CDC, from 6 percent per 100,000 people in 1999 to 20 percent in the year 2016.6
Be aware, tolerance to the positive effects of opioids, such as euphoria, develop much faster than the body’s ability to handle opioid's dangerous effects, creating a high risk for overdose by mistake.
Coming to TERMS with: Drug Misuse6
Drug misuse is not a diagnosis when discussing prescription opioids; it indicates the presence of a problematic pattern of drug use.
- Taking medication without a prescription (i.e., taking medication meant for someone else such as a family member or friend)
- Taking medication for a reason or incident other than what it was prescribed for
- Taking the medication at higher doses or for a longer time than prescribed
Though our current opioid crisis is built on the framework created by all of the previous unresolved opium epidemics, this new wave of life-destroying overuse has features that make it unique from past outbreaks. For instance, we have an “exact” start date for our crisis, the year 1995. That was the year that the megalithic pharmaceutical industry brought forth the first of another set of wonder drugs to curb overuse and addiction to opioids. Most overlook the similarity to how the fight against morphine overuse brought heroin forward. Specific to our contemporary crisis is the new drug OxyContin, a long-acting form of oxycodone, one of the first of the time-released opioids. OxyContin hit the pain relief market with great promises as an end-all to both pain and the risk of narcotic abuse.6 The assurances from Purdue Pharma, the company which aggressively marketed OxyContin, was that it was a much safer, less addictive opioid, able to be safely used for months at a time in the treatment of chronic pain.6
Forceful marketing with incentives such as ‘befriending,’ then manipulating tired, overworked prescribers and lures such as weekend first-class resort training on the new medications helped pharmaceutical companies flood the market with hundreds of millions of new opioid pills and capsules.4 Meanwhile pain suffers found themselves developing drug tolerance and addiction to the new products. Just as the old, and those abusing themselves with prescription meds found that crushing the tablets or capsule contents and snorting or injecting the powder, delivering a potent ‘high’ much more powerful and quicker than swallowing a pill.5
Coming to TERMS with: Illicit vs. Illegal
Illicit behaviors are those considered beyond the norms of society, its rules, and behaviors, and are usually committed in secret. Illicit acts are usually against the law; however, if circumstances change would be legally allowed, such as the trade of drugs that are banned in one country yet supplied from a country where their sale is legal.
Illegal behaviors are actions directly against the rules of law.
A key factor differentiating illicit from illegal is the secrecy that surrounds the act.
In response to the reassurance that patients would not become addicted to the new opiate pain medications, prescribers engaged in a frenzy of prescription writing, often giving thirty or more days’ supply to those whose pain would be diminished or gone within two or three days. The glut of available opium compounds sitting available in medication cabinets in households across the country became a source of temptation to those with no ill intent who on stressful days recalled the mild euphoria and feeling of relaxation, as well as those attempting to follow misunderstood prescriber orders on the presumption that they are to finish the prescription. To heighten the danger, other opioids add to the current crisis. Heroin, no longer a monopoly of the far east, was being produced cheaply and efficiently in neighboring Mexico and Central American countries. Easy transport across a long, laxly secured land border made the new heroin cheap and easily obtainable. Many chronic pain patients have, in fact, readily accepted inexpensive street heroin into their self-treatment when they realize there is an alternative to expensive, difficult to obtain from prescriber prescription medication. During the early years of our current crisis, other potent opioids such as fentanyl, a synthetic opioid 100 times more powerful than morphine, began to become available to street drug vendors becoming rapid favorites to those seeking inexpensive, powerful effects.
Fentanyl and its street produced analogs (acetyl fentanyl, furanyl fentanyl, and carfentanil, among others) are synthetic opioids meant to mimic the effects of opium. Pharmaceutical grade fentanyl is fifty times more potent than heroin, and 100 times more potent than the same amount of morphine. Medicinal use fentanyl is a very useful tool in managing severe pain, such as in cancer treatment or palliative, end-of-life care. Black market fentanyl sometimes referred to as IMF (illicitly manufactured fentanyl), varies in strength and purity, yet remains incredibly potent. Street drug dealers often mix IMF into cocaine or heroin to up the drug’s effects.
Carfentanil, a fentanyl knock-off, is roughly 10,000 times more powerful than morphine and requires specialized toxicology to detect.
The seriousness of synthetic opioids, such as fentanyl and its close mimics, is reinforced by a study published in the May 2018 Journal of the American Medical Association that found in the year 2016, 46 percent of opioid deaths were attributed to a synthetic opioid. That’s up from the 14 percent synthetic opioid death rate in 2010.