Opioid painkiller addiction

Opiates are chemicals found naturally in the opium plant (opium poppy), while opioids are synthetic drugs that are made to mimic the effects of opiates. There is a third type – semi-synthetic opioids – made by mixing opiates with other chemicals (National Institute for Health and Care Excellence (NICE), 2022a).

This article will use the term ‘opioid’ to describe all three and will focus on legal opioids rather than illegal drugs like heroin.

Opioids are used for their analgesic properties. They include the over-the-counter painkiller codeine, and the stronger drugs morphine, tramadol and fentanyl. They also have a euphoric effect, which is why some people become dependent. When people take opioids regularly for a prolonged period to treat pain, dependence can develop.

The time required for dependence to develop depends on how much and how often the patient takes an opioid, as well as the route of administration. Other factors

Opioid addiction may be evident in the patient’s behaviour and the effects it is having on their life, and manifest in consequences to their physical and mental health. Often, it is the patient’s close family members or friends who notice that problems are worsening.

NICE (2022a) describes indicators of opioid dependence as:

• a strong desire or sense of compulsion to take opioids
• difficulty in controlling use
• a physiological withdrawal state when opioid use has ceased or been reduced
• evidence of tolerance
• progressive neglect of alternative pleasures and interests
• persistence with opioid use despite clear evidence of overtly harmful consequences

Further, signs and symptoms of dependence and addiction can be categorised according to the physical, psychological and behavioural/social effects (Centers for Disease Control and Prevention (CDC), 2021; Khatri, 2021; Spinks, 2022).

Physical effects of opioid addiction include:

• nausea and vomiting
• constipation
• weight loss
• itchy skin
• shallow breathing
• blurred vision
• constricted pupils

Aetiology and risk factors

As well as controlling pain, the body’s opioid system plays a part in the brain functions that are involved in reward and addiction. When an opioid enters the bloodstream, it binds to opioid receptors in the brain.

One effect of this is to cut off pain signals, but it also switches off a nerve cell that leads to the brain releasing the neurotransmitter dopamine. Known as the ‘feel-good’ chemical, dopamine is responsible for feelings of euphoria and well-being.

The brain normally produces dopamine naturally, but this process stops in people who take opioids over a prolonged period and the brain becomes reliant on the drug to trigger dopamine release. Therefore, the only way a person can feel the euphoric effects is by taking more of the opioid.

Over time, a patient may no longer need the opioids for their original purpose, but if they stop taking

Opioid addiction might be suspected based on the presence of signs, symptoms and effects listed above. A patient might present in several ways, for example requesting help directly for dependence; with a medical complication of dependence; with clinical signs of opioid intoxication or withdrawal; with social and problems and evidence of risk factors; or by disclosing their opioid use during a consultation about something else (Knott, 2016).

According to the ICD-10 (the International Classification of Diseases), a diagnosis of opioid dependence can be made if a patient displays the following:

• a strong desire or sense of compulsion to take the substance
• difficulty in controlling use
• a physiological withdrawal state
• neglect of alternative pleasures and interests
• persistent use despite harm to the patient and others (Knott, 2016)

In some cases, investigations might help aid diagnosis and determine the appropriate course of action. Urine analysis and a mouth swab can be used

As a first step, a patient should be assessed for physical and mental health complications of opioid addiction. So, they might have blood tests and other investigations to check their liver, renal and thyroid function, cardiovascular and respiratory systems, a full blood count, and a neurological examination (NICE, 2022d).

Treatment and management of opioid addiction will depend on the drug(s) involved, the extent of the problem, the impact the addiction is having on the patient’s everyday life, and several other factors (NHS, 2020).

Opioid substitution therapy: Some patients are prescribed a substitute drug – methadone or buprenorphine – as a safer alternative to the one to which they have become addicted. Substitute therapy can help prevent withdrawal symptoms that the patient might experience from stopping the original opioid. After the patient has become stable on the substitute, the dose can be tapered over time (NICE, 2022e).

Detoxification: Another option for

References

Addiction Center. Understanding The Dependence Vs. Addiction Debate. 2021. www.addictioncenter.com/addiction/addiction-vs-dependence/ (accessed 29 November 2021)

Centers for Disease Control and Prevention. Prescription Opioids. 2021. www.cdc.gov/opioids/basics/prescribed.html (accessed 29 November 2021)

Khatri, M. What are opioids? 2021. www.webmd.com/pain-management/opioids-opiates-explained#1 (accessed 29 November 2021)

Knott, K. Opioid Misuse and Dependence. 2016. www.patient.info/doctor/opioid-abuse-and-dependence#nav-2 (accessed 29 November 2021)

Mayo Clinic. How opioid addiction occurs. 2022. www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372 (accessed 29 November 2021)

NHS. Drug addiction: getting help. 2021. www.nhs.uk/live-well/healthy-body/drug-addiction-getting-help/ (accessed 29 November 2021).

National Institute for Health and Care Excellence. Opioid dependence: What is it? 2022a. https://cks.nice.org.uk/topics/opioid-dependence/background-information/definition/ (accessed 19 December 2022)

National Institute for Health and Care Excellence. Opioid dependence: When should I suspect a person has a problem with opioid dependency? 2022b. https://cks.nice.org.uk/topics/opioid-dependence/diagnosis/suspecting-opioid-dependency/ (accessed 19 December 2022)

National Institute for Health and Care Excellence. Opioid dependence: What investigations should I consider? 2022c. https://cks.nice.org.uk/topics/opioid-dependence/diagnosis/initial-investigations/ (accessed 19 December 2022)

National Institute for Health and Care Excellence. Opioid dependence: Scenario: