Opiate is a classical pharmacology term, which means drug made from opium and is a relatively newer term used for designating all such substances, both synthetic and natural, which binds opioid receptors. Opiates are essentially alkaloid compounds that are naturally found in opium poppy plant, Papaver somniferum. Various psychoactive compounds like codeine, morphine and thebaine are also found in the opium plant. There are semi-synthetic opioids also.
Semi-synthetic drugs include oxycodone, fentanyl, hydrocodone along with antagonist drugs such as naloxone and endogenous peptides like endorphins. Opioids act on opioid receptors in order to produce a morphine-like effect and is indicated for mild-to-severe pain relief, though it is usually reserved for moderate-to-severe pain. Both opiate and narcotic are used interchangeably and mean opioid. Opiate is, however, limited to natural alkaloids that is found in tree extract of opium poppy, even though it sometimes might include semi-synthetic derivatives also.
All opioids are similar to opiates and are considered drugs with high abuse potential and find mention in the “substance-control schedules” under Uniform Controlled Substances Act of the United States. The US is the biggest consumer with nearly 80% of the world’s opioid supply being consumed by Americans. Globally, opioids are consumed by approximately 13.5 million people, which include around 9.2 million heroin users.
Psychoactive opiates like papaverine, noscapine and 24 other alkaloids that are present in opium have little to no effect on human central nervous system and are not considered as opiates. The other psychoactive opiates present are morphine, codeine and thebaine. Dihydrocodeine, oxymorphone, oxymorphol, oxycodone, and metopon are some of the other hydromorphone and morphine derivatives found in opium, albeit in trace quantities.
Despite morphine being most medically significant opiate, large quantities of codeine (mostly synthesized from morphine) are consumed medically. Codeine has greater and more oral bio-availability, which makes dose titration easier. Moreover, codeine has lesser abuse potential when compared to morphine. This, however, results in people requiring large doses of codeine for effective pain relief. Codeine is usually combined with one or more other drugs, and readily available without a prescription.
Opiates and Opioid Use
Opiates and opioids are essentially used for treating acute pain in post-surgical patients, in order to get immediate relief of pain that ranges from moderate to disabling in severity. These type of pain generally occurs in patients who have degenerative conditions and terminal conditions such as cancer.
In many cases, opioids are used successfully for long term care. Sometimes, opiate and opioids are used for treating severe cough and diarrhea. These also find use in veterinary science where highly potent opioids are approved for various veterinary purposes such as immobilizing large mammals.
Opioids act by binding to the opioids receptors found in central and peripheral nervous system as well as gastrointestinal tract. Opioid drugs also include partial agonists like anti-diarrheal drug loperamide and antagonists like naloxegol (used for treating opioid-induced constipation), which do not cross the blood-brain barrier, but can displace other opioid from binding with those receptors.
When used for headache, back pain or fibromyalgia, the risk quotient of opioids is greater than its benefits. In treating chronic pain, opioids can be tried after less risky pain killers such as NSAIDs (naproxen or ibuprofen) are tried and tested. If possible, opioids should be avoided for treating fibromyalgic or migrainous pain.
When used for treating headaches, they impair alertness and increases risk of dependence and episodic pains or aches can become chronic. Opioid and opiates tend to increase sensitivity to pain and should be used only if any other alternative is not there or other treatments have failed.
They should be used only under proper monitoring since abrupt stopping or reduction of opiates can result in withdrawal syndrome effects. However, ignorance and willful non-compliance on part of patients has resulted in the problem of opioid misuse and addiction reaching epidemic proportions.
What is a Narcotic
Narcotic originally referred medically to any psychoactive compounds that had sleep-inducing properties. In the US, it has become associated with opioids and opiates, commonly heroin and morphine, and derivatives of various other compounds that is found within the raw opium latex. The three major compounds are codeine, morphine and thebaine.
In legal terminology, “narcotic” is not defined very accurately and generally carries negative connotations. In the US, in legal context, narcotic drugs are the ones which is completely banned like heroin, or one which is used violating governmental regulations. In medical community, narcotic is more clearly defined and essentially do not carry negative connotations.
Statutory classification of any drug as narcotic generally increases penalties for violating drug control statutes. For example, though US federal law classifies both amphetamines and cocaine as Schedule II drugs, penalty for possessing cocaine is higher that penalties for possessing amphetamines, because unlike amphetamines, cocaine is classified as narcotic.
Side effects of Narcotics
Some of the common side effects of opioids are euphoria, nausea, sedation, itchiness, hypoventilation, and constipation. Tolerance of drug and its dependency increases with sustained use, which ultimately leads to increased doses and development of withdrawal syndrome upon stopping its use.
To start with, opioid abuser uses opioids for recreational purposes, which generally leads to addiction when used frequently and in higher doses. Opioid doses taken accidentally or along with other depressants can result in death due to choking or respiratory depression. Most of substances found in opioid drugs are controlled substances due to its reputation for overdose and addiction, which can cause severe effects, very often with fatal consequences.
Enforcement and regulatory authorities have met with limited success in curbing illegal production, smuggling along with addiction to opioid. UNODC estimates that number of global opiate users has not seen any major changes in the recent years and opiate use continued to affect nearly 0.4% of global population in the age bracket of 15-64 years, an equivalent of approximately 17 million people, in 2014.
Over-prescribing opioid medicine and illicit heroin were two main causes of increased usage rates of these drugs and subsequent addiction. Conversely, exaggerated side effects, over-prescribing and addiction fears have led to reports of pain being under-treated. It means doctors and medical practitioners are reducing amount of painkillers prescriptions for fear of addiction and other side effects.
In the US (the leading opiate and opioid consumer with consumptions ranging above 80% of global supply), more than 300 million opiate prescriptions were filled in the year 2015 with 1.9 million Americans addicted to opioids and 4.3 million people (adults and adolescents) admitting use of prescription opiate drugs for non-medical purposes in 2014.
Studies by CDC have revealed that nearly 4 out of out 5 users of heroin were previously prescribed opiate. The over-prescription of painkillers has become one of the leading causes for many deaths in the US.
Vicodin and OxyContin are two easily obtainable opiates for teens. Young users tend to use this substance largely due to misconception regarding its risks. According to National Institute on Drug Abuse reports, in the year 2014 while only 1% of high school seniors used heroin in their lifetime, around 3% of high school seniors had used OxyContin in 2013, while 8% of the users had used Vicodin as well in 2013. Teens generally club use of an opiate with alcohol leading to even more hazardous effects including risk of severe hypoventilation.
Addiction / Dependence / Withdrawal / Treatment
Year 2015 saw nearly 300 million pain prescriptions written in the US and nearly 1.9 million Americans addicted to painkillers. Prescription painkillers also known as opioid pain relievers include oxycodone, hydromorphone, and hydrocodone among others. A majority of patients who use these become dependent on them and graduate to abusing illegal drugs/narcotics like heroin too.
Once person becomes addicted to opiates, sudden reduction or abrupt stopping of these drugs results in person experiencing uncomfortable withdrawal symptoms. Moreover, avoiding discomfort during detox, as well fear of these difficult symptoms results in continued abusing of drugs.
Though these withdrawal symptoms are not life-threatening, the process, in itself, may cause symptoms that are painful and not so manageable. Some health complications may arise due to withdrawal symptoms and is directly related to level of dependence one has over opioid.
Though withdrawal challenges the abuser, but breaking dependence over the drug is the first vital step in living a full and healthy life.
Once opiates are used for a long period of time, the body becomes desensitized to the drug and this would mean one may need more of it to feel its effects. Extended use of opiates changes the structure of nerve cells in the brain of the abuser and these cells needs drug just to function properly. The body reacts once opiates are stopped abruptly leading to the symptoms of withdrawal.
Generally, opiate withdrawal happens in two phases – the first phase includes a lot of symptoms like anxiety, agitation, muscle ache, runny nose, restlessness, teary eyes, profuse sweating, insomnia, excessive yawning and low energy for much of the time. The second phase is marked by development of more severe symptoms like abdominal cramps, diarrhoea, dilated pupils, nausea and vomiting, racing heartbeat, and goose bumps.
These phases lasts for a week to one month and then the person goes into long-term withdrawal phase that are often lesser physical and more of emotional and behavioural connection.
When dependency on opiates is more, the body is used to it in its system and it builds tolerance. Sudden stopping of opiates causes a strong reaction and if one tends to bear the withdrawal on their own, they need to be fully prepared and ensure slow and steady tapering off of opiates before weaning away completely. This limits the intensity of withdrawal.
If there has been compulsory addiction, most people find it difficult and may often times relapse into addiction. Vomiting and diarrhoea may lead to dehydration and severe health complications, with many ending up in the hospital with dehydration. Plenty of hydrating fluids and electrolyte solutions like Pedialyte may help the person keep hydrated during this time.
Over-the-counter help with correct doses of medicines can help too. Considering loperamide (Imodium) for diarrhoea, meclizine (Antivert or Bonine) for nausea can help too. Antihistamines like Benadryl, acetaminophen (Tylenol) or NSAIDs like ibuprofen (Motrin, Advil) can help with aches and pains. Medications should be used only for the recommended period and not continued longer.
Some success with Alternative support with vitamins and supplements in treating the effects of opioid withdrawal has been shown in studies and complementary medicine along with acupuncture and Chinese herbal medicine combined with medication do help and are effective in sorting the symptoms.
Report of studies on Chinese herbal medications found that herbs were most effective actually in managing withdrawal symptoms than clonidine. A few examples of Chinese herbal medications used to treat opiates addiction include Tai-Kang-Ning (moderate-to-severe heroin withdrawal), ginseng, and U’finer™ (a Chinese herbal blend for repairing damage caused by opiates to the brain).
Pointers and Tips
Withdrawal symptoms begin approximately 12 to 30 hours after last use and lasts for 4 to 10 days in most situations, though for people on drug like methadone, the withdrawal phase lasts for 21 days. The phase doesn’t end here, but may continue and they are called post-acute withdrawal symptoms (PAWS), protracted withdrawal and chronic withdrawal.
PAWS may last for months with symptoms like depression, anxiousness, fatigue, sleep disturbances, irritability, increased tearing, runny nose, yawning, sweating, muscle aches, abdominal cramps, diarrhoea, dilated pupils, goose bumps, agitation, nausea, vomiting and overall lesser decision making skills.
Staying comfortable and safe is always recommended for people who have gone through withdrawal. Keeping the mind occupied with movies, books or other distraction is highly recommended. Make sure all amenities are provided to the one who need this care and comfort. Ensure soft blankets, fan, extra sheets, beddings are fully stocked at home and make family and friends aware that the plan on attempting the withdrawal process is on.
It is also important to keep one engaged in things that one enjoys the most as this helps in increasing body endorphins. This release of endorphins contributes towards the long-term success. Eating chocolate, getting outdoor exercise or just a walk may also help. Staying positive and belief in oneself that he/she shall overcome dependence on opiates is a strengthening point.
Person undergoing withdrawal process should seek doctors’ or other medical professionals’ help and take prescription to ease symptoms one may experience make withdrawal period easier to manage.
Detox facilities can help monitor the health of a person undergoing this tough period and make process effective and safe. A personalized treatment plan can support in the extreme side effects, if any complications are experienced. The detox facility provides medicines to ease out the withdrawal process and brings in comfort to the patient.
Medicines like Clonidine may diminish symptoms though a few give relief. Librium also diminishes agitation and chloral hydrate or Trazadone helps one sleep well. If a person is going through the withdrawal process all by oneself, they may not have these valuable resources.
Severe withdrawal may make one feel repulsive to food and drink and may lead to dehydration, so calling the doctor if the patient is vomiting and unable to eat is important. Symptoms of dehydration include extreme thirst, dry mouth, urination difficulty, fever, irritation, rapid heartbeat, fast breathing, and sunken eyes.
Finding support groups like Narcotic Anonymous and SMART recovery can enormously help those addicted to opiates and help one get better and sober. These groups help prevent people relapse on opiates again and lessens the struggles in keeping away from the drugs.
Medications to treat opiate withdrawal are methadone (which helps relieve withdrawal symptoms and makes detoxification period easier), buprenorphine (shortens detox time and lessens withdrawal symptoms), clonidine (treats symptoms like anxiety, agitation, and muscles aches), Revia (naltrexone), Suboxone or Subutex. The mental and physical pain disturbs the person due to the withdrawal symptoms and medical help should be available as they are the ones who help administer medication for opiate addiction.
There is one alternate treatment process for drug rehab also known as Rapid Drug Detox Programs for Opiates or Ultra Rapid Opiate Detoxification (UROD). This procedure is done under anaesthesia in which general anaesthesia is used for rapidly detoxifying the body from opiates. The long-term success rates for UROD are not so good.
Most of the time, the patient gets up from the anaesthesia with severe craving and discomfort as well as has physiological instability even after the schedule is followed well. Rapid drug detox programs alone are not enough for a long term recovery as detoxification does not treat drug dependence, but is a necessary step before any treatment for the same begins.
The American Society of Addiction Medicine does not consider traditional detoxification or UROD as a sole method for treatment of drug dependence. Drug detox centres begins treatment with measuring opiates level in blood. Then the detox meds are administered to subside withdrawal symptoms.
Once the patient is medically stabilized and in control, he is weaned off the detox medication and transitioned into drug rehab program to continue opiate addiction treatment. In this process, patients learn coping skills, relapse prevention and how to live without continued use of these opiates or opioid medication.
A psychologist or a psychiatrist determines the mental health condition of the patient, treating them by lessening anxiety, depression and bipolar disorder and how they speak about the drugs. Dual diagnosis treatment is recommended for patients as they have best treatments for addiction. Detox alone is not the solution, detox plus rehab is the complete treatment.
The focus during treatment for opiate addiction is on three major options, detoxification or detox programs, inpatient rehabilitation and outpatient therapy. Some patients require more support during the recovery from opiate addiction and this may take the form of sober living facilities which gives them a chance to get sober and rebuild their lives in a safe and supportive environment, while others may just need a peer support group such as Narcotics Anonymous.
Urine and blood tests to screen for drugs can confirm the opiate leftover after the process has begun and even after completion of the treatment. Other testing may depend on the patient’s problems. Tests like blood chemistries and LFTs, chem 20, CBC (complete blood count), chest x-ray, EKG / ECG are all done to ensure the fitness or improvement of the patient undergoing the treatment process. Testing for hepatitis C, HIV, and TB are also done, as many people who abuse opiates also have these diseases.