OpioidDependency :

Understanding Opioid Dependence

More and more, opioid dependence is being accepted as a chronic disease, much like high blood pressure or diabetes

Yet unlike these other diseases, opioid dependence carries a very powerful stigma. (To illustrate: Imagine that you are interviewing for a new job. Would you think twice before asking whether the company's health plan covers costs related to your insulin dependence? Would you also not hesitate to ask about coverage of costs related to your opioid dependence?)

This stigma is rooted in the centuries-old belief that opioid dependence is a moral failure. It was only within the last 20 years that researchers began to realize opioid dependence was a medical condition caused by changes in the brain—changes that didn't go away, sometimes for months, after patients stopped using opioids

Today, opioid dependence in the United States is growing at unprecedented rates. Sadly, fear of the stigma associated with treatment keeps many people from seeking help.

Removing the stigma of opioid dependence is critical to helping patients receive proper care. A key part of achieving this goal is wider recognition that opioid dependence is a medical—not a moral—issue.

The information here is offered to help promote better understanding of opioid dependence as a medical condition by exploring the prevalence, biological origins, impact on behavior, and symptoms of this disease.

Opioid Use—Then & Now

Human beings have been using opioids for the better part of at least 6000 years. In this time, the demand for opioids—regardless of whether it is driven by medical or recreational use—has been more or less cyclical in that periods of heavy use alternate with periods where use appears almost nonexistent.

The History of Opioids traces the use of opioids beginning with the earliest recorded mention around 4000 BC, through their introduction into Asia and, later, Europe and America. Events that shaped the course of opioid use (such as the invention of morphine) are described here, as are their consequences, notably in the United States.

Opioid Dependence in the US picks up where History of Opioids leaves off. This section offers a wealth of information about the current state of opioid use and dependence in the United States, including changes in how opioids are used, who is using them, and the speed with which certain use has increased.

History of Opioids

Opioids have been used for pleasure and for treating pain for almost 6 millennia.^1,2 Around 3400 BC, the Sumerians, in what is now the Middle East, referred to the opium poppy as Hul Gil or the "joy plant.

In 1300 BC, opioid use in Egypt spread to Greece and other parts of Europe.² In ancient Greece, Homer wrote in The Odyssey that a daughter of Zeus served a grieving Odysseus a drink containing opium. In 460 BC, Hippocrates, the great Greek physician, used opium to treat everything from headaches and coughing to asthma and melancholy.

Opium use disappeared from record in Europe for 200 years during the Holy Inquisition. The drug reappeared in 1527 when it was reintroduced for its medicinal properties by Paracelsus.2

Opioid abuse became prevalent during the second half of the 19th century, after the invention of the hypodermic syringe. Injecting opium allowed for a more rapid, potent effect. During the American Civil War, morphine was used to treat injuries, and opioid dependence became so common among the armed forces that it was referred to as the "soldiers' disease.^"1

In 1898, the Bayer Company began marketing a cough suppressant featuring a new ingredient called "heroin.²

In part because it did not produce many of the side effects common to morphine, heroin was widely assumed to be nonaddictive—so much so that in the early 1900s, free samples of heroin were available by mail to recovering morphine addicts as a "step-down" cure.²

By 1914, however, heroin's addictive properties were no longer in doubt. That year, the US government tried to curb heroin use by imposing a hefty tax on heroin. Then, in 1924, the government banned the nonmedical use of heroin, and in 1970 banned the medical use of heroin, as well.^1-3

Despite the many changes in medicine over the past 6000 years, one thing that has not changed is that opioids are still regarded as highly effective, well-tolerated analgesics. Ongoing demand for pain relievers has led to the development of stronger, longer-acting medications, most of which are opioid based.

As the potency of opioid pain relievers has increased, so has patients' risk of becoming physically or psychologically dependent on them—even when the medications are taken as directed.

In 2001, opioid dependence accounted for 18% of all substance abuse treatment admissions, exceeding cocaine admissions for the 5th consecutive year.⁴ At present, the number of untreated opioid-dependent patients in the United States is believed to be at least 1.2 million.5

Recognition of the urgent public health need for opioid-dependence treatment alternatives was one of the reasons SUBOXONE was developed in cooperation with the National Institute of Drug Abuse.

In 2000, Congress approved the Drug Addiction Treatment Act (DATA 2000), giving physicians the right to use approved opioids to treat opioid dependence in their offices.6 Prior to DATA 2000, this was illegal to do outside a hospital or clinic.

In October 2002, the US Food and Drug Administration (FDA) approved buprenorphine for use in treating opioid dependence.⁷ France approved buprenorphine for the treatment of opioid dependence in 1996, and Australia followed in 2001.^8,9

Now approved in more than 30 countries, buprenorphine is marketed in the United States under the brand names SUBOXONE and SUBUTEX® (buprenorphine HCl sublingual tablets).

Opioid Dependence in the United States

Over the past decade, the use of opioids, such as prescription painkillers and heroin, has grown significantly.¹ As the use of opioids increases, so does the number of people who abuse or become dependent on them. According to the National Survey on Drug Use and Health (NSDUH), in 2003 more than 1.5 million people were dependent on or abusing prescription painkillers or heroin.¹

(NOTE: Other surveys calculated the heroin-dependent population to be 4 to 5 times larger than what was reported in the 2003 NSDUH. Using these numbers, the size of the opioid abusing/dependent population in the United States is between 2.2 million and 2.4 million—or slightly bigger than the population of Houston, Texas.^1-3)

The problem of opioid dependence in this country is explored further in the sections listed below:

Prescription Painkillers—A Growing Presence
Opioid Use—The Changing Profile
Heroin—Hitting Closer to Home
Barriers to Treatment

 

Prescription Painkillers—A Growing Presence

Between 1990 and 2001, the number of people who used prescription painkillers recreationally for the first time grew by 335% to include almost 2.5 million people.¹

Over an 8-year period (1994-2002), emergency rooms saw a big jump in the number of admissions involving prescription painkillers, including:

• Admissions involving oxycodone rose 450%4
• Admissions involving hydrocodone rose 170%4




Opioid Use—The Changing Profile

Through most of the 1980s, opioids were rarely used except when needed for medical reasons. The rising recreational use of drugs like marijuana and cocaine, for example, was considered much more important than the recreational use of opioids.¹ By the mid-1990s, however, the use of opioids for nonmedical reasons not only was increasing but also had become much more mainstream. This shift meant that new populations were now at risk, specifically, younger users2,5:

• 44% of new recreational use of prescription painkillers in 2001 was by people under younger than age 181

The number of 18- to 25-year-olds admitted to treatment for prescription painkillers more than doubled between 1993 and 2002⁶

Frequency of Treatment Admissions for Prescription PainkillersAmong Persons Ages 18-25: selected years⁶

Heroin—Hitting Closer to Home

Heroin has now spread to many communities where, until recently, it was virtually unheard of.2,9,10 Even as heroin use falls in larger metropolitan areas, use in the suburbs continues to rise.5,10,11 Heroin today is cheap and relatively pure—the national average is about 35% pure (compared with less than 5% pure during the 1960sand 1970s).2,5,9,12 This purity increases heroin's appeal to new users, because12:

• No needles—higher purity heroin can be smoked or snorted11
• Fewer obstacles—because smoking and snorting involve minimal preparation, they make it easier to use heroin "casually"⁵,^11-13
• Fewer deterrents—many people unwilling to inject heroin are willing to snort or smoke heroin ⁵,^11-13
• Misinformation—many new users believe that heroin is less addictive when smoked or snorted ²,¹²




Barriers to Treatment

Overall, opioid dependence accounted for 18% of all substance abuse treatment admissions in 2001, surpassing cocaine admissions for the 5th consecutive year.¹⁴

This figure is believed to understate the true size of the opioid dependence problem, because:

• In several states, the number of people who want treatment is greater than the resources available to actually provide treatment¹⁵
• The stigma attached to opioid dependence can be so overwhelming that thousands of patients every year choose to continue using opioids rather than risk possible exposure by receiving treatment^15,16
• 20% of patients who wanted help for substance abuse in 2001 did not seek treatment because of their fear of being stigmatized¹
• Only about 15% of heroin-dependent persons are in treatment

As a result of these and other factors, in 2004, at least 1.2 million opioid-dependent patients in the United States are believed to be untreated.¹⁷

Dependence vs Tolerance

Tolerance, physical dependence, and psychological dependence are related—but still distinct—conditions that are often confused with one another. Understanding the difference between these conditions is important because the treatment considerations can vary widely. Pain patients, in particular, may be interested to learn that the likelihood of their becoming opioid-dependent is relatively slim, even when opioid use leads to tolerance or physical dependence.

Opioid Tolerance
Physical Dependence on Opioids
Psychological Dependence on Opioids
Common Characteristics of Opioid Dependence

Opioid Tolerance

Over time, repeated use of an opioid causes certain receptors in the brain to become tolerant (ie, less responsive) to opioids—in other words, more of an opioid is needed to produce the same effect.1,2 The neurological changes that cause opioid tolerance are predictable and well understood. These changes appear to correct themselves within a period of weeks after opioid use stops.2 Although tolerance is one of the traits often seen in opioid-dependent patients (see Common Characteristics of Opioid Dependence), in the absence of other symptoms, tolerance is not evidence of opioid dependence or misuse.¹

Physical Dependence on Opioids

A physical dependence on opioids means that the brain has made so many changes in response to repeated opioid stimulation that it now actually needs opioids to function "normally.^"2
Pain medicine and addiction medicine specialists agree that most patients treated with opioids for long periods of time become physically dependent on them.¹

If opioid use suddenly stops, patients who are physically dependent will experience withdrawal symptoms. Avoiding this withdrawal is the main reason behind the drug seeking and drug use of someone who is physically dependent on opioids.

(NOTE: SUBOXONE is not indicated for pain management. Patients with a clinical need for pain management should not be transferred to a SUBOXONE regimen, even if they are physically dependent on opioids.)

The neurological changes associated with physical dependence on opioids are predictable and well understood. These changes appear to correct themselves within a period of weeks after opioid use stops.2

Physical dependence on opioids almost always precedes opioid dependence (see Common Characteristics of Opioid Dependence). However, unless other symptoms of opioid dependence are present, physical dependence should not be viewed as "proof" of opioid misuse.

Psychological Dependence on Opioids

Psychological dependence involves continued drug use for reasons other than tolerance and withdrawal, such as a desire to experience a drug's pleasurable effects. The hallmark of psychological dependence—compulsive drug seeking and use—stems in large part from intense opioid cravings caused by complex neurological changes.⁶
An individual is generally considered psychologically dependent when his or her opioid use continues in spite of its negative effect on the individual's life. For example, people who are opioid-dependent feel a need to keep using opioids even if it hurts their health, job, finances, or family.⁷

Common Characteristics of Opioid Dependence

A person who shows 3 or more of the following behaviors over a 12-month period is most likely opioid-dependent:

• Opioid tolerance
• Withdrawal symptoms occur when opioids are not used
• Taking other drugs to help relieve the withdrawal symptoms
• Taking larger amounts of opioids than planned and for longer periods of time
• Persistent desire to or unsuccessful attempts to quit
• Spending a lot of time and effort to obtain, use, and recover from opioid use
• Giving up or reducing social or recreational activities; missing work
• Continued use of opioids, regardless of negative consequences

SUBOXONE is appropriate for the treatment of people who have become physically dependent or psychologically dependent on opioids AND who are not in need of opioids for pain management. SUBOXONE is not indicated for treating pain.

See the Dependence Identifier for a list of questions that can help identify possible opioid dependence, in yourself or someone you are close to.