When I was working at the methadone clinic, an older conservative woman I know asked me what the people there looked like. I told her that quite a few of the women looked just like her. She found this shocking. She could not imagine that people that looked like her and had lives like her could also be addicted to opioids.
When it comes to drugs, but opioids in particular, our society has simultaneously romanticized the use and demonized the user. The 90’s even saw a fad of looking “heroin chic”, which served to illuminate how flawed our view of drugs really is.
If there has been any benefit to the opioid crisis (which took countless lives and made millionaires and billionaires out of unscrupulous physicians and pharmaceutical companies) it is the societal realization that there is no stereotypical drug user. There are simply people with certain vulnerabilities (physical pain, emotional distress, loneliness, trauma, etc.). When that aligns with rampant availability, an epidemic ensues. We can no longer cling to the belief that drug users are the “other”—they are us, under slightly different circumstances.
Opiate versus opioid: what’s the difference?
All opiates are opioids, but not all opioids are opiates. Opioid is a broad term for any drug (natural, semi-synthetic or synthetic) that interacts with opioid receptors on nerve cells in the body and brain. All opioids will produce similar effects such as a euphoric state, reduced pain, slowed breathing, constipation, and pinpoint pupils.
Opiates refer to natural opioids only. This includes opium, heroin, morphine, and codeine.
Opium comes from the resin inside of the opium poppy and it contains two active ingredients: morphine and codeine. Heroin is essentially modified morphine. There is some disagreement on whether heroin is fully natural. The DEA considers it semi-synthetic; the CDC considers it natural. Ugh.
Semi-synthetic opioids are synthesized from naturally occurring opium products, and include oxycodone (OxyContin), hydrocodone (Vicodin), and hydromorphone (Dilaudid).
Examples of fully synthetic opioids include methadone and fentanyl.
Potency among opioids varies widely. Fentanyl is the most potent, followed by Dilaudid and heroin. Less potent opioids include Vicodin and codeine.
Opioids and the brain
We all have endogenous (meaning ‘from within’) opioids. They are chemical neurotransmitters that control movement, moods, and physiological functions such as digestion and breathing. They also help us process pain sensations and they activate reward circuits. When we flood our body with exogenous (meaning ‘from outside’) opioids, it is like every endogenous opioid neuron in the brain is firing at the same time.
When we take opioids, dopamine is released, then they bind to endorphin and enkephalin receptor sites. The job of endorphins is to regulate our mood, our breathing and create calming sensations when under stress. Enkephalins are responsible for communicating messages in parts of the brain that process pain sensation and regulate breathing, and in parts where the dopamine (reward) system operates.
Although we have several opioid receptors, the main one is the mu opioid receptor and it is responsible for the major effects of opioids, such as analgesia, euphoria, and respiratory depression.
What does all this mean? It means we are wired to like opioids, a lot. The trouble is, after a period of “importing” opioids into our bodies, it can cause our endogenous opioids to shut down and stop performing. This often causes feelings of depression or anhedonia, even long after an individual has stopped using.
Opioids and your body
We have all seen the movies. Someone shoots up and suddenly there is cool music playing and their face distorts into something peaceful and orgasmic. So, what is happening when we take opioids?
The route of administration matters in terms of how quickly the substance reaches your brain, i.e. the rush. The fastest method is intravenous (IV) injection, followed by smoking. Using these methods, peak levels will occur within minutes. However, because Fentanyl is the most fat soluble, it peaks in seconds. This is also why the overdose risk is so high with Fentanyl. After swallowing a pill (i.e. oxycodone), the peak will occur within about 30 minutes.
Although there is variation caused by amount used, individual characteristics, etc., an opioid high will typically last between 4-6 hours. However, there are two notable exceptions. Methadone will last between 12-24 hours—this is especially important in terms of overdose. Someone who has overdosed on methadone may need additional monitoring and follow-up treatments of naloxone. Fentanyl on the other hand, will last only about an hour.
All opioids produce that dreamy, euphoric state and depress our central nervous systems. This is often referred to as “nodding out” and people describe this state as relaxing, calm, and safe. Some people, especially novice users will experience some nausea or vomiting, but this usually subsides. Breathing will slow down, and pupils will constrict. Tension in the gastrointestinal tract occurs and most opioid users experience constipation.
Tolerance will develop to the pleasurable feelings, meaning you will eventually need more and more to get the same feeling. Over time, many people no longer experience the intense pleasurable feelings, only the absence of withdrawal.
Overdose is primarily due to respiratory depression or over-sedation. Taking additional central nervous system depressants (alcohol, benzodiazepines) will produce a synergistic effect, making overdose even more likely.
If opioid induced euphoria and feelings of safety are the prize, then withdrawal is the tax owed on that prize. (Sort of like winning a car only to find out you must pay all sorts of taxes and fees you cannot afford).
Not all people who use opioids will become dependent on them. Many people have taken them for pain, or even recreationally and not developed dependence.
However, once someone has become dependent, the cessation of use will cause withdrawal. Often the withdrawal is the opposite of the high. The first signs that withdrawal is approaching are yawning, watery eyes, runny nose, and sweating. Body aches, intense anxiety, diarrhea, depression, and difficulty sleeping are some of the more common effects. Someone described it to me once as having the flu, then getting food poisoning while constantly having a panic attack. Miserable, yes. Life threatening? Typically, not. However, the long-term effects of the dysphoria are often what people identify as the worst part and it tends to far outlast the physical symptoms of withdrawal.
Opioid overdose and treatment
All opioid overdoses are potentially reversible with naloxone (Narcan). (Note for movie lovers: Trainspotting portrays this well, whereas Pulp Fiction gets it wrong in every way possible).
Treatment for opioids may include detox to manage the physical symptoms. Since we have specific opioid receptors in our brain, there are medication assisted treatments that help manage withdrawal, cravings and even depression. Examples of these include buprenorphine, methadone, and naltrexone.
Due to the prolonged periods of depression that occur for many, participating in counseling can be an important part of treatment.
Substance Use Therapy is available to support you were you are, whether you are needing harm reduction support, want to work toward decreasing or are looking to abstain or maintain positive changes. You don’t have to manage opioid dependence alone.
Denning, P., & Little, J. (2017). Over the Influence: The Harm Reduction Guide to Controlling Your Drug and Alcohol Use. The Guilford Press.
Kuhn, C., Swartzwelder, S., & Wilson, W. (2019). Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy. W.W. Norton & Company.
About the Author:
Kimberly May, LPC-S, LMFT is a therapist at Substance Use Therapy in Austin, TX. Kimberly works with individuals, couples and families whose lives have been affected by substance use. By utilizing a harm reduction framework, Kimberly works effectively with people in any stage of use. In addition to substance use, she works with other issues such as anger, burn-out, anxiety and grief. Contact today to schedule a no-charge, 30 minute, in-person consultation. *Note: telephone and telehealth sessions are currently available.