Prescription opioid problems: Overview​

Key points

• Opioid medications relieve pain. They include drugs such as fentanyl, Percodan, Percocet, Demerol and Dilaudid.
• Opioid misuse can lead to dependence, addiction and even death.
• Most people who use opioids for pain relief do not become addicted.

In this animated video, Dr. Mike Evans, founder of the Evans Health Lab, gives advice about using prescription opioids in a safe way.

Types of opioid problems

People can develop different types of opioid use problems:

• Physical dependence: Anyone who takes opioids regularly will develop physical dependence. It is the result of the body adapting to the presence of the drug. The person develops tolerance to the drug and experiences withdrawal symptoms when opioid use stops. Physical dependence is not the same as addiction.
• Addiction: The person feels a compulsion to keep using the drug even though it is creating social, financial or psychological difficulties. A person can be addicted to opioids without being physically dependent on them.
• Misuse: The person uses the opioid in ways other than intended by the prescriber. Misuse includes taking too much of the drug, altering the route of delivery or acquiring the drug from other sources, such as on the street or through double doctoring. This practice involves obtaining a prescription from more than one doctor without telling the prescribing doctor about other recent prescriptions.

Symptoms

Various behaviours may indicate an opioid addiction:

• Rapidly escalating the dose. The person often ends up on doses well above what would normally be required to control the pain (e.g., greater than 200 mg morphine equivalent per day).
• Taking larger doses than prescribed and running out early. The person tends to binge on the opioid to achieve the desired psychoactive effect. Demanding fit-in appointments or being angry with the doctor may be signs that the person has run out of opioids.
• Acquiring opioids from other sources. The person may access opioids illegally, for example, on the street, through double doctoring or at emergency departments.
• Altering, stealing or selling prescriptions. The person may engage in these illegal activities to obtain opioids or get money to buy them.
• Altering the route of delivery. The person chews, injects or snorts oral medications to increase the speed of entry into the body, creating a more powerful euphoric effect.

Prevalence

Most people who use opioids do not become addicted to them. About 3% of patients on long-term opioid therapy become addicted. However, the number of people using prescription opioids is growing:

• Canadians are the second-largest consumers per capita of prescription opioids after the United States.
• Deaths in Ontario related to prescription opioid use doubled in just over 10 years, from 14 deaths per million people in 1991 to 27 deaths per million people in 2004.
• Opioid addiction is more common in men, in people under age 40 and in people who have untreated concurrent disorders.

Causes

Opioids activate the brain's natural reward system. Repeated opioid use can lead to dependence.

• People who use opioids regularly for their pleasurable effects soon develop a tolerance. They need to use more and more of the drug to achieve its original intensity.
• Prolonged opioid use produces changes in the brain that lead to addiction. These changes include activation of the brain's reward system, a shift in the brain's biological or physiological set point so that it takes more of the drug to achieve the desired result, and sensitivity to environmental cues that lead to opioid cravings.
• According to the cognitive-deficit model, people with addiction have abnormalities in the pre-frontal cortex of the brain, which is important for executive functioning, planning and judgment.
• Many studies show that physical and psychological stressors can trigger drug craving in people who are addicted.

Prognosis

Like other chronic medical conditions, opioid addiction is a long-term problem and frequent recurrences are likely. However, treatment can minimize the effects of opioid problems and improve functioning.

Pharmacological interventions are very effective, and a holistic approach would also include various psychosocial treatments.

Evidence summary

Canadian Centre on Substance Abuse. (n.d.). Prescription Drugs. Ottawa, ON: Author.

Centre for Addiction and Mental Health. (n.d.). Opioid Medications. Toronto, ON: Author.

Dhalla, I., Mamdani, M., Sivilotti, M., Kopp, A., Qureshi, O. & Juurlink, D. (2009). Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. Canadian Medical Association Journal, 81(12), 891–896.

International Narcotics Control Board. (2012). Narcotic Drugs: Estimated World Requirements for 2013 – Statistics for 2011. New York: Author.

Kahan, M. & Watts, K. (Eds.). (2011). Opioid misuse and addiction. Primary Care Addiction Toolkit. Toronto, ON: Centre for Addiction and Mental Health.

Kosten, T.R. & George, T.P. (2002). The neurobiology of opioid dependence: Implications for treatment. Science & Practice Perspectives, 1(1), 13–20.

Shaham, Y., Erb, S. & Stewart, J. (200). Stress-induced relapse to heroin and cocaine seeking in rats: A review. Brain Research Reviews, 33(1), 13–33.