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Opioid drugs, also called opiates or narcotics,
have been used since the beginning of recorded
history. Opium is derived from a white liquid
produced by the poppy plant, first cultivated in
the Middle East and Asia. It was used
therapeutically in ancient cultures to induce calm
and to relieve pain, and recreationally to induce
euphoric dream states. Today, physicians prescribe
narcotics for pain relief. Whether plant derived
(natural) or synthetic, narcotics are sometimes
still referred to as opioids.
Narcotics
produce intense pleasure and general calmness:
-
Drowsiness, tranquilization, or sleep
-
Feeling of well-being
-
Pain relief (analgesia)
-
Temporary euphoria; a "high"
Narcotics like morphine, heroin, codeine,
opium, hydrocodone, oxycodone, meperidine, and
methadone bind to certain painkilling sites
in the brain. With consistent use, they build up
in the brain and block the production of
endorphins, the brain's natural painkilling
chemicals. Opium, morphine, and heroin (a
derivative of morphine) were commercially
available for purchase in the United States
throughout the 19th century. For complaints of
diarrhea, menstruation, and headache, physicians
commonly prescribed opioids in the form "tonics,"
elixirs," and "cordials" much in the way aspirin
is used today. Their use, and even abuse, was less
likely to be seen as problematic. Opium dens
provided a place for people to smoke the drug.
However, as policy makers began to address the
social consequences surrounding narcotic
addiction, drug use became stigmatized as a
lower-class recreation. Shortly thereafter, the
general public became intolerant of narcotic, now
illicit, drug use. Abuse was defined as a problem
and using heroin and smoking opium were eventually
made illegal.
Narcotic abuse is defined by impaired
function and interference in the daily life of the
user. Users often develop serious physical,
social, and mental health problems that compromise
well-being and affect family and friends. Narcotic
abuse costs the nation $10 billion a year in
treatment, care, and lost productivity; this does
not include the cost of treating use-related
diseases, like AIDS.
Incidence and Prevalence
A 1999 National Household Survey on Drug Abuse
reported that approximately 15,000,000 people in
the United States use illicit drugs. Approximately
1% of the adult population in the United States
abuses narcotics. Some evidence suggests that
about 5% of adults aged 18 to 25—the group with
the highest lifetime prevalence of use—use or have
used narcotic drugs like heroin. Other estimates
put this number higher. Men in the United States
use illicit drugs slightly more than women.
Narcotic abuse among non-Caucasian people is
reportedly highest, especially in urban areas.
Addiction: How Narcotics Work
The biochemical effects of narcotic drugs are what
make them addictive. Narcotics bind to painkilling
sites throughout the brain, known as opioid-U
receptors or the "reward pathway." This leads to
slower uptake of neurotransmitters, like dopamine,
between neurons. Immediate effects include
cessation of pain, drowsiness, and a feeling of
well-being associated with pain reduction. With
chronic use, the brain may stop producing
endorphins, natural painkilling chemicals, and the
user develops tolerance. The user must replace the
missing endorphins with narcotics in order to feel
good and to avoid the painful effects of narcotic
withdrawal.
The user becomes dependent on increasing amounts
of the drug to feel good. Abuse usually leads to dependence.
Addiction is a chronic illness of the brain.
Although one initially chooses to use narcotics,
addiction is more than a behavioral problem; it is
physiological and psychological. Compulsive use
and relapse after recovery are a few of the
behavioral problems that result from dependence.
Use and relapse may be enforced by environmental
cues, like peer influence and specific cultural
stimuli. Breaking the habit of drug addiction is
difficult and requires detoxification, changes in
lifestyle, and therapy.
Risk Factors
Psychological and environmental risk factors for
narcotic use include the following:
-
Antisocial and experimental attitudes (i.e.,
rebellious nature) during adolescence
-
Environmental factors
-
Family problems
-
Gang membership
-
Inner-city culture
-
Poverty
-
Wealth or disposable income
-
Family history of substance abuse and drug
addiction
-
Low self-esteem
Symptoms
The symptoms of narcotic use are considered
disorders:
-
Intoxication
-
Withdrawal
-
Tolerance
-
Abuse
-
Dependence
Intoxication
and withdrawal
are described as opioid-induced disorders by the
American Psychiatric Association in the
Diagnostic and Statistical Manual of Mental
Disorders (DSM).
Intoxication
is the immediate effect of an opiate drug, which
occurs more quickly when the drug is taken
intravenously (IV) or nasally ("snorted") as
opposed to orally. When taken IV, there is a
"rush" of the drug to the brain, which causes a
"high." If taken orally, the drug's effects are
gradual. Physical signs of intoxication include
slurred speech, strange behavior, lack of
coordination, constricted pupils, and constipation
(caused by drying of natural secretions).
Psychological effects include euphoria,
tranquility, apathy, and impaired judgment.
Although the initial effects are generally calming
or dulling, psychomotor agitation and
aggressiveness can occur.
Overdose
(OD), severe intoxication, occurs when too much of
the drug enters the body too quickly, usually
after IV injection. Variations in the potency,
quality, and dose of narcotic drugs lead to most
overdoses. Severe respiratory depression and death
can result from OD.
Diagnostic Criteria for Opioid Intoxication
-
Recent use of an opioid
-
Clinically significant maladaptive behavioral or
psychological changes (e.g., initial euphoria
followed by apathy, dysphoria (i.e., general
irritability, depression, etc), psychomotor
agitation or retardation, impaired judgment, or
impaired social or occupational functioning)
that developed during, or shortly after, opioid
use
-
Pupillary constriction (or pupillary dilation
due to anoxia (loss of oxygen) from severe
overdose) and one (or more) of the following
signs, developing during, or shortly after,
opioid use:
1.
Drowsiness
2.
Slurred speech
3.
Impairment of attention or memory
-
The symptoms are not due to a general medical
condition and are not better accounted for by
another mental disorder.
From the Diagnostic and Statistical Manual of
Mental Disorders, IV, TR ed. 2001. Washington,
DC: American Psychiatric Association (APA). Used
with permission.
Withdrawal
may occur 4 to 12 hours after stopping heavy and
prolonged use of narcotics, depending on the drug,
and may last 14 days. Physical signs include
gooseflesh, muscle aches (often in the legs and
back), abdominal cramping and diarrhea, and insomnia.
Mentally, a person may experience
depression,
anxiety, panic,
irritability, and craving.
Diagnostic Criteria for Opioid Withrawal
1.
Cessation of (or reduction in) opioid use
that has been heavy and prolonged (several weeks
or longer)
2.
Administration of an opioid antagonist
after a period of opioid use
-
Three (or more) of the following, developing
within minutes to several days after Criterion
A:
1.
Diarrhea
2.
Dysphoric mood
3.
Fever
4.
Insomnia (chronic)
5.
Lacrimation (producing tears) or rhinorrhea
(running nose)
6.
Muscle aches
7.
Nausea or vomiting
8.
Pupillary dilation, piloerection (goosebumps),
or sweating
9.
Yawning
-
The symptoms of Criterion B cause clinically
significant distress or impairment in social,
occupational, or other important areas of
functioning.
-
The symptoms are not due to a general medical
condition and are not better accounted for by
another mental disorder.
From the Diagnostic and Statistical Manual of
Mental Disorders, IV, TR ed. 2001. Washington,
DC: American Psychiatric Association (APA). Used
with permission.
Tolerance
describes the body's need for increasing amounts
of a drug to get the same effects and, ultimately,
to avoid withdrawal. People who have long-time
addictions may take dangerously high doses that
would kill first-time users.
Abuse
is defined as the recreational use of a substance
that results in impairment, negative consequences,
and decline. Typically, those who abuse substances
use them and experience withdrawal less frequently
than those who are dependent. However, prolonged,
intermittent use of narcotics is uncommon; most
people who abuse them become dependent.
Dependence
means that a drug user is unable to reduce dosage
or stop using because the brain is chemically
dependent on the drug. The most significant sign
of psychological dependence is that the
user plans daily activities around obtaining and
using the drug. Physiological signs of
dependence include withdrawal.
Diagnosing narcotic abuse and dependence is
complicated because users are aware that their
drug use activity is illegal. Physiologically, the
user's brain requires the drug as a substitute for
endorphins, which makes it difficult to stop
regardless of whether or not the user recognizes
the problem. Drug dependency may be discovered by
friends or family members, though the stigma
associated with drug use causes families to deny
or avoid the problem. Frequently, something in the
life of the user reveals his or her dependence.
Difficulty at work; criminal activity (e.g.,
theft, forgery); prescription records gathered by
insurance companies and doctors; withdrawal; or
the discovery of an illness, like
HIV
infection, may uncover the problem.
The physical signs of drug dependence, like
injection marks on the skin ("tracks"),
deterioration of nasal tissue from snorting and
constricted or dilated pupils may be present.
Screening for the presence of narcotics in the
body may involve laboratory tests, like urinalysis
or hair analysis. Testing cannot determine the
length of time that drugs have been used.
Differential diagnosis
may be necessary in cases where signs indicate
nonnarcotic drug use or the presence of a medical
condition. Benzodiazapine and barbiturate use can
produce symptoms similar to narcotic intoxication
and withdrawal. Hypoglycemia (low blood-sugar,
fatigue), electrolyte imbalance,
head or brain injury,
and stroke can
produce delirium and cause slurred speech,
inability to concentrate, and impaired memory,
which are also signs of intoxication.
Course
The average age range of onset for drug use is 18
to 25. Those who use narcotic drugs usually
progress to drug dependency. Narcotic addiction
may develop after medical treatment. Some users
become dependent on the euphoric effects of
narcotics following surgery or long-term treatment
for pain. It is likely that risk factors
for drug abuse are present in these people before
treatment.
Complications
Bacterial diseases of the heart and liver
(acquired through infected needles), and other
infectious diseases like AIDS, hepatitis, and
tuberculosis may also develop during the course of
drug dependency. In some large, urban areas, it is
estimated that 60% of those dependent on heroin
are infected with HIV.
"Tracks," visible puncture scars, are
caused by repeated injection. Scarring of the
veins may lead to swelling. Many users switch from
the veins in the forearm to those in the feet,
inside the thigh, or in the neck. Others stop
using veins and inject directly into the first
layer of skin, known as "skin-popping." It
eventually leads to cellulitus (infection into
connective tissue) and abscess, where cell death
causes pus to collect beneath the skin. Round,
healed scars are common signs of skin-popping.
Criminal activity
associated with drug dependency includes theft and
forgery (of doctors' signatures), as well as the
transportation, sale, and production of illegal
substances.
Prognosis
The estimated death rate in those dependent
on narcotics includes death by overdose as well as
by murder associated with drug-related crime. It
increases 2% for every year of use, so those who
have been using for 10 years stand a 20% chance of
drug-related death.
Treatment
Intoxication
is treated in cases of overdose, when severe
respiratory depression occurs. Naltrexone, an
opiate agonist drug, may be used to revive a
person who has overdosed. It binds to opioid
receptors in the brain and counteracts the effects
of drugs like heroin, morphine, and codeine. Its
side effects include nausea and headache
and it may be associated with liver toxicity.
Detoxification
is the first step in treatment. Withdrawal
may last from a couple of days to 2 weeks. Two
drugs, methadone and clonidine, are used to treat
it. Methadone (a synthetic narcotic) can reduce
the discomfort of withdrawal and is given in
tapering doses until withdrawal ends. Because
methadone is a narcotic, side effects are
similar to the effects of heroin or morphine, but
they have a slower onset, last longer, and are
less severe. Also, respiratory depression can
occur in high doses. Clonidine, an
antihypertension medication, affects the nervous
system and can block the physical manifestations
of withdrawal, like anxiety and irritability. Its
most common side effects are dry mouth,
dizziness, and drowsiness.
Dependence
must be overcome by abstinence. Drug counseling,
self-help groups, half-way houses, and narcotics
anonymous may instill in a user the behavioral and
psychological changes necessary to break a drug
habit. Methadone maintenance is helpful when
combined with these strategies. Tapering initially
large doses of methadone can help people gradually
overcome dependence. Methadone is abused and its
use remains controversial. Still, long-term
treatment plans (30 days to more than a year) can
keep people away from street drugs, needles, and
disease. They improve the quality of life for most
people who attempt to recover.
Over 11,000 drug treatment centers in the United
States provide treatment for intoxication,
withdrawal symptoms, and dependence. The aim in
detoxification is abstinence. Staff is trained in
substance dependence, and most centers employ
physicians. Patients choose an inpatient or an
outpatient treatment program, depending on the
severity of dependence, availability of
facilities, insurance coverage, and other
considerations. Some facilities specialize only in
detoxification or long-term treatment; others
provide both |
