Opioid Dependence

What is Opioid Dependence?

Opioid Dependence is a type of medical condition that is characterized by the inability of an individual to refrain from opioid drugs, even when it requires him or her to do so.

An individual having such a drug dependency tends to give high priority to the consumption of opioid drugs and exhibit persistent drug-seeking behavior. The reasons that one can get addicted to these forms of drugs may be biological, social or psychological in nature. It can adversely affect one’s cognitive and behavioral skills as well as have implications on all sectors of the person’s life.

Opioid Dependence ICD-9 Code

The ICD-9 Code for this disorder is 304.0.

What are Opioids and what is Opioid Dependence?

Opioids are drugs or chemicals that attach themselves to sites within the brain known as opioid receptors. A human body is capable of manufacturing its own opioids, known as endorphins. However the opioids referred to in opioid addiction or dependence are the ones that are available from plants or made in a laboratory. For example, codeine and morphine are extracted from the opium seeds which are obtained from poppy plant, after which opium is then processed into heroin. The majority of the prescription painkillers such as hydrocodone, hydromorphone and oxycodone are synthesized in laboratories. If a person becomes addicted or dependent on these drugs, he or she needs to seek treatment for Opioid dependence.

What are the common forms of opioids?

Opioids can either be prescribed legally by doctors for relieving pain or suppression of cough symptoms or they can be taken illicitly for their mood altering properties. These drugs can cause a feeling of euphoria or sedation, which can make someone feel ‘better’ or ‘normal’. Not everybody who is taking opioid medications is at risk of developing dependence though. The most common types of opioids that are often abused are listed below:

• Tramadol – present in Ultram
• Fentanyl – present in Duragesic
• Meperidine – present in Demerol
• Oxymorphone – present in Opana
• Methadone – present in Dolophine
• Hydromorphone – present in Dilaudid
• Buprenorphine – present in Suboxone
• Morphine – present in Kadian, MS Contin and MSIR
• Hydrocodone – present in Lortab, Lorcet and Vicodin
• Oxycodone – present in Percocet, Percodan and OxyContin
• Codeine – present in Tylenol 3, Fiorinal, Fiorecet 3, as well as in certain cough syrups

Opioid Dependence Risk Factors

Although specific causes might vary from one person to the other, scientists and researchers believe that one’s heredity plays a major role in making one susceptible to develop an opioid addiction. Psychological factors such as stress, depression or anxiousness as well as social environment also have an important part to play in the developing opioid dependence. The unpleasant effects that might occur due to opioid withdrawal might cause many individuals to continue abusing illegal or prescription opioids, thereby leading to a prolonged dependence.

Effects of Opioid Dependence on the Brain

A prolonged usage of opioid medications can cause changes in the architecture as well as the chemistry of the brain. Architectural changes can occur in the brain circuitry – especially in the neuronal wiring of reward pathway. The human brain is wired to make sure that life-sustaining activities such as intake of proper food and water is carried out, which are associated with reward or pleasure. Whenever the reward circuitry gets activated, the brain keeps a record of it and propels us to repeat that experience again. Intensely emotional memories might get permanently hard wired.

In people having opioid dependence, the reward pathway is excessively stimulated by an opioid drug which makes the brain believe that the opioid medication is necessary for survival, much like regular food and water. This motivates people to repetitively consume opioids, even when they understand that it is clearly damaging to do so.

Chemical changes take place within the brain as it attempts to adapt to this excessive opioid stimulation. The brain tries to compensate for the intense highs and lows associated with repeated opioid usage and withdrawal by lowering the number of opioid-receptors in brain. This enables an opioid tolerance in individuals who are addicted to this drug. Due to this, more and more quantities of the drug are needed to produce the same effect. This eventually makes the addict feel depressed, lifeless, and unable to actively participate in regular activities that normally bring them pleasure.

To make matters further complicated, repeated opioid consumption leads to severe impairment of one’s intellectual abilities – thereby making it difficult for one to make sound judgments and appropriate decisions. As this area of one’s brain is still undergoing development in an adolescent, opioid dependence in teenagers is often far more severe and resistant to treatment. Such teens may have difficulty in admitting that they have a drug issue, and may justify their use of drugs to friends and family as well as ignore the consequences of their addictive behavior. They can even exhibit serious behavioral problems, such as lying, stealing or committing criminal acts just to get hold of the drugs that they believe to be an essential part of their survival.

Opioid Dependence Causes

It has been seen that the majority of opioid addicts have at least one severe psychiatric problem. As the opioids used in the pain therapy hardly leads to any of such conditions, they are believed to exist from a time prior to development of this dependence. Opioids have got strong antipsychotic, antidepressive and anxiolytic properties. As a result, opioid dependence frequently develops from self medication. Opioids are an excellent form of acute pain medication. However, it is their tendency to produce a euphoric effect that makes them so appealing to addicts.

Some studies also suggest that chronic exposure to these medications can lead to a permanent deregulation of endogenous opioid receptor system in the brain. Recent studies have shown that increase in the brain-derived neurotrophic factor or BDNF in ventral tegmental area (VTA) of rats can lead opiate-naive rats to display opiate-dependent behavior, such as drug-seeking tendencies and withdrawal. It is seen that when opiate-naïve individuals start taking opiates at euphoria-inducing levels, a similar increase in brain-derived neurotrophic factor takes place.

Opioid Dependence Withdrawal Symptoms

The following withdrawal symptoms may be seen in people having opioid dependence:

Physical Symptoms

The physical symptoms caused due to opioid withdrawal include:

• Itch
• Chills
• Cough
• Cramps
• Anxiety
• Tremors
• Diarrhea
• Yawning
• Priapism
• Anorexia
• Sneezing
• Vomiting
• Insomnia
• Irritability
• Weakness
• Perspiration
• Goosebumps
• Hypertension
• Dilated pupils
• Flu-like symptoms
• Abdominal cramps
• Restless legs syndrome
• Muscle and bone pains
• Increased bowel sounds
• Tachycardia or rapid heartbeats
• Rhinitis or runny, inflamed nose
• Akathisia (profound inner restlessness)

Psychological Symptoms

The psychological symptoms include:

• Malaise
• Nausea
• Cravings
• Paranoia
• Dizziness
• Insomnia
• Dysphoria
• Depression
• Anxiety or panic attacks

The duration of the withdrawal symptoms may last from 2 to 60 days, depending on the type of drug, quantity taken as well as duration and frequency of usage.

Opioid Overdose Symptoms

An individual experiencing an overdose of opioids will exhibit the following symptoms:

• Fainting
• Seizures
• Muscle spasms
• Pinpoint pupils
• Reduced heart rate
• Reduced rate of breathing
• Decreased levels of consciousness
• Blue nails and lips caused by insufficient amounts of oxygen in blood

Opioid Dependence Complications

Opioid dependence can lead to major complications in relation to the physical and mental health of an individual as well as his or her social life.

Health problems

The condition leads to the following health complications:

• Death
• Strokes
• Seizures
• Septicaemia
• Dehydration
• HIV infection
• Poor nutrition
• Dental disease
• Infective endocarditis
• Tuberculosis infection
• Hepatitis A, B, C infections
• Heart problems such as cardiac arrhythmias
• Skin infections at the injection sites, such as necrotizing fasciitis
• Arterial and venous thrombosis, caused by poor injecting techniques

Psychological problems

The addiction leads to the following psychological problems:

• Guilt
• Anxiety
• Suicidal tendencies
• Strong craving for opioids
• Loss of memory and other cognitive skills

Social problems

Opioid dependence can give rise to the following social issues:

• Criminal activities
• Relationship problems
• Homelessness and deprivation
• Issues related to child protection
• Working in improper and demeaning jobs

Opioid Dependence Diagnostic Criteria

Based on the diagnostic criteria clearly identified by the WHO and DSM-IV-TR, the clinical guidelines required for a proper diagnosis of opioid dependence makes it mandatory that three or more of these following six characteristic features be exhibited or experienced:

• A strong sense of compulsion or desire to take opioid
• Difficulties in controlling the drug-taking behavior in terms of onset, termination, or the levels of usage
• A physiological state of withdrawal experienced when use of opioid is halted or reduced, as marked by characteristic withdrawal symptoms and/or use of the same opioid drug or some similar medication to get rid of the withdrawal symptoms
• Signs of tolerance, which require an increased dosage of the opioid drug to produce the same effects that were originally produced by lower doses
• A progressive neglect of other alternative interests or pleasures due to opioid use; increased durations of time needed to take or obtain the drug or recover from the effects produced by it
• Continued use of drugs despite apparent evidence of significantly harmful effects, such as cardiac difficulties, impaired cognitive functioning or depressive mood states.

Opioid Dependence Treatment

Opioid dependence is a serious condition that frequently requires long term treatment. Treatment of this disorder is necessary due to the physical, psychological and social consequences associated with it and to bring overall general well being to the patient. The prime objectives of therapy are:

• To reduce dependent tendencies on opioid or other illicit drugs
• To reduce the risks of morbidity and mortality associated with illicit use of these drugs
• To reduce criminal or antisocial tendencies
• To facilitate reintegration of the patient into workforce and/or education system as well as improve his or her social functioning

Although the main goal is to bring a patient to a complete drug-free living state, achieving such a goal in short terms might be difficult.

As there is no single treatment that works for all patients, diverse methods of treatment are required which includes both pharmacological remedies as well as psychosocial procedures. Relapse following a detoxification procedure is quite common. Naturally, this method is hardly considered to be an adequate remedy on its own. However, this is often the first step used in many forms of long-term treatment based on abstinence. Both detoxification combined with subsequent abstinence-oriented treatment as well as substitution maintenance therapy are essential elements of effective treatment of this condition.

At present, there is a rising trend to abuse prescription opioids compared to the illicit forms such as heroin. This also has implications for prevention, therapy and treatment of Opioid dependence.

Methadone Programs

Methadone Maintenance Treatment (MMT) is a type of opioid replacement therapy that reduces or eliminates usage of illicit opiates and helps patients to increase their physical and social productivity. It also reduced the possibilities of contamination of infectious disorders like HIV and hepatitis. The main aims of this program are:

• To reduce narcotic craving
• To relieve abstinence syndrome
• To block the euphoria associated with opiates

It can also be used for pregnant women who are addicted to opiates. A methadone reduction program can be used to get rid of dependence on opioids completely.

Buprenorphine

Buprenorphine is proven to be a safer alternative to methadone due to its reduced propensity to cause overdose related mortalities during the ongoing course of treatment. Opioid dependence is often managed by Buprenorphine sublingual preparations such as Suboxone and Subutex.

Naltrexone

Naltrexone is an FDA-approved medication that is available both as an oral as well as an injectable drug.

Diamorphine

In many countries, pure injectable diamorphine is used to treat opioid dependence in patients who show resistance to treatment by methadone or other medications.

Experimental treatments

These drugs have shown varied levels of success in managing the condition:

• Ibogaine
• Ketamine
• Tramadol
• Clonidine
• Mitragynine
• Medical cannabis
• Dextromethorphan

Treatment of the condition with the aid of these medications is still at an experimental stage.

12-Step Support Groups

Once an addict overcomes the initial stages of withdrawal, attending 12-step support group programs such as Narcotics Anonymous (NA) can help one to further overcome his or her addictive tendencies.

Opioid Dependence Prognosis

The prognosis for opioid-dependent individuals is good once they have been given proper treatment. According to reports presented by the National Drug Treatment Monitoring System in UK, 49% of patients who have attended the UK drug treatment service have achieved abstinence from illegal opiate drugs when reviewed at 6 months. Another 24% showed reliable improvement and 2% had shown deterioration.

References:

http://en.wikipedia.org/wiki/Opioid_dependence

http://www.northlandaddictiontreatmentrehabcenter.com/resources/opioid-addiction

http://psychcentral.com/lib/2011/opioid-dependence-and-withdrawal/

http://www.patient.co.uk/doctor/Opioid-Abuse-and-Dependence.htm