The Stages of Opioid Use Disorder

Addiction tends to occur in stages, and it can be helpful to think of it in that way. However, it also needs to be noted that not all people who have opioid use disorder (OUD) will cleanly go from one stage to the next. It’s often better to think of OUD, or addiction in general, as a cycle one can get trapped in, with steps one can then take to escape the cycle.

The Stages of Opioid Use Disorder

OUD is a form of substance use disorder (SUD), or addiction. There is strong evidence that addiction tends to operate in a three-stage cycle.[1] 

A person binges on a drug and then goes through a period of withdrawal or otherwise experiences a negative effect resulting from the absence of the drug. They then begin to become preoccupied with acquiring more of the drug, anticipating reengaging in drug use. This cycle then repeats unless a person can take the steps needed to break out of the cycle.

These are the three stages:[1]

1. Binge or Intoxication

This is the first stage of OUD, where one engages in opioid use and experiences the euphoric high associated with opioid misuse. While opioid misuse is destructive, it’s important to understand this can be highly pleasurable and/or relaxing to the person using opioids at the moment. 

On a chemical level, the brain registers this behavior as highly rewarding and can start to “rewire” itself with repeated udse.[2] This causes a person to become physically dependent on opioids and potentially leads them to become addicted.

2. Withdrawal or Negative Affect

Once a person becomes physically dependent on opioids, they will experience withdrawal if they go for too long without engaging in opioid use. This can actually occur even if a person only ever takes opioids as prescribed by their doctor, but withdrawal will generally be more intense if a person has been misusing opioids. 

This makes stopping drug use difficult. Not only is the person no longer experiencing the pleasurable effects they know opioids can cause, but they’re also experiencing negative consequences for not engaging in drug misuse, including severe negative emotionality and physical distress. 

3. Preoccupation or Anticipation

After a period of drug abstinence, a person with OUD will increasingly become preoccupied with acquiring and using opioids in order to re-experience the high they achieved earlier in the cycle of addiction, or to mitigate the withdrawal and feelings of negative affect. How strongly they crave opioids will depend on the severity of their OUD and their specific circumstances, but this drive can feel overwhelming.[3] A person often feels as if they have no choice but to engage in further drug use. 

This is typically where the cycle of addiction will begin again unless a person can admit they are struggling with OUD and begin to seek treatment. 

Other Stage Models

There are different stage models of addiction, and some involve more stages than others. Here is another example of a four-stage model:[4]

1. Experimentation

Someone tries a drug for the first time. They begin to dabble in use. They may experiment with opioids due to peer pressure, to cope with pain or out of curiosity. Early intervention is important, as opioid misuse can be more easily addressed in this early stage.

2. Regular Use

The person continues to misuse opioids. As they enjoy the pleasurable effects, such as euphoria and pain relief, use may escalate. While they may not be dependent on opioids at this stage, a tolerance to the drugs is growing.

3. Risky Use & Dependency

With regular use, physical dependence forms. If the person tries to stop taking opioids at this point, they’ll experience unpleasant withdrawal symptoms, such as nausea, muscle pain and anxiety. They crave opioids, so psychological dependency is also present, and they engage in risky behavior in order to continue misuse.

4. Addiction & Consequences

At this point, OUD is present. The person compulsively seeks out and uses opioids. The effects of opioid misuse are often seen in various areas of life, including consequences at school or work, relationship issues, physical health problems as well as legal and financial issues.

The Steps Out of OUD

The first step to getting treated for OUD is to talk with a professional. The standard approach to treatment is to combine the use of certain medications (like Suboxone) with talk therapy to help a person regain control over their life. Through medication and skill-building work, patients can begin to reduce their cravings for opioids and better resist them when they occur. 

This is an ongoing process and a person may still relapse, re-entering the cycle of addiction. While relapse can be dangerous and should be avoided, it shouldn’t be viewed as a total reset of progress. It’s important to regain control as soon as possible. Work to understand what triggered the relapse and how to avoid further opioid misuse.

Long-Term Abstinence

Long-term abstinence is sometimes viewed as the last stage of OUD.[5] This is when a person can reliably resist using opioids for an extended period, even when they experience drug cravings or encounter their triggers. 

This doesn’t mean relapse is impossible; relapse is always a possibility in recovery. Instead, it means a person has regained significant control over their life, and relapse isn’t considered to be a serious risk (although in times of extreme stress or otherwise intensely triggering events, this may temporarily change). 

Even at this stage, many people will benefit from some level of ongoing addiction treatment. They may continue to take medication like Suboxone, attend therapy or meet with other people struggling with addiction to discuss their struggles. This helps a person maintain their mental well-being and address any issues that could potentially lead to opioid misuse, so they can’t spiral out of control. 

Why Do People Get Addicted to Opioids?

Some of the common reasons that lead to opioid misuse include the following:[4,6]

• Curiosity 
• Peer pressure
• Desire to escape uncomfortable feelings
• Stress
• Mental health issues
• Lack of opportunities
• Access to opioids

OUD may begin with a legitimate prescription for opioids, such as oxycodone or hydrocodone. Someone may begin taking doses too close together, taking more than prescribed or combining the painkillers with other substances like alcohol. Once misuse begins, particularly if physical dependence is already present due to prolonged use, OUD quickly follows.[4]

Recognizing the Signs

Signs of opioid misuse and OUD include the following:[4]

• Drowsiness
• Sleep issues, including insomnia
• Flu-like symptoms (withdrawal symptoms when without opioids)
• Isolation from loved ones
• Changes in hygiene habits
• Financial problems
• Difficulties meeting expectations in school or at work
• Relationship problems
• Cravings for opioids
• Engaging in risky behaviors to get opioids
• Pinpoint pupils
• Weight changes
• Slow breathing

Getting Help & Treatment

Recovery from OUD is about breaking the cycle of addiction. Without help, people will generally flow between the established three stages of addiction, with their mental and physical health deteriorating as their opioid misuse continues and likely worsens. This is a very destructive cycle that can destroy lives and potentially lead to overdose, which can be fatal. 

Breaking this cycle isn’t easy. It requires admitting one has a serious problem and talking to a professional about what can be done to help. While many people would prefer to overcome OUD on their own, this isn’t typically realistic. Professionals can prescribe Medication for Addiction Treatment (MAT) and equip you with tools and understanding that would be difficult to develop on your own.

Remember that it isn’t a moral failing to seek help for addiction. Drugs rewire your brain and drive you to engage in more drug misuse. Professional help is needed to get back in control.

FAQs: Common User Questions

Some frequently asked questions on this topic include the following:

Preventing Opioid Addiction

These steps can help to prevent opioid addiction in communities:

Education Efforts

The more people understand the dangers of opioids, the difference between legitimate and illegitimate uses of these drugs, and the overall nature of addiction, the more easily people can resist addiction and, when it does occur, find ways to enter into recovery. 

Only Use if Necessary

From the perspective of medical professionals, it’s important that opioids are only prescribed when necessary.[7] They can be useful drugs for providing pain relief but should typically only be used to treat moderate or severe pain, and should be used for as short a period of time as possible. They should only be used when a drug with less misuse and addiction potential won’t provide the needed relief. 

Community Support

Keeping addiction treatment programs widely available and affordable to community members helps people get the help they need.[8] Rather than stigmatizing drug misuse and SUD, a community benefits from staying aware of the dangers of drugs and the realities of addiction, including how drugs can effectively hijack a person’s life and how helping that individual (not blaming or verbally attacking them) is the best way to help them recover.[9]

Personal Steps

If you’re prescribed an opioid, only use it as prescribed and for only as long as absolutely necessary. Stay in contact with the medical professional who prescribed the drug. Tell them if you believe your medication may no longer be necessary or if you are starting to struggle with using it only as prescribed. They can help modify your treatment plan to best suit your needs and reduce your risk of opioid misuse.