A Complete Guide on Opioid Use Disorder

Opioid use disorder impacts millions of Americans, often destroying families and taking lives. 

The opioid crisis in the U.S. has had a significant economic impact, with the estimated cost of opioid addiction in the United States reaching tens billions of dollars each year. According to Pew Trust, opioid use disorder and deaths cost $35 billion in medical care, $14.8 billion in law enforcement and court costs, and $92 billion in lost productivity in the workplace.[1]

Treatment is the best hope for individuals with OUD. Different levels of intensity of treatment are available, from medication-based therapies to behavioral therapies. If you or a loved one is in crisis due to opioid use disorder (OUD), the key to recovery is a unique treatment plan that speaks specifically to the individual circumstances and goals for treatment. 

History of Opioid Use & Misuse

Opioids have been used for medicinal and recreational purposes for centuries, but the history of opioid use and misuse in the United States is relatively recent.

In the late 19th and early 20th centuries, opium and its derivatives were widely used for medicinal purposes. However, the widespread misuse of these drugs led to the passage of the Harrison Narcotics Tax Act in 1914, which regulated their distribution and sale.[2]

In the decades that followed, pharmaceutical companies developed new opioid painkillers, such as oxycodone and fentanyl, which were marketed as safe and nonaddictive. These drugs were widely prescribed, and their overuse and misuse led to a significant increase in opioid use disorder and overdose deaths.

The opioid epidemic in the United States started to gain national attention in the early 2000s, when the number of overdose deaths rose sharply. In response, the government and healthcare industry took a number of steps to address the crisis, including increasing access to addiction treatment, distributing overdose reversal drugs, cracking down on illegal drug trafficking and restricting the prescription of opioids.

Despite these efforts, the opioid epidemic continues to be a major public health crisis, with thousands of deaths each year from opioid overdose. This is partially due to the influx of synthetic opioids now available, particularly fentanyl in recent years. 

What Is an Opioid Use Disorder?

Opioid use disorder is a medical condition characterized by the compulsive use of opioids despite negative consequences, according to the National Library of Medicine. [3] 

It is also defined by the American Psychiatric Association as a pattern of opioid use that leads to harm or distress, shown by two or more of the following within a one-year period:[4]

• Consuming opioids in greater amounts or over a lengthier period than planned

• A tenacious desire or failed attempts to lessen or control opioid use

• A significant amount of time spent related to opioid use, acquiring the drugs, or recovering after use

• Cravings for the drugs

• Frequent opioid use that leads to an inability to satisfy obligations at school, work or home

• Continued opioid use even though there are frequent interpersonal problems triggered or worsened by opioid use

• Abandoning important activities because of opioid use

• Repeated opioid use in circumstances in which it is dangerous

• Continued opioid use despite problems that are likely to have been triggered or aggravated by the substance

• Tolerance, which is either a need for distinctly bigger amounts of the opioid to get high or achieve desired effect, or a clear reduced effect with the same dose of the opioid

• Physiologic withdrawal symptoms 

What Causes Addiction to Opioids?

Opioid addiction is a complex condition that is caused by a combination of genetic, environmental and psychological factors.[5]

Some of the key causes of opioid addiction include the following:

• Genetics: Certain genetic variations may make some individuals more susceptible to opioid addiction than others. These variations can affect the way opioids are metabolized in the body and how they interact with the brain's reward system.

• Environmental factors: Exposure to traumatic or stressful events, poverty and lack of access to healthcare increases the risk of opioid addiction.

• Psychological factors: People with certain mental health conditions, such as depression, anxiety, or post-traumatic stress disorder (PTSD), may be more likely to develop opioid addiction. 

• Medical factors: Chronic pain and other medical conditions that require the use of opioids for long periods of time can increase the risk of addiction. When opioids are used for long periods of time, the brain may adapt to the drug, making it harder to stop using.

• Social factors: People who have a history of substance misuse, who have friends or family members who use drugs, or who are exposed to drugs at a young age may be at a higher risk of developing opioid addiction.

Opioid use disorder can happen to anyone regardless of their social status, age, gender or race. Conversely, having any of the risk factors above is not a guarantee that someone will develop opioid use disorder. Who will develop OUD is very hard to predict. 

Key Facts About Opioid Use Disorder 

• According to the National Center for Drug Abuse Statistics, about 50,000 Americans die due to opioid overdose every year.[6]

• Opioid use disorder is caused by a combination of genetic, environmental, and psychological factors, according to Providers Clinical Support System. [7]

• More than 2 million people in the U.S. and about 15 million people around the world misuse opioids every year.[8]

• Opioid use disorder can have serious physical and mental health consequences, including increased risk of overdose, respiratory depression, and infectious diseases such as HIV and hepatitis C.[9]

• Medications such as methadone, buprenorphine and naltrexone are effective in treating opioid use disorders.[10]

What Are the Symptoms of Opioid Use Disorder?

The symptoms of OUD can vary depending on the individual and the severity of their addiction. However, some common symptoms include the following: 

• Lying about pain to get more prescriptions for opioid painkillers
• Isolation from loved ones
• Changes in appearance, such as weight loss, malnourishment or poor hygiene
• Multiple health issues including Digestive issues, heart failure, liver failure, skin rashes and infections, bone infections, loss of limbs, etc. 
• Social isolation and interpersonal conflicts
• Engaging in criminal activity, like stealing money, to get opioids
• Giving up or reducing important social, job-related or entertaining activities because of opioid use
• Reduced motor skills and balance
• Mood swings
• Personality changes
• Physical and mental withdrawal symptoms when without the substance or the need to take a medication in order to avoid withdrawal symptoms[11]
• Depression and overall irritability

What Are the Stages of Opioid Use Disorder?

The stages of opioid use disorder are not well-defined or universally agreed upon, but some researchers have proposed a general framework for understanding the progression of the disorder. These stages include the following:

• Experimentation: This stage is characterized by preliminary recreational use of opioids. At this stage, the individual may not experience significant negative consequences and may not have a strong desire to use opioids regularly.

• Regular use: When regular opioid use begins, it is often a way to cope with stress, anxiety or pain. At this stage, the individual may begin to experience negative consequences, such as problems at work or school, but may not yet be dependent on opioids.

• Misuse: Continued use of opioids becomes problematic when it manifests as using more than prescribed, using opioids in dangerous situations or using opioids despite negative consequences. At this stage, the individual may be dependent on opioids and may experience withdrawal symptoms when they try to stop using.

• Addiction/use disorder: Addiction occurs when use of opioids becomes compulsive despite negative consequences. The individual may have a strong desire to use opioids and may feel unable to stop using them without help.

Like the stages of addiction, there are also stages of recovery, namely:

• Pre-contemplation: The person does not yet believe that their opioid use is problematic and does not have any intention to change their behavior.[12]

• Contemplation: There is awareness that their opioid use is problematic, but they are not yet ready to change their behavior.

• Preparation: The individual may be preparing to change their behavior, such as seeking information about treatment options or discussing their concerns with friends or loved ones.

• Action: The person takes an action to decrease or stop their opioid use such as starting treatment with a therapist or taking medication assisted treatments (MAT). 

• Maintenance: The most rigorous parts of treatment are over, allowing the individual to do the work of maintaining their recovery and building a new life. This period may or may not be characterized by occasional and brief relapses.

Risk Factors for OUD

There are several risk factors that can increase a person's likelihood of developing an opioid use disorder. Some of these include:

• Genetics: Studies have shown that if someone has a family history of substance use disorder and substance misuse, they are more susceptible to addiction to all substances, including opioids.[13]

• Mental health disorders: Depression, anxiety or PTSD may increase the risk of substance misuse, including opioids. 

• Trauma: Traumatic experiences, such as physical or sexual abuse have been linked to increased risk of opioid use disorder.

• Age: Younger individuals and older adults are more susceptible to developing opioid use disorder. The reasons for this are not entirely understood but there is thought that this is due in part to the fact that younger individuals have more malleable brain chemistry and may be more susceptible to the biochemical changes that occur with drug use. 

• Access to opioids: People with easy access to opioids, such as those prescribed opioids for chronic pain, are at a higher risk of developing OUD.

• Substance misuse history: A history of substance misuse with a non-opioid is also a risk factor for the subsequent development of OUD. 

• Social and environmental factors: People who grow up in poverty, who are exposed to violence, or who have limited access to higher education or healthcare are at a higher risk of developing an addiction to drugs.

These are not the only factors that can contribute to the development of an opioid use disorder, nor does the presence of these factors make addiction a foregone conclusion. They are, however, correlated with higher rates of addiction compared to the general population. 

Co-Occurring Disorders & OUD

Co-occurring disorders, also known as comorbidities, are the presence of two or more conditions that occur simultaneously in an individual. In the context of opioid use disorder, the term co-occurring disorders usually refers to the presence of an OUD as well as one or more other mental health disorder. 

Some common co-occurring disorders that are associated with opioid use disorder include the following:

• Depression: Living with depression can cause some to seek escape through the use of opioids. Regular use of opioids as a coping mechanism for the management of depression can make it harder to stop using the drugs.

• Anxiety: Symptoms of anxiety can also contribute to the use of opioids for symptom relief. Unfortunately, as anxiety symptoms recur, so does misuse of opioids. 

• Post-traumatic stress disorder (PTSD): Living through trauma can cause extreme physical and emotional symptoms. Some may self medication with substances like opioids. 

• Attention deficit hyperactivity disorder (ADHD): ADHD has been linked with substance use and misuse in children who live with the disorder, but the relationship is complex and not as simply defined as addiction that co-occurs with other mental health issues.[14]

• Other substance use disorders: People who live with an addiction to opioids are at a higher risk of misusing other substances, such as alcohol or cocaine.

The coexistence of OUD and mental health disorders is common. These conditions often interact and exacerbate each other. Therefore, treating co-occurring disorders requires an integrated approach that addresses all conditions simultaneously.

How Does Opioid Use Disorder Impact the Mind & Body?

Opioid use disorder has a significant detrimental impact on both the mind and the body. Even occasional or intermittent recreational use can harm the user mentally and physically, even putting them at risk of death due to overdose or accident while under the influence. Overdose can occur even with first time use or even after years of taking a drug consistently. 

Physical Impact: Short-Term Effects

Opioids have a number of immediate effects, and can cause drowsiness, sedation, pruritus/itching, rashes, and constipation. 

Additionally, opioids can slow down breathing and heart rate, which can be dangerous for people with certain medical conditions, such as asthma or heart disease. In cases of overdose, breathing can slow to the point that it stops altogether. This is called an overdose. 

Physical Impact: Long-Term Effects

Long-term opioid use can lead to physical dependence, which can cause withdrawal symptoms when use of the drug stops. These withdrawal symptoms can include muscle aches, insomnia, diarrhea, vomiting, tremors and anxiety. 

While withdrawal is not generally life-threatening, it can be so uncomfortable that patients are forced to use over and over again to avoid the symptoms and “just to feel normal”. Eventually they are using not even in an attempt to get high but merely just to feel well enough to function. 

Prolonged opioid use can also lead to tolerance, requiring the person to use more and more of the drug to achieve the same effects. In order to avoid withdrawal symptoms, a tapering schedule is required. Often, the use of medications such as Suboxone as part of a Medication for Addiction Treatment (MAT) program is the best option. 

With regular use, opioids can cause problems in several organ systems. They can slow down breathing and cause respiratory depression or death, especially when taken in combination with other substances.[15]

Mental Impact: Short-Term Effects

Opioids Interact with the brain's reward system, releasing large amounts of dopamine, which is a neurotransmitter associated with pleasure and reward. This can cause feelings of euphoria and sedation, as well as a reduction in pain perception. 

Opioids can also affect other neurotransmitters and receptors in the brain, leading to changes in mood, cognition and behavior.

Mental Impact: Long-Term Effects

Prolonged opioid use can lead to changes in brain chemistry and function, which can contribute to the development of mental health disorders, such as depression, anxiety, and post-traumatic stress disorder (PTSD). 

Opioid use can also affect the structure and function of the brain, leading to changes in memory, attention and decision-making. It can also affect the brain's reward system, leading to addiction and compulsive drug-seeking behavior.

Social Impact

Due to the physical and mental effects of opioid use and misuse, the social impact on social and professional life can be significant. Financial and legal problems, as well as social stigma and discrimination, are not uncommon. An ongoing opioid use disorder can translate into difficulty maintaining healthy relationships, problems holding down a job, and an inability to meet responsibilities at home and in the community. It may also lead to legal repercussions if individuals engage in illegal activity in an attempt to secure or distribute the drug. 

The Dangers of OUD & Suicide

According to a 2021 study published in Current Addiction Reports, people who are dependent on opioids have a risk of suicide that is 14 times higher than the general population.[16]

There are several factors that may contribute to this increased risk, such as: 

• Mental health disorders: There is a higher risk of co-occurring mental health disorders, such as depression, anxiety, and post-traumatic stress disorder (PTSD), among those with opiate use disorder. The combination of OUD and another mental health condition can increase the risk of suicide.

• Social isolation: Feeling alone or struggling with the stigma of opioid use disorder can lead to feelings of hopelessness and helplessness, which in turn can lead to suicide. 

• Withdrawal symptoms: Withdrawal symptoms from opioids can include anxiety, irritability, insomnia and depression. These symptoms can last for days, weeks or even months, and are one of the primary reasons that people end up returning to opioid use even if they really want to quit. 

• Physical pain: If opioids are used in an attempt to manage chronic pain, the co-occurrence of OUD and ongoing pain can lead to suicide, especially as the opioids stop working and the pain is uncontrolled. 

How to Prevent Opioid Use Disorder

The prevention of opioid use disorder is a big topic in the medical community. There are several strategies that have been developed and found to be useful in the prevention of opioid use disorder, including:

• Education and awareness: Increasing public awareness about the risks associated with opioid use, and providing education about the signs and symptoms of opioid use disorder, can help to stop the problem before it starts and help concerned loved ones intervene early.

• Prescription drug monitoring: Prescription drug monitoring programs can help prevent the diversion of prescription opioids and reduce the number of prescriptions written for these drugs, which in turn will cut down on the availability of these substances on the streets and in medicine cabinets. 

• Avoiding the combination of opioids and other substances: Combining opioid use with the use of other substances such as alcohol can amplify the effects and contribute to the development of addiction more quickly.[17]

• Safe prescribing practices: Healthcare providers can reduce the number of opioid prescriptions written and the amount of opioids available for misuse, especially for minor issues and outpatient treatment. Efforts have been made to educate providers about appropriate use of opioids and the dangers of over-prescribing. 

• Access to treatment: Increasing access to medication assisted treatment (MAT) for opioid use disorder can help decrease the stigma associated with the disorder and help more people to get the care they need to heal. 

• Naloxone: Naloxone is a medication that can reverse an opioid overdose. It works incredibly quickly, and it can be administered by laypeople. Making naloxone available at pharmacies, often without necessitating a prescription, has helped to prevent deaths due to opioid overdose.

• Alternative pain management: Encouraging the use of non-opioid pain management options, such as physical therapy, acupuncture and cognitive behavioral therapy also reduces the over-prescription of opioids.

Treatment Options for Opioid Use Disorder 

Treatment for opioid use disorder includes a combination of medication and behavioral therapy. Medication for Addiction Treatment (MAT) is the gold standard for treating the physical dependence on opioids, making space for the individual to focus on mental health treatment that addresses issues underlying addiction long term. 

The type of therapies that will be most effective in treating opioid use disorder will depend on the individual’s needs. Standard options include cognitive behavioral therapy, peer support groups, group therapy, contingency management, among others. 

Medication also plays an important role in the recovery process. The following are some of the most commonly used medications for treating opioid use disorder:

• Methadone: Methadone is a synthetic opioid that is used to reduce withdrawal symptoms and cravings for opioids. It can be prescribed in pill or liquid form. Many community rehab programs offer this option on an outpatient basis. Unfortunately at this time, patients have to visit a specially licensed clinic to get their daily dose, which is inconvenient for many people. 

• Buprenorphine-Naloxone (Suboxone): Buprenorphine is a partial opioid agonist that is used to reduce withdrawal symptoms and cravings for opioids. Unlike methadone, it can be prescribed by a physician a month at a time, instead of requiring daily visits to a methadone clinic. In addition, it can be used to treat pain and may be an especially effective choice for people who are also living with chronic pain.[18]

• Naltrexone: Naltrexone is an opioid antagonist that blocks the effects of opioids, so it works as an effective deterrent against relapse in recovery. It can be taken as an oral pill or as a monthly injection (Vivitrol).

Opioid use disorder is a chronic medical condition that requires long-term treatment and monitoring. The choice of medication and the duration of treatment will depend on the individual's needs and should not be undertaken without the support of a substance use treatment professional. 

Opioid Overdose 

Anyone using opioids should be aware of the risk of overdose. An overdose occurs when too much of an opioid drug is taken, overwhelming the body. This slows the respiratory system and can then stop it entirely. Overdoses can occur even after first time use. Overdoses can also occur in individuals when they are taking opioids exactly as prescribed by a doctor. Thus, anyone who is using an opioid - whether with a prescription or illicit - should be aware of the possibility of an overdose and know what to do should it occur. 

Common signs of opioid overdose include:[19]

• Slow or shallow breathing
• Loss of consciousness or unresponsiveness
• Pinpoint pupils
• Cold, clammy skin
• Bluish lips or fingers
• Nausea and vomiting
• Confusion or disorientation

If an opioid overdose is suspected, it is important to call emergency medical services immediately. If you have naloxone (brand name: Narcan), the opioid overdose reversal drug, it can be administered immediately. This provides an immediate reversal of the overdose in most cases. 

Naloxone works by binding to the same receptors in the brain as opioids, effectively kicking the drug off the receptors, stopping their effect and restoring normal breathing. Naloxone is available as an injectable medication and as a nasal spray. It can be administered by a healthcare professional or by a layperson with very limited training required. In most states, it can be obtained at a pharmacy without a prescription. 

Naloxone has very few adverse effects and therefore it should be administered liberally to anyone who is expected to be overdosing without fear that it will cause any adverse side effects. 

It should be noted that naloxone is a temporary solution, and emergency medical attention is still required after administering the medication. Naloxone can wear off, and the overdose can return. The effects of naloxone only last for a short period of time, so multiple doses may be needed if large doses of opioids were taken. If you do administer Narcan, you should still call 911 or seek emergency attention so the individual can receive monitoring for a period of time until they are out of the window for an overdose. 

What Are the Recovery Rates for Opioid Use Disorder? 

The recovery rates for opioid use disorder vary depending on the individual and the type of treatment they receive. It’s normal to try different types of therapies, medications and treatments over time in order to find the right combination for the individual. 

The first pillar of treatment is medication for addiction treatment (MAT). One 2020 study published in Progress in Community Health Partnerships: Research, Education, and Action looked at 228 people enrolled in a Medication for Addiction Treatment program. The study found that a year after treatment, about 84% were still no longer actively using opioids and 62% were completely drug-free.[20] 

The second pillar of treatment is behavioral therapy in some form. This can mean individual therapy, group therapy, cognitive behavioral therapy, meditation/mindfulness practice, etc. Different kinds of therapy can work best for an individual depending on their needs. Therapy can take place either in an intensive inpatient program or a less frequent outpatient program. 

Some of the factors that can affect recovery rates for opioid use disorder include the following:

• The type of treatment received: While some individuals may recover with therapy alone or with medication alone, it is generally thought that combining medication with behavioral therapy simultaneously is the most effective treatment. 
• The duration of treatment: Longer treatment periods are generally associated with better outcomes. NIDA states that treatment in any form should be consistent for least 90 days to ensure the best chances of a lasting recovery. Many people may benefit from treatment - either medication or therapy - for many months, years, or even life long. 
• Co-occurring disorders: Individuals with co-occurring mental health disorders, such as depression or anxiety, may have more difficulty in recovery, but they can improve their odds by receiving treatment for the co-occurring disorder alongside substance misuse treatment. If only one issue is addressed, relapse on both fronts is more likely.
• Social support: Having a strong support system can improve the chances of doing well in treatment. This includes a support network of family and friends, participation in support group meetings, and activities with likeminded people.

Recovery from OUD is a continuous process. Relapses can happen throughout life, but with the right treatment, individuals with OUD can improve their quality of life and reduce the risk of relapse and overdose.

There is no one-size-fits-all approach to treating OUD. The best course of treatment will depend on the individual's needs and circumstances. At Bicycle Health, we can help you determine the most appropriate treatment plan for your situation. Reach out today to learn more.

Resources & Support for Opioid Use Disorder 

There are many resources for overcoming opioid use disorder, both for the person in crisis and their loved ones, including in-person and online support and support groups. 

Here are a few examples of resources for OUD:

In-Person Resources

• Substance misuse treatment centers: These facilities provide a range of services including detox, counseling, and MAT for opioid use disorder.
• 12-step programs: Organizations like Narcotics Anonymous (NA) and Heroin Anonymous (HA) provide peer support for people who are ready to commit to stopping the use of substances.[21,22]
• Mental health clinics: Many clinics offer counseling and therapy for individuals with an opiate use disorder, especially in conjunction with other mental health conditions. 

Online Resources

• SAMHSA’s National Helpline: The Substance Abuse and Mental Health Services Administration offers a national helpline at 1-800-662-HELP (4357). This is a free, confidential, 24/7, 365-day-a-year treatment referral and information service available in both English and Spanish for individuals and families facing mental and/or substance use disorders.[23]

• SAMHSA's Behavioral Health Treatment Services Locator: This online tool helps individuals find substance abuse treatment facilities in their area.[24] 

• Support groups: Support groups offer a forum for individuals with OUD to connect. Support groups come in many different forms. Here are some of the popular options:

• Narcotics Anonymous (NA) is a 12-step program for individuals in recovery from any substance other than alcohol, though those who struggle with co-occurring substance use disorders are welcome.[21] 
• Families Anonymous (FA) is a 12-step program for families and friends of individuals with opioid use disorders and other substance use disorders.[25]
• Pills Anonymous (PA) is a 12-step program for individuals in recovery from OUD that is specifically related to prescription painkillers.[26]

As critical as online and in-person help and support groups can be in the context of a comprehensive treatment program, they are not always enough, and should be offered in combination with medication (MAT). 

At Bicycle Health, we provide people who are ready to move away from chronic opioid use and misuse with resources that are needed to effectively recover. With a specialization in Medication for Addiction Treatment, we are on standby 24 hours a day to answer your questions about treatment and recovery and help you to determine the best possible path forward in your recovery.