Opioid Use Disorder

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Not a single day goes by without news outlets reporting on the opioid crisis. It is truly a national emergency with no signs of improvement.

Opioid use disorder (OUD) is defined as the chronic use of opioids that causes clinically significant distress or impairment. Symptoms include an overpowering desire to use opioids, increased opioid tolerance, and withdrawal syndrome when opioids are discontinued. OUD can range from dependence on opioids to addiction. OUD affects over 16 million people worldwide and over 2.1 million in the United States.(1)

Opioids are chemicals classified as natural, semi-synthetic, or synthetic that interact with the opioid receptors in the body and brain. They reduce the perception of pain.(2)

The CDC’s National Center for Health Statistics (NCHS) released provisional data that estimates more than 110,713 drug overdose deaths occurred in the 12-month period ending September 2023 in the United States.

Data, specific to Texas, from April 2023 predicted overdose cases was 5,770 and April 2024 predicted overdose cases was 5,688 with a note that these are underreported due to incomplete data.

For a person to be diagnosed with opioid use disorder, The Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition (DSM 5-TR) indicates a person, within a 12-month period leading to problems or distress, must meet at least two or more of the following (2):

Taking larger amounts of drugs over a longer period than intended.
Persistent desire or unsuccessful efforts to cut down or control opioid use.
Spending a great deal of time obtaining or using the opioid or recovering from its effects.
Craving, or a strong desire or urge to use opioids.
Problems fulfilling obligations at work, school, or home.
Continued opioid use despite having recurring social or interpersonal problems.
Giving up or reducing activities because of opioid use.
Using opioids in physically hazardous situations such as driving while under the influence of opiates.
Continued opioid use despite ongoing physical or psychological problems likely to have been caused or worsened by opioids.
Tolerance (i.e., need for increased amounts or diminished effect with continued use of the same amount).
Experiencing withdrawal (opioid withdrawal syndrome) or taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.

Drugs Identified as Opioids

The following information regarding each drug has been taken directly from the United States Drug Enforcement Administration (DEA) website. This website also provides information via the National Clandestine Laboratory Register Data for 2023 listing the state, county, city, and addresses law enforcement agencies reportedly found chemicals or other items, indicating the presence of either clandestine drug laboratories or dumpsites for 2023. Specific to the Dallas, Texas area, the cities included Dallas, Grand Prairie, Lancaster and Richardson.

Oxycodone

It is a semi-synthetic opioid drug prescribed for pain as Tylox^®(this brand has been discontinued in the U.S.), Percodan^®, or Oxycontin^®. It is derived from the poppy plant and has a high potential for abuse. It is used by chewing or swallowing pills or tablets, inhaling vapors by heating the tablet on foil, and or the pills or tablets may be crushed and sniffed or dissolved in water and injected.

Street Names

Hillbilly Heroin, Kicker, OC, Ox, Roxy, Perc, and Oxy

Effects on the Body

Feelings of relaxation, euphoria, pain relief.
Addictive.
Chronic use of oxycodone with acetaminophen (Tylenol) may cause severe liver damage.
Overdose may lead to coma and possible death.

Opium

A non-narcotic extracted from the poppy plant, made into a liquid, powder, or solid. Opium poppy is a key source for many narcotics. Opium can be smoked or injected intravenously, taken in pill form, and used in combination with other drugs, such as marijuana and/or methamphetamine.

Street Names

Aunti, Aunti Emma, Big O, Black pill, Chandu, Chinese Molasses, Dopium, Dream Gun, Fi-do-nie, Gee, Guma, Midnight Oil, and Zero

Effects on the Body

Euphoric rush, relaxation and relief of physical pain.
Slow breathing, seizures, and loss of consciousness.
Addictive.
Coma or death.

Morphine

This is a non-synthetic narcotic (opioid) made from opium, prescribed as Kadian^®, MS-Contin^®, Oramorph SR^®, MSIR^®, and Roxanol^®. It is very effective for pain relief and has a high potential for abuse. Morphine may be injected, used in oral solutions, taken in tablets, capsules, or suppositories.

Street Names

Dreamer, Emsel, First Line, God’s Drug, Hows, MS, Mister Blue, Morpho, and Unkie

Effects on the Body

Euphoria and relief of pain.
Addictive.
Overdose signs: cold and clammy skin, sleepiness, lowered blood pressure and slowed pulse rate, coma, and possible death.

Methadone

It is a synthetic opioid prescribed as Methadose^® and Dolphine^®. Methadone is used for detoxification and maintenance of opioid addiction and as a pain reliever for moderate to severe pain. It is either swallowed as a pill or liquid and may also be injected.

Street Names

Amidone, Chocolate Chip Cookies, Fizzies, Maria, Pastora, Salvia, Street Methadone, and Water

Effects on the Body

Sweating, itchy skin, or sleepiness.
Addictive.
Overdose effects include shallow breathing, stomach spasms, clammy skin, convulsions, weak pulse, coma, and death.

Hydromorphone

Prescribed as Dilaudid^®, it is used as a pain reliever. Hydromorphone is 2-8 times more potent than morphine, but has a shorter duration and greater sedation effect. It is available in tablets, rectal suppositories, oral solutions, and injectable formulations.

Street Names

D, Dillies, Dust, Footballs, Juice, and Smack

Effects on the Body

Euphoria, relaxation, sedation, and reduced anxiety. It may also cause mental clouding, changes in mood, nervousness, and restlessness.
Constipation, nausea, vomiting, impaired coordination, loss of appetite, rash, slow or rapid heartbeat, and changes in blood pressure.
Overdose symptoms: severe respiratory depression, stupor or coma, lack of skeletal muscle tone, cold and clammy skin, constricted pupils, and reduces blood pressure and heart rate.

Heroin

An opiate (narcotic) drug processed from morphine and extracted from certain poppy plants. Heroin comes in a white or brownish powder, or a black sticky substance known as “black tar heroin.” It is often “cut” with other drugs or substances such as sugar or powdered milk. The user is unaware how much actual heroin is being used, creating the likelihood of overdose. Heroin is injected, smoked, or sniffed/snorted. High purity heroin is usually snorted or smoked.

Street Names

Big H, Black Tar, Chiva, Hell Dust, Horse, Negra, Smack, and Thunder

Effects on the Body

Highly addictive.
Initial surge of euphoria or “rush,” followed by a twilight state of sleep and wakefulness.
Physical symptoms of use include: drowsiness, respiratory depression, constricted pupils, nausea, a warm flushing of the skin, dry mouth, and heavy extremities.
Overdose symptoms: slow and shallow breathing, blue lips and fingernails, clammy skin, convulsions, coma, and possible death.

Fentanyl

Fentanyl is a synthetic opioid that is 80-110 times stronger than morphine and 50 times more potent than heroin as an analgesic. Pharmaceutical fentanyl was developed for pain management treatment of cancer patients, applied in a patch on the skin, and as an anesthetic. Because of its powerful opioid properties, fentanyl is also diverted for abuse. Fentanyl is added to heroin to increase its potency, or be disguised as highly potent heroin. Many users believe that they are purchasing heroin and actually don’t know that they are purchasing fentanyl – which often results in overdose deaths. Clandestinely-produced fentanyl is primarily manufactured in Mexico. It is typically injected or inhaled like heroin.

Street Names

Apace, China Girl, China Town, China White, Dance Fever, Goodfellas, Great Bear, He-Man, Poison, and Tango & Cash

Effects on the Body

Intense, short-term high.
Temporary feelings of euphoria.
Slowed respiration and reduces blood pressure.
Nausea.
Fainting.
Seizures.
Death.

A DEA intelligence report, Fentanyl Flow to the United States, dated January 2020, indicated “the flow of fentanyl into the United States in 2019 is more diverse compared to the start of the fentanyl crisis in 2014, with new source countries and new transit countries emerging as significant trafficking nodes. Mexico and China are the primary source countries for fentanyl and fentanyl-related substances trafficked directly into the United States. India is emerging as a source for finished fentanyl powder and fentanyl precursor chemicals.”

Fentanyl Seizures:

In 2023, DEA seized more than 80 million fentanyl-laced fake pills and nearly 12,000 pounds of fentanyl powder. The 2023 seizures are equivalent to more than 390 million lethal doses of fentanyl. The 2024 fentanyl seizures represent over 269 million deadly doses. Only 2 mg. of fentanyl equates to a deadly dose.

As of September 23, 2024:37,700,000+ fentanyl pills seized.5,444+ pounds of fentanyl seized.

HOW TO RECOGNIZE AN OPIOID OVERDOSE (3)

The skin is blue—usually the lips and fingertips turn blue first.
The body is very limp.
The face is very pale.
The person is conscious but unable to respond.
The person makes choking sounds or a gurgling/snoring noise.
Breathing is very slow, irregular, or has stopped.
The pulse (heartbeat) is slow, erratic, or not there at all.
Vomiting occurs.
The person loses consciousness.

Opioid Withdrawal Symptoms (1)

Muscle aches.
Diarrhea.
Rhinorrhea.
Nerve excitability.
Chills with cessation of use.

Treating Opioid Use Disorder (4)

Medications approved by the U.S. Food and Drug Administration (FDA) for opioid addiction, overdose, and withdrawal work in various ways.

Opioid Receptor Agonist: Medications attach to and activate opioid receptors in the brain to block withdrawal symptoms and cravings.
Opioid Receptor Partial Agonist: Medications attach to and partially activate opioid receptors in the brain to ease withdrawal symptoms and cravings.
Opioid Receptor Antagonist: Medications attach to and block activity of opioid receptors in the brain. Antagonist medications that treat substance use disorders do so by preventing euphoric effects (the high) of opioids and alcohol and by reducing cravings. Antagonist medications used to treat opioid overdoses do so by reversing dangerous drug effects like slowing or stopping breathing.
Adrenergic Receptor Agonist: A medication that attaches to and activates adrenergic receptors in the brain and helps alleviate withdrawal symptoms.

Medications prescribed to reduce opioid use and cravings

Methadone is available in daily liquid or tablets.
Naltrexone is available in a monthly injection.
Buprenorphine is available in a daily tablet and weekly or monthly injection.
Buprenorphine/naloxone is available in daily film that dissolves under the tongue or tablet.

Medication prescribed to treat withdrawal symptoms

Lofexidine is available as a tablet taken as needed.

Medication used to reverse overdose

Naloxone is available as an emergency nasal spray or injection.
Nalmefene is available as an emergency nasal spray or injection.

The Cost of Opioid Treatment (5)

Although the price for opioid treatment may vary based on a number of factors, recent preliminary cost estimates from the U.S. Department of Defense for treatment in a certified opioid treatment program (OTP) provide a reasonable basis for comparison:

Methadone treatment, including medication and integrated psychosocial and medical support services (assumes daily visits): $126.00 per week or $6,552.00 per year.
Buprenorphine for a stable patient provided in a certified OTP, including medication and twice-weekly visits: $115.00 per week or $5,980.00 per year.
Naltrexone provided in an OTP, including drug, drug administration, and related services: $1,176.50 per month or $14,112.00 per year.

To put these costs into context, it is useful to compare them with the costs of other conditions. According to the Agency for Healthcare Research and Quality, annual expenditures for individuals who received health care are $3,560.00 for those with diabetes mellitus and $5,624.00 for kidney disease.

It is also important to remember the costs associated with untreated opioid use disorders, may include costs associated with:

Criminal justice.
Treating babies born dependent on opioids.
Greater transmission of infectious diseases.
Treating overdoses.
Injuries associated with intoxication (e.g., drugged driving).
Lost productivity.

The amount paid for treatment of substance use disorders is only a small portion of the costs these disorders impose on society. An analysis suggested that the total costs of prescription opioid use disorders and overdoses in the United States was $78 billion in 2013. Of that, only 3.6 percent, or about $2.8 billion, was for treatment.

In addition to the use of medications in the treatment of OUD, there are different levels of treatment that may be needed by different individuals including (2):

Outpatient counseling.
Intensive outpatient treatment.
Inpatient treatment.
Long-term therapeutic communities.

References

Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. [Updated 2024 Jan 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553166/
American Psychiatric Association. Patients and Families – Opioid Use Disorder. Psychiatry.org – Opioid Use Disorder
American Psychological Association (APA) 20 8 – The Opioid Guide: A Resource Guide for Practicing Psychologists. https://www.apa.org/topics/substance-use-abuse-addiction/psychologist-guide.pdf
NIDA. Overview. National Institute on Drug Abuse website. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/overview. December 2, 2021. Accessed September 16, 2024.
NIDA. How much does opioid treatment cost? National Institute on Drug Abuse website. https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-much-does-opioid-treatment-cost. April 13, 2021. Accessed September 16, 2024.

Cynthia Blair RN MA–September 2024

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