Why Are Opiates So Addictive and Who’s Most at Risk?

Factors Associated with Opioid Addiction and The Benefits of MAT

By Jennifer Morgenstern, MBA, PHR, LCDC III, Regional Director, Ohio, Pinnacle Treatment Centers

I wonder if you can remember back to the end of 2019 or the beginning of 2020.

I know – it’s tough.

The last two years and change have felt like a decade, at least. And thinking back to December 2019 or January 2020 – for me, at least – is like trying to remember parts of my childhood. I know I was there, I know what happened, but everything in between – i.e. adulthood – has blurred the details, and I literally have to look at a calendar to remember where I was and what I was doing.

The thing that blurred the last two years, obviously, was the pandemic.

But allow me to take you back to 2019, and remind you of the nationwide public health crisis that dominated the news: the opioid epidemic. In 2019, addiction professionals were experiencing a bit of whiplash.

Here’s what happened.

The Opioid Crisis: 2016-2019

Around 2016, we got the attention of local, city, and state policymakers about the crisis. They, in turn, got the attention of policymakers at the highest level, including the President of the United States, who declared the opioid epidemic a public health emergency and released a plan to address the situation. This, in turn, got the attention of the entire nation, and galvanized an effort that spread from the grassroots to the highest levels – from community centers to the White House – to reverse the trends in opioid misuse, addiction, and overdose death.

In some areas of the country, we made real progress. After an increase in overdose deaths between 1999 and 2017, when overdose deaths exceeded 70,000 the largest number on record, the trend started to turn. In 2018, the CDC reported 67,367 deaths – and we thought our efforts were finally paying off. Then, in 2019, overdose rates went back up.

Whiplash.

But we didn’t panic, because we knew exactly why. A dramatic increase in the prevalence of two powerful and deadly synthetic opioids used on the black market – fentanyl and carfentanil – increased the risk of accidental overdose by anyone who purchased street heroin or illegally produced opioid medication.

That’s where we were when the pandemic hit.

The Opioid Crisis: A Reset

I know it may be a stretch to say now that the pandemic has eased up a bit, but I’ll say it anyway: in the wake of Delta and Omicron, we’re approaching a new normal. Which means we can refocus our attention on the opioid crisis, which never went away. In fact, during the pandemic, it got worse. During 2020 and 2021, opioid overdose deaths and overdose deaths from all drugs increased significantly, along with a host of factors that increase the risk of opioid addiction, such as isolation, depression, stress, and anxiety.

That brings me to the two questions I pose in the title of this article:

Why are Opiates So Addictive?

Who’s Most at Risk?

First, I’ll talk about why opiates are so addictive. The simple answer is that opiates have the power to make an individual feel euphoric: that’s how that question is related to the stress and pain of the pandemic. The isolation and stress associated with the past two years led many people to self-medicate with opiates. Their euphoric properties offered temporary relief from all the worst emotional and psychological consequences of the pandemic. Repeated use for those purposes can easily lead to addiction, especially with opioids.

But why? Why are opioids so addictive?

Opioids Hijack Our Natural Systems

The primary reason it’s so easy to get addicted to opioids is that they leverage two very powerful, naturally occurring systems in our bodies. The first is the reward system in our brain. The reward system activates when we engage in essential human functions like eating, sleeping, exercising, or having sex: in short, our reward system directs our behavior towards anything that feels good. Opioids activate this system – but they do it much more efficiently than normal human activities, which increases the risk of misuse.

The second system opioids leverage is our endogenous opioid system, which is the most powerful pain-relieving system we have in our bodies. Endogenous means internal, so what exogenous opioids do – exogenous meaning medications like oxycontin or drugs like heroin – is mimic the characteristics of our internal system, and trigger a release of chemicals that both relieve pain and make us feel pleasure. This also increases risk of misuse.

Therefore, opioids are so addictive because they leverage our naturally occurring systems of pain-relief and reward, when they do, they turn it up. Not just to ten – more like a hundred.

But there’s more.

An additional characteristic of opioids that increases the likelihood of misuse or abuse is a phenomenon called tolerance. Tolerance, in a nutshell, means that which each successive dose of an opioid, the effect of that opioid decreases. Here’s a simplified description of the process whereby tolerance to opioids can lead to addiction, or opioid use disorder.

1. Tolerance

With each dose, more of the opioid is required to achieve the same effect.

2. Physical Dependence

When there are no opioids present in the bloodstream, the body enters a state of withdrawal.

3. Psychological Dependence

Intense need for opioids – called cravings – leads to habitual use, although the person using opioids know habitual use has significant negative consequences.

That’s the one-two punch that makes opioids dangerously addictive. They trigger feelings of pleasure that are hard-wired into our brains and bodies, by leveraging our body’s natural systems. Then, when we stop taking them, the symptoms of withdrawal are so uncomfortable they drive us to continued use, despite the fact we know continued use is bad for our physical, psychological, and emotional health and wellbeing.

Now I’ll address the second question in the title of this article:

Who’s Most at Risk?

Opioid Addiction: Risk Factors

In 2017, Dr. Lynn Webster published a paper called Risk Factors for Opioid-Use Disorder and Overdose in which she defines the terms related to opioid use and misuse, describes the criteria addiction professionals use to diagnose opioid use disorder, and identifies the factors that increase risk for opioid addiction.

I’ll use information from her article – firmly grounded in peer-review research – to discuss opioid addiction risk factors. In the next section, I’ll talk about medication-assisted treatment (MAT), which is the gold-standard treatment for opioid use disorder (OUD).

First, I’ll define the important terms:

Definitions Related to Substance Use and Misuse

Substance Misuse

Use of a medication prescribed for a medical purpose other than as directed or indicated, whether willful or unintentional, and whether harm results or not.

Substance Abuse

Any use of an illegal drug or the intentional self-administration of the drug for a nonmedical purpose such as altering one’s state of consciousness, such as getting high

Substance Use Disorder

A primary, chronic disease involving brain reward, motivation, memory, and related brain circuitry that can lead to relapse and progressive development, and that is potentially fatal if left untreated. Primary characteristics include intense craving for the substance and continued use despite adverse outcomes

Next, let’s look at the criteria treatment professionals use to diagnose opioid use disorder (OUD):

DSM-V Criteria for Diagnosing Opioid Use Disorder

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

Now that you know how opioid addiction happens, what the various terms related to opioid addiction mean, and how physicians diagnose OUD, let’s take a look at the various factors that may increase the likelihood of developing OUD.

Risk Factors for Opioid Use Disorder

• Personal history of substance use, misuse, or abuse
  • Personal history of substance use treatment
• Family history of substance abuse, misuse, or abuse
• Elevated stress, including:
  • Isolation
  • Financial difficulty
  • Job instability
  • Housing instability
• History of childhood trauma, including:
  • Emotional abuse
  • Physical abuse
  • Sexual abuse
  • Exposure to violence in the home or community
• Diagnosis of a mental health disorder, including:
  • Anxiety
  • Depression
  • Personality disorders
• Young age
• Cigarette smoking
• Absence of social support
• Absence of family support
• Current illicit drug use
• Past or current involvement with the criminal justice system
• History of substance-abuse treatment

Dr. Webster closes her article with this warning:

“Stress because of pain that is uncontrolled can also lead to opioid misuse or abuse in a patient with no other risk factors… [as well as] … despair within economically depressed communities, binge use, thrill-seeking behavior, and social environments that encourage illicit substance use.”

In addition to these risk factors for opioid addiction, please read our recent article on a demographic that’s recently been identified as at increased risk of both OUD and fatal opioid overdose:

Opioid Overdose Among Older Black Men

That’s a lot of information to process.

I understand.

However, everything I shared above is important to know: why opiates are addictive, what all the terms related to addiction and treatment mean, the risk factors, and the new data on increased risk among older black men.

It’s also important to refocus our attention on the opioid crisis, which I discuss in the opening of this article: our attention was on the pandemic for two years. Now, finally, we have the space in our national consciousness to think about something else.

Right now, I want you to learn about – and think about – the most effective known treatment approach for opioid use disorder: medication-assisted treatment, or MAT.

Medication-Assisted Treatment for Opioid Use Disorder (MAT for OUD)

MAT is what it sounds like: the use of medication to treat people with opioid use disorder. Here’s how the Substance Abuse and Mental Health Services Administration defines MAT:

“MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a ‘whole-patient’ approach to the treatment of substance use disorders. Medications used in MAT are approved by the Food and Drug Administration (FDA) and MAT programs are clinically driven and tailored to meet each patient’s needs.”

Pay special attention to the phrase “in combination with counseling and behavioral therapies.” MAT always exists in the context of a holistic approach to treatment, which includes addressing the psychological, emotional, and personal factors that contribute to addiction. There are three common medications used in MAT: methadone, buprenorphine, and naltrexone.

The supervised use of these medications:

• Normalizes brain chemistry
• Blocks the euphoric effects of opioids
• Blocks the ability of other opioids to activate the reward and pleasure systems in the human body
• Relieve physiological cravings
• Normalize body functions without the negative/euphoric effects
• Can reverse the course of overdose and prevent fatality (naloxone)

In combination with individual therapy, group therapy, lifestyle changes, and community support programs like Narcotics Anonymous (NA), evidence shows that for people with opioid use disorder, MAT programs:

• Decrease opioid use
• Reduce opioid-related overdose deaths
• Decrease criminal activity
• Decrease transmission of infectious diseases
• Improve social functioning
• Increase time in treatment
• Increase gainful employment
• Improve birth outcomes for pregnant women with OUD

To summarize, MAT makes treatment and recovery possible where most other approaches fail. Many people try to quit using opioids but relapse for various reasons. In some cases, people resist using MAT because they think they’re simply substituting one drug for another.  That’s a common misconception – like the methadone myths and misconceptions you can read about in our article here – and it’s simply not the case. Using medication to treat a medical condition is logical: it means you’re using the best available resource to address your need.

In the case of MAT for OUD, using medication improves lives, improves communities, and, in many cases, saves lives.