The Facts about Opioid and Heroin Addiction

As declared by the National Institute on Drug Abuse and the Centers for Disease Control and Prevention, the U.S. is in the midst of an opioid epidemic. Individuals, families and communities all across the country are impacted by widespread opioid dependence and heroin addiction, which is why it's more important than ever to understand the potential dangers of opioid use, including:

• How prescription opioid painkillers, heroin and other opiate drugs work 
• Why opioid dependence (or heroin addiction) can develop before you realize it
• When opioid overdose risk is greatest 
• Which treatment approaches for opioid use disorder are most effective

Let's start with some basic definitions. 

What Are Opioids?

"Opioid" is an umbrella term for both natural and synthetic painkiller drugs derived from or based on the poppy plant. The related term opiate is used to define the drugs that use only natural opium poppy products. For example, the illicit drug, heroin, is classified as an opiate because it is derived from the poppy plant. Whereas "opioid" prescription medications are designated as such because they include other synthetic compounds in their mixtures. Both opiates and opioids present great risks for opioid dependence, addiction, overdose and even death. 

Physicians often prescribe opioid medications to relieve acute pain—from injuries, surgeries, toothaches, or other medical and dental procedures—or to alleviate chronic pain. However, studies show that long-term opioid use for chronic pain can be ineffective and comes with the risk of addiction. You might recognize some of the more well-known opioid drugs prescribed for pain, including:

• Morphine 
• Codeine
• Diacetylmorphine 
• Hydromorphone (Dilaudid)
• Hydrocodone (Vicodin, Lortab) 
• Isotonitazene
• Opium 
• Oxycodone (OxyContin, Percocet)
• Oxymorphone 
• Meperidine (Demerol)
• Methadone 
• Fentanyl (Sublimaze, Actiq)
• Tramadol

What Are the Differences in These Various Opioids?

The form of the drug—such as powder, pill, liquid or tar—is one of the biggest differences. Opioids may also vary in potency, how long they affect the brain, and the risk or potential for opioid addiction. Some prescription drugs are classified as “controlled substances,” which means the drugs are regulated and therefore produced in a standardized manner.  

Other drugs like heroin are illegally produced and distributed, which heightens the risk for overdose. Whether regulated or unregulated, prescription or illicit, all of these drugs have the potential for misuse, dependence and addiction. And when used in combination with other prescription medications or street drugs like cocaine, dangerous reactions and effects are produced.

Is Heroin the Most Popular Opioid?

Potency, cost and accessibility are all factors that affect the popularity and recreational use of these substances. More recently, an opioid known as Isotonitazene—commonly referred to as “iso”—has been linked to an increase in opioid overdose-related deaths. A synthetic opioid more powerful than fentanyl, iso is actually legal across most of the United States. Like other "designer drugs," iso has been developed to differ chemically from its outlawed version while still producing similar effects on the brain. Of course, new synthetic opioids will continue to saturate the marketplace, and they pose a constant and deadly risk for opioid addiction, overdose and death, regardless of legality.

What's the Connection between Prescription Painkillers and Heroin? 

The nation's dependence on prescription opioids (painkillers) has helped to “popularize” the use of heroin because it's a less expensive, more readily available substitute. Heroin—a highly addictive illegal drug known for its euphoric effect—comes in the forms of black tar, or a white or brown powder. Street names include "horse," "smack," "brown sugar" and "junk." In the U.S., heroin use and heroin addiction are at an all-time high.

Heroin can be smoked or snorted, but the drug is more typically injected into a vein in order to achieve the quickest high. Injection causes the greatest risk to users because heroin overdose can more easily occur, and because disease and infections can be spread by dirty needles. 

How Do Opioids Work and Why Are They So Addictive?

When opioid molecules travel through the bloodstream and into the brain, they attach to opioid receptors on the surface of certain cells. They trigger a chemical response in the brain that’s similar (but more extreme) to the pleasure that we derive from eating, drinking, caring for babies and having sex—all necessary for survival of the species.  

These rewarding and survival-based activities result in the release of dopamine in the brain's reward center. But opioid use, like the use of any drug of abuse, triggers the release of dopamine in excess amounts, far beyond what is needed to provide pleasure or keep us alive. In the process, the brain has been signaled: something extremely important has taken place, and it needs to be repeated. The brain's desperate need for repeated use creates opioid dependence and opioid addiction.

Prescription opioids can also produce the feeling of euphoria, especially when a drug is taken in non-recommended ways. For example, although the prescription painkiller OxyContin is prescribed in pill form, the medication can be snorted or injected to enhance the euphoric effects. Unintended consequences of misusing opioid drugs in this way can include serious medical problems, including addiction, opioid overdose or death. 

What Are the Signs, Symptoms and Side Effects of Opioid Addiction?

Every person's situation is different, but in general, opioid use disorder is a condition that involves both physical and psychological processes. Addiction and dependence can happen in small increments, and a person might not recognize the signs of addiction until a crisis occurs.  

Here are eight potential warning signs of opioid or heroin abuse:

1. Taking the drug in larger amounts or over a longer period than intended or prescribed 
2. A persistent desire or unsuccessful efforts to cut down or control drug use
3. An excessive amount of time and effort spent getting, using and recovering from the effects of use 
4. Intense cravings or a strong desire or urge to use
5. Failure to fulfill obligations at work, school or home due to drug abuse 
6. Continued use despite persistent or recurrent social or personal problems caused by usage
7. Continued use despite situations that could be physically hazardous, including overdose risk 
8. Continued use despite awareness of potential physical or mental health problems

As with all types of drug or  alcohol addiction, having a family history of substance abuse increases the risk of developing dependence. 

Other signs, symptoms and side effects of prescription opioid abuse or heroin use include:

• Problematic mental health, behavioral or psychological changes such as agitation, poor judgement or apathy 
• Drowsiness or coma
• Impaired mental functioning 
• Slurred speech
• Constricted pupils 
• Euphoria
• Slowed-down respiration 
• Dry mouth
• Nausea 
• Constipation
• Abdominal cramping 
• Skin rashes and infections
• Weight gain 
• Menstrual problems
• Depression 
• Headaches
• Bad dreams 
• Loss of libido, sexual dysfunction
• Mood swings 
• Collapsed veins
• Risk of HIV, hepatitis B or C 
• Miscarriage
• Infections of the heart lining and valves 

What Are the Symptoms or Warning Signs of a Heroin/Opioid Overdose?

Taking a large, single dose of heroin or any opioid drug can cause severe respiratory depression (where breathing slows or even stops) with the potential for accidental drug overdose and death. Opioid abuse is also associated with a higher risk of suicide.  

• Symptoms of an overdose may include:
• Shallow breathing 
• Pinpoint pupils
• Convulsions 
• Coma
• Nervous system changes 
• Decreased vital signs
• Cold or clammy skin, or bluish lips 

The strength of heroin is unpredictable because other drugs, such as fentanyl, are sometimes added to increase volume or enhance potency. Heroin is one of the substances most frequently reported by medical examiners in drug abuse deaths. 

What Is Opioid Withdrawal? What Are the Symptoms? 

Opioid withdrawal occurs as the body adjusts to a decrease or discontinuance in drug use. If someone quits cold turkey without medical supervision and support, the withdrawal effects may prove difficult to manage. The withdrawal effects can even prevent some people with addiction from entering recovery or seeking the help they need and deserve. 

Opioid withdrawal symptoms include: 

• Restlessness
• Muscle aches, pain, stiffness, spasms or bone pain 
• Insomnia
• Diarrhea 
• Vomiting
• Cold flashes with goose bumps 
• Involuntary leg movements
• Agitation 
• Anxiety, panic
• Itching 
• Irritability
• Rapid heart rate 
• Mild hypertension
• Runny nose 
• Sweating, shaking
• Flu-like symptoms, fever 
• Yawning
• Seizures 
• Sleep difficulties
• Fear, Paranoia

At the height of opiate or opioid withdrawal, symptoms typically include intense anxiety, tremors, shakes and muscle cramps. Joint ache and deep bone pain often manifest, as well.

The long-term consequences of opioid or opiate withdrawal, including anxiety, depression and cravings, can continue for months or even years after the last use. Recovering addicts may also have an increased sensitivity to real or imagined pain, and greater vulnerability to stressful events. 

The desire to feel "normal" again, to escape the seemingly permanent state of dysphoria—a state of generalized unease—puts recovering opioid addicts at a high risk of relapse and, even more tragically, at a high risk of accidental overdose, respiratory suppression and death. When people with opioid dependence stop using—for weeks, months or years—and then pick up again, their tolerance for the drug changes so that an amount they could previously tolerate can become a lethal dose.

What Is the Most-Effective Treatment for Opioid Addiction?

Given the unique treatment and recovery challenges associated with heroin and opioid addictions, including challenging withdrawal symptoms and an increased vulnerability to relapse and accidental death, clinicians at the Hazelden Betty Ford Foundation developed an evidence-based opioid addiction treatment protocol that includes the use of certain medications, an extensive level of continuing care and close monitoring of medication use. 

Known as Comprehensive Opioid Response with Twelve Steps (COR-12), the approach is designed to provide patients with a sufficiently long enough time in treatment programming to begin forming healthy new practices and taking in new information essential to recovery. Treatment programming is delivered with Twelve Step facilitation and other evidence-based therapies (including integrated care for  co-occurring disorders, as appropriate), with abstinence from drug use as the ultimate goal. 

As part of the COR-12 treatment protocol, physicians work with the patient to determine the treatment course that best fits his or her clinical needs. Patients may receive Suboxone, a combination of buprenorphine and naloxone, during detox to ease withdrawal symptoms. Some patients might be recommended for a monthly, extended-release injection of the medication Vivitrol, also known as naltrexone, to block cravings and prevent relapse. 

Is Methadone Still Used to Treat Opioid and Heroin Addiction?

Although methadone is commonly used to ease opioid and heroin withdrawal, buprenorphine has been deemed a better medication for Hazelden Betty Ford's patient population, as we prefer transitional and temporary medication-assisted treatment versus long-term medication maintenance. Learn more about methadone vs Suboxone (buprenorphine with naloxone) for treatment of opiate addiction and withdrawal.

Learn more about medication-assisted treatment programs for opioid use disorder. 

You may also be interested in Prescription Painkillers: History, Pharmacology, and Treatment  by Marvin D. Seppala, MD (Hazelden Publishing, 2010).

Learn more with our What You Need to Know series. This program is ideal for educating patients and their families, school faculty and staff, behavioral and mental health professionals, and more.