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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Co-Occurring Disorders:
Integrated Dual Disorders Treatment
Integrated Dual Disorders Treatment Workbook
Chapter 5: Opiates and Opioids
INTRODUCTION
The term opiate refers to morphine and codeine (which occur naturally in opium from some types of poppy plants). Similar synthetic drugs are called opioids. Some of these substances are prescribed by doctors to treat pain. Others, such as heroin, are manufactured illegally for non-medical use. These substances affect many parts of the body and can be lethal when people accidentally overdose. This chapter describes a person who became addicted to heroin. The related discussion addresses basic facts about opiates and related drugs and their effects on the body during intoxication, withdrawal, and dependence, as well as the effects on persons with severe mental illness. One specific aspect of treatment, opioid agonist therapy, is briefly described.
VIGNETTE
Jane is a 35-year-old divorced, unemployed woman with schizophrenia and polysubstance abuse. At age 18, Jane entered mental health treatment because she believed that people on the TV were talking to her and commanding her to do things like shop lift or hurt herself. She was already abusing alcohol, marijuana, and nicotine when she entered treatment.
Jane completed high school and worked as an office cleaner until she was 20. During her first two years in treatment, she was hospitalized three times. She married a man whom she met during her third hospitalization and had her oldest child, Jennifer, with him. Jennifer is now 16 and living in foster care. During and following the pregnancy, Jane was abstinent, attended all her medication evaluations, and became an active member of a relapse prevention group.
Jane's marriage ended in divorce when she was 22. She and her daughter moved back to her parent's house. Following a car accident and surgery, Jane was prescribed narcotic pain medications, which she found herself using more and more. She soon stopped mental health treatment and renewed smoking marijauna and drinking alcohol with her old friends. A new boyfriend introduced her to heroin, which she began using regularly. Gradually, her paranoia and delusions returned. She became alternately angry and aggressive or withdrawn and paranoid. Her parents, who regularly participated in an AL-ANON support group, asked her to leave and took custody of her daughter.
Jane moved in with drug-using friends, began to shoplift and trade sex for drugs. Her friends left town, her boyfriend disappeared, and she began staying with strangers and occasionally living on the streets. She was kicked out of the homeless shelter because she threatened staff. She was later arrested for drug possession and prostitution many times, and referred by police back to the clinic for treatment at the age of 33.
Though Jane said she did not want treatment, she was referred to an assertive community treatment team. For several months, team members met with her and befriended her while she was living on the streets. They helped her get clothes and food. During this time, Jane became worried that she was pregnant again, so her case manager helped her with a doctor's appointment. When she learned that she was pregnant and also that she had HIV, Jane became very delusional and was hospitalized involuntarily. In the hospital, she began taking medications for the HIV and for her mental illness. After several months in the hospital, Jane became less paranoid and more organized in her thinking. She was concerned about her baby and agreed to move into a transitional housing building that was associated with the mental health center. One of the terms of the housing was to remain substance-free. She agreed to stop using substances to comply with the rules, but also because she did not want to hurt the baby.
Jane worked intensively with the team over the next two years. Her mother became involved with her treatment as well. Jane and her mother decided that the baby should live with her parents while she lived in supported housing. She participated in treatment in the mornings and cared for her baby in the afternoons. Her mother helped her remember her medications at dinnertime. Jane had difficulty with ongoing paranoia but was able to interact with her family appropriately. Her HIV was stable while she continued to take medications.
BASIC FACTS ABOUT OPIATES AND OPIOIDS
The term opiate refers to morphine and codeine (which occur naturally in opium from some types of poppy plants). Similar synthetic drugs are called opioids. Some of these substances, such as morphine, codeine and oxycontin, are prescribed by doctors to treat pain. Others, such as heroin, are manufactured illegally for non-medical purposes. All of these types of drugs have wide-ranging effects on mood, motivation, pain, stress, breathing, and many other body functions. The human body naturally makes similar substances, called endorphins, which help people to tolerate pain, cope with stress, and experience pleasure.
These drugs are often prescribed and used for medical reasons such as pain control with minimal risk of addiction, but the risk is much greater when they are used for non-medical purposes without medical supervision. The tendency to become addicted is partly genetic and partly related to psychological, social, and environmental factors. When opiates and opioids are prescribed by a doctor, red flags for abuse include running out of medication before the prescription in over, demanding medications, and obtaining extra prescriptions from other doctors and emergency rooms. People involved in abusing prescription medications may also buy them or sell them illegally.
INTOXICATION AND SHORT-TERM EFFECTS
Intoxication with an opiate often produces relief from anxiety, a pleasurable sensation such as a "rush" or "thrill," and a longer-lasting relaxed, calm and soothing state, the "high." When the drug is injected into the bloodstream, the effect occurs faster than if it is taken by mouth. Some opiates have a slower onset then others and are less likely to cause a "rush."
When people use opiates, they typically appear calm and/or sleepy. Their pupils are constricted or small. They can be distracted and unable to participate in regular activities. When they come down from the high, they are often anxious, agitated, depressed, or sometimes in withdrawal (described in the next section).
Due to a combination of several factors, opiates and opioids can be extremely dangerous drugs. The purity of street drugs is highly variable. When these drugs are taken in large amounts or very pure varieties, they suppress the breathing center in the brain. Additionally, most people who use opiates or opioids also abuse other drugs at the same time. Because of these factors, accidental overdoses are common and can result in coma and death. Medications that block the effects of these drugs are used to treat people in emergency rooms to prevent the severe problems associated with overdose.
TOLERANCE AND WITHDRAWAL
People who use opiates regularly without medical supervision are highly prone to develop abuse or dependence because of the properties of these substances. As with other substances, dependence is defined by loss of control, increased substance use, giving up usual activities, and the development of tolerance and withdrawal. Symptoms of withdrawal from opiates and opioids include increased pain sensitivity, dysphoric mood, anxiety, muscle and bone aches, kicking movements caused by spinal reflex hyperactivity, dilated pupils, stomach cramps, diarrhea, yawning, sweating, and runny eyes. Once a person is using these drugs regularly, he or she will often continue to use to avoid the uncomfortable symptoms of withdrawal.
DETOXIFICATION
Because symptoms of withdrawal are so uncomfortable and craving is severe, detoxification from opiates can be very difficult. Medical treatments are often used to reduce the severity of symptoms during this process.
LONG-TERM EFFECTS
Unlike alcohol, cannabis, and stimulants, opiates do not tend to destabilize mental illness immediately. Opiate use is associated, however, with many long-terms risks for people with mental illness. The long-term effects of opiate or opioid abuse and dependence include behavioral problems and health problems related to intravenous drug use. Behaviorally, opiate addicts typically reduce and abandon usual activities in order to focus on drug-seeking and drug-using behaviors, for example, seeking prescriptions from doctors, stealing or other illegal activity to get money to buy drugs, and dangerous sexual activity related to obtaining drugs. Common health problems include serious infections, such as HIV and hepatitis, which are discussed in Chapter 15.
As Jane's story illustrates, clients with severe mental illness need all of their resources to manage their mental illness, to meet basic needs, to maintain satisfying living conditions, and to function in normal adult roles, like worker, spouse, and parent. Substance abuse quickly puts them into catastrophic circumstances. As Jane did, they often lose interest in taking care of themselves and abandon self-management, taking medications, and other therapeutic activities. They thus experience a recurrence of mental illness symptoms, which may be worsened by the direct effects of the substance they are using.
Clients with severe mental illness are more vulnerable to having problems when they use substances than people who do not have a mental illness. Jane does reasonably well when she is not using substances, but when she uses, she completely loses her ability to take care of herself, to manage her illness, to function in normal roles, and even to avoid life-threatening situations and illnesses. In short, her life becomes a disaster.
OPIOID AGONIST THERAPY
Integrated dual disorder treatment is discussed in subsequent chapters, but we present here one aspect of treatment that is unique for opiate and opioid addiction. Opioid agonist therapy (previously called methadone maintenance) refers to standard and well supported treatments for persons with chronic addiction to heroin or other opiates. In this treatment, a medication is prescribed in a regular dose that prevents withdrawal symptoms and improves outcomes. The medication is dispensed by health professionals in treatment facilities certified by the Substance Abuse and Mental Health Services Administration. All states are developing a process to license and regulate opioid agonist therapy. For more information, you can access the SAMHSA website at www.dpt.samhsa.gov or contact your local state substance abuse agency.
Opioid agonist therapy uses medications that attach to the same chemical receptors in the body as heroin and opioid and opiate pain medications. Methadone has been in use for many years, and two other medications, buprenorphine and L-Alpha-Acetylmethalol (LAAM), are more recent alternatives to methadone. Buprenorphine may be less likely to be abused, but was not approved for use as of 2002. LAAM is longer acting, so clients only take it three times a week, as opposed to methadone, which is taken daily.
Opioid agonist therapy reduces illegal drug use and dangerous activities to obtain drugs, such as stealing and prostitution, and also reduces the risk of serious medical problems associated with intravenous drug use (HIV and hepatitis). When opioid agonist therapy is used with counseling, case management, or other social services, clients experience improvements in housing, relationships, and work. Though it has been extensively studied in persons with opiate use disorders, opioid agonist therapy hasn't been studied in persons with severe mental illness and is rarely used for this group.
Literature
To learn more about opiate addiction, you can consult one of the basic textbooks, such as Introduction to Addictive Behaviors, by D.L. Thombs (NY: Guilford, 1999).
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