Opioids

Use, Abuse, and Addiction

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Opioids are probably the classic drugs of addiction. A pattern of drug taking evolves, including an intense intoxication via the intravenous or smoked routes for heroin and via the oral or intravenous routes for opioid analgesics (Box 5.3). Tolerance develops, and intake escalates, with profound dysphoria, physical discomfort, and somatic withdrawal signs during abstinence. Intense preoccupation with obtaining opioids (craving) develops that often precedes the somatic signs of withdrawal, and this preoccupation is linked not only to stimuli associated with obtaining the drug but also to stimuli associated with withdrawal and internal and external states of stress. The drug must be obtained to avoid the severe dysphoria and discomfort of abstinence.

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However, a popular, virtually universal misconception about opioid use is that any opioid use within or outside medical settings inevitably leads to intractable physiological dependence and addiction. Extensive work has established a wide variety of patterns of non-medical opioid consumption, ranging from non-problematic to abusive. Three modes of opioid use have been described: controlled subjects or “chippers,” marginal subjects or abusers, and compulsive subjects with addiction. Controlled use is generally recognized as occasional use and most often indicates a non-addictive pattern of opioid use. A marginal user could have possibly met the criteria for Substance Abuse defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), and may meet the criteria for Substance Use Disorder for Opioids as defined by the DSM-5. A person with addiction, in contrast, definitely meets the criteria for Substance Dependence as defined by the DSM-IV and will probably meet the criteria for severe Substance Use Disorder for Opioids as defined by the DSM-5. Controlled opioid use has several characteristics that differ from the other extreme of a compulsive user.

Controlled substance users (“chippers”) limit their use of the drug, often to amounts or periods of time that do not interfere with social and occupational functioning. To do this, they develop elaborate rules, such as refusing to inject intravenously, planning for use, budgeting money for only a certain amount of use, and deferring use when opioids are not available. Controlled use patterns can be stable and last as long as 15 years (Table 5.2).

An example of controlled opioid use is the following:

“Arthur, a ‘controlled user,’ was a forty-year-old white male who had been married for 16 years and was the father of three children. He had lived in his own home in a middle-class suburb for 12 years. He had been steadily employed as a union carpenter with the same construction firm for five years. During the ten years prior to the first interview, Arthur used heroin on weekends, occasionally injecting during the week, but during the previous five years mid-week use had not occurred.”

(Harding WM, Zinberg NE. Occasional opiate use. Advances in Substance Abuse, 1983, (3), 27–61).

BOX 5.3

It is so long since I first took opium, that if it had been a trifling incident in my life, I might have forgotten its date: but cardinal events are not to be forgotten; and from circumstances connected with it, I remember that it must be referred to the autumn of 1804. During that season I was in London, having come thither for the first time since my entrance at college. And my introduction to opium arose in the following way. From an early age I had been accustomed to wash my head in cold water at least once a day: being suddenly seized with toothache, I attributed it to some relaxation caused by an accidental intermission of that practice; jumped out of bed: plunged my head into a basin of cold water; and with hair thus wetted went to sleep. The next morning, as I need hardly say, I awoke with excruciating rheumatic pains of the head and face, from which I had hardly any respite for about twenty days. On the twenty-first day, I think it was, and on a Sunday, that I went out into the streets; rather to run away, if possible, from my torments, than with any distinct purpose. By accident I met a college acquaintance who recommended opium. Opium! dread agent of unimaginable pleasure and pain! I had heard of it as I had of manna or of ambrosia, but no further: how unmeaning a sound was it at that time! what solemn chords does it now strike upon my heart! what heart-quaking vibrations of sad and happy remembrances! Reverting for a moment to these, I feel a mystic importance attached to the minutest circumstances connected with the place and the time, and the man (if man he was) that first laid open to me the Paradise of Opium-eaters. It was a Sunday afternoon, wet and cheerless: and a duller spectacle this earth-of-ours has not to show than a rainy Sunday in London.

Arrived at my lodgings, it may be supposed that I lost not a moment in taking the quantity prescribed. I was necessarily ignorant of the whole art and mystery of opium-taking: and, what I took, I took under every disadvantage. But I took it: and in an hour, oh! heavens! what a revulsion! what an upheaving, from its lowest depths, of the inner spirit! what an apocalypse of the world within me! That my pains had vanished, was now a trifle in my eyes: this negative effect was swallowed up in the immensity of those positive effects which had opened before me – in the abyss of divine enjoyment thus suddenly revealed. Here was a panacea – a for all human woes [literally a “drug of forgetfulness”]: here was the secret of happiness, about which philosophers had disputed for so many ages, at once discovered: happiness might now be bought for a penny, and carried in the waistcoat pocket: portable ecstasies might be had corked up in a pint bottle: and peace of mind could be sent down gallons by the mail coach. But, if I talk in this way, the reader will think I am laughing: and I can assure him, that nobody will laugh long who deals much with opium: its pleasures even are of a grave and solemn complexion; and in his happiest state, the opium-eater cannot present himself in the character of l’Allegro: even then, he speaks and thinks as bccomes Il Penseroso. Nevertheless, I have a very reprehensible way of jesting at times in the midst of my own misery: and, unless when I am checked by some more powerful feelings, I am afraid I shall be guilty of this indecent practice even in these annals of suffering or enjoyment. The reader must allow a little to my infirm nature in this respect: and with a few indulgences of that sort, I shall endeavour to be as grave, if not drowsy, as fits a theme like opium, so antimercurial as it really is, and so drowsy as it is falsely reputed.

The elevation of spirits produced by opium is necessarily followed by a proportionate depression, and that the natural and even immediate consequence of opium is torpor and stagnation, animal and mental. The first of these errors I shall content myself with simply denying; assuring my reader, that for ten years, during which I took opium at intervals, the day succeeding to that on which I allowed myself this luxury was always a day of unusually good spirits.

Thus I have shown that opium does not, of necessity, produce inactivity or torpor; but that, on the contrary, it often led me into markets and theatres. Yet, in candour, I will admit that markets and theatres are not the appropriate haunts of the opium-eater, when in the divinest state incident to his enjoyment. In that state, crowds become an oppression to him; music even, too sensual and gross. He naturally seeks solitude and silence, as indispensable conditions of those trances, or profoundest reveries, which are the crown and consummation of what opium can do for human nature.

One day a Malay knocked at my door. What business a Malay could have to transact amongst English mountains, I cannot conjecture: but possibly he was on his road to a sea-port about forty miles distant.

He lay down upon the floor for about an hour, and then pursued his journey. On his departure, I presented him with a piece of opium. To him, as an Orientalist, I concluded that opium must be familiar: and the expression of his face convinced me that it was. Nevertheless, I was struck with some little consternation when I saw him suddenly raise his hand to his mouth, and (in the school-boy phrase) bolt the whole, divided into three pieces, at one mouthful. The quantity was enough to kill three dragoons and their horses: and I felt some alarm for the poor creature: but what could be done? I had given him the opium in compassion for his solitary life, on recollecting that if he had travelled on foot from London, it must be nearly three weeks since he could have exchanged a thought with any human being. I could not think of violating the laws of hospitality, by having him seized and drenched with an emetic, and thus frightening him into a notion that we were going to sacrifice him to some English idol. No: there was clearly no help for it: he took his leave: and for some days I felt anxious: but as I never heard of any Malay being found dead, I became convinced that he was used to opium: and that I must have done him the service I designed, by giving him one night of respite from the pains of wandering.

However, as some people, in spite of all laws to the contrary, will persist in asking what became of the opium-eater, and in what state he now is, I answer for him thus: The reader is aware that opium had long ceased to found its empire on spells of pleasure; it was solely by the tortures connected with the attempt to abjure it, that it kept its hold.

I saw that I must die if I continued the opium: I determined, therefore, if that should be required, to die in throwing it off. How much I was at that time taking I cannot say; for the opium which I used had been purchased for me by a friend who afterwards refused to let me pay him; so that I could not ascertain even what quantity I had used within the year. I apprehend, however, that I took it very irregularly: and that I varied from about fifty or sixty grains, to 150 a-day. My first task was to reduce it to forty, to thirty, and, as fast as I could, to twelve grains.

I triumphed: but think not, reader, that therefore my sufferings were ended; nor think of me as of one sitting in a dejected state. Think of me as of one, even when four months had passed still agitated, writhing, throbbing, palpitating, shattered.


From: De Quincey T, Confessions of an English Opium Eater, Penguin Books, New York, 1986.

TABLE 5.2

Characteristics of Controlled vs. Compulsive Chippers

 

Controlled Subjects
(n = 61)

Compulsive Subjects
(n = 30)

Age (mean)

25.9 years

25.9 years

Male

77%

67%

Female

23%

33%

Duration of current style of use (months)

53.4 months

59.5 months

Average frequency of use (last 12 months):

 

 

 > 2 times daily

23%

 once every 1–2 days

23%

 2 times weekly

41%

47%

 1–3 times monthly

36%

3%

 < once monthly

23%

3%

Length of use (mean)

7.2 years

6.8 years

Peak frequency of use:

 

 

 > 2 times daily

23

87%

 once every 1–2 days

54%

13%

 2 times weekly

16%

 1–3 times monthly

5%

 < once monthly

2%

Percentage who selected rules for use:

 

 

 never use in strange place

20%

13%

 never use with strangers

31%

28%

 never inject

13%

 special schedule for

34%

20%

 use

30%

 plan for use

28%

31%

 never share needles

26%

10%

 never use alone

53%

20%

 caution in “copping”

48%

23%

 budgets for use

 

 

History of adverse reactions

36%

45%

[Data from Harding WM, Zinberg NE. Occasional opiate use. Advances in Substance Abuse, 1984, (3), 105–118.]


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In contrast, many individuals report “controlled, recreational” opioid use prior to eventual compulsive use. The person may experiment with various drugs and then snort or smoke heroin. Subsequently, the person is often initiated into using heroin intravenously, which produces a pronounced high, but repeated use leads to the negative effects of withdrawal symptoms. The transition to the intravenous route of administration signals the beginning of the addiction cycle of regular injections, withdrawal, and craving. An example of a compulsive opioid user is the following:

“Bob, a ‘compulsive user,’ was a twenty-six-year-old white male who lived alone, a college graduate with a degree in psychology. Following separation from his wife and child three years before interview, he had worked sporadically in part-time jobs. Dealing drugs had become his major source of income. He had used heroin at least three to four times per week since beginning use 30 months before interview, and had had many periods of daily use lasting for as long as two weeks.”

(Harding WM, Zinberg NE. Occasional opiate use. Advances in Substance Abuse, 1983, (3), 27–61).

One can ask what constitutes the difference, from a clinical perspective, between a “chipper” and a “junkie.” Clearly, personality deficits and physiological states induced by the drug itself interact. Limited access will not produce the neuroadaptations that drive compulsive opioid abuse, but personality factors can increase the vulnerability to engage in the compulsive use that then evokes those same neuroadaptations, leading to the vicious cycle of opioid addiction

The natural history of opioid addiction reflects a disorder that is remarkably stable over time. Although repeated cycles of remission and resumption of use occur, these patterns extend over long periods of time. Longitudinal studies have shown that heroin addiction, at least for some individuals, is a lifelong condition. Similar results were obtained in a longitudinal study of 581 males with heroin addiction admitted to the California Civil Addict Program during the years 1962–1964 and followed for 33 years. In 1995–1997, 33 years later, 21% of the subjects tested positive for heroin, 10% refused urine analysis, and 14% were incarcerated. This was very similar to the data from 1974–1975, in which 23% had positive urine, 6% refused urine analysis, and 18% were incarcerated (Figure 5.5). The rate of abstinence in 1996–1997 was related to the amount of time previously abstinent, and most subjects (75%) who reported abstinence for longer than five years were still abstinent in 1996–1997. The number of negative urine samples was also relatively stable, but the number of deaths progressively increased. The most common causes of death were overdose, chronic liver disease, cancer, and cardiovascular disease. By age 50–60, only about half of the interviewed subjects tested negative for heroin, which argues against the hypothesis that drug addiction lessens with age.

FIGURE 5.5 The natural history of narcotics addiction among a sample of male individuals with heroin addiction (n = 581) admitted to the California Civil Addict Program, a compulsory drug treatment program for heroin-dependent criminal offenders, during the years 1962 through 1964. This 33-year follow-up study updated information previously obtained from admission records and two face-to-face interviews conducted in 1974–1975 and 1985–1986. In 1996–1997, at the latest follow-up, 284 were dead and 242 were interviewed. The mean age of the 242 interviewed subjects was 57.4 years. Age, disability, years since first heroin use, and heavy alcohol use were significant correlates of mortality. Of the 242 interviewed subjects, 20.7% tested positive for heroin. The group also reported high rates of health problems, mental health problems, and criminal justice system involvement. Long-term heroin abstinence was associated with less criminality, morbidity, psychological distress, and higher employment. While the number of deaths increased steadily over time, heroin use patterns were remarkably stable for the group as a whole. For some, heroin addiction had been a lifelong condition associated with severe health and social consequences. [Taken with permission from Hser YI, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotic addicts. Archives of General Psychiatry, 2001, (58), 503–508.]


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