Opioid Addiction Treatment
OPIOID USE DISORDER
Definition and Diagnostic Criteria (DSM-5)
According to the DSM-5, an OUD diagnosis requires meeting at least two of the following criteria within a 12-month period:
- Compulsive Use & Cravings: Persistent desire, unsuccessful efforts to cut down, and intense cravings.
- Negative Impact:
Failure to meet obligations, continued use despite social, interpersonal, or physical hazards.
- Physical Adaptation: Tolerance (needing more for the same effect) or withdrawal symptoms, excluding instances where medication is used under proper medical supervision.
Key Aspects of OUD
- Severity: Classified as mild (2–3 symptoms), moderate (4–5), or severe (6+ symptoms).
- Dependence vs. Addiction: While dependence involves physical withdrawal, addiction (OUD) centers on compulsive, harmful behavior.
- Treatment: OUD is manageable with a combination of medication (methadone, buprenorphine, or naltrexone) and behavioral therapies.
Based on the latest data from the Centers for Disease Control and Prevention (CDC) and other research organizations:
- 2024 Estimates (U.S.): Opioid-related overdose deaths fell to 54,045 in 2024, down from 79,358 in 2023. Despite this decrease, they remained higher than in 2019.
- 2023 Data (U.S.): There were 79,358 opioid-involved overdose deaths, with synthetic opioids (primarily fentanyl) accounting for 72,776 of them.
- Daily Average (U.S.): In 2023, on average, 217 people died each day from an opioid overdose.
- Global Context: Worldwide, close to 80% of approximately 600,000 annual drug-related deaths are related to opioids.
Key Trends:
- Synthetic Opioids: Illicitly manufactured fentanyl is the primary driver of these deaths, accounting for nearly 60% of all overdose deaths in recent years.
- Recent Declines: After years of sharp increases, opioid overdose deaths fell significantly between 2023 and 2024 (a drop of over 30%).
- Demographics: In 2024, death rates were highest among adults aged 26–64, males, and American Indian/Alaska Native (AIAN) or Black individuals
Why are opioids so addictive?
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.
DSM-V Criteria for Diagnosing Opioid Use Disorder
- Taking larger amounts or taking 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.
- 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.
Yes, chronic opioid use and addiction (Opioid Use Disorder – OUD) can significantly change both the structure and function of the brain. While opiates provide pain relief and feelings of euphoria, they rewire the brain’s reward system, create dependencies, and can cause long-lasting cognitive impairment.
Structural Brain Changes
Research indicates that long-term, chronic, or high-dose, misuse of opioids can lead to measurable physical alterations in brain anatomy:
- White Matter Reduction: Chronic opioid use can decrease the volume of white matter in the brain, impacting how different brain regions communicate, specifically affecting areas responsible for emotion regulation, stress, and reward seeking.
- Gray Matter Changes (Atrophy): Studies have found gray matter reduction (atrophy) in the fronto-temporal regions, including the orbitofrontal cortex, insula, and amygdala.
- Amygdala Changes: Long-term prescription opioid use has been associated with reduced volume in the amygdala, a region critical for processing emotions and fear.
- Dendritic Spine Alteration: Chronic use modifies the density of dendritic spines—the sites where brain cells connect and communicate—in areas involved in learning and reward, such as the prefrontal cortex and nucleus accumbens.
- DNA Damage: Research on postmortem brain tissue of individuals with OUD has shown increased DNA damage in brain cells (neurons and microglia) within the striatum.
Functional Brain Changes
Beyond physical structure, opioids alter how the brain operates:
- Desensitization to Dopamine: Opioids flood the brain with dopamine, creating a “high.” Over time, the brain compensates by decreasing natural dopamine production and reducing the number of receptors, leading to “tolerance”—the need for more of the drug to feel the same effect.
- Reduced Natural Pleasure: The brain’s reward system becomes dependent on the drug to feel pleasure, making it difficult for users to experience pleasure from natural rewards.
- Impaired Decision Making: Changes in the brain’s prefrontal cortex (the “stop” system) can impair judgment, memory, and cognitive control.
- Hypoxia-Induced Damage: Opioids depress the central nervous system, which can cause slow breathing (respiratory depression). In cases of overdose, this can lead to hypoxia (too little oxygen reaching the brain), resulting in damage or death of brain cells.
Reversibility and Recovery
- Long-Term Effects: These structural changes often persist even after the person stops using opioids, which contributes to the high rate of relapse.
- Recovery Potential: Some studies suggest that certain structural changes may begin to reverse after long-term abstinence (e.g., 30 days or more), particularly in specific frontal regions, though some impairments can last for years.
- Treatment Impact: Medication-assisted treatment (MAT) with methadone or buprenorphine may help stabilize brain function, although they are associated with their own, milder, cognitive impacts compared to active addiction.
Signs of opioid abuse
Taking a substance in larger or longer amounts than intended: Prescription painkillers are meant to be a short-term fix; extended use can signal trouble. “Typically, people don’t need opioids for more than three days,” Morrow says. Only in rare cases should use exceed a week, he adds.
Unsuccessful efforts to curb or control substance use: Even if a person wants to quit, this can be harder for some individuals. That’s because genetic, environmental and psychological factors put some opioid users at an elevated risk for addiction.
Excess time spent obtaining, using or recovering from a substance: A person addicted to opioids might spend a lot of time and money seeking drugs, or they might find other substances to use instead. “Pills tend to be more expensive,” Morrow says. “At some point, they’re told or they figure out that heroin is cheap.”
Craving or strong urge to use the substance: A user might be well aware that opioids have negative consequences. But that’s often of little concern: “The drugs make the brain seek out more,” Morrow says, “regardless of what the outcome of that drug use was.”
Repeat failure to fulfill work, home or school obligations: Because opioid use can disrupt sleep patterns and cause sedation, the effects can affect existing life duties — and be noticeable to others. Still, Morrow says, “the person is often unaware they have an addiction.”
Continued opioid use despite related social or interpersonal problems: Personality changes such as irritability may indicate an opioid problem. “A person can get very defensive about their drug use; arguments with family, friends or a health care provider are a sign,” Morrow says.
Withdrawal from social, occupational or recreational activities: Skipping leisure pursuits or group outings isn’t uncommon for people with opioid addiction. Says Morrow: “You see a decline in function. They’re doing less and less; it might not be clear why.”
Recurrent substance use in physically hazardous situations: Much like those who struggle with an addiction to alcohol, acting recklessly under the influence of opioids is a known side effect. Those behaviors may include recklessness while swimming, driving or using machinery or having unsafe sex.
Continued use despite a persistent physical or psychological issue: Opioids can exacerbate mental health conditions such as depression and bipolar disorder. And those patients already are more vulnerable to addiction. “That’s why it’s important to treat the addiction and any kind of mood or anxiety disorder at the same time,” Morrow says.
A need for more substance to achieve intoxication: Continued opioid use slows endorphin production, leading a user to seek more to receive the same pleasure. “If you use a drug for a longer period or in larger amounts, that increases your risk of addiction.”
Withdrawal symptoms are evident: Diarrhea, sweating and moodiness, among other things, can occur when the drugs wear off. “It’s not medically dangerous, but it can be extremely uncomfortable,” Morrow says. That can inspire more opioid use to counteract the effects.
Medication-Assisted Treatment at PAMCC
Primary Addiction Medicine Care of Connecticut recommends and prescribes Buprenorphine – Naloxone (Suboxone, Zubsolv) as our main choice for Medication-Assisted Therapy.
Based on our experience and medical literature, Suboxone is the safest and most effective treatment for opioid dependence and/or use disorder. We do not prescribe or manage Methadone.
The National Institute of Health reports that Suboxone (buprenorphine/naloxone) is a safer medication-assisted treatment than alternatives due to its lower risk of fatal overdose. It matches methadone’s effectiveness for reducing cravings and relapses, but with less risk of respiratory depression and mortality, especially for long-term recovery.
Key Findings on Safety and Effectiveness:
- Lower Overdose Risk: Suboxone acts as a partial agonist, creating a “ceiling effect” for respiratory depression, which makes it less likely to cause fatal overdoses compared to full agonists like methadone.
- Reduced Mortality Rates: Studies, including those analyzing insurance claims, show that buprenorphine (active ingredient in Suboxone) and methadone significantly reduce the risk of death compared to no treatment, with buprenorphine sometimes showing better safety outcomes in studies.
- Safety in Pregnancy: The MOTHER trial (2010) found that buprenorphine was safer for the neonate compared to methadone, resulting in shorter hospital stays and milder neonatal abstinence syndrome, though methadone showed higher treatment retention rates.
- Lower Abuse Potential: Suboxone includes naloxone, which is designed to prevent injection abuse, further improving its safety profile in supervised care settings.
- Increased Treatment Success: Research indicates that maintaining Suboxone treatment for 12 months or longer is associated with better outcomes, lower relapse rates, and reduced risk of contracting infectious diseases like HIV and hepatitis C, often outperforming other treatments in retention studies.
Participation in our program necessitates a confidential controlled substance contract, which the patient must review and sign. This process serves to uphold safety standards and regulatory compliance with the DEA (Drug Enforcement Agency), given that Buprenorphine – Naloxone is classified as a Schedule III controlled substance.
Additionally, patients will be required to undergo scheduled urine drug screenings to promote accountability and ensure ongoing safety. All new patients must complete an initial blood screening that provides a comprehensive evaluation of the liver, kidneys, thyroid, endocrine systems, STD (HIV, Hep C) screening, and cardiac health assessment.
Furthermore, a physical examination and EKG will also be scheduled to thoroughly assess heart health and readiness for treatment.