Opioid Use Disorder

What is opioid use disorder?

Opioid use disorder (OUD) is a mental health condition in which a problematic pattern of opioid misuse causes distress and/or impairs your daily life.

OUD exists on a spectrum and may be mild, moderate or severe. It typically involves an overpowering drive to use opioids despite consequences, increased opioid tolerance and/or withdrawal symptoms when you stop taking opioids.

Opioid use disorder is a chronic (lifelong) condition with serious potential consequences, including disability, overdoses, relapses and death.

What are opioids?

Opiates and opioids are narcotics. Narcotics are a class of drugs that are chemicals — natural or synthetic — that interact with nerve cells and have the potential to reduce pain. Opiates occur in nature, though they can still be very dangerous in their purified and concentrated forms. Opioids are almost always made by using chemistry.

Prescription narcotics are meant to treat acute pain (such as recovering from an injury or post-surgery) and can sometimes help chronic pain. Some examples of prescription opioids and opiates include:

• Oxycodone.
• Oxymorphone.
• Morphine.
• Codeine.
• Fentanyl.

Heroin is another opiate that’s a derivative of morphine. It’s exclusively used for recreational purposes.

Opioids and opiates can become addictive because they not only dull pain, but can also produce a sense of euphoria in some people. This, combined with tolerance build (needing to increase doses to produce the same effect) can lead to opioid use disorder.

Not everyone who takes prescription narcotics develops a use disorder, especially when you take them short-term, such as recovering from surgery in a hospital. When you carefully follow prescription instructions, the chances of developing a dependence decrease.

What is the difference between opioid use disorder and opioid dependence?

Opioid dependence simply refers to the development of tolerance or withdrawal. Tolerance is needing higher doses to produce the same effect or getting less benefit from the same dose over time. Withdrawal is experiencing nausea, diarrhea, a runny nose or other problems when you stop taking opioids.

Opioid use disorder is a pattern of opioid use that causes life problems or distress. The person finds it difficult to adjust or eliminate their use in response to problems caused by the drug.

Opioid use disorder may involve physical dependence and psychological dependence. People are psychologically dependent when a drug is so central to their thoughts, emotions and activities that the need to continue its use becomes a craving or compulsion despite negative consequences.

Who does opioid use disorder affect?

Opioid use disorder affects people of all ages, races, sexes and socioeconomic levels.

Approximately 3% to 19% of people who take prescription opioid medications develop OUD. People misusing opioids may try to switch from prescription drugs to heroin when it’s easier to get. This indicates that the disease is getting more dangerous.

About 45% of people who use heroin started with misuse of prescription opioids. Some people develop OUD by starting with heroin use.

How common is opioid use disorder?

Opioid use disorder is common. It affects over 20 million people worldwide and over 3 million people in the United States. Opioid use disorder is an epidemic in the U.S.

Opioids are responsible for over 120,000 deaths worldwide every year.

What are the signs of opioid use disorder?

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the signs of opioid use disorder include:

• Taking larger amounts of opioids or taking them over a longer period than prescribed.
• Having a strong desire or urge to use opioids.
• Having unsuccessful efforts to cut down or control opioid use.
• Continuing to use opioids despite having recurring social or interpersonal issues due to using them.
• Spending a great deal of time obtaining or using opioids or recovering from their effects.
• Having issues fulfilling responsibilities at work, school or home due to opioid use.
• Giving up or reducing activities because of opioid use.
• Using opioids in physically hazardous situations.
• Continuing opioid use despite an ongoing physical or psychological problem that’s likely caused or worsened by opioids.
• Developing tolerance (need for increased amounts to get the same effect).
• Experiencing withdrawal (opioid withdrawal syndrome) or taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.

Seeking medical care as soon as you have signs and symptoms of OUD is essential.

Symptoms of opioid withdrawal syndrome

If you have a physical dependence on opioids, you may experience the following withdrawal symptoms if you stop taking them:

• Generalized pain.
• Chills and fever.
• Diarrhea.
• Dilated pupils.
• Restlessness and agitation.
• Anxiety.
• Nausea and vomiting.
• Intense cravings.
• Elevated heart rate and blood pressure.
• Sweating.
• Insomnia.

How does opioid use disorder develop?

Several complex factors contribute to the development of opioid use disorder, including:

• Opioids’ effect on brain chemistry.
• Access and exposure to opioids.
• Genetics and biology.
• Mental health and medical conditions.
• Adverse childhood experiences.

Opioids’ effect on brain chemistry

The likelihood of developing dependence following opioid use is high compared with most other drugs. Opioids have high addiction potential because they activate powerful reward centers in your brain.

Opioids trigger your brain to release endorphins. This neurotransmitter both decreases your perception of pain and creates feelings of euphoria. Once the opioid has worn off, so do these sensations. You may have a strong desire to continue using opioids to continue the feeling.

Opioids can lead to physical dependence within a short time — as little as four to eight weeks. People who use opioids for a long period of time can actually experience worse chronic pain because of the long-term toxic effects of opioids on pain signaling in their bodies.

In addition, once someone has physical dependence to opioids, the severe withdrawal symptoms create significant motivation to continue using opioids.

Access and exposure

Access to opioids is a particularly significant environmental risk factor. The availability and volume of prescription opioids, especially in North America, Western Europe and Australia, make them easier to access.

Other factors that increase the extent of exposure and the opportunity for opioid use include:

• Being prescribed opioids for pain. About 3% to 19% of people who take prescription opioid medications develop OUD.
• Use of opioids by a member of your household.
• Use of opioids by your peers.

Heroin is often easier to get than opioids that are meant to be prescriptions. This can also contribute to the development of OUD. Lately, powders and pressed pills that are illegally sold as heroin, cocaine, crystal meth or even prescription opioids pills actually contain doses of fentanyl that are very dangerous and often deadly.

Genetics and biology

Researchers estimate that genetic factors are responsible for 40% to 60% of the vulnerability to any substance use disorder. If you have a first-degree relative (biological sibling or parent) with OUD, you’re more likely to develop it as well.

Mental health and medical conditions

Several studies have found that about half of people who experience a mental health condition during their lives will also experience a substance use disorder and vice versa.

Overlapping factors such as genetic vulnerabilities, issues with similar areas of your brain and environmental influences cause both substance use disorders, such as OUD, and other mental health conditions.

Research shows that mental illness may contribute to substance use disorders, and substance use disorders can contribute to the development of mental illness.

Having any of the following mental health conditions can contribute to the development of OUD:

• Attention-deficit/hyperactivity disorder (ADHD).
• Bipolar disorder.
• Borderline personality disorder.
• Depression.
• Generalized anxiety disorder.
• Panic disorder.
• Post-traumatic stress disorder (PTSD).

Having certain physical health conditions, such as chronic pain, can increase people’s use of opioids and the eventual development of OUD.

Adverse childhood experiences

Adverse childhood experiences (ACEs) are strongly related to the development of a wide range of health issues throughout a person’s lifespan, including substance use disorders.

Several family-related ACEs increase the risk of drug use during adolescence (and adulthood), including:

• Poor quality of parent-child interactions and relationships.
• Parental conflict and domestic violence.
• Childhood abuse and neglect.
• Parent incarceration.

Other childhood factors that can increase your risk of developing OUD include:

• Behavioral disorders in childhood, such as conduct disorder.
• Untreated childhood ADHD.
• Poor school performance and low commitment to education.

How is opioid use disorder diagnosed?

A single test can’t diagnose opioid use disorder. Instead, healthcare providers rely on a thorough evaluation of your medical history and behaviors surrounding opioid use. They may order drug tests and evaluate prescription drug monitoring program reports.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a person must have at least two of the signs listed in the symptoms section to be diagnosed with OUD.

It’s important to remember that OUD exists on a spectrum of severity:

• Two to three signs is mild OUD.
• Four to five signs is moderate OUD.
• Six or more signs is severe OUD.

What is the treatment for opioid use disorder?

Effective treatments are available for opioid use disorder. Treatment is highly individualized — one person may need different types of treatment at different times.

Treatment for OUD often requires continuing care to be effective, as OUD is a chronic condition with the potential for both recovery and relapse.

Different types of treatment programs include:

• Outpatient counseling.
• Intensive outpatient treatment.
• Short-term residential treatment.
• Long-term therapeutic communities, such as sober living communities.

The most effect overall form of OUD treatment is called medication-assisted treatment (MAT), meaning that medications are combined with different types of counseling for a holistic approach.

Psychotherapy for OUD

Cognitive behavioral therapy (CBT) is a structured, goal-oriented type of psychotherapy (talk therapy).

Mental health professionals, including psychologists, therapists and counselors, use it to treat or manage mental health conditions.

During CBT, a mental health professional helps you take a close look at your thoughts and emotions. You’ll come to understand how your thoughts affect your actions. Through CBT, you can unlearn negative thoughts and behaviors and learn to adopt healthier thinking patterns and habits.

For OUD, CBT involves encouraging motivation to change and education about treatment, as well as preventing relapse.

CBT can also help manage other co-occurring mental health conditions a person with OUD may have.

There are many other types of psychotherapies that benefit people with OUD. CBT isn’t the only option. A well-trained therapist can recommend an individualized plan for you.

Self-help programs for OUD

Participating in self-help programs, such as Narcotics Anonymous, can also play a significant role in OUD treatment.

These programs support behavioral modification and better emotional regulation through self-help and peer support. The underlying principle of these programs is that people with OUD get well through:

• Understanding their condition.
• Sharing their challenges with others who have a similar problem.
• Working on personal improvement and recovery skills.

Group therapy supports people with OUD in learning healthier coping skills and reducing relapse risks.

Medications for OUD

Certain medications can help modify your brain chemistry to help treat OUD. They can also relieve cravings, relieve withdrawal symptoms and block the euphoric effects of opioids.

The three medications that are U.S. Food and Drug Administration (FDA)-approved to treat OUD include:

• Methadone: This medication prevents withdrawal symptoms and reduces cravings in people who have OUD. It’s only available in specially regulated clinics.
• Buprenorphine: This medication blocks the effects of opioids, reduces withdrawal symptoms and reduces cravings. Buprenorphine treatment is provided by specially trained healthcare providers in office-based settings. It’s available in pill form or monthly injections.
• Naltrexone: This medication blocks the effects of opioids, preventing the feeling of euphoria. It’s available from office-based providers in pill form or monthly injections.

What are the complications of OUD treatment?

Unfortunately, people with OUD are at the highest risk of death in the first four weeks of OUD treatment and in the four weeks after treatment ends if they relapse.

This is because it’s easy to miscalculate and use doses that they previously tolerated. But these doses lead to overdose due to loss of tolerance from a break in opioid use.

How can I prevent opioid use disorder?

If you or a family member is seeking treatment for acute or chronic pain, talk to your healthcare provider about pain medications or therapies that aren’t opioids to avoid bringing opioids into your home.

If you’re taking prescribed opioids, it’s essential to take them with extra care to prevent dependence and OUD. Helpful tips include:

• Take your medication exactly as prescribed by your healthcare provider — do not take extra doses.
• Check the instructions every time you take a dose.
• Don’t break, chew, crush or dissolve opioid pills.
• If you feel that you’re dependent on opioids or your prescribed dosage isn’t helping you manage your symptoms, don’t take more than your recommended dosage and talk with your healthcare provider immediately.
• Never share your opioid medication with someone else or sell your medication. Always store it in a safe place away from children.
• If you have leftover prescription opioids at the end of your treatment, find your community drug take-back program or your pharmacy mail-back program to safely dispose of them.

Talk to your children about how dangerous opioid drugs can be and why it's important to use them (and all other medications) only as prescribed. If you think you or your child may be using opioids nonmedically or are developing dependence, seek help as soon as possible.

What is the prognosis for opioid use disorder?

Left untreated, the prognosis (outlook) for opioid use disorder is often poor.

People who have severe OUD have an increased risk of:

• Injuries, such as from falls and traffic accidents.
• Blood-borne virus infections, such as hepatitis B (HBV), hepatitis C (HCV) and the human immunodeficiency virus (HIV) if they use shared injection equipment.
• Incarceration.
• Opioid overdose(s).
• Dying from an opioid-related overdose.
• Dying by suicide.

In addition, the mortality rate for people with OUD is 10 times higher than that of the average population.

It’s important to remember that OUD is treatable. However, only about 1 in 4 people with OUD receive professional treatment.

Medication-assisted treatment (MAT) for OUD decreases:

• Opioid use.
• Opioid-related overdose deaths.
• Infectious disease transmission.
• MAT increases social functioning and treatment retention. In addition, treatment with methadone or buprenorphine for pregnant people with OUD improves health outcomes for their babies.

What are the signs and symptoms of opioid overdose?

An opioid overdose can happen when a person takes too much of an opioid or a combination of opioids and other drugs.

Signs of an overdose include:

• Unresponsiveness or unconsciousness.
• Slowed or stopped breathing.
• Pinpoint pupils.
• Snoring or gurgling sounds coming from their mouth.
• Cold or clammy skin.
• Blue lips or fingernails.

Immediate action is needed to help someone experiencing an opioid overdose. Naloxone (commonly known by the brand name Narcan®) is a drug that treats the overdose immediately. Naloxone can reverse the effects of an opioid overdose if it’s given to the person quickly. Medical attention is still urgently needed after the administration of naloxone.

How can I help a loved one with opioid use disorder?

It can be very challenging and stressful to learn that someone you love may have opioid use disorder. Here are some tips to help your loved one and yourself:

• Speak up sooner rather than later: The earlier a person with OUD receives treatment, the better. Address your concerns and help them find treatment as soon as possible. Suggest calling a helpline, talking to a healthcare provider or mental health professional, entering a treatment program or going to a 12-step program like Narcotics Anonymous (NA). Offer your help and support without being judgmental.
• Practice empathy: Even when you don’t agree with your loved one, listen thoughtfully to them. The more your loved one feels heard, the more they’ll see you someone they can trust.
• Be patient: Don’t expect a single conversation or action to fix your loved one’s opioid use. OUD is a complex chronic condition, and there’s no quick fix to overcoming it.
• Take care of yourself: The friends and family members of people with OUD often experience stress, depression, grief and isolation. It’s important to take care of your mental health and seek help if you’re experiencing these symptoms. Consider joining a support group or organization in your community.
• Carry naloxone (Narcan®): If your loved one has an overdose, naloxone can potentially save their life. If you can, carry naloxone on you at all times. In response to the U.S. epidemic of opioid misuse, many communities are providing or prescribing naloxone overdose kits to first responders, people with OUD and family members of people with OUD. They’re also providing appropriate training to administer the naloxone. Naloxone is also often available without a prescription from local pharmacies.

When should I see my healthcare provider?

If you’re currently taking prescription opioids and are concerned you may be developing a use disorder, talk to your healthcare provider immediately.

If you think your child or a friend may be misusing opioids, get them medical help as soon as possible.

A note from Cleveland Clinic

Opioid use disorder is a complex mental health and brain condition. Opioids affect your brain, including your decision-making ability. These changes make it hard to stop taking opioids, even if you want to. If you or a loved one has opioid use disorder, talk to a healthcare provider as soon as possible. A trained provider can help guide you to the treatment you need.