Opiate Abuse and Mental Illness
The term “opiate” refers to a number of different substances—both legal and illegal—originally synthesized from the poppy plant and sharing certain chemical properties. Both legal opiates (e.g., oxycodone [Oxycontin, Percocet], hydrocodone [Vicodin], codeine, morphine [MS Contin], hydromorphine [Dilaudid]) and illegal opiates (e.g., heroin or illegally obtained prescription opiates) are highly addictive substances. Most people are aware of the dangers that heroin poses, yet approximately 100,000 Americans will use this drug for the first time each year.
Many people are prescribed opiate medications and use them responsibly and without experiencing significant adverse effects. In spite of this, prescription opiates are amongst the most commonly abused substances in America: approximately two million new individuals will use these drugs for non-medical purposes each year. While some people may try it a single time, people who abuse opiates are very likely to experience consequences of their opiate use. Someone who has difficulty stopping their habit, gets sick, injured or arrested due to their use—or who experiences problems at work, school or at home due to being intoxicated—may be dependent on opiates.
What happens when a person abuses opiates?
A person who uses opiates may begin to feel “high.” This can involve peaceful feelings—such as being happy or relaxed—which are most likely related to the drug’s interactions with certain chemicals in the brain (including opiate receptors). People with mental illness may be more likely to also experience negative emotions such as depressed mood.
People who regularly abuse opiates may become addicted (e.g., their body becomes physically dependent on the substance). An addicted person who abruptly stops using opiates will experience opiate withdrawal—a group of symptoms causing intense physical and psychological distress. Opiate withdrawal generally begins within six to 12 hours of one’s last use but can take days if a person had been abusing a longer-acting opiate drug. In most cases, opiate withdrawal is not a medical emergency and consists of uncomfortable symptoms such as low mood, restlessness, muscle and joint pain, runny nose, tearful eyes and stomach upset (e.g., nausea, vomiting, cramping, diarrhea). Some people may also experience changes in their vital signs, developing high blood pressure or an elevated heart rate. In certain groups of people (e.g., children, elderly individuals and people with heart disease) opiate withdrawal can become a medical emergency when symptoms cause cardiovascular instability. In such situations a person may require medical attention to avoid long-lasting consequences of opiate-withdrawal.
Many people seek assistance in going through the process of stopping their opiate abuse. This can include inpatient detoxification which can involve admission to a hospital—either a general hospital or a detoxification facility—and treatment with the appropriate medications to avoid serious complications of opiate withdrawal. The specifics of detoxification are largely beyond the scope of this review; in brief, available treatments include the use of opiate-agonist treatments such as buprenorphine (Suboxone, Subutex) or methadone or the use of non-opiate medications such as clonidine (Catapres).
What is the relationship between opiate abuse and mental illness?
The relationship between opiate abuse and mental illness is complex, and the treatment of both is more complicated than the treatment of either condition alone. Certain groups of people with mental illness—including males, individuals of lower socioeconomic status, military veterans and people with other medical illnesses—are at increased risk of abusing opiates. Scientific data is clear that regular opiate abuse is linked to increased risk of legal troubles and jail time, difficulties at school and at work, as well as abuse of other drugs. When opiates are used together with other drugs—including alcohol—the risk of unintentional lethal overdose is greatly increased.
Opiate abuse results in a worse prognosis for a person with mental illness. People who are actively using are less likely to follow through with their treatment plans. They are less likely to adhere to their medication regimens and more likely to miss appointments, which lead to more psychiatric hospitalizations and other adverse outcomes. Active users are also less likely to receive adequate medical care for similar reasons and are more likely to experience severe medical complications and early death. People with mental illness who abuse opiates are also at increased risk of impulsive and potentially violent acts. Perhaps most concerning is that people who abuse opiates are more likely to both attempt suicide and to die from their suicide attempts.
People with mental illness and active opiate abuse are less likely to achieve lasting sobriety. They may be more likely to experience severe complications of their substance abuse, to end up in legal trouble from their substance use, and to become physically dependent on opiates.
What is the relationship between opiate abuse and medical illness?
The potential health benefits of controlled opiate use are largely beyond the scope of this review. However, it should be noted that while controlled use of opiates has been shown to be helpful in certain specific medical illnesses (e.g., certain chronic pain syndromes), it is by no means a first-line treatment for these conditions. In fact, the majority of people who inappropriately use opiates are at risk of significant medical illness.
Many people use opiate drugs intravenously—injecting the drugs into their veins. This method of drug abuse carries specific health risks due to the use of shared, dirty needles. Intravenous drug use remains the second most common means of contracting HIV/AIDS in America and the most common means of contracting hepatitis C, a potentially deadly liver disease. While using clean needles is much safer, people who inject drugs into their body are at risk of strokes, blood vessel disease and developing severe infections (including endocarditis and tuberculosis).
Some people may not be familiar with the significant risk of fatal overdose that accompanies opiate abuse. Opiate overdose is a life-threatening emergency that occurs when a person uses too much and becomes sedated, then unconscious. At this point, a person may stop breathing and require immediate medical care to avoid death or permanent brain damage. This can happen to people who use any kind of opiate, whether the substance is swallowed, snorted or injected.
What treatments are available for people with opiate abuse and dependency?
For people with severe opiate abuse, the first step is to ensure a safe detoxification. After this is achieved, many options exist for people who are newly sober or who are trying to avoid relapse on opiates. These can include inpatient rehabilitation centers or supportive housing (e.g., sober houses, group homes or residential treatment facilities). Others may choose to return home to their friends and family who can be helpful in encouraging the newly-sober individuals to continue their efforts.
Some people find therapy to be a helpful part of maintaining their sobriety. This can include self-help groups such as Narcotics Anonymousor SMART Recovery. Individual therapy can also be useful, and some people will find that cognitive behavioral therapy is an important part of their treatment plan. Another form of therapy called “motivational interviewing”—an interactive, patient-centered model of treatment focused on finding inspiration for behavioral change—has been found to be effective in helping people to stop abusing opiates. These and other tools can be useful, as a significant majority of people will relapse at some point in their lives, even if they are eventually able to achieve long-lasting sobriety.
There is no medication that can cure opiate abuse. A number of different medications have been studied in the treatment of opiate abuse, and the specifics of each should be discussed with one’s prescribing physician and the rest of the treatment team. Naltrexone (Revia, Vivitrol) is an opiate-antagonist, approved by the FDA for the treatment of opiate abuse, which is helpful in decreasing drug cravings. A significant percentage of people will find opiate-agonist treatments (e.g., buprenorphine [Suboxone, Subutex] and methadone) to be helpful, and these medications are also approved by the FDA. While some people may feel unsure about long-term treatment with these medications, opiate-agonist treatments have been shown to decrease the frequency of opiate abuse as well as the risk of relapse. People involved in treatment with buprenorphine and methadone are at lower risk of death than those who are not treated with these medications.
Family, friends and others can be most helpful in providing empathic and non-judgmental support of their loved one. With this support and effective psychiatric treatment, many people with opiate abuse and mental illness will be able to actively participate in their recovery journey.
Reviewed by Ken Duckworth, M.D., and Jacob L. Freedman, M.D., March 2013