Opioid Addiction (Opioid Use Disorder)?
Addiction is a brain disease and when treated like a chronic medical illness, results are similar to other chronic medical illnesses such as hypertension, asthma, and diabetes.1,2 This means that long term treatment is necessary and it is not going to disappear the way an acute illness would resolve after a short term treatment.
It often has its roots in genetics, mental health conditions, trauma, and unstable living situations. Effective treatment for Opioid Use Disorder involves appropriate medication assisted treatment (MAT), counseling, and group support. It often involves treatment for underlying conditions such as depression, anxiety, and trauma. Family members may also need support.
It is characterized by tolerance, cravings, and withdrawals. It is marked by the inability to stop using despite harmful consequences of using opiates that can affect personal relationships, education, and employment. Harmful consequences of Opioid Use Disorder include: dysfunctional relationships, inability to hold a job, criminal behavior, Hepatitis C, HIV/AIDs, endocarditis, osteomyelitis, and overdose.
There are three phases of addiction3:
The Binge/Intoxication phase is characterized by rapid release of dopamine in the reward centers of the brain. As addiction progresses, it takes more of the substance to achieve the same effect. Often, the individual uses the opiates just to achieve a feeling of normalcy.
The Withdrawal/Negative Affect phase is characterized by dysphoria, emotional pain, and irritability. There is an increase in anxiety and stress like responses.
The Preoccupation/Anticipation phase occurs weeks to months after withdrawals are completed, it is characterized by craving and it is a key element of relapse. It is characterized by increased cravings, increased brain levels of dopamine and glutamate. It is also characterized by decreased activity in the areas of the brain that regulate decision making, inhibitory control and working memory
Addiction is defined by the American Society of Addiction Medicine as:
Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences.
Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.
Opioid Use Disorder is diagnosed based upon the 11 criteria established by the DSM-V:
Opioids are often taken in larger amounts or over a longer period of time than intended.
There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
Craving, or a strong desire to use opioids.
Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
Important social, occupational or recreational activities are given up or reduced because of opioid use.
Recurrent opioid use in situations in which it is physically hazardous
Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by opioids.
*Tolerance, as defined by either of the following:
(a) a need for markedly increased amounts of opioids to achieve intoxication or desired effect
(b) markedly diminished effect with continued use of the same amount of an opioid
*Withdrawal, as manifested by either of the following:(a) the characteristic opioid withdrawal syndrome(b) the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms
*tolerance and withdrawal are not considered to be met for those individuals taking opioids solely under appropriate medical supervision.
Criteria from American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,. Washington, DC, American Psychiatric Association page 541
Volkow, N, G. Koob, and A. McLellan. Neurologic Advances from the Brain Disease Model of Addiction. N Engl J Med 2016;374:363-371.
Mclellan AT, et.al. Drug Dependence, A Chronic Medical Illness, implications for Treatment, Insurance, and Outcomes Evaluation. JAMA 2000: 284:1689-169
Koob G, and N. Volkow. Neurobiology of Addiction: A neurociruitry analysis. Lancet Psychiatry. 2016 August; 3(8):760-773