Opioids and Opiates Explained

Opioids vs. Opiates

• Opioids can be natural/organic, synthetic, or partially synthetic.
• Opioids interact with opioid receptors in the body and brain.
• Opioids reduce pain signals and feelings.
• Opiates are natural opioids from the opium poppy, including heroin, morphine, and codeine.

How Opioids Work

• Endorphins are naturally occurring opioids that produce feelings of euphoria.
• Opioid pain receptors are tiny "docking stations" at the end of nerve cells that prevent pain signals from traveling.
• Opioids block pain signals when attached to pain receptors.
• Opioids release dopamine throughout the body.
• Dopamine is important for reward, motivation, memory, attention, and learning, and can regulate body movements.

How Prescription Opioids Work

• Prescription opioid drugs mimic endorphins and attach to receptors.
• The body produces more pain receptors in response to large amounts of prescription opioids.
• More pain receptors mean more opioids are needed.
• Opioids decrease the ability to create and use natural endorphins over time, causing a loss of the ability to reduce pain naturally.

Uses of Prescription Opioids

• Prescription opioids treat moderate to severe pain.
• They are often prescribed after surgery/injury, cancer, or chronic pain conditions.
• They have also been used for long-lasting chronic pain (e.g., back pain, osteoarthritis), despite risks and a lack of evidence for long-term effectiveness.

Prescription Opioid Categories

• Natural opioids include morphine and codeine.
• Semi-synthetic opioids include oxycodone, hydrocodone, hydromorphone, and oxymorphone.
• Synthetic opioids include methadone, tramadol, and fentanyl; methadone can be for pain reduction or opioid use disorder treatment.

Prescription Fentanyl

• Fentanyl is a synthetic opioid for severe pain, typically for advanced cancer pain relief and surgery.
• Prescription fentanyl is 50 to 100 times more potent than morphine.
• It can be prescribed as transdermal patches or lozenges/oral swabs.

Illicitly Manufactured Fentanyl (IMF)

• IMF is illegally sold for its heroin-like effects and linked to overdose deaths.
• It is often pressed into counterfeit pills or mixed with heroin/cocaine.
• Fentanyl analogs are chemically related drugs that mimic fentanyl's effects.

Opioid Prescribing Practices in the US

• There is wide variability at the county level in the amount of prescription opioids prescribed per resident.
• Counties with higher opioid prescribing rates often:
  • Are generally smaller cities or larger towns
  • Have a higher percentage of white residents
  • Have more dentists and primary care physicians per capita
  • Have more uninsured or unemployed people
  • Include more residents with diabetes, arthritis, or a disability (CDC, 2020)

History of Prescription Opioids

• 1800s:
  • German pharmacist Friedrich Serturner first isolated and extracted the alkaloid from the poppy plant, creating morphine.
  • Morphine was named after the Greek god of dreams, Morpheus.
  • It was used to treat wounded soldiers.
  • The majority of those addicted were women.
• 1900s:
  • Tens of thousands of Americans were addicted to morphine.
  • By 1914, physicians and patients were advised to avoid opiates, which continued until the 1990s.
• 1995:
  • The American Pain Society urged more aggressive and long-term use of prescription opioids for chronic, non-cancer pain.
  • Purdue Pharma released extended-release oxycodone (OXYCONTIN®).
• 1997-2007:
  • OXYCONTIN® prescriptions in the U.S. increased from 670,000 to 6.2 million.
  • Purdue Pharma pleaded guilty to federal charges related to misbranding OXYCONTIN® and misleading physicians and the healthcare industry.
  • Afterwards, the U.S. experienced high levels of deaths related to prescription opioid use, referred to as the Opioid Epidemic or Opioid Crisis.
• 2013-2016:
  • Synthetic prescription opioids emerged, which are highly potent drugs mimicking naturally occurring opioids (e.g., Fentanyl).
  • Fentanyl caused nearly 20,000 additional drug-related deaths in 2016.
• 2019:
  • Numerous states are passing laws to lessen the effects of the opioid crisis
  • Purdue Pharma files for Bankruptcy
• 2020:
  • Purdue Pharma pleaded guilty to three felony accounts of criminal wrongdoing.
  • Purdue Pharma was reorganized into a public benefit corporation, with profits from future prescription opioid sales funding programs to alleviate Opioid Use Disorder in the U.S.

Side Effects of Prescription Opioids

• Increased sensitivity to pain
• Constipation
• Nausea, vomiting, and dry mouth
• Sleepiness and dizziness
• Confusion
• Depression
• Low levels of testosterone (lower sex drive, energy, and strength)
• Itching and sweating

Non-Medical Use of Prescription Opioids

• Non-medical use refers to taking prescribed/diverted prescription drugs (drugs not prescribed to the person using them):
  • Not in the prescribed way
  • Not for the prescribed reasons
  • Not in the prescribed amount
  • Not during the prescribed time-period.
• The term "non-medical use" has replaced "misuse" to reduce stigmatizing language.

Risks of Non-Medical Use of Prescription Opioids

• Opioid tolerance: Reduced response to medication, requiring more opioids for the same effect.
• Physical dependence: The body adjusts to regular opioid use. Unpleasant/excruciating physical symptoms occur when medication is stopped.
• Opioid Use Disorder: A problematic pattern of unsuccessful attempts to cut down/control use or when use causes social problems.
• Overdose: Injury to the body (poisoning) from excessive amounts of a drug. Can be fatal or nonfatal. "Opioid-based" drugs cause respiratory depression (slows/stops breathing).

Physical Consequences of Non-Medical Use of Prescription Opioids

• Short term include: feelings of euphoria, dry mouth, headache, flushing, mental fog, constipation, drowsiness, itching, respiratory depression, lethargy
• Long term include: developing Opioid Use Disorder, irregular heartbeat, increased risk of heart attack, fatigue, breathing problems, low blood pressure, chest pain, depression, severe constipation, severe abdominal pain, hormonal problems, weak bones, increased

Mental Health Consequences of Non-Medical Use of Prescription Opioids

• Anxiety
• Anger
• Depression
• Confusion
• Paranoia
• Mood swings
• Irritability
• Hallucinations
• Suicidal ideations
• Impaired judgment
• Loss of pleasure
• Reckless behavior

Consequences of Non-Medical Use of Prescription Opioids

• Societal: Children removed from home, high incarceration rates, car crashes, suicidal deaths.
• Economic: Costs to individuals and society.

Belzak et al. (Canadian Context)

• The opioid crisis is growing in Canada, driven by both illegal and prescription opioid use; fentanyl/analogues are fuelling opioid-related deaths.
• The crisis has a devastating impact on Canadians, their families, and communities. In 2016, there were 2861 opioid-related deaths and 16 opioid-related hospitalizations each day.
• Western Canada and the northern territories have experienced the highest burden.
• Most opioid-related deaths occurred among males (74%); individuals between 30 and 39 years accounted for the greatest proportion (28%).
• The crisis is not restricted to opioids: 82% of apparent opioid-related deaths from January 2016 to June 2017 involved one or more non-opioid substances.

Selfridge et al.

• Overdoses are common.
• Communities and friend groups take care of each other.
• Some people do not have confidence in the police, especially for overdose calls, because they think if you are using drugs authorities do not care.
• In some cases, police can be helpful in overdose situations.
• The Good Samaritan Drug Overdose Act (GSDOA) is part of protocol during overdose events.

Selfridge et al.: Recommendations to Support & Enhance Interventions

• Continue to improve access to naloxone and information about overdose response for youth.
• Increase youth knowledge of the GSDOA.
• Police departments must continue to work collaboratively with local stakeholders to review and revise community-specific policies around jurisdiction, interactions with first responders, and liability issues related to overdose events and naloxone administration.
• Continue police training and collaboration to reduce negative experiences at overdose events with all people who use drugs.
• Structure and create support for youth who witness or are traumatized by overdose experiences.

Government of Canada Initiatives to Address the Opioid Crisis include:

• Making naloxone more readily available
• Regulatory amendments have been made which over turn the ban on diacetylmorphine (heroin) and they allow for consideration of applications made through The Special Access Program.
• Introducing Bill C-37 to simplify and streamline the application process for supervised consumption sites