Opioids

The use of opioids in the United States is much less prevalent than reported for the other drugs discussed above. For example, as of the 1990s, less than 0.5 percent of young adults have reported trying heroin at some time during their lives. There are three basic patterns of opioid use and dependence in the United States. The first group constitutes the smallest percentage of opioid users— those who initially began using morphinelike drugs medically, for the relief of PAIN. The second group began using illegal drugs through experimentation and then progressed to chronic use and dependence. The third group represents physically addicted individuals who eventually switched to oral METHADONE, obtained through organized treatment centers. Interestingly, the incidence of opioid addiction is greater among physicians, nurses, and related health-care professionals (who have access to these drugs) than in any group with a comparable educational background. In many instances (but not all), those addicted either to heroin (usually purchased illegally on the street) or to metha-done (usually from treatment centers) are able to hold jobs and raise a family. Opioids reduce pain, aggression, and sexual drives, so the use of these drugs is unlikely to induce crime. Those who can not afford opioids, those who like the ''drug life," and those who are unable or unwilling to hold a job, resort to crime to support their drug habits.

Opioid drugs produce their pharmacological effects by binding to opiate RECEPTORS. The euphoria associated with the use of opioids results from interactions of these drugs with the mu-opiate receptor, possibly resulting in the stimulation of mesocorticolimbic dopaminergic neuronal activity. The rapid intravenous injection of morphine (or heroin, which is converted to morphine once it enters the brain) results in a warm flushing of the skin and sensations in the lower abdomen that are often described as being similar in intensity and quality to sexual orgasm. This initial rush (''kick'' or ''thrill'') lasts for about 45 seconds and is followed by a high—described as a state of dreamy indifference. Depending on the individual and the social circumstances, good health and productive work are not incompatible with the regular use of opioids. Tolerance can develop to the ANALGESIC, respiratory depressant, sedative, and reinforcing properties of opioids, but the degree and extent of tolerance depends largely on the pattern of use. Desired analgesia can often be maintained through the intermittent use of morphine. Tolerance develops more rapidly with more continuous opioid administration.

The abrupt discontinuation of opioid use can lead to a withdrawal syndrome that varies in degree and severity depending on the individual as well as the particular opioid used. Watery eyes (lacrima-tion), a runny nose (rhinorrhea), yawning and sweating occur within twelve hours from the last dose of the opioid. As the syndrome progresses, dilated pupils, anorexia, gooseflesh (''cold turkey''), restlessness, irritability, and tremor can develop. As the syndrome intensifies, weakness and depression are pronounced, and nausea, vomiting, diarrhea, and intestinal spasms are common. Muscle cramps and spasms, including involuntary kicking movements (''kicking the habit''), are also characteristic of opioid withdrawal; however, seizures do not occur and the withdrawal syndrome is rarely life-threatening. Without treatment, the morphine-induced withdrawal syndrome usually runs its course within seven to ten days. Opiate-receptor antagonists (e.g., NALOXONE) are con-traindicated in opioid withdrawal, since these drugs can precipitate a more severe withdrawal on their own. Rather, longer-acting, less potent, opi ate-receptor agonists such as methadone are more commonly prescribed. The symptoms associated with methadone withdrawal are milder, although more protracted, than those observed with morphine or heroin. Therefore, methadone therapy can be gradually discontinued in some heroin-dependent individuals. If the patient is unwilling or unable to withdraw from methadone, the individual can be maintained on methadone indefinitely.

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