Opioids and Heroin

Summary

• Mix of substance use disorders and mental health disorders
• Treatment should be well planned and client-centered

The term co-occurring disorders or COD means having at least one mental illness along with one or more substance use disorder. But there is nothing simple about having this condition. The two or more disorders will negatively impact each other. This requires that each disorder be treated separately but also at the same time. Recovery is not an easy process, but it is a goal that can be reached.

Types of COD

Substance use disorder can occur along with any mental illness. Some of the more common mental health issues linked with COD include:

• Depression
• Anxiety
• Schizophrenia
• Bipolar disorder
• Post-traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)

Other disorders related to mood, anxiety, sleep, eating, and personality also often occur with COD.

Some common classes of substance use disorders include:

• Alcohol
• Nicotine
• Caffeine
• Cannabis
• Cocaine
• Amphetamines
• Sedatives
• Opioids

People with COD can have any mixture of substance use disorders and mental health disorders, but at least one of each.

Risks of COD

People with COD have certain higher risks than people with a single disorder. They also tend to be in poorer health and have a greater chance of relapse. Some of this is due to not taking or responding to treatment as well. The time and cost involved in this treatment is also higher.

Among these increased risks are:

• Violence
• Physical illness
• Psychosis
• Hospitalization
• Homelessness
• Unemployment
• Incarceration
• HIV/AIDS

Screening for COD

About half of all people with severe mental illnesses also have substance use disorders. The rate of people with substance use disorders who have mental illnesses is even higher. Despite these facts, screening for COD can be a challenge. A mental health service may not be able to spot substance use disorder. A substance use treatment center may not be able to spot mental illness. The screening process should decide whether or not the person needs to be further assessed. This assessment is then performed by a mental health doctor or other trained health care worker.

Treatment and recovery

Treatment for COD must target each disorder by itself and at the same time. This may occur in one setting or a number of settings. Treatment should be well planned and client-centered. This means the person with COD needs to be involved with all aspects of care. The type of care will depend on the types of substance use and mental disorders. It should also be tailored to the person’s unique needs and goals.

COD takes a toll on those who have it and on those around them. Coping skills must be taught to the individual as well as to her support group. Progress may be slow and sometimes hard to measure. The chance of relapse seems to always be right around the corner. Setbacks should be met with support rather than blame. The person will respond to praise much more than to guilt. Recovery is a long process that will require a group effort. It is not an easy task but it is well worth it.

Resources

Alcoholics Anonymous
www.aa.org

Narcotics Anonymous
www.na.org

National Alliance on Mental Illness
www.nami.org

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

By Kevin Rizzo

©2022 Carelon Behavioral Health

Summary

Recovery from meth addiction is hard work, but there are people who have succeeded. Recovery takes:

• A multidisciplinary approach
• A lifetime commitment
• Hard work

Success in drug rehabilitation is counted in small steps. Each step is a victory over monumental forces, moving a person toward a new, healthier life.

Addiction starts innocently, usually around age 14, when a young person starts experimenting. At that age, teens are testing the waters of adulthood. Many have problems with their parents, as they learn how to grow out from under their parents’ protective wings. Some are bullied, or are turned away by those they want as friends.

Teens sometimes yearn for the freedom age will bring, but also fear the responsibilities that face them.

“The kids I worry about are the ones who are depressed or bullied,” said drug counselor William Shryer. “So many young people do not receive proper guidance from parents or other adults, so they turn into aimless wanderers and get addicted. Instead, they need to be learning how to get their lives in order, and how to take on the responsibilities of adulthood.”

“How a person gets addicted is complex,” explains Jenny Karstad, Addiction Treatment Counselor for an inpatient facility in New England. “Parents often blame themselves for their kid’s addiction, or they do just the opposite and deny any responsibility. By the time young people come to us for help, many of their families have written them off.”

Treatment counselors will tell you that addiction is the same, whether it is to alcohol, heroin, or meth. However, crystal methamphetamine brings special problems along with an extraordinary high. Someone addicted to alcohol or heroin can rid himself of the substance through carefully managed detoxification, but meth makes physical changes to the brain and body that last a long time, slowing down the rehab and recovery processes.

Richard Rawson, M.D., Associate Director of the UCLA Integrated Substance Abuse Programs, explained why those processes are difficult for people dealing with meth addiction, in the “Frontline” series “Meth and the Brain”:

“The difficult part with methamphetamines isn’t stopping, it’s not relapsing,” Rawson said.

“Methamphetamine actually will sit [in the brain] for eight to 12 hours … [while it] destroys the nerve terminals. Now, luckily for meth users they regrow, however the bad news is they take quite some time. The reward center of the brain has essentially been damaged. Other areas of the brain are also affected. Meth users in early recovery really don’t have the ability to make good decisions. Individuals do stupid things that end up with them relapsing and going back to using. It’s a wonder any meth users ever get better, but in fact they do.”

Those who beat it may take the long road back, finding other addictions along the way. Families generally need to be involved in the process, so they can learn how to change the home environment in a way that will help their loved one.”

Here are two success stories. Both people were addicted to meth. They started using drugs as teens, got addicted and fell into dangerous lifestyles. In each case, the paths downhill and uphill were not straight ones, and both men have yet to reach their destination. But they are pointed in the right direction, with a good chance at enjoying sober, healthy, and happy—or at least, normal—lives.

Trading up

Walter Barrera was mad when his father left his family in war-torn El Salvador to go to the U.S. to work. At a young age, Walter was sexually molested. By age 16, he and his father were reunited when the entire family moved to suburban Washington, D.C. Walter completed high school there, and also started using party drugs on weekends with his friends.

Eventually he found meth, and addiction set in quickly. Urged by his family, Walter went to a residential treatment program in California, but returned home addicted to crack cocaine. His life continued to go downhill. He was robbed and injured, stole money to pay for drugs, and eventually ended up in jail.

By 2006, Walter was ready to try to beat addiction, once again. He voluntarily entered the La Casa in-patient treatment program in D.C., where he lived for two months. Every night he dreamed about drugs, and longed for the day when he could get out to find some.

But the treatment began to work, in spite of his longings for drugs. Little by little, he found ways to fight against the pull of addiction. He worked one on one with a counselor, setting short-term and long-term goals for himself. He also attended daily group sessions.

One day, a representative from a self-help organization spoke to his group about running. Barrera was not impressed, but the runner explained that athletes build skills the same way addicted people build lives without drugs:

Running a marathon may look like an impossible goal, she said, but it’s not. Plenty of people have done it. They started slowly, then took one step at a time. Eventually, they were running long distances.

And, that is exactly what Walter did. At first, it was hard for him to run a block, let alone a mile. His body complained, but he kept pushing. He ran one, then two, then three miles. He gave up cigarettes and started going to church. He lost weight, started working out, and working in a restaurant. Walter told people he felt better about himself, and they noticed the difference. Over time, he gained the trust of the staff at La Casa, who allowed him more and more freedom to pursue running.

Walter said running brings him closer to peace than he has ever been. He puts everything he learned at La Casa to use, by setting mileage goals, keeping himself healthy, and finding inner peace while he is close to nature, while running.

But, everything in his life was not rosy. He still needed to learn responsibility. In 2011, he did just that when he turned himself in to serve a short prison sentence for an outstanding warrant. This time, he dreamed about running.

Today, he is a super-long-distance runner. To train, he pushes himself to run more than 100 miles a week. When he runs less, he doesn’t feel good, so his desire for the runner’s euphoria drives him to meet his goals.

He has a job, shares a house with roommates, and is involved in a church, where he gets support he needs.

In the past year, Walter’s recovery story has been told repeatedly in newspapers, magazines, and on television. He is a hero and idol for many in the recovery community.

Addiction counselors are not so quick to applaud, however. They insist that it is dangerous to substitute one addiction for another. The goal of rehabilitation and recovery is to learn how to cope with life’s difficulties, setbacks, boredom, and ups and downs, without being high from drugs or even from sports.

“You have to have a balance. Without it, your life is always going to be up and down,” says Gabrielle McCraney, Program Director at La Casa.

“What if he sprains an ankle and can’t run?” commented Shryer, upon hearing Walter’s story.

In a story in The Washington Post, Walter responded to those concerns.

“I’m a new person. I’m a new creation,” he says. “I don’t think I run to stay sober. I do it just to have fun, to feel like myself—something I didn’t do for so long.”

Back from the brink

Nic Sheff grew up in California, the son of a writer and artist. At age 11, he started drinking. Then he tried marijuana. By the time he got to high school, he was using drugs daily, including meth, but he hid his problem from his parents.

In spite of his addiction, he got into college and that’s when his drug use became obvious. His father spoke to doctors and arranged for treatment. Nic went, and then went back to using. This process repeated for years. At one point, his family took out a second mortgage to pay for an expensive residential program.

Although Nic said he wanted to get clean, nothing worked. He turned to shoplifting, drug dealing, and prostitution to pay for drugs and to escape his parents. He stole from them, as well as from friends. Although he went home for periods of time, for a while, he mostly experienced homelessness.

In his book, Tweak: Growing Up On Methamphetamines, Nic looks back on those years:

“And though I have done many shameful things, I am not ashamed of who I am. I am not ashamed of who I am because I know who I am. I have tried to rip myself open and expose everything inside—accepting my weaknesses and strengths—not trying to be anyone else. ‘Cause that never works, does it?”

Nic’s father, David Sheff, never gave up on him, although he came close. David Sheff tells the story from his perspective in his best-selling book Beautiful Boy: A Father’s Journey Through His Son’s Addiction.

Addiction is a family problem, says William Shryer. When helping people deal with addiction, Shryer reminds people, “You may think that your use only affects you, but it affects everyone around you. People don’t want to offend you or drive you away, but you need to do something about this problem because you are killing us all!”

And, Nic nearly did. Not only did he come close to death, members of his family suffered, mightily.

Why couldn’t he stop? Like many people with addiction, Nic always believed he could, if he really wanted to. He thought he could beat meth, but meth was getting the better of him. It was not until he found out more about himself and the way his mind operated, that he could stay in treatment long enough to make a difference.

One treatment program discovered that Nic has bipolar disorder and attention-deficit/hyperactivity disorder. These problems often go hand and hand with alcohol or substance use disorder, according to Shryer.

He explains that many people get addicted to drugs, inadvertently, because they self-medicate with drugs or alcohol to compensate for an underlying, undiagnosed illness. They sense there is something amiss, but do not know what it is. Because meth is a stimulant, it helps a person with those problems feel better, so they take it and get addicted.

Once Nic was treated for bipolar disorder, it was easier for him to stay in a rehabilitation program for meth. He was in an interdisciplinary program, which means it used a variety of means to help him, including medicine, one-on-one therapy and counseling, group sessions, goal setting, 12-step techniques, mentoring, good nutrition, and physical activity. It took more than two years of hard work and the expertise of many professionals to help Nic, but he finally stabilized his life. He has had relapses, but now sees recovery as an ongoing, lifelong process.

He chronicled that treatment in his book, We All Fall Down: Living with Addiction.

Today, Nic is a columnist for the addiction and recovery website The Fix and writes about addiction. He is especially interested in writing for and speaking to young people about his own story. He volunteers for an organization that helps teenagers battling addiction.

Speaking about his own recovery on The Fix, he wrote, in a February 2013 column:

“It wasn’t just the medication, of course. It was therapy, meds, 12-step stuff, and my outpatient program, too. With all of those things, my emotions stopped controlling my life and I was able to have a real, healthy, honest relationship. I’m now married. I work a steady job. I have a great relationship with my family. I have friends … My life is now completely different. Bipolar disorder is very real for me. But it’s also completely manageable.”

Resources

“Walter Barrera’s 12-million Step Recovery Program” by Kent Babb, The Washington Post. May 24, 2013.

To hear Walter Barrera tell his own story, watch a video of a Washington Post reporter’s interview with him at Running from Addiction.

HBO series, “Addiction.” www.hbo.com/addiction/thefilm

Clean: Overcoming Addiction and Ending America’s Greatest Tragedy by David Sheff. Eamon Dolan/Houghton Mifflin Harcourt, 2013.

Tweak: Growing Up on Methamphetamines by Nic Sheff. Atheneum Books for Young Readers, 2009.

We All Fall Down: Living With Addiction by Nic Sheff. Little, Brown Books for Young Readers, 2011.

By Paula Hartman Cohen

©2013-2019 Carelon Behavioral Health

Source: Gabrielle McCraney, Program Director, La Casa Transitional Rehabilitation Program, Washington, D.C.; Jenny Karstad, M.A., L.A.D.C., Addiction Treatment Counselor for Inpatient and Outpatient Recovery, Brattleboro Retreat, Brattleboro, VT; William J. Shryer, D.C.S.W., L.C.S.W., Clinical Director, Diablo Behavioral Healthcare, Danville, CA

Reviewed by Paulo R. Correa, M.D., Associate Medical Director, Beacon Health Options

Summary

• There is a high rate of depression and alcohol use.
• Bipolar disorder and marijuana use co-occur frequently.
• Schizophrenia and tobacco use is very common.

Co-occurring disorders (COD) means having at least one mental illness and one or more substance use disorder. The substance use can be any drug or drugs. The mental illness can be any mental disorder. There are many types of COD. Some, though, are more common than others.

Depression and alcohol use

Depression is a mental illness that is often ignored. Sometimes it is from some other health issue. Symptoms can be weight loss, lack of sleep and lack of energy.

A third of people with low spirits also have a substance or alcohol use disorder. Many people drink as a way of dealing with depression. While it may give short-term help, drinking makes things worse in the long run. It can even cause a person to feel even lower. Alcohol use often hinders a person’s mental health care. The person who is drinking is less likely to stick to her doctor’s plan. She may forget to take her pills and miss doctor visits.

Alcohol use has its own set of risk factors. Short-term can include bad judgment and motor skills as well as more risk taking. This can lead to alcohol-linked car crashes, injuries and death. Long-term issues can include liver and heart disease.

Bipolar disorder and marijuana use

A person with bipolar disorder has mood swings that get in the way of his normal life. These mood shifts can cause problems at home, at school, or at work. The low stages are much like states of depression. The difference is that people with bipolar disorder also have high stages called mania. Mania symptoms include high energy, rapid thoughts and speech, and reckless actions.

As with depression, there is a high rate of alcohol use among people who have bipolar disorder. Studies show an even higher rate of marijuana use among these same people. Marijuana is believed to be a trigger for those who are prone to the disease. It is not known if marijuana is a cause of the illness. It does appear to make the risk of getting such disorders higher.

Schizophrenia and tobacco use

Schizophrenia is a long-term mental illness that touches millions of adults. It upsets a person’s thinking, which can cause strange outward actions. People with the illness often hear voices. They may also see things that aren’t really there. These voices and visions are very real to the person. This can cause great fear within the person. It can also cause other people to be fearful of them and to stay away from them.

It is very common for people with schizophrenia to also use tobacco. Smokers with this illness have a greater dependence and a harder time quitting. When they do stop smoking, the withdrawal symptoms are worse than for those without the disease. The link between these disorders is thought to be the central nervous system. People with schizophrenia can have a hard time with memory and staying focused. Nicotine may make them feel better, but the long-term hazards of smoking greatly offsets any benefit.

Treating COD

No matter what type of COD you have, you should be treated for each issue separately. This is because one will affect the other. Treatment will most likely be talk therapy as well as taking meds. A 12-step program might be needed for substance use issues. Treatment may be long-term, but if you stick with it, you will get better.

Resources

Alcoholics Anonymous
www.aa.org

Depression and Bipolar Support Alliance
www.dbsalliance.org

Mental Health America
www.mentalhealthamerica.net

Narcotics Anonymous
www.na.org

National Alliance on Mental Illness
www.nami.org

National Institute of Mental Health
www.nimh.nih.gov

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

By Kevin Rizzo

©2014-2019 Carelon Behavioral Health

Source: National Center for Biotechnology Information, www.ncbi.nlm.nih.gov/pmc/articles/PMC2215390/ www.ncbi.nlm.nih.gov/pmc/articles/PMC2811144/ and www.ncbi.nlm.nih.gov/pubmed/21288470; National Institute of Mental Health, www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml; National Alliance on Mental Illness, www.nami.org; Mental Health America, www.nmha.org/conditions/co-occurring-disorders-and-depression

Reviewed by Sanjay Vaswani, M.D., C.M.Q., D.F.A.P.A., Regional Medical Director, Beacon Health Options

Summary

• Treatment should be client-centered.
• You may also need help with housing, child care, or finding a job.
   

Having a mental illness or a substance use disorder can be hard to deal with. Having both is even harder. Studies show that people with co-occurring disorders (COD) are less likely to comply with or respond to treatment. This puts them at a greater risk for relapse. They are also more likely to become violent, experience homelessness, or go to jail. The risk of getting AIDS and other illnesses is higher as well.

There is hope though. You can improve with proper treatment. This means being treated for both issues separately but at the same time. This is because the disorders not only co-exist, but they also co-affect each other. For instance, someone with depression may drink alcohol to try to feel better. A person who drinks may do so because he feels depressed. If only one issue is being addressed, the other issue can disrupt its treatment.

Before you can begin feeling better, you must first realize the need for treatment. You may not want to admit to your family or yourself that you have a mental illness. You may be afraid to tell your doctor or your boss about your substance use. You may be trying to hide one or both issues from your friends or co-workers. Maybe you simply are not sure if you have any serious issues or not.

Signs of mental illness

The symptoms of mental illness will vary depending on the disease. Often a person may not realize she is impaired. This is true whether it is the onset of a disease or a relapse. It is therefore good to have friends or family nearby looking out for you.

Some of the signs that could indicate a mental illness include:

• Extreme moodiness
• Depression
• Nervousness
• Paranoia
• Withdrawal
• Apathy
• High-risk taking
• High sensitivity
• Extreme irritation
• Inattention
• Trouble with eating or sleeping
• Sexual dysfunction

Signs of substance use disorder

Substance use disorder can have some of the same symptoms of mental illness. Some other signs that you may have a substance use disorder include:

• Getting drunk or high regularly
• Drinking or doing other drugs by yourself
• Driving while drunk or high
• Building up a tolerance to alcohol or other drugs
• Hiding or lying about drinking or taking other drugs
• Withdrawing from friends or hobbies to get drunk or high
• Going to work or school high or drunk
• Missing work or school because of drugs or alcohol
• Passing out or being hung over often

If you think your drinking or drug use may be an issue, get help right away. Do not try to carry the burden all by yourself. Seek out a trusted friend or loved one. Speak to a pastor or counselor. Then find a substance use treatment center and get involved in a 12-step program.

Client-centered treatment

To be successful, both disorders should be treated at the same time. Once you have reached out for help, you must stay involved in the treatment process. This means being active in the planning and decision making. Other people can give you advice but you should make your own choices. This will help empower you to better promote your own recovery.

Talk therapy will be a big part of your treatment. This may include one-on-one, group and family counseling. A 12-step program may be needed for help with substance use issues. Social skills and stress coping skills should be addressed. You may also need help with housing, child care or finding a job. Though you have the lead role, you will need the support of many others. Welcome the input from your doctor or health care worker, as well as family and friends. Realize that they all want what is best for you.

Be aware that recovery may take months or even years. Your progress may be slow at times and there could be setbacks. Do not lose hope. Instead, focus on short-term goals and ask for extra support. Distance yourself from negative influences and surround yourself with positive people. Believe that if you stay on course with your treatment, you can and will get better.

By Kevin Rizzo

©2014-2021 Carelon Behavioral Health

Source: Substance Abuse and Mental Health Services Administration; National Alliance on Mental Illness, www.nami.org; Mental Health America, www.mentalhealthamerica.net/conditions/co-occurring-disorder-and-youth

Summary

• Attend doctor appointments and support group meetings.
• Help her establish daily routines for eating, sleeping, and taking pills.
• Praise her successes and don’t dwell on her failures.

No one likes to see someone they care about go through hard times. A friend with a substance use disorder is hard to be around. A child with a mental illness is tough on the whole family. If you know someone with both issues, then you know it is even harder. As taxing as it may be, your support is a vital part of their recovery.

Identify the issues

The first step is to realize there is a co-occurring disorder (COD). Your friend or loved one may be in denial about her own situation. Her doctor or health care worker may not be aware of the other issue either. Therefore, the person is only getting treated for one issue. This is less than ideal since the two conditions affect each other. For instance, someone being treated for depression may drink alcohol to try to feel better. A person attending Alcoholics Anonymous meetings may continue drinking because she feels depressed. If only one issue is being addressed, the other issue can get in the way of its treatment. For treatment to work, it must be given for both disorders at the same time.

You may know your friend or loved one better than anyone. Therefore, you may be the first one to notice when he isn’t acting like himself. Watch out for sudden changes that may indicate mental illness or substance use or both.

Some of these changes may include:

• Extreme moodiness, touchiness or irritation
• High-risk drinking
• Violence
• Depression
• Apathy
• Inattention
• Nervousness
• Paranoia
• Withdrawal
• Eating, sleeping, or sexual troubles

Ways to promote recovery

When someone you care about has COD, you may feel helpless. This is a normal feeling, but it is far from the truth. Not only can you help, but your friend or loved one needs your help. Helping does not mean taking on the burden yourself. It does not mean you become the person’s enabler or watchdog either. A person with COD has to first be willing to get help. Recovery is hard work and no one can do the work for her. Your job is to show your support throughout the process. This means during both the good times and the bad times.

Sometimes, the best way to help someone with COD is just to be there for him. This allows your friend or loved one to open up about his struggles. You don’t need to have all the answers. You just need to give encouragement and support. Listen to him, and let him know he is not alone.

Here are other ways to help a friend or loved one recover:

• Go with her to doctor appointments.
• Attend support group meetings.
• Help her establish daily routines for eating, sleeping, and taking pills.
• Praise her successes and don’t dwell on her failures.
• Be patient with her.
• Encourage her by staying positive yourself.
• Invite her to partake in healthy activities.
• Stay informed about the disorders.
• Don’t ignore thoughts of suicide—call their doctor or 911.

Resources

Alcoholics Anonymous
www.aa.org

Narcotics Anonymous
www.na.org

National Alliance on Mental Illness
www.nami.org

National Institute of Mental Health
www.nimh.nih.gov

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

By Kevin Rizzo

©2014-2019 Carelon Behavioral Health

Source: Substance Abuse and Mental Health Services Administration; National Institute of Mental Health, www.nimh.nih.gov/health/topics/schizophrenia/index.shtml

Reviewed by Sanjay Vaswani, M.D., C.M.Q., D.F.A.P.A., Regional Medical Director, Beacon Health Options

Summary

• Screening for both issues can be difficult
• Certain mental illnesses occur more commonly with substance use disorders
• Alcohol and nicotine are common drugs linked with COD

Checking for a mental illness is often fairly clear-cut. That is because a lot of research has been done to make this process better. The same can be said for substance use disorders. We now know a great deal more about this field than we ever did before.

It is harder to screen for more than one issue at the same time. One reason for this is a lack of dual training. A mental health service may not be able to spot a substance use disorder. A substance use treatment center may not be able to spot a mental illness. So just how does one know if he has a co-occurring disorder (COD)?

COD means having at least one mental illness and one or more substance use disorder. The substance use can be any drug or drugs. The mental illness can be any mental disorder, but some are more common with COD.

Depression and COD

Depression is a mental illness that is often ignored. Sometimes it is the result of another health matter. Symptoms can be weight loss, lack of sleep, and lack of energy. These signs are also common among other health issues. Studies show that a third of people with depression also have a substance use disorder.

Bipolar disorder and COD

Roughly 60 percent of people with bipolar disorder also have a substance use issue. It is thought that these two disorders affect the same chemicals in the brain. Studies suggest that people with this illness may try to medicate themselves through alcohol use. It is also believed that bipolar disorder may be a risk factor for substance use. Marijuana use can be very common with this disorder.

Schizophrenia and COD

Substance use disorder happens quite often with schizophrenia. Drinking and drug use can also mask some of its symptoms. This is true both during times of use as well as times of withdrawal. Marijuana use can even make the symptoms worse.

Obsessive-compulsive disorder and post-traumatic stress disorder also happen often with COD. Other disorders linked to mood, anxiety, sleep, eating, and personality can be common as well.

Substance use disorders and COD

Any drug can be the source of a substance use disorder. This can range from caffeine and nicotine to cocaine and heroin. When the drug use causes harm or makes normal living hard it is a disorder. Social, legal, and physical problems are often the result.

Alcohol and nicotine are among the most common drugs linked with COD. These types of addictions are very hard to break, but it can be done. Recovery requires a strong support group. Substance use must be treated apart from, but at the same time as, mental disorders.

Signs of substance use disorder

Substance use disorder has a broad range of symptoms based on the drug or drugs. Many of these are the same as those for a mental illness. Here is a list of some of the more common signs to look for:

• Moodiness
• Nervousness
• Touchiness
• Low spirits
• Numbness
• Forgetfulness
• High-risk taking
• Withdrawal

You may not realize that your drinking or substance use is an issue. You may be in denial about your need for help. Here are some other signs that you may have a substance use disorder:

• Getting drunk or high all the time
• Drinking or doing other drugs by yourself
• Driving while drunk or high
• Building up a tolerance to drinking or other drugs
• Hiding or lying about drinking or taking other drugs
• Withdrawing from friends or hobbies to get drunk or high
• Going to work or school high or drunk
• Missing work or school because of drugs or drinking
• Passing out or being hung over often

Get treatment

If you think you may have COD you should tell your doctor right away. You can then be evaluated to see if you need to be looked at further. If you do have COD, early care will help with your recovery. You should also notice feeling much better when you are being treated for both issues. With the right help and support, people can and do recover.

Resources

Alcoholics Anonymous
www.aa.org

Depression and Bipolar Support Alliance
www.dbsalliance.org

Mental Health America
www.mentalhealthamerica.net

Narcotics Anonymous
www.na.org

National Alliance on Mental Illness
www.nami.org

National Institute of Mental Health
www.nimh.nih.gov

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

By Kevin Rizzo

©2014-2019 Carelon Behavioral Health

Source: Substance Abuse and Mental Health Services Administration; Mental Health America, www.nmha.org/conditions/co-occurring-disorders-and-depression and www.mentalhealthamerica.net/conditions/co-occurring-disorder-and-youth; National Alliance on Mental Illness, www.nami.org; National Institute of Mental Health, www.nimh.nih.gov/health/publications/bipolar-disorder/complete-index.shtml

Reviewed by Sanjay Vaswani, M.D., C.M.Q., D.F.A.P.A., Regional Medical Director, Beacon Health Options

Summary

• There are many types of behavioral therapies for opioid misuse.
• They can help with pain management that may have caused misuse.
• Medication-assisted treatment uses medicine and behavioral therapies.

Opioid misuse is a long-term condition. Treatment is not a one-time thing. Successful treatment helps people learn to manage opioid misuse. Behavioral therapies are important. They help change people’s attitudes and habits. They get people to participate in their own treatment.

A note on chronic pain

Chronic, or long-term, pain makes treatment harder. Many doctors treat pain with opioids. This is usually fine for acute, or short-term, pain. It is risky for chronic pain. Our brains make chemicals that make us feel good. They attach to opioid receptors. Opioid receptors tell the brain to feel pleasure. It is the body’s pain reliever. Opioids add to this pain relief. They attach to opioid receptors and make us feel good.

But opioids change the brain. It gets used to the opioids. It stops making the chemical that makes us feel good. This makes more pain. So people take more opioids. This makes a pain cycle, or pain loop, especially in people with chronic pain. It sometimes drives people to misuse opioids. It can lead to using illegal opioids, like heroin or fentanyl.

Behavioral therapies

Medication-assisted Treatment (MAT)

Behavioral therapies are important. But they are usually not enough. MAT is very effective. It combines medicines, behavioral therapies, and services. MAT helps some people stop misusing opioids for life. Common medicines are methadone, buprenorphine, and naltrexone.

Cognitive-behavioral therapy (CBT)

Certain feelings, thoughts, and actions can lead to opioid misuse. CBT teaches people about their feelings, thoughts, and actions. Adaptive actions are helpful. Maladaptive actions are unhelpful. CBT helps people trade maladaptive thoughts and actions for adaptive ones.

Contingency management

With this method, people get rewards when they do things that help their treatment. This is called positive reinforcement. Examples are things like not taking opioids or sticking with the treatment plan.

Twelve-step programs

These programs offer ongoing support from the group and a higher power. People who misuse opioids go to meetings and work through 12 steps to recovery. The program teaches them to take life one day at a time. The goals of the program are acceptance, surrender, and participation in the program. Al-a-non and Al-a-teen are 12-step programs for family members.

Family behavioral therapy (FBT)

FBT helps families learn to support and help each other. Opioid misuse affects everyone in the home. It changes relationships. It can create an unfriendly or unsafe home. Family members may pick up habits that lead to misuse. In fact, substance misuse can run in families. People who misuse opioids have to change their thoughts and actions. So do their family members. FBT can help them do that.

Motivational enhancement therapy (MET)

MET helps people find a reason to change. People who misuse opioids may feel hopeless. MET helps people feel like an opioid-free life is worth fighting for. MET therapists follow five rules of behavior:

• Be empathetic.
• Help the client see who he wants to be versus who he is now.
• Do not argue.
• React calmly to clients who resist treatment.
• Encourage self-confidence in their abilities.

Adjunctive therapies

Adjunctive, or add on, therapies can make a person’s treatment plan stronger.

Mindfulness

This is an awareness of the present moment. It is about paying attention to ourselves and the world around us. Mindfulness has three traits. It is on purpose, without judgment, and right now. People treating opioid misuse may be stressed, anxious, or depressed. Mindfulness reduces these bad emotions.

Some ways of using mindfulness are:

• Meditation—focusing and clearing the mind
• Breathing exercises—inhaling and exhaling in different ways
• Mindfulness-based stress reduction (MBSR)—mixes mindfulness and yoga
• Guided imagery—a guide talks you through a meditation practice

Peer support

This brings together people who are treating opioid misuse. People find it freeing to talk to people who understand what they are going through. They feel less alone when they listen to other people’s stories. They may be more likely to continue treatment if they feel understood.

Hypnosis

This is a state of deep relaxation where a therapist uses focus and relaxation to hypnotize clients. Then he makes suggestions to the client. For example, therapists may talk about ignoring opioid cravings. Hypnosis reduces pain and anxiety. It helps people with chronic pain.

Exercise

Moving reduces pain and relieves stress. Exercise increases fitness, flexibility, and strength. Choose activities you like. Make sure they are good for your body. Look into exercises that are mindful and use gentle movement. Yoga and tai chi are two such exercises.

Resources

American Chronic Pain Association
https://theacpa.org
(800) 533-3231

Narconon
www.narconon.org
(800) 775-8750

National Center for Complementary and Alternative Medicine
www.nccam.nih.gov
(888) 644-6226

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: American Psychological Association’s “Hypnosis.” (2016) www.apa.org/topics/hypnosis/index.aspx; “Motivational Enhancement Therapy.” (2016) www.goodtherapy.org/learn-about-therapy/types/motivational-enhancement-therapy; National Institute on Drug Abuse’s “Principles of Drug Addiction Treatment: A Research-based Guide,” third edition. (2012) www.drugabuse.gov/publications/principles-drug-addiction-treatment/evidence-based-approaches-to-drug-addiction-treatment/behavioral-therapies; SAMHSA’s “Opioids.” (2016) www.samhsa.gov/atod/opioids

Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

Summary

Opioid misuse treatment is a long-term process. Programs should use science-based methods just right for you.

Finding the right care for heroin and opioid misuse may be one of the hardest choices that you have to make. Maybe you are looking for help with your own opioid misuse. Maybe you are looking for help for a loved one. Either way, chances are you are scared and overwhelmed. You want to find the best care. This might be a matter of life and death. How do you choose?

Do not panic. Finding the right treatment is a matter of understanding:

• Opioid misuse in general
• Details of you or your loved one’s opioid misuse
• The choices available to you
• Qualities of effective treatment

Opioid misuse

Experts know that opioid misuse is not a short-term issue. Opioids change the way the brain works. Over time, the changes can become lasting. This makes opioid misuse a long-term issue. It cannot be solved by short-term treatment. Simply detoxing cannot solve it. Getting opioids out of your system is only the first step.

Experts also know that the most effective treatments combine different types of care. Treatment programs should include support services and behavioral and health care treatments. This includes medicine and therapies that teach people to replace harmful thoughts and actions with healthy ones. Medication-assisted treatment (MAT) is very helpful, and it is available in many places.

Before starting your search for care, think about the details of your or your loved one’s misuse. What areas of your life has it touched? Why are you seeking treatment? What are your biggest challenges? What might be holding you back?

Your options

Opioid misuse treatment can be very costly, depending on the extent of the person’s issues. Some treatments are covered by health insurance. Some are not. Start by contacting your health insurance company. Ask what types of treatments they pay for. Ask about deductibles, limits, and options. This applies to Medicaid, Medicare, or other public health insurance, too. If you cannot understand the information, ask someone you trust to help you.

You are not limited to treatments in your health insurance plan. Some people spend their own money on treatment. This may or may not be possible for you. Getting as much information as you can will help you keep costs down.

Qualities of effective treatment

There are many types of opioid misuse treatment programs. Treatment can be either inpatient/residential or outpatient. People in inpatient/residential programs live at a hospital or rehabilitation center. People in outpatient programs live at home and go to a variety of treatment settings. Common settings are doctors’ offices, hospitals, and rehab centers.

Opioid misuse treatment does not have to be inpatient to be effective. Every person is different. Some people do better with inpatient programs. Others do better with outpatient programs. What matters most is the quality of the care and matching it to the person’s needs.

Look for medical professionals who are specifically trained in treating opioid misuse.

Look for programs with these qualities:

• Is focused on you
• Will pay attention to your progress
• Sees you as a part of your treatment team and lets you make decisions
• Uses methods backed by research
• Professionals that give you behavioral and medical care, including for chronic pain
• Services like transportation, education, parenting, and job training
• Helps you build up motivation
• Teaches you to switch bad habits to good ones

Here are some questions to ask:

How does the program work?

• Does it make sense to you? It should sound logical, not complicated or fancy.
• Is it backed by science? Some programs have not changed their methods in many years. They do not listen to experts about opioid misuse treatments. Science now backs MAT. “Abstinence-only” isn’t the only option any more. Different things work for different people, but everyone deserves to know about MAT.

How does the program adjust to change?

Your needs might change as you go through treatment. The program treatments should be able to change to fit you.

How long is treatment?

Opioid misuse cannot be treated with only short-term methods. Treatment should be tailored to each person’s needs. Look for programs that individualize treatment plans and length of care for what that person needs. Some people need inpatient care (for example, inpatient hospital, residential). Many people need treatment in an outpatient setting so they can learn to use their skills in the places they spend most of their time (at home, work, etc.). Outpatient services include things like intensive outpatient, partial hospitalization, counseling, and MAT.

How do you approach re-entry into society?

You may need to ease back into your life after a while. It will be a changed life. And you may have done a lot of damage to parts of your life. Ask how the program will help you deal with that. Examples would be counseling, 12-step programs, recovery housing, and social services.

How will the program meet all my needs?

Look for programs that will take care of all parts of you. It should include counseling or other behavioral treatment. It should include medical care. Experts say it should include medication-assisted treatment (MAT).

What type of training and educational backgrounds do employees have?

Look for medical professionals who are specially trained in treating opioid misuse. Many people who give this type of care are not trained. They often do not understand opioid misuse well enough to offer the right care. They might not use science-based therapies such as MAT.

Things to avoid

Stay away from these programs:

• Programs that say theirs is the only way to tread opioid misuse. No program has the magical treatment, and different people need different types of treatment.
• Programs that are not licensed by the state government. Most states have substance use disorder program licensing requirement with websites that list licensed treatment programs.
• Programs that say you have to go far away for treatment. The American Society of Addiction Medicine says that some types of treatment should not be far away from home; they should be offered close to home.
• Programs that say “abstinence-only” is the only way to be in recovery. While MAT isn’t for everyone, it is an option that everyone deserves to know about and it’s an option that is backed by science. MAT is not substituting one drug for another.
• For-profit programs that are costly and not covered by your insurance. They are often motivated by profit and may charge more than is normal. If they are not covered by your insurance, your insurance company does not have the ability to ensure they have the properly trained staff and treatment.

Resources

American Society of Addiction Medicine
www.asam.org
(301) 656-3920

National Institute on Drug Abuse
www.drugabuse.gov
(301) 443-1124

SAMHSA Behavioral Health Treatment Services Locator
https://findtreatment.samhsa.gov
(800) 662-4357

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: American Society for Addiction Medicine’s “Treating Opioid Addiction as a Chronic Disease.” (2014) www.asam.org/docs/default-source/advocacy/cmm-fact-sheet—11-07-14.pdf?sfvrsn=0#search=”treating opioid addiction as a chronic disease”; National Institute on Drug Abuse’s Seeking Drug Abuse Treatment: Know What to Ask (2013) www.drugabuse.gov/publications/seeking-drug-abuse-treatment-know-what-to-ask/introduction; SAMHSA’s “Substance Use Disorders.” (2016) www.samhsa.gov/tribal-ttac/resources/substance-use-disorders

Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

Summary

• Opioids are narcotics used to manage pain.
• Long-term use can help or hurt people with pain. Long-term use of opioids can cause physical, emotional, and social problems.

Health experts have tried for a long time to find helpful and safe drugs for chronic pain. One challenge is that chronic pain is complicated. Physical feelings of pain create bad emotions, like fear or stress. Bad emotions cause physical changes, like tight muscles or poor sleep. These changes make more pain. This is called a pain cycle, and it is hard to treat or escape. The other challenge is that people with chronic pain need treatments for a long time. Sometimes, drugs that are safe for short-term use are not safe for long-term use. This is true for opioid pain drugs.

What are opioids?

Opioids are a type of narcotic pain drug. People have used opioids to treat pain for hundreds of years. Heroin is an illegal opioid. Doctors do not use heroin to treat pain. Commonly used legal opioids include:

• Morphine
• Codeine
• Hydrocodone (Vicodin®)
• Oxycodone (OxyContin, Percocet)
• Meperidine (Demerol)
• Hydromorphone (Dilaudid)

What do opioid pain drugs do?

Opioid pain drugs change the way the brain handles pain. They attach to parts of the brain called pleasure centers, creating a feeling of happiness or well-being. This is how opioids make people feel less pain. The pain signals are still there, but the drug makes pleasure stronger than pain.

Side effects

Opioids come with unwanted side effects. These effects include:

• Slow or stopped digestion
• Constipation
• Low sex drive or other sexual dysfunction
• Poor memory, concentration, and balance
• Slowed reflexes
• Uneven heartbeats called cardiac arrhythmias
• Slowed breathing

Opioids can even cause comas, seizures, and death. People develop more side effects the longer they use opioids. This is why opioids that might be safe for acute pain are not always safe for chronic pain.

Risks

Opioid pain drugs change the nervous system over time. The pleasure centers of the brain get used to the opioids. People need to take higher doses to get the same feeling. This is called drug tolerance. At the same time, the brain stops making the hormone that causes pleasure. This makes more pain. People can get stuck in this loop, especially people with chronic pain.

Opioids can cause physical dependence. That means the body needs the opioids to work properly. If it does not get the opioid, it will go through withdrawal and get very sick. In the early stages of withdrawal, people may experience:

• Nervousness
• Fear
• Muscle aches
• Tearing eyes
• Drooling
• Sleep problems
• Runny nose
• Sweating
• Yawning
• Urination
• Defecation

In later stages, people may experience:

• Abdominal cramping
• Diarrhea
• Dilated pupils
• Goose bumps
• Nausea
• Vomiting

Physical dependency becomes addiction when using the drug interferes with life. Signs of this include:

• Missing work or school due to use of opioid pain drugs
• Changes in personality
• Emotional, behavioral, or physical problems
• Problems with social and personal relationships
• Taking more of the drug than the doctor prescribed
• Looking for opioid pain drugs from other doctors
• Obsession with using and getting the drug
• Getting into dangerous situations for the drug
• Craving only the high of the drug
• Continuing to take the drug when it interferes with daily life

Opioid addiction is widespread in the United States. More than 4 million people take opioid drugs that are not prescribed by their doctors. Almost a third of people with chronic pain become addicted to an opioid drug. People who become addicted to opioid pain drugs sometimes find that illegal drugs are less expensive.

Opioid pain drugs may help some people with chronic pain. But the side effects and risk of addiction are high. Doctors question whether opioid pain drugs help people with chronic pain enough to take that risk. Research on opioids and chronic pain may help doctors make that decision.

Resources

Academy of Integrative Pain Management

American Chronic Pain Association
(800) 533-3231

Nar-Anon
800-477-6291

By Beth Landau

©2016-2019 Carelon Behavioral Health

Source: American Academy of Pain Management, www.aapainmanage.org; American Chronic Pain Association, https://theacpa.org; Narcanon’s “Signs and Symptoms of Prescription Pain Reliever Abuse” (2015), www.narconon.org/drug-abuse/signs-symptoms-pain-relievers.html; National Institute of Drug Abuse’s “What Science Tells Us About Opioid Abuse and Addiction” (2016), www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/what-science-tells-us-about-opioid-abuse-addiction; “Opiate and Opioid Withdrawal”(2016) MedlinePlus. U.S. National Library of Medicine, www.nlm.nih.gov/medlineplus/ency/article/000949.htm; SAMHSA’s “Managing Chronic Pain and Medication Misuse” (2015) http://newsletter.samhsa.gov/2015/03/03/managing-chronic-pain/; SAMHSAs “Opioids” (2016), www.samhsa.gov/atod/opioids

Reviewed by Lily Awad, M.D., Associate Medical Director, Beacon Health Options

Summary

• People need both behavioral and medical treatments for opioid misuse.
• Treatment comes in inpatient and outpatient settings.
• Medicine-assisted treatment (MAT) is the health care part of opioid misuse treatment.

Treatment for opioid misuse looks the same in most movies and shows. First, people who misuse opioids suddenly stop using them. Some call this cold turkey. Next, they go through a long, hard withdrawal. They get violently sick. Then, they go to an inpatient rehabilitation center. Counseling teaches them how to live without opioids. In the movies, all it takes to stop using opioids is willpower.

Real life is not like the movies. It takes much more than willpower to stop using opioids.

Opioid misuse causes long-term or permanent changes in the brain. It is a long-term, or chronic, condition. Treatment should include different types of care over a long time. It should help people learn to manage their opioid misuse.

It is not enough to treat opioid misuse as a short-term condition. People who get long-term care are less likely to start misusing opioids again. That is important because 2.5 million people misuse opioids in the U.S. More than 33,000 people died from opioid overdoses in 2015 alone.

Long-term care can include medication-assisted treatment (MAT). Examples of MAT are methadone or buprenorphine with Naloxone. When someone is on MAT, they are not using one drug instead of another. When someone is on MAT he is not still using; he is in recovery. MAT can be a life-saving treatment option. MAT is an evidenced-based best practice.

Health care treatments

There are different types of treatment for opioid misuse. They can be very expensive. People looking for treatment should contact their health care providers. They should ask what types of treatments are covered by their insurance. The goal is to get the most effective care.

The most effective care varies from person to person. Experts say the best treatment plans:

• Are centered on the person
• Use methods that work best for that person
• Use methods that limit the person the least

Settings

There are two main settings for opioid misuse treatments:

• Inpatient withdrawal management—stay at a hospital or rehabilitation center for care
• Outpatient withdrawal management—stay at home and go to a doctor, hospital, or rehabilitation center for care

Inpatient withdrawal management settings offer safe, 24-hour a day care. Programs are highly structured. Clients get medical care and counseling. Not everyone needs inpatient or residential treatment.

Types of inpatient settings include:

Inpatient withdrawal management:

• This used to be called “inpatient detox.”
• This level of care helps people stop misusing substances.
• MAT may be started while inpatient.
• Aims to help people get ready for outpatient treatment.

Short-term residential programs:

• Used in the beginning of treatment
• Helps people through withdrawal management
• Begin counseling
• Get people ready for outpatient treatment

Recovery housing:

• Supervised group living
• Safe place to live after inpatient/residential treatment
• Often teach life-skills like using transportation and finding work
• Aims to ease people back into the community

Outpatient settings include many types of treatment. They often focus on behavioral treatments for opioid misuse. Behavioral therapies include:

• Psychotherapy
• Cognitive-behavioral therapy (CBT)
• Family therapy
• Mindfulness-based Stress Reduction (MBSR)

The outpatient setting is where ongoing MAT occurs. While MAT may be started during inpatient withdrawal management, it continues in the outpatient setting. Some people do not need inpatient treatment and may start MAT in the outpatient setting.

Settings include:

• Hospitals
• Treatment centers
• Doctors’ and therapist’ offices

Successful outpatient treatment includes medical treatment. Medication-assisted Treatment (MAT) combines behavioral therapy and medicine.

Medication-assisted Treatment (MAT)

MAT helps people more than medicine or behavioral therapy alone. Some people do not understand using medicine for opioid misuse. They think it trades one bad habit for another. This is not true. People who misuse opioids have strong cravings. Some medicines help reduce those cravings.

MAT helps people use opioids less. It leads to fewer deaths from overdose. It leads to fewer illegal acts and shared diseases. MAT helps people be more social and stay in treatment longer. MAT is helpful for pregnant women. It leads to fewer babies born dependent on opioids. It also shortens mothers’ hospital stays.

Doctors use several medicines to treat opioid misuse. They include:

• Methadone (Methadose®, and Dolophine®)
• Buprenorphine (Butrans®, Subutex®, Belbuca®, Probuphine®)
• Naltrexone (Vivitrol®, Revia®, Depade®)
• Naloxone (Narcan®)

Methadone has been around for a long time. It can make withdrawal easier by stopping or reducing symptoms and cravings. It is safe to take with opioids. Doctors decide how much people should take each day. Some people take pills at home. Others take liquid doses or wafers at a doctor’s office or clinic.

People must be careful with methadone. It builds up in the body. People could get sick or overdose if they take too much. People should tell their doctors if they take other medicines. They should avoid alcohol and other opioids.

Buprenorphine is a very weak type of opioid. It lasts a long time. This reduces people’s cravings. People take it every day as a film, tablet, or skin patch. Doctors mostly use buprenorphine with other medicines.

The U.S. Food and Drug Administration just approved a new type of buprenorphine. Doctors put a Probuphine® implant under clients’ skin. It lets out a small amount of buprenorphine for six months. Doctors only give it to people who have been stable on buprenorphine. They hope Probuphine® will help people stick to their treatment plans.

Naltrexone blocks the effects of opioids. People take naltrexone as a pill or long-lasting injection. Long-lasting injections are more effective for opioid misuse.

Naloxone is used for opioid emergencies. It blocks opioid receptors to reverse opioid overdoses. Emergency professionals carry naloxone. It comes as a shot that can go under the skin or into a muscle or vein. It also comes as a nasal spray.

Clients or their families may be able to get naloxone so they have it at home and are prepared in case of an opioid overdose emergency.

Looking ahead

Researchers are looking for new ways to treat opioid misuse. Experts are testing the following treatments to see if they work and are safe. They include:

• Naltrexone implant
• Vaccine to keep opioids away from the brain
• Transcranial Direct Current Stimulation (TDCS)

Resources

Narconon
www.narconon.org
(800) 775-8750

National Institute on Drug Abuse
www.drugabuse.gov
(301) 443-1124

Substance Abuse and Mental Health Services Administration
www.samhsa.gov
(877) 726-4727

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: American Society for Addiction Medicine’s “Treating Opioid Addiction as a Chronic Disease.” (2014) www.asam.org/docs/default-source/advocacy/cmm-fact-sheet—11-07-14.pdf?sfvrsn=0#search=”treating opioid addiction as a chronic disease”; Centers for Disease Control and Prevention’s “Injury Prevention and Control: Opioid Overdose.” (2016). www.cdc.gov/drugoverdose; National Institute on Drug Abuse’s ﾓEffective Treatments for Opioid Addiction.” (2016) www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction; SAMHSA’s “Treatments for Substance Use Disorder.” (2016) www.samhsa.gov/treatment/substance-use-disorders; University of Utah’s Genetic Science Learning Center’s “Addiction Treatments Past and Present.” (2016) http://learn.genetics.utah.edu/content/addiction/treatments/; Whitehouse.gov’s “Fact Sheet: Obama Administration Announces Public and Private Sector Efforts to Address Prescription Drug Abuse and Heroin Use.” (2015) www.whitehouse.gov/the-press-office/2015/10/21/fact-sheet-obama-administration-announces-public-and-private-sector

Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

Summary

• Opioid misuse should be treated as a chronic illness.
• Let the person know he is not alone and that help is available.
• Always treat her with kindness and respect.

People do not think it could happen to their family or friends. They think only other people misuse opioids: people on the news or people who are weak or bad. But people from all backgrounds can misuse opioids. They are not bad or weak. They are the people we know. They are our family members or friends. Opioid misuse has become a national crisis.

Recognizing opioid misuse

Not all opioid use is misuse. Some people safely use opioids their doctors give them. In some cases, legal opioids can help treat acute, or short-term, pain. People may use opioids after surgery or an accident.

How can you tell if someone is misusing opioids? There are many signs, including:

• Changes in how they look, act and relate to other people
• Changes in physical or behavioral health
• Sneaking around or lying
• Missing work or school
• Poor work or school performance
• Problems with personal relationships
• Increased dangerous behavior
• Switching groups of friends
• Slurred speech or stumbling
• Empty prescription bottles
• Needle marks from use
• Taking opioid medicine after an injury or illness is healed

One example

Dot had knee surgery in May. She felt better by June. She and her friend Susan rode bikes, went out to lunch and met friends for poker every Wednesday night. Then, Dot started acting strangely. She cancelled plans and did not answer the phone. Dot seemed confused on poker night. She mumbled and slurred her words. She picked a fight when Susan drove her home. Susan was surprised and worried. Dot’s usually tidy house was a mess. There were dishes in the sink, clothes on the floor and prescription bottles on the counters. Susan told Dot she was worried. Dot said she was fine. Her medicine for knee pain made her sleepy, she said. Susan remembered Dot’s knee feeling better a couple weeks ago. Why was she still taking medicine? Susan realized Dot’s medicine might be the root of the problem. She wanted to help, but what could she do?

How not to help

• Do not try to save them.
• Do not tell them to just stop and never use again.
• Do not yell or nag.
• Do not threaten them in any way.
• Do not force them to go to a support group or rehab.
• Do not argue with them about the misuse.

How to help

You cannot fix opioid misuse for someone else. It is not easy to stop misusing opioids. A person’s body becomes used to opioids. They change the way the brain handles pain and pleasure. After a while, the body needs the opioid to function. The person may need more and more opioids to feel good. This creates a cycle that is hard to break. Asking someone to simply stop is not fair. It is almost never possible. Professionals say opioid misuse should be treated like a chronic illness.

What kind of help can you give? Your role is to give kind support.

• Let the person know you care, and offer your support.
• Talk to them about your concerns.
• Let them share their thoughts and feelings. Do not assume you know how they feel.
• Let them know that hethey are not alone. Urge them to seek help. Encourage them to talk to a doctor about it, even if they do not think it is a problem. Offer to take them to a support group. Many religious and nonreligious groups offer substance misuse support.
• Help them find treatment choices. Different insurance plans cover different services. The insurance provider can give them information. There are many types of treatment programs. Offer to help them pick a place to start.
• Try to ease their mind about what opioid misuse treatment looks like. The most common image is of a cold-turkey detox—suddenly stopping the opioid and going through a withdrawal. Though detox followed by a 12-step program is still common, it is generally not the best method. This is also called “abstinence-only”. “Abstinence-only” approaches may work for some but not all. Everyone who misuses opioids deserves to understand all treatment options including medication-assisted treatment (MAT). MAT is backed by science. There are MAT medicines that help people detox and not start using again.
• Help reduce stigma. There is a lot of negative judgment about substance misuse. Many people do not understand it. They believe things that are not true. Common stereotypes show people who misuse opioids as bad, lazy or dangerous. This makes it hard to see the person instead of just the misuse. People may be prejudiced against these stereotypes. That leads to unfair treatment and unkind words or actions. It makes people who misuse opioids feel ashamed and depressed. This makes them avoid seeking help and makes it harder to stick with treatment.
• Be aware of your own beliefs and stereotypes. Avoid judging the person. Be kind and open-minded. Make it clear that you see the person, not just the misuse. Make your relationship with the person or your home a stigma-free zone. It may help to learn more about substance misuse. You can also speak to others in your life about this type of stigma.
• Help them look at the way their family uses or misuses substances such as alcohol or drugs. This includes pain medicine. Sometimes substance misuse runs in families. It is partly genetic—certain DNA handed down to each generation. It is also partly behavioral. Families may have habits or actions that make using alcohol or drugs risky. Looking for substance use or misuse patterns in families can help someone understand their own misuse.

By Beth Landau

©2017-2021 Carelon Behavioral Health

Source: Addiction Technology Transfer Center Network’s “Anti-Stigma Toolkit.” (2012) www.attcnetwork.org/RegCenters/productDocs/2/Anti-Stigma%20Toolkit.pdf; Narconon’s “Signs and Symptoms of Prescription Pain Reliever Abuse.” (2015) www.narconon.org/drug-abuse/signs-symptoms-pain-relievers.html; SAMHSA’s “Opioids.” (2016) www.samhsa.gov/atod/opioids

Summary

Before forming an opinion about someone with substance use problems, consider these common myths.

“Those who overuse substances have a moral flaw.”

“People with alcohol and substance use disorders don’t want to quit—if they did, they would just stop using.”

“Locking up all the people who overuse substances will solve the problem.”

These and many other myths about drug use add to the problem. The stigma tied to drug use discourages treatment for addiction and limits chances for work, housing, and social relationships. Although drug use has a deep, harmful impact on society, it is not an insurmountable problem. Become part of the answer by helping to stop stigma.

Identifying the problem

Most American families have been touched in some way by a loved one with problems with drugs or drinking. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) National Survey on Drug Use & Health, 24.6 million Americans aged 12 or older said they had used an illicit drug during the month before the survey.

Unfortunately, many people who have problems with drug use will come across stigma that hinders them from integrating back into society. Police, the legal system, ER staff, and even family members and friends can keep the stigma going, and stigma limits the attention and resources dedicated to solving problems linked to substance use. “Stigma is about discrimination,” says Ivette Torres, Director of Consumer Affairs for SAMHSA’s Center for Substance Abuse Treatment.

Separating myth from fact

Stigma comes from the myths about drug use. Before forming an opinion about someone with substance use problems, think over these common myths:

Myth: Those who overuse substances have a moral flaw—they could will themselves to stop using if they wanted to quit.

Fact: One common and false stereotype about people with substance use disorders is that they are all social misfits and outcasts. “Stigma can also get at the idea that the person is weak of character or untrustworthy,” explains Jim Beek, a SAMHSA information officer. In reality, “normal” people deal with drug use issues, which can touch whole families. Drug and alcohol dependence meet the standards for treatable, chronic health issues; dependence is not simply a matter of choice. “One of the biggest and most pervasive myths is that … a user can stop using alcohol or drugs by willing themselves to,” agrees Torres. “Society at large has to accept addiction treatment and begin to look at it as a public health issue.”

Myth: Addiction is not reversible: Once an addicted to a substance, it is always that way.

Fact: Many people don’t realize how helpful programs and services can be in treating substance use disorder. In fact, drug addiction treatment works as well as established medical treatments for other illnesses such as diabetes and asthma, the Physician Leadership on National Drug Policy has reported. Another study found that for each dollar invested in treatment, taxpayers saved $7 in future costs, according to the National Institute on Drug Abuse.

Unfortunately, the shame tied to being labeled or viewed negatively by others can keep people from seeking care. “Stigma is a factor,” Torres notes. “That’s why you see so many individuals speaking out, saying, ‘Recovery is possible. I am an example of that.’’’ And luckily, new choices, such as the prescription addiction treatment drug buprenorphine, can help stop the stigma linked to lining up outside a clinic.

Myth: Harsher criminal penalties for using drugs or increasing efforts to cut off the drug supply will solve the problem.

Fact: This common wisdom is at odds with research showing the effectiveness of treatment. And, keep in mind that there is no “silver bullet” when it comes to solving drug use problems. While a blend of things such as treatment, parental influence, and education programs can help, taken alone, “get tough” approaches don’t address the underlying social and family issues linked to drug use.

You can help

While views about people with drug problems and treatments have gotten better, we still have a long way to go toward skillfully addressing these issues. You can help by facing your own attitudes. If you know someone who may have a drug problem, treat him with concern, dignity, and respect. Rather than turning your back or getting angry, offer your support.

Resources

National Institute on Drug Abuse
www.drugabuse.gov

Physician Leadership on National Drug Policy
www.plndp.org

Substance Abuse and Mental Health Services Administration
www.samhsa.gov/

By Kristen Knight

©2022 Carelon Behavioral Health

Summary

• Narcan© is naloxone, an emergency medicine that blocks the effects of opioids.
• It can reverse symptoms like breathing problems, and stop an overdose.

Narcan© is the brand name of the drug naloxone. It is used in opioid emergencies. It can stop an overdose. Naloxone saves lives.

What does naloxone do?

Opioids work by attaching to opioid receptors. Opioid receptors send messages of pleasure to the brain. The brain then makes a chemical that makes people feel good or high. It also changes the way people feel pain. Taking too much opioid medication or heroin can cause an overdose. It can make breathing hard and hurt the body and brain. This is also called an opioid emergency.

Naloxone works by blocking opioids. It attaches to opioid receptors and stops the overdose. It can help people breathe again and reduce harm to the body and brain.

Side effects

A common side effect of naloxone is opioid withdrawal. Signs of opioid withdrawal include:

• Achiness
• Dizziness
• Weakness
• Diarrhea
• Fever or chills
• Nervousness

Another risk or side effect is an allergic reaction. Signs of an allergic reaction include swelling of the lips, tongue, or face.

Opioid emergencies

People overdose on opioids for a few reasons. They may not know how to take opioids. They may take more than their doctor prescribed. Sometimes people take opioids that were not prescribed for them. Others may drink alcohol or use other legal or illegal drugs with opioids. These actions can lead to an opioid crisis. Signs of opioid crises include:

• Not being able to wake up
• Sweaty skin
• Blue or discolored fingernails
• Slow or no breathing
• Choking or throwing up

Trained health care workers give people naloxone a few ways. One form of naloxone is a nasal spray. Another is a shot under the skin or into a muscle or vein. People need to go to the hospital after they get naloxone. There, health care workers can watch them and give other care.

People can get naloxone from many sources such as:

• Paramedics
• Trained firefighters
• Emergency room professionals
• Police officers
• Doctors

Doctors may give naloxone to people with opioid misuse disorder or their families for emergencies. They often do this if they think a person is likely to overdose. In some states a pharmacist can give naloxone to people who are reliant on opioids without a prescription, by virtue of a collaborative agreement with the state’s health department.

Medication-assisted treatment (MAT)

Naloxone can be part of MAT for opioid misuse. MAT is a type of treatment plan for people who misuse opioids. It combines behavioral therapies and medicines. Science shows that this is the most helpful way to treat opioid misuse long-term. Doctors may give people in MAT a prescription for a low dose of naloxone in pill form. They often use it with another drug called buprenorphine.

Who should use naloxone?

Naloxone is not for everyone. Doctors consider giving naloxone to people who are likely to overdose. They consider giving people naloxone when they leave the hospital after an overdose. They also consider giving naloxone to people who use opioids:

• To treat pain
• For a long time
• In large doses
• In long-lasting forms
• For required detoxification

Some people have a higher risk of side effects from naloxone. People who have heart disease may get low or high blood pressure, irregular heartbeat, or fluid in the lungs. People who have seizure disorders may have seizures if they take naloxone. People who take long-lasting opioids may have a second opioid emergency after naloxone wears off. They should watch for signs the overdose is coming back. Opioid overdose can be much more dangerous than most of these side effects.

Resources

Harm Reduction Coalition
http://harmreduction.org
(212) 213-6376 East Coast
(510) 444-6969 West Coast

National Institute on Drug Abuse
www.drugabuse.gov
(301) 443-1124

Substance Abuse and Mental Health Services Administration
www.samhsa.gov
(877) 726-4727

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: Centers for Disease Control and Prevention’s “Injury Prevention and Control: Opioid Overdose.” (2016). www.cdc.gov/drugoverdose; SAMHSA’s “Naloxone.” (2016) www.samhsa.gov/medication-assisted-treatment/treatment/naloxone; SAMHSA’s “Opioid Overdose Prevention TOOLKIT: Five Essential Steps for First Responders.” (2016) http://store.samhsa.gov/shin/content/SMA16-4742/FiveEssentialStepsforFirstResponders.pdf; Terman, Gregory W. “Naltrexone: Effects and Side Effects.” (2010). www.fda.gov

Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

Summary

• Stricter rules about prescription opioids can cause people to seek illegal opioids.
• Heroin is easily available and cheaper than illegal prescription opioids.
• Screening can help people avoid future heroin use.

More are using opioids in the United States than ever before. Pharmacies filled 76 million prescriptions for opioids in 1991. In 2013, they filled 207 million. Opioid misuse and overdoses are increasing. More than 33,000 people died from opioid overdoses in 2015 alone.

Heroin use is on the rise, too. Twice as many people died from heroin use in 2013 than in 2011. And the numbers keep getting higher.

What is the connection between prescription opioids and heroin use?

Many people switch to heroin after misusing prescription opioids.

Why is this happening?

Some doctors freely prescribed opioids in the past. They prescribed large numbers of opioids. They let people have many refills. They did not closely watch people who used opioids. People used them without understanding the risks. This led to misuse. And it was easy for people to get more. Many times, insurance would even pay for it.

When experts saw the rise in people misusing prescription opioids, they made stricter rules and regulations. Fewer doctors prescribe them now. They are more careful about who they give opioids. They give smaller numbers of pills. They do not give automatic refills. Doctors now closely watch people who use opioids. It is harder to get opioids. More importantly, it is harder to misuse legal prescription opioids.

Some people switch to illegal prescription opioids. They are easy to find, but they are not cheap. People may have paid a small co-payment for a bottle of prescribed opioids. Now they pay between a few dollars to $40 a pill. The rising cost does not end there. Opioid misuse leads to tolerance and physical dependence. People need more and more opioids to get the same high. Their bodies get used to opioids and feel sick without them. Fear of withdrawal deters them from getting needed treatment.

Eventually, many people cannot afford illegal opioids. They look for a cheaper option. Heroin is a cheaper option. It is easy to get and gives people a strong high for a lot less money. In this way, prescription opioids can be a gateway to heroin use.

Does everyone who uses prescription opioids switch to heroin?

No. Studies show that only a small percent of people who use prescription opioids switch to heroin. The switch from legal prescription opioids to heroin is not a simple issue. Many things factor into a person’s risk for heroin use.

Risk for opioid misuse

Many new heroin users first misuse prescription opioids. People who have a high risk for opioid misuse may have a high risk of heroin use. Risk factors for opioid misuse include:

• A history of alcohol or other substance misuse
• A family history of opioid misuse
• Chronic, or long-term, pain
• Lack of close supervision by a doctor who understands the dangers of opioids
• No education about taking the smallest amount of opioids for the shortest time needed
• Access to prescriptions for large amounts of opioids at one time

Risk for switch to heroin use

Risk factors for switching from prescription opioids to heroin include:

• Opioid misuse
• Use of multiple opioids
• Use of other illegal drugs
• Non-oral use of prescription opioids, such as crushing and snorting or cooking and injection
• Beginning to use illegal prescription opioids at a young age
• Exposure to heroin
• Easy availability of heroin

How to avoid the switch to heroin

People can take steps to stop the switch from legal prescription opioids to heroin. Steps include:

• Learn about the risks of opioids.
• Work with doctors who understand the dangers of opioids.
• Talk with a doctor about your specific risk factors.
• Know if your condition is long-term or short-term.
• Talk with a doctor about other pain relief options.
• Talk with your doctor right away if you start to misuse opioids.

Resources

U.S. Department of Health and Human Services
www.hhs.gov
(877) 696-6775

Narconon
www.narconon.org
(800) 775-8750

National Institute on Drug Abuse
www.drugabuse.gov
(301) 443-1124

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: Cicero, Theodore J., Ellis, Matthew S., Surrat, Hillary L., Kurtz, Steven P. “The changing face of heroin use in the United States: A retrospective analysis of the past 50 years.” (2014) JAMA Psychiatry. 71(7):821-826. http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575; National Institute on Drug Abuse’s “Factors Predicting the Transition from Prescription Opioids to Heroin.” (2016) www.drugabuse.gov/news-events/latest-science/factors-predicting-transition-prescription-opioids-to-heroin; National Institute on Drug Abuse’s ﾓPrescription Opioids and Heroin: Heroin use is driven by its low cost and high availability.” (2015) www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-abuse-heroin-use/heroin-use-driven-by-its-low-cost-high-availability; Volkow, Nora D. National Institute on Drug Abuse’s “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.” (2016) www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

Summary

• Heroin and opioid misuse is not invisible.
• It changes the way people look and act.
• Objects like baggies, bent spoons, and needles are also clues.

Doctors may treat pain with legal opioid medicines. These medicines help people not feel as much pain. It also makes some people feel high or very good. But people’s bodies can become used to opioids. This can lead to misuse.

There are two things that happen when a body becomes used to opioids. Tolerance means it takes more and more medicine to treat pain or feel high. Physical dependence means the body will get sick without opioids. This type of sickness is called withdrawal. A person going through withdrawal may have:

• Anxiety and distress
• Trouble sleeping
• Pain
• Sweating
• Chills
• Stomach cramps
• Diarrhea
• Feeling sick to your stomach
• Throwing up
• Fever

Opioid misuse

Opioid misuse is a widespread disease in America. More than 2 million people misuse prescription opioids. At least half a million people use heroin. Sadly, more and more people are dying from opioid misuse. Some people overdose. The Centers for Disease Control and Prevention reports that nearly 80 people die from opioid overdoses every day. Many others die in accidents caused by opioid misuse.

Signs of misuse

Misuse of opioids can cause problems in all areas of a person’s life. It can be hard to tell if a person is misusing opioids. She probably will not tell you. But you may find signs of misuse. You may see differences in how she looks, acts, and interacts with others. These signs include:

• Obsession with getting the opioid
• Sneaking around or being dishonest
• Missing money or valuables
• Too much time spent getting and using opioids
• Missing work or school
• Poor work or school performance
• Changes in personality or appearance
• Changes in physical or behavioral health
• Problems with social and personal relationships
• Getting into dangerous situations for opioids
• Switching groups of friends
• Using opioids even when it creates problems
• Slurred speech or stumbling
• Itchiness
• Any use of heroin

Other clues that someone is misusing prescription opioids include:

• Taking more medicine than prescribed
• Continuing to take the medicine after a condition is healed
• Claiming to lose opioids
• Trying to refill prescriptions early
• Asking for a higher dose
• “Doctor shopping” or visiting other doctors to get opioids
• Buying opioids illegally
• Empty prescription bottles before their refill date
• Bottles from different drug stores
• Several written prescriptions
• A blank prescription pad
• Fake identification

Other clues that someone is using heroin or other illegal opioids include:

• Long sleeves in the summer
• Needle marks from use
• Little plastic bags
• A burnt or bent spoon
• Syringes or medical needles
• A belt or rubber tubing
• A glass pipe

Risk factors

Opioid misuse does not happen only to some groups of people. Anyone can misuse opioids. However, some things raise peoples’ risk. A family history of substance misuse can be a factor. Children who show signs of violent behavior are more likely to misuse opioids. Experts say they these children struggle with self-control. Having a parent or other caregiver around is important for all children. Children who do not have a lot of supervision may also be at risk for opioid misuse later in life, so may children and teens that spend time with people who misuse opioids.

Resources

Narconon
www.narconon.org
(800) 775-8750

National Institute on Drug Abuse
www.drugabuse.gov
(301) 443-1124

Substance Abuse and Mental Health Services Administration
www.samhsa.gov
(877) 726-4727

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: Benyamin R, Trescot AM, Datta S, Buenaventura R, Adlaka R, Sehgal N, Glaser SE, Vallejo R. (2008) “Opioid complications and side effects.” Pain Physician. Issue 11: S105-S120. 11: S105-S120. www.ncbi.nlm.nih.gov/pubmed/18443635; National Council on Alcoholism and Drug Dependence’s “Signs and Symptoms.” (2015). www.ncadd.org/about-addiction/signs-and-symptoms/signs-and-symptoms; National Institute on Drug Abuse’s “Recognizing Opioid Abuse.” www.drugabuse.gov/sites/default/files/files/RecognizingOpioidAbuse.pdf; Narconon’s “Signs and Symptoms of Heroin Use.” www.narconon.org/drug-abuse/signs-symptoms-heroin-use.html; SAMHSA’s “Opioids”(2016) www.samhsa.gov/atod/opioids

Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

Summary

• It is only safe and legal to use medicines prescribed just for you.
• They are dangerous even if you think they help you.
• They can hurt brain development and cause overdose or addiction.

What are prescription drugs?

Almost anyone can walk into a store and buy headache or allergy medicine. These drugs may seem to be safe for most people to use without a doctor’s care. They are called over-the-counter (OTC) drugs.

You need a note from your doctor to buy prescription drugs. In general, prescription drugs have more risks than OTC drugs. They may be strong or have dangerous side effects. They may carry a risk of addiction. Or they may be for illnesses doctors have to watch carefully. Some prescription drugs, like opiates and stimulants, are called controlled substances. They can be addictive, or habit-forming. Other risks of controlled substances include:

• Overdose
• Thinking problems
• Breathing problems
• Heart attack

Before doctors prescribe medicine for you, they gather personal information, including:

• Medical history
• Family history
• Allergies
• Other drugs you use
• Details of your condition
• Your age
• Your weight
• Your other activities
• Your risk of substance misuse

This is how they pick the safest drugs in the safest amounts for you.

What does prescription drug misuse mean?

Prescription drug misuse means taking medicine:

• Prescribed for another person
• In higher doses than prescribed
• More often than prescribed
• For longer than the doctor prescribed
• To get high
• With alcohol or other drugs

What prescription drugs do teens and young adults misuse?

Teens and young adults misuse three main types of prescription drugs:

Opioids treat pain. They tell the brain to make chemicals that make you feel good. Examples include:

• Oxycodone (Oxycontin®)
• Oxycodone/acetaminophen (Percocet®)
• Hydrocodone/acetaminophen (Vicodin®)

Stimulants speed up brain activity. They treat attention and focus issues, like attention-deficit/hyperactivity disorder (ADHD). Examples include:

• Methylphenidate (Ritalin®, Concerta®)
• Dextropamphetamine (Dexedrine®, Adderall®)

Depressants slow down brain activity. They treat anxiety, insomnia, and seizures. Examples include:

• Alprazolam (Xanax®), diazepam (Valium®)
• Zolpidem (Ambien®), eszopiclone (Lunesta®)
• Phenobarbital (Luminal Sodium®)

What are some myths about prescription drugs?

Myth: Prescription drugs are safe.

No! Prescription drugs are only safe if you:

• Are under a doctor’s care
• The doctor follows the prescribing guidelines
• Use the medicine prescribed to you (not to someone else)
• Follow all your doctor’s directions

Taking medicine prescribed to someone else is dangerous. Thousands of adolescents overdose or become addicted to prescription drugs every year. Early prescription drug misuse can raise your risk of using illegal drugs later in life.

Myth: You cannot get in trouble with prescription drugs.

No! They are only legal if they are:

• Prescribed to you by a doctor
• Purchased in a pharmacy
• Taken for medical purposes

It is illegal to use prescription drugs that do not belong to you. This includes your parent or caregiver’s medicine or giving one to your friend.

Myth: Prescription drugs are not harmful if they help you function.

No! Prescription drugs are meant to help with specific health issues. Some teens and young adults use them to:

• Stay awake to study
• Focus better in school or on tests
• Decrease stress
• Get enough sleep
• Lose weight

Growing up is hard. You are under a lot of pressure to meet people’s expectations. But misusing prescription drugs only hides your problems. You are risking your life instead of finding a safer strategy.

What is so dangerous about prescription drug misuse?

You may have heard the bad things misusing drugs can do to you. Things like:

• Health issues
• School, work, and relationship problems
• Legal problems
• Addiction
• Death

But did you also know that misusing drugs during adolescence could permanently hurt your brain?

Our brains do not stop growing until our mid-20s. The last part to mature is called the frontal lobe. It would be fair to call it the “adult-ing” lobe. It controls things like:

• Impulse control
• Problem-solving
• Decision-making
• Prioritizing
• Abstract thinking
• Understanding consequences

Misusing drugs messes with chemical signals in the brain called neurotransmitters. This can keep them from moving through your brain. Parts of your frontal lobe may never develop properly. This makes it very hard to function like an adult.

Get help

If you or your friends are misusing prescription drugs, get help. You may worry about getting in trouble. But addiction, overdose, and brain damage are bigger trouble. Support and treatment can help you get back on track. Talk to a trusted parent or adult, or call the toll-free number on this site for help.

Resources

Narconon
www.narconon.org

National Institute on Drug Abuse for Teens
teens.drugabuse.gov

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: National Institute on Drug Abuse’s “Abuse of Prescription (Rx) Drugs Affects Young Adults Most.” (2016) www.drugabuse.gov/related-topics/trends-statistics/infographics/abuse-prescription-rx-drugs-affects-young-adults-most; National Institute on Drug Abuse’s “Misuse of Prescription Drugs: Adolescents and Young Adults.” (2016) www.drugabuse.gov/publications/research-reports/prescription-drugs/trends-in-prescription-drug-abuse/adolescents-young-adults; SAMHSA’s “Specific Populations and Prescription Drug Misuse and Abuse.” (2015) www.samhsa.gov/prescription-drug-misuse-abuse/specific-populations; Science and Management of Addiction’s “The Effects of Drugs And Alcohol on The Adolescent Brain.” (2005) www.samafoundation.org/the-effects-of-drugs-and-alcohol-on-the-adolescent-brain.html

Reviewed by Heather Lober, MS, LMFT, Director, Strategic Initiatives and Enrique Olivares, MD, Director, Addiction Services, Beacon Health Options

Summary

• Teens and young adults misuse prescription drugs to get high, focus, and relieve stress.
• Common sources are their homes and school.
• Misusing these drugs can cause permanent brain changes.

Who are teens and young adults?

Teens means people aged 13 to 18. Young adulthood stretches from the mid-teens to 25 years old. There are definite differences between 13-year-olds and people in their early twenties. But they share two things: freedom and vulnerability.

What are prescription drugs?

Prescription drugs are medicines that require a doctor’s note, or prescription. People must be under a doctor’s care to use them. Some prescription drugs treat conditions that doctors must watch closely. Some can be dangerous to use for the wrong reason. Some have high risk profiles. They may be very strong or have dangerous side effects. Some are called controlled drugs. They come with a high risk of addiction.

What prescription drugs do teens and young adults misuse?

Teens and young adults misuse three main types of prescription drugs:

Opioids—narcotic pain medicines. They attach to opioid receptors in the body and tell the brain to release pleasure hormones. Examples include:

• Oxycodone (Oxycontin®)
• Oxycodone/acetaminophen (Percocet®)
• Hydromorphone (Dilaudid®)
• Hydrocodone/acetaminophen (Vicodin®)
• Methadone (Methadose®)
• Morphine (Astramorph®)

Stimulants—drugs that increase a chemical message in the brain called dopamine. They treat attention and focus issues like attention-deficit/hyperactivity disorder (ADHD). Examples include:

• Methylphenidate (Ritalin®, Concerta®)
• Dextropamphetamine (Dexedrine®, Adderall®)

Depressants—drugs that slow brain activity, also known as sedatives or anxiolytics. They treat insomnia, anxiety, or seizures. Examples include:

• Alprazolam (Xanax®), diazepam (Valium®), and other benzodiazepines
• Zolpidem (Ambien®), eszopiclone (Lunesta®), and other sleep medicine
• Phenobarbital (Luminal Sodium®) and other barbiturates

What is prescription drug misuse?

Doctors look at a lot of information before they write prescriptions, including:

• Health history: personal and family history, drug allergies, and other medicines
• Personal statistics: vital signs, height, weight, age, and metabolism
• Lifestyle: school or work schedule, hobbies and activities, and risk of substance misuse

Doctors use this information to choose the safest prescription drugs and doses.

Misuse means taking medicine:

• Prescribed to another person
• In higher doses than prescribed
• More often than prescribed
• For longer than the doctor ordered
• To get high
• With alcohol or other drugs

Why is prescription drug misuse so dangerous for teens and young adults?

Most dangers of prescription drug misuse apply to everyone, including:

• Unwanted side effects
• Physical and behavioral health problems
• School, work, and relationship problems
• Addiction
• Possible risk of future heroin use

It is especially dangerous for teens and young adults. Our brains continue to develop into our twenties. The area called the frontal lobe develops during adolescence. It is made of two parts: the prefrontal cortex and the outer mantel. They control thoughts and behavior, such as:

• Impulse control
• Problem-solving
• Decision-making
• Prioritizing
• Abstract thinking
• Understanding consequences

Neurotransmitters are chemical signals in the brain. Prescription drugs can slow down or disturb neurotransmitters. This can permanently hurt the frontal lobe, making it hard to function.

Why do teens and young adults misuse prescription drugs?

People think that young people misuse prescription drugs to get high, or feel good. But other reasons include:

• Staying up to study
• Focusing in school or on tests
• Relaxing or de-stressing
• Escaping from problems
• Relieving pain
• Feeling less socially awkward
• Losing weight

It is important to remember that young people have complex lives. They are under pressure to do well in school, develop responsibility, and be accepted. Sometimes, they turn to prescription drugs to cope.

Where are teens and young adults getting these drugs?

Prescription drugs are everywhere. It is easy for teens and young adults to get them. Common sources include:

• Their own prescriptions
• Their parents’/caregivers’ drugs
• Other people’s homes
• Friends or family members who share or sell them
• Dealers, often fellow students
• Online

What can I do?

Keep your home safe.

• Get rid of old prescription drugs.
• Do not get refills if you do not need them.
• Lock up family members’ prescription drugs.
• Be in charge of young people’s prescription drugs.

Talk about prescription drugs.

• Tell your adolescent about the dangers.
• Ask family members to throw out or lock up their medicines.
• Talk to friends and your community about it.
• Talk to your adolescent’s doctor about alternatives to drugs such as non-opioid pain relievers instead of prescription opioids.

If you think your teen or adolescent is misusing prescription drugs, don’t panic. Help is available by calling the toll-free number on this site.

Resources

Narconon
www.narconon.org

National Institute on Drug Abuse
www.drugabuse.gov

Substance Abuse and Mental Health Services Administration
www.samhsa.gov

By Beth Landau

©2017-2022 Carelon Behavioral Health

Source: National Institute on Drug Abuse’s “Abuse of Prescription (Rx) Drugs Affects Young Adults Most.” (2016) www.drugabuse.gov; National Institute on Drug Abuse’s “Misuse of Prescription Drugs: Adolescents and Young Adults.” (2016) www.drugabuse.gov; SAMHSA’s “Specific Populations and Prescription Drug Misuse and Abuse.” (2015) www.samhsa.gov; Science and Management of Addiction’s “The Effects of Drugs And Alcohol on The Adolescent Brain.” (2005) www.samafoundation.org

Summary

• Opioids relieve pain but do not fix the problem causing the pain.
• Opioids must be used with caution to avoid side effects or overdose.
• Physical dependence and addiction are possible risks of opioid use.

Opioids are narcotic pain medicines used for pain relief. Narcotic medicines dull the senses, make people sleepy at times and relieve pain. The name opioid means “like opium.” Opium is a narcotic made from poppy flowers. It is a strong drug. People have used it for hundreds of years for all sorts of reasons. Pure opium is not used medically.

Some opioids are legal and available by prescription. Examples include:

• Codeine (Tylenol 3, certain cough syrups)
• Hydrocodone (Vicodin®, Lortab)
• Oxycodone (Percocet, OxyContin®)
• Hydromorphone (Dilaudid)
• Morphine (MS Contin, MSIR)
• Fentanyl (Duragesic®)
• Methadone
• Buprenorphine (semisynthetic opioid)
• Propoxyphene (Darvocet, Darvon)

Heroin is an illegal opioid. People smoke, inject with a needle or inhale heroin to get a feeling of extreme pleasure or high feeling. It is not used to treat pain.

How do opioids treat pain?

Pain is unpleasant, but it is useful. Problems in the body send pain messages to the brain. That tells us we are sick or hurt and need to treat the problem. Usually, when the problem is healed, the pain messages stop. Doctors prescribe opioid medicines to help people deal with the pain while they heal.

Opioids do not treat causes of pain. They change how we feel pain. Opioids attach to parts of the nervous system called opioid receptors. The opioid receptors send signals to the parts of the brain that feel pleasure. The result is a feeling of happiness or calm that is stronger than the pain. This way, people do not feel as much pain.

Side effects and risks

Opioids do other things in the body. They suppress, or slow down, the nervous system. This slows down digestion, heart rate, breathing and thinking. Other problems can include:

• Constipation
• Low sex drive
• Poor memory and concentration
• Loss of balance and slow reflexes
• Coma, seizures
• Death

Physical dependence can be another side effect of opioid use. When people use opioids, their bodies get used to them over time. Eventually, their bodies need the opioids to feel normal. This is the body’s natural response to certain medicines and not always a problem. The unpleasant part of physical dependence is withdrawal. If a person who is dependent on an opioid stops taking it, they will feel sick. They might feel anxious, have trouble sleeping, have muscle or bone pain, sweat too much, or get stomach cramps or diarrhea. Doctors can help by slowly lowering the dose of the opioid. This lets the body get used to less and less medicine without causing withdrawal symptoms. Another way to treat opioid withdrawal is by the use of medications like buprenorphine and Naloxone (Suboxone®, Zubsolv®). If used in tapering doses, they can alleviate the discomfort associated to withdrawal.

Opioid use can create addiction, or misuse. Physical dependence can be one sign of misuse, but they are not the same thing. When a person misuses opioids, they keep using opioids even when it causes problems in their life. These problems include issues with work, school and relationships. They may have emotional, behavioral or physical problems. Some other signs of misuse include:

• Personality changes
• Needing more and more medicine to get pain relief
• Switching to illegal opioids, like heroin
• Doing dangerous or illegal things to get the drug
• Getting medication from several doctors
• Visiting hospital emergency rooms to get the drug

By Beth Landau

©2017-2021 Carelon Behavioral Health

Source: Academy of Integrative Pain Management. www.aapainmanage.org; American Chronic Pain Association. https://theacpa.org; Narconon’s “Signs and Symptoms of Prescription Pain Reliever Abuse.” (2015). www.narconon.org/drug-abuse/signs-symptoms-pain-relievers.html; “Opiate and opioid withdrawal.” (2016) MedlinePlus. U.S. National Library of Medicine, www.nlm.nih.gov/medlineplus/ency/article/000949.htm; SAMHSA’s “Opioids.” (2016) www.samhsa.gov/atod/opioids

•  Summary

• Opioid misuse is a chronic illness and should be treated that way.
• Medicines include methadone, buprenorphine, and naltrexone.
• Different types of counseling and public services support medicine-based treatment.

For a long time, people thought the best way to stop misusing opioids was to quit cold turkey, or all at once. This forced people’s bodies to get very sick, or go through withdrawal. After the opioids left their system, they could start behavioral therapies, like counseling, training, or 12-step programs. This is also called “abstinence-only” treatment.

But withdrawal is a traumatic experience. It leaves people feeling physically and emotionally wiped out. What’s worse, studies show that quitting cold turkey does not help people stop using opioids. Abstinence-only approaches do not work for everyone. After withdrawal, people’s bodies still crave opioids. This craving is very strong. Many people use again. This is called a relapse. When people relapse, some overdose and die.

Luckily, studies show that a combination of medicines, counseling, and services does help people stop misusing opioids for good. This is called medication-assisted treatment (MAT).

Since the 1950s, people have used medicine to help people get off opioids. Methadone (Methadose®, Dolophine®) is a type of opioid. Doctors found that a daily dose gets rid of withdrawal symptoms. It also cuts down on strong cravings. These things are useful but limited. Some people think this trades one drug for another, so that the person is still using. However, experts believe that MAT is not the same as using drugs. It’s more like how someone with diabetes might need a medication called insulin. People who are on MAT are in recovery. They are not still using.

Opioid misuse is a chronic illness. Chronic illnesses need different kinds of treatments. One example is someone with diabetes. The person sees a doctor for this illness. She also works with diet and exercise. She sees doctors for pain or other illnesses. She talks to a counselor about the challenges of her life. Opioid use disorder is similar. Treatment must work on symptoms, habits, and how people see the world. That is where MAT can help.

Medicines

Methadone is one medicine used to treat opioid misuse. People can take it while there are still opioids in their system. It can stop or reduce withdrawal symptoms and cravings. Doctors give a daily dose just right for each person. It comes in pill, liquid, or wafer form. People often go to a doctor’s office or clinic every day to get their dose. Sometimes, doctors give people pills to take at home.

Buprenorphine (Butrans®, Subutex®, Belbuca®) is another medicine used in MAT. It is long-lasting and reduces cravings. It comes in a thin film, a tablet for under the tongue, or a skin patch. Buprenorphine is a daily medicine. It is often used with other medicines or therapies.

Naltrexone (Vivitrol®, Revia®, Depade®) is often used in MAT. It blocks the effects of opioids. Naltrexone attaches to opioid receptors. People do not get the high they are looking for. Naltrexone makes people not want to use opioids. Naltrexone comes as a pill or a long-lasting injection.

Counseling and services

People need to understand their feelings, thoughts, and actions for treatment to work. Counseling and other services help people with this.

There are many types of counseling. People can get counseling in hospitals or rehabs. But counseling is mostly done outside of hospitals or rehabs in an outpatient setting. A person can work with a counselor alone or with a group. Cognitive-behavioral therapy is often a part of MAT. It helps people notice their feelings, thoughts, and actions. This helps people learn why they feel and act certain ways. That knowledge gives people tools to change their habits.

Other important support includes:

• Peer support groups
• Twelve-step programs
• Faith-based fellowship recovery groups

Regular parts of life do not stop during opioid misuse treatment. People still need to have a home, pay bills, and get to appointments. However, opioid misuse creates problems in people’s lives. So, people may need help in other areas of their life too. Here are examples of other helpful services:

• Case managers
• Patient advocates
• Transportation services
• Job skills training or job placement
• Educational programs
• Food support programs
• Housing programs
• Parenting classes
• Legal services

Resources

U.S. Department of Health and Human Services
www.hhs.gov
(877) 696-6775

Narconon
www.narconon.org
(800) 775-8750

National Institute on Drug Abuse
www.drugabuse.gov
(301) 443-1124

Substance Abuse and Mental Health Services Administration
www.samhsa.gov
(877) 726-4727

By Beth Landau

©2017-2019 Carelon Behavioral Health

Source: American Society for Addiction Medicine’s “Treating Opioid Addiction as a Chronic Disease.” (2014) www.asam.org/docs/default-source/advocacy/cmm-fact-sheet—11-07-14.pdf?sfvrsn=0; SAMHSA’s “Medication-Assisted Treatment.” (2016) www.samhsa.gov/medication-assisted-treatment; SAMHSA’s “Treatments for Substance Use Disorder.” (2016) www.samhsa.gov/treatment/substance-use-disorders

Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

• Summary

  • Know the signs of an opioid emergency.
  • Assess the situation.
  • Call for help.

  Opioid emergencies are becoming more and more common. Luckily, there is often time to treat and save someone who is overdosing. It is important to move quickly if you witness an opioid emergency. Here is how to recognize an opioid emergency and what do to.

  Signs of an opioid emergency

  The following are signs of an overdose or opioid emergency:

  • Asleep or unconscious and will not wake up
  • Awake or conscious but cannot talk or respond
  • Limp body or no muscle tone
  • Slow, shallow, uneven, or stopped breathing
  • Nails, lips, or skin look blue, purple, or gray
  • Discolored tongue
  • Throwing up, heaving, or stomach cramps
  • Pulse is light or absent
  • Choking, snoring, gurgling, or other strange sounds when sleeping

  What to do

  Opioid emergencies can be scary. You may feel that you have to move very quickly or worry that you will make a mistake. Getting upset or flustered will not help, so try to stay calm. You will be able to help more if you stay calm. Take a few deep breaths and slowly let them out to calm down. Then, focus on the emergency.

  First, assess the situation. Decide if someone is having an opioid emergency. It is an emergency if he:

  • Has any of the signs listed above
  • Will not wake up even if you call his name or rub his breastbone with your knuckles
  • Cannot move or talk
  • Is awake but cannot focus

  If you are not sure that it’s an emergency, err on the side of safety and call 911.

  Second, get help. Here’s how:

  • Stay with the person having the emergency.
  • Call 911.
  • Give the dispatcher your exact location.
  • Describe what you see: Is she is having breathing problems? Will she wake up? Which signs can you see?
  • Tell the dispatcher what drug or medicine she used.
  • You may have to leave the person to get your phone or let in paramedics. If so, follow the directions the 911 operator gives you before you leave the person.
  • Naloxone (Narcan®) is a medicine that can stop an opioid overdose. Paramedics carry it with them. If a person has a history of opioid misuse, doctors may prescribe a dose of naloxone for the family or caretaker to use in case of emergency. If you have been given naloxone and have been trained to use it, give it to the person having the emergency. Follow all instructions.

  Third, listen to the paramedics. Remember that the paramedics are the experts. They need you to step aside and let them do their job. Once they arrive, your job is to give them what they need:

  • As much detail as you know about the drug or medicine she used, including naloxone
  • Room to work and remove the person having the emergency
  • A calm and quiet environment

  The paramedics will tell you where they are taking the person having the emergency and what steps to take next.

  Resources

  Harm Reduction Coalition
  http://harmreduction.org
  (212) 213-6376 East Coast
  (510) 444-6969 West Coast

  Substance Abuse and Mental Health Services Administration
  www.samhsa.gov
  (877) 726-4727

  Narconon
  www.narconon.org
  (800) 775-8750

  By Beth Landau

  ©2017-2019 Carelon Behavioral Health

  Source: Centers for Disease Control and Prevention’s “Opioids drive continued increase in drug overdose deaths.” (2013) www.cdc.gov/media/releases/2013/p0220_drug_overdose_deaths.html; Narconon’s “Signs and Symptoms of Prescription Pain Reliever Abuse.” (2015) www.narconon.org/drug-abuse/signs-symptoms-pain-relievers.html; National Institute on Drug Abuse’s “What Are the Possible Consequences of Opioid Use and Abuse?” (2014) www.drugabuse.gov; “Opiate and opioid withdrawal.” (2016) MedlinePlus. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/000949.htm; SAMHSA’s “Opioids.” (2016) www.samhsa.gov/atod/opioids

  Reviewed by Enrique B. Olivares, M.D., Director of Addiction Services, Beacon Health Options

• Summary

  • Opioids are pain medicines that can be legal or illegal.
  • All opioids come with side effects and serious risks.
  • Illegal opioids are not controlled and are especially dangerous.

  Doctors use opioid pain medicines for pain relief. Opioids do not treat the cause of pain. Instead, they attach to opioid receptors in the body. These tell the brain to increase the production of a neurotransmitter that causes pleasure. This makes the person feel pleasure instead of pain.

  Types of opioids

  Legal opioids include:

  • Codeine (Tylenol 3, certain cough syrups)
  • Hydrocodone (Vicodin®, Lortab)
  • Oxycodone (Percocet, OxyContin®)
  • Hydromorphone (Dilaudid)
  • Morphine (MS Contin, MSIR)
  • Fentanyl (Duragesic®)
  • Methadone
  • Buprenorphine (semisynthetic opioid)
  • Propoxyphene (Darvocet, Darvon)

  Illegal opioids are not used by doctors. People mostly use them for the high or good feelings they cause. Heroin and krokodil (desomorphine) are illegal opioids.

  Opioids for pain relief

  Some pain is acute. It is short-term. It usually has a specific cause, like a broken bone or surgery. Some pain is chronic. It is long-term. It is often caused by a chronic illness or condition. Opioids are best used for acute pain. They can help people feel less pain while they heal. Doctors also use opioids for chronic pain. This can be risky. Causes of chronic pain do not often heal and go away. They keep making pain. This means using opioids for longer times. People who take opioids longer have higher risks of side effects and complications.

  Side effects

  Opioids can be used safely as part of a pain management plan. But they can come with side effects, or unwanted symptoms. Constipation is the most common side effect. Others include:

  • Trouble sleeping
  • Feeling sick to your stomach or throwing up
  • Increased pain
  • Muscle stiffness
  • Itchiness

  Another common side effect is trouble breathing. This is not only a dangerous short-term problem. Opioids cause less oxygen to reach the brain. This is called hypoxia. Over time, hypoxia can cause nerve issues, coma or permanent brain damage.

  Long-term use of opioids can lead to tolerance and physical dependence. Tolerance means you need more and more medicine to get the same pain relief. Plus, your body stops making a hormone that causes pleasure. This increases pain. Tolerance can make a “pain loop.” This means your body needs more and more medicine for similar pain control.

  Physical dependence means your body gets used to the medicine and needs it to work well. Without it, you will experience withdrawal symptoms. These include:

  • Anxiety and worry
  • Aches and pains
  • Problems sleeping
  • Sweating
  • Tearing eyes and runny nose
  • Stomach cramps and diarrhea
  • Feeling sick to your stomach or throwing up
  • Large pupils
  • Fever

  Long-term use of opioids can also lead to misuse or addiction.

  Is physical dependence the same as addiction?

  No. Physical dependence means your body needs the medicine. This happens with all sorts of medicines. Addiction is the misuse of a substance. It means you keep using something even when it causes problems in your life. You may have problems with work, school, or relationships. Misuse can cause emotional, behavioral, or physical problems. People sometimes mess up big parts of their lives just to keep getting and using opioids. Some signs of opioid misuse are:

  • Taking more opioids than prescribed
  • “Doctor shopping” or going to many doctors for opioids
  • Being obsessed with getting opioids
  • Reckless actions to get opioids
  • Looking for a high, not pain relief
  • Missing work or school
  • Personality changes
  • Physical or behavioral health changes
  • Relationship troubles

  Research suggests that opioid addiction, or misuse, is a problem with no quick fix. In fact, the medical community views it as a long-term or chronic illness. As with all chronic illnesses, treatments need to deal with all parts of opioid misuse. This includes medical, emotional and behavioral parts.

  “Abstinence-only” used to be the treatment for opioid use disorders, however, medication-assisted treatment (MAT) is now an evidenced-based best practice that helps many people. Examples of MAT are methadone or buprenorphine with Naloxone. Pregnant women should inform their prescribers before taking Naloxone or Suboxone. When someone is on MAT, he is not using one drug instead of another. When someone is on MAT he is in recovery, not still using. MAT is medicine, similar to how someone with diabetes might need to take insulin.

  Risk factors for opioid misuse

  Anyone can become addicted to opioids. It is a major problem in the United States. More than four million people misuse opioids. However, some things increase a person’s risk, including:

  • Chronic or long-term use
  • Genetics
  • Mixing alcohol or other substances with opioids
  • Emotional or behavioral problems
  • Personality

  Dangers of illegal opioids

  All opioids can cause the side effects and risks discussed above. But illegal opioids have dangers all their own. Illegal opioids are dangerous because they are not regulated.

  The production of legal opioids is highly controlled. In the United States, all drugs must be tested and approved by the Food and Drug Administration (FDA). The FDA controls how drugs are made. They check ingredients, doses, and quality. This lets doctors and people who use it know exactly what they are getting. No one checks illegal opioids to see if they are what they say they are. The doses may be high or low. They may have poisonous ingredients. These unknowns can lead to trouble, including overdose and death.

  For example, heroin is a strong illegal opioid. It can be inhaled, smoked, or injected. It is usually mixed with other substances. This can include fentanyl, another strong opioid that has contributed to deaths. Heroin is not controlled. People do not know the strength of their heroin. A person never knows what their heroin is mixed with. If she gets pure heroin or heroin mixed with fentanyl, she can easily overdose.

  Another example is krokodil (desomorphine). It is a very strong and dangerous street drug. It is even stronger than heroin. Years ago, the drug desomorphine was legal in Switzerland. Krokodil is a street version of desomorphine. It is made with codeine and cooked with other substances. Krokodil’s strength is not the only problem. It is also full of poisonous chemicals. Krokodil can damage a person’s veins, kidneys or liver. It also causes skin infections, tooth loss and problems with memory.

  People sometimes buy oxycodone, fentanyl, or other legal opioids illegally. They often take more than a doctor would prescribe. They also do not know if these drugs are real or fake.

  By Beth Landau

  ©2017-2021 Carelon Behavioral Health

  Source: “Desomorphine.” (2013) U.S. National Library of Medicine’s Toxicology Data Network, https://toxnet.nlm.nih.gov/cgi-bin/sis/search/a?dbs+hsdb:@term+@DOCNO+8070; Narcononﾒs “Effects of Desomorphine Abuse” (2016). www.narconon.org/drug-abuse/desomorphine-effects.html; National Institute of Drug Abuse’s “Fentanyl” (2016). www.drugabuse.gov/drugs-abuse/fentanyl; National Institute of Drug Abuse’s “What Are the Possible Consequences of Opioid Use and Abuse?” (2014). www.drugabuse.gov