Opioid Abuse and Dependence

Opioids are either derived from naturally occurring opium (e.g. heroin) or are made synthetically (e.g. methadone, buprenorphine).¹ If used continuously, they have the potential of causing both physical and psychological dependence within 2-10 days.²

Opioids have two main effects: an analgesic affect and a euphoric effect. It is their euphoric effect that is the reason why they can be abused. They can be used intravenously, subcutaneously, intranasally or smoked. Remember that if someone reports opioid abuse, they may also be abusing other drugs.

Characteristic features include drug craving and maladaptive behaviour focussed on obtaining opioids at any cost. Opioid misuse can be defined as a continuous compulsion to use opioids despite physical, psychological or social harm to the user.³

The World Health Organisation suggests that the following are required for the diagnosis of opioid dependence:⁴

• A strong desire or sense of compulsion to take the substance.
• Difficulty in controlling use.
• A physiological withdrawal state.
• Tolerance.
• Neglect of alternative pleasures and interests.
• Persistence of use despite harm to oneself and others.

• In the UK, it is estimated that 9.35 per 1000 population aged 15-64 have problem drug use and that 3.2 per 1000 inject drugs.⁵
• The National Drug Treatment Monitoring System estimates that in 2006-7 there were 195,464 people in contact with treatment services in England and the majority were primary opioid users.⁶
• It is estimated that there are about 280,000 opioid users in the UK.⁶
• Men make up the majority of people presenting for treatment for opioid dependence.
• In 2005, there were 1608 deaths in England and Wales related to drug misuse. Heroin or morphine were mentioned on the death certificate in 842 deaths, and methadone was mentioned in 220 deaths.⁷

These include:

• Sweating
• Watering eyes
• Rhinorrhoea
• Yawning
• Feeling hot and cold
• Anorexia and abdominal cramps
• Nausea, vomiting, and diarrhoea
• Tremor
• Insomnia, restlessness, anxiety, and irritability
• Generalised aches and pains
• Tachycardia, hypertension
• Goose flesh (goosebumps)
• Dilated pupils
• Increased bowel sounds
• Coughing

Fatigue and insomnia tend to follow these acute symptoms. Cravings can last for up to 6 months. Acute heroin withdrawal symptoms tend to ease after 5 days. Methadone withdrawal symptoms can take 10-12 days to subside.

• Health problems:
  • Death (which may be due to overdose, suicide, accidents or health-related complications)
  • Skin infection at injection sites (can be severe; necrotising fasciitis can occur)
  • Septicaemia
  • Infective endocarditis
  • HIV infection
  • Hepatitis A, B and C infection
  • Tuberculosis infection
  • Venous and arterial thrombosis (due to poor injecting techniques)
  • Poor nutrition and dental disease
• Social problems:
  • Crime
  • Relationship problems
  • Child protection issues
  • Homelessness and deprivation
  • Working in the sex industry
• Psychological problems:
  • Craving
  • Guilt
  • Anxiety
  • Loss of cognitive skills and memory

Someone who is opioid dependent may present to primary care in a number of different ways including:

• With a direct request for help for their dependence.
• With a medical complication due to their dependence.
• With clinical signs of opioid intoxication or withdrawal.
• With social problems including evidence of a forensic history.
• By disclosing their opioid abuse whilst presenting for another problem.

• All GPs have a duty to provide basic medical services to people who are dependent on opioids and they should screen patients for drug misuse.
• If detoxification and/or substitute prescribing are requested, after an initial assessment, GPs can refer to local specialist community drug services and there are usually locally agreed shared care guidelines. A care plan between the drug misuser and the service provider can then be drawn up.
• A GP may have a special clinical interest in the management of substance misuse in primary care and may be able to take more responsibility in the treatment of patients, particularly in complex cases.
• A multidisciplinary approach to care is needed.
• Strict practice policies surrounding the care of drug misusers are advised.
• There are UK guidelines for drug misuse and dependence produced by the Department of Health (England), the Scottish Government, the Welsh Assembly Government and the Northern Ireland Executive. Further information can be found in the article Drug Misuse and Dependence Guidelines.

• The assessment of someone with drug dependence is discussed in detail in the article Assessment of Drug Dependence.
• Details about the nature of drug and alcohol abuse should be determined.
• Appropriate history and examination should be carried out including a mental state examination.
• Drug testing should be performed to confirm opioid abuse.
• Assessment of risk and social functioning should be carried out.
• Screening including for HIV and hepatitis B and C should be offered.

• If a patient has collapsed and is thought to be acutely intoxicated, call 999 and refer urgently to hospital.
• Naloxone (a pure opioid antagonist used for reversing opioid intoxication) has a rapid onset of action and can be given IM, IV or subcutaneously.
• Therapy is otherwise mostly supportive, e.g. maintain airway, ventilation if necessary and IV fluids.

• A keyworker needs to work with the drug misuser to determine if they are suitable for substitute prescribing.
• The drug misuser also has to decide whether they would prefer opioid detoxification or induction and maintenance substitute prescribing.
• Detoxification from maintenance therapy at a later stage is an alternative.
• There is a separate article that discusses Opioid Detoxification in detail.
• There is another article that discusses substitute prescribing for opioid dependence in detail.
• Psychosocial components of treatment are also important and are outlined in the article Drug Misuse and Dependence UK Guidelines.

Between a quarter and a third of those entering drug treatment for opioid dependence achieve long-term sustained abstinence.⁸