There’s been a lot of news coverage of the opioid epidemic in recent years, and along with it, you may find yourself wondering: What are the signs someone is addicted to opioids?
You have good reason to be concerned, because the drugs — pharmaceutical narcotics distributed primarily to treat pain — may be legal, but they can still be deadly. According to the Centers for Disease Control and Prevention , “Opioids were involved in 47,600 overdose deaths in 2017 (67.8% of all drug overdose deaths).” The overdose death rate from prescription opioids in 2017, in fact, was five times higher than it was in 1999, and the CDC reports that “from 1999 to 2017, almost 218,000 people died in the United States from overdoses related to prescription opioids.” 
There are many reasons for that, not the least of which is the misconception that because prescription opioids are recommended by a physician and manufactured by pharmaceutical companies and therefore meet certain standards of quality control, they must somehow be “safer.” Nothing could be further from the truth, because opioids act on the body and the brain in the same manner as other opioids — heroin, for example.
The body doesn’t distinguish between drugs bought on the street or those obtained from a doctor, and opioids in any form can play a huge role in the growing addiction epidemic in the United States. So what are the signs someone is addicted to opioids? Let us first explore what they are where they come from.
A History of Pain Medication Through the 1800s
Pain, it turns out, is the great motivator. As Dr. Marcia L. Meldrum writes in a paper for the Journal of the American Medical Association , “Pain is the oldest medical problem and the universal physical affliction of mankind … the philosophical, political and religious meanings of pain defined the suffering of individuals for much of human history.” While it would be many years before concerned individuals began to wonder about the signs someone is addicted to opioids, the same ingredient in modern opioids has been unchanged, according to the Foundation for a Drug-Free World : “Opiates, originally derived from the opium poppy, have been used for thousands of years for both recreational and medicinal purposes. The most active substance in opium is morphine — named after Morpheus, the Greek god of dreams.”
Before morphine, however, there was opium, and in 1680, a man named Thomas Sydenham mixed it with sherry for a concoction known as laudanum . However, the stoic nature of society in those days, combined with the punitive views of religion, valued the experience of pain as much as the relief from it, and it wasn’t until the Romantic period that pain medication came to be seen as a necessary component of physical healthcare.
Ether as a surgical anesthesia was first used on a patient in 1846, and two years later, a British physician suggested the use of chloroform in both childbirth and surgery. By that point, morphine had been around for nearly half a century: It was developed in Germany in 1804, was being industrially produced there by the 1820s and came to the United States a decade later. According to Meldrum, “Alexander Wood in 1855 devised a syringe with a hollow needle for subcutaneous injection, which was of immediate practical benefit. The syringe made frequent administration so convenient that it probably contributed to the overuse of morphine.”
By the Civil War, the first opioid epidemic was taking place in America: “The Union Army alone issued nearly 10 million opium pills to its soldiers, plus 2.8 million ounces of opium powders and tincture,” according to the magazine Smithsonian . “An unknown number of soldiers returned home addicted, or with war wounds that opium relieved.” Throughout the latter half of the 19th century, opium-based products were unregulated and dispensed with alarming regularity, until roughly 1895, when the epidemic began to decline: “Advances in medicine and public health played a role: acceptance of the germ theory of disease, vaccines, x-rays, and the debut of new pain relievers, such as aspirin in 1899.” 
Signs Someone Is Addicted to Opioids: 20th Century and Beyond
By the early 20th century, the introduction of opium dens in the American West had changed the face of opioid addiction. No longer were addicts limited to wealthier citizens and older women who had free access to it in the late 1800s; young men discovered the euphoria of it and began to draw attention to themselves, according to David T. Courtwright, the author of “Dark Paradise: A History of Opiate Addiction in America” : “In the late 19th century, as long as the most common kind of narcotic addict was a sick old lady, a morphine or opium user, people weren’t really interested in throwing them in jail,” Courtwright wrote. “That was a bad problem, that was a scandal, but it wasn’t a crime. When the typical drug user was a young tough on a street corner, hanging out with his friends and snorting heroin, that’s a very different and less sympathetic picture of narcotic addiction.”
The first federal law regulating opium passed in 1909, and the Harrison Narcotic Act of 1914 ensured that “morphine and other narcotics were heavily regulated, and prolonged administration was sanctioned only for the dying.”  What followed, Meldrum writes, were “disabling and drastic remedies” that included procedures like the crushing of nerve fibers to stop the transmission of pain from the brain. There were pharmacologists, however, who understood the need for a pain reliever that existed in the shadowy landscape between aspirin and narcotics, and as such several pursuits of this ended up in 1938 at the National Institute of Health, where scientists endeavored to separate the addictive properties of opioids from the analgesic ones. However, “although the program has tested many new analgesics, including oxycodone, meperidine, methadone and pentazocine … the strong nonaddicting morphine derivative has continued to elude the researchers.” 
By the mid-20th century, advances in pain management led to the introduction of acetaminophen, the active ingredient in Tylenol, in 1955, according to New York Magazine . Hydrocodone, which was first synthesized in 1920 by the German pharmaceutical company Knoll, was combined with Tylenol in 1978, and Vicodin was first introduced to the market. Although the federal government addressed concerns about the addictive nature of semi-synthetic opioids like oxycodone (first synthesized in 1917) and hydrocodone by adding them to the Controlled Substances Act, passed in 1971, their use as legitimate medical pain relievers was of less concern than illegal opioids like heroin.
In 1991, oxycodone was formally approved for use in the United States, and since then, “it has become one of the most commonly prescribed drugs in medical practice.”  During the 1990s, the medical community took a liberal approach to “the use of opioids in the treatment of pain, particularly for chronic non–cancer-related pain. Purdue pursued an ‘aggressive’ campaign to promote the use of opioids in general and OxyContin in particular,” according to a paper published in the American Journal of Public Health : “When Purdue Pharma introduced OxyContin in 1996, it was aggressively marketed and highly promoted. Sales grew from $48 million in 1996 to almost $1.1 billion in 2000. The high availability of OxyContin correlated with increased abuse, diversion, and addiction, and by 2004 OxyContin had become a leading drug of abuse in the United States.”
According to the U.S. Department of Health and Human Services (HHS) , the effort by pharmaceutical companies to reassure “the medical community that patients would not become addicted to opioid pain relievers” led to a drastic uptick in prescriptions, to the point that by 2016, “an estimated 40% of opioid overdose deaths involved a prescription opioid.” The next year, HHS declared a public health emergency and announced a five-point strategy to combat the crisis, but the fallout continues to reverberate.
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Signs Someone Is Addicted to Opioids: How They Work
To understand how prescription opioids work, it’s important to know the correct terminology. According to a 2008 paper in the journal Experimental and Clinical Psychopharmacology :
- Opioid “refers to all compounds that bind to opiate receptors” and includes “semi-synthetic opiates, i.e., drugs that are synthesized from naturally occurring opiates (such as heroin from morphine and oxycodone from tehbaine), as well as synthetic opioids such as methadone, fentanyl and propoxyphene.”
- Opiate “can be used to describe those opioids that are alkaloids, derived from the opium poppy; these include morphine and codeine.”
- Narcotic is a legal term that refers to opioids and some other drugs grouped alongside them by law enforcement “and should not be used in the clinical setting.”
While there are dozens of prescription opioids on the market, none of them have the word as part of their brand name. Some of the most popular types of opioids, and their brand name equivalents, include:
- Morphine: MSIR, Roxanol, MSContin, Oramorph SR, Kadian, Avinza
- Oxycodone: Oxycontin, OxyIR, Oxyfast, Endocodone
- Oxycodone with acetaminophen: Roxilox, Roxicet, Percocet, Tylox, Endocet
- Oxymorphone: Opana, Opana ER
- Hydromorphone: Diluadid, Hydrostat
- Hydrocodone with acetaminophen: Vicodin, Lorcet, Lortab, Zydone, Hydrocet, Norco
- Fentanyl: Duragesic patch
As prescribed, most of these narcotics are dispensed in pill form, which are taken orally. One of the signs that someone is addicted to opioids, however, is that they’re using them more frequently than prescribed and in ways that obviously aren’t recommended by a physician:
- Crush and inhaling;
- In the case of fentanyl patches, transdermally; and
Once ingested, “opioids act by binding to specific proteins, called opioid receptors,” according to that 2008 paper. “Receptors are widely distributed. Those involved in pain modulation are situated in both the central nervous system and the peripheral nervous system. These receptors also bind endogenous opioid peptides (endorphins), which are involved in pain modulation and numerous other functions in the body. Among these functions are those mediated by deep structures of the brain, which are involved in the modulation of reinforcement and reward mechanisms, mood and stress.”
Those reinforcement and reward structures are key to encouraging an addictive pattern of use. The euphoria produced through the reward mechanism means that “powerful reinforcement occurs, expressed as efforts to repeat the administration and these reinforcing outcomes may be associated with craving and with positive mood effects such as euphorigenic or pleasurable effect.” Dopamine, the chemical associated with pleasurable responses, is released in modest increments when pleasurable experiences take place — sex, food, roller coaster rides and any number of other normal human activities that make us feel good.
Opioids, however, act like a clinched fist around a soaking wet sponge: The receptors flood the brain with dopamine, and the intensity of that torrent triggers a demand in some individuals to repeat the experience. However, the body’s supply of dopamine is limited, and as a result, repeated use means it takes more opioids to achieve the desired effect.
How Do Opioids Affect the Body?
According to the U.S. National Library of Medicine , “Taking opioids over a long period of time produces dependence, such that when people stop taking the drug, they have physical and psychological symptoms of withdrawal (such as muscle cramping, diarrhea, and anxiety). Dependence is not the same thing as addiction; although everyone who takes opioids for an extended period will become dependent, only a small percentage also experience the compulsive, continuing need for the drug that characterizes addiction.”
The National Institute on Drug Abuse (NIDA)  lays out the short-term effects of opioids: “In the short term, opioids can relieve pain and make people feel relaxed and happy. However, opioids can also have harmful effects, including:
- Slowed breathing.”
The most alarming long-term effect of opioid use, of course, is dependence and/or addiction, which despite being used interchangeably, are not the same, although the symptoms of both are identical, according to the Partnership for a Drug-Free World : “The body adapts to the presence of the drug and withdrawal symptoms occur if use is reduced or stopped. These include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, and cold flashes with goose bumps (‘cold turkey’). Tolerance can also occur, meaning that long-term users must increase their doses to achieve the same high.”
One of the signs that someone is addicted to opioids is the fact that their bodies are so dependent on the drugs that they go into withdrawal when they stop taking them. Withdrawal is one of the most difficult symptoms of opioid addiction to manage, because while the physical discomfort is intense, the psychological discomfort is agonizing: Writing for the publication Kaiser Health News , Brian Rinker describes is this way: “For many users, full-blown withdrawal is often foreshadowed by a yawn, or perhaps a runny nose, a sore back, sensitive skin or a restless leg … these telltale signals — minor annoyances in and of themselves — set off a desperate panic: I’d better get heroin or some sort of opioid into my body as soon as possible, or else I would experience a sickness so terrible I would do almost anything to prevent it: cold sweats, nausea, diarrhea and body aches, all mixed with depression and anxiety that make it impossible to do anything except dwell on how sick you are. You crave opioids, not because you necessarily want the high, but because they’d bring instant relief.”
So What ARE Signs Someone Is Addicted to Opioids?
It’s important to note that not everyone who uses opioids develops a problem. In fact, numerous studies have concluded that “the majority of healthy non-drug-abusing volunteers do not report euphoria after being administered opioids in the lab either with or without pain," according to Dr. James Zacny of the University of Chicago . In other words — the brain chemistry of those with a propensity for addiction seems to produce greater euphoric effects than the brains of those with no such propensity.
For individuals who do develop a problem, however, the over-excitement of the reward circuit in the brain can reinforce patterns of behavior that include telltale signs someone is addicted to opioids, including:
- Taking a substance in larger or longer amounts than intended. According to Dr. Jonathan Morrow, an assistant professor of psychiatry with the University of Michigan , “Prescription painkillers are meant to be a short-term fix; extended use can signal trouble.”
- Excessive concern over the medication. Those who have a problem count pills, no how many they have left in a bottle, often keep the prescription with them at all times and count down the days until they can get a refill.
- A fixation on the euphoria rather than pain relief. If an individual talks at length about how good opioids make them feel rather than how effective they are at blocking pain, then they may have a problem.
- Coming up with excuses for refills. If someone is constantly “losing” their medication or “forgetting” it, therefore necessitating a need to seek more, then they may have a problem.
- Excess time spent obtaining, using or recovering from a substance, according to Morrow , which may include an inordinate amount of time coming up with money to get opioids, or turning to cheaper alternatives: “Pills tend to be more expensive. At some point, they’re told or they figure out that heroin is cheap.”
- Psychological and physiological changes, according to the Mayo Clinic , including “mood changes, including excessive swings from elation to hostility; changes in sleep patterns; (and) poor decision-making, including putting himself or herself and others in danger.”
- Theft of medication. If you have leftover opioids from a medical procedure in your home, and you notice signs someone is addicted to opioids, dispose of them — lest they turn up missing. Many opioid addicts turn to the medicine cabinets of friends and families to supplement their supply.
- Vocational, legal and social consequences. Because opioids affect the body in the same manner as heroin, opioid withdrawal can be debilitating. One of the signs someone is addicted to opioids is frequent tardiness from work and/or school, and a constant avoidance of social functions that may interfere with their ability to obtain or consume the drugs.
- They continue to take opioids in spite of negative consequences. If they’ve admitted they have a problem, or they’ve been confronted about a problem, but they can’t seem to stop even when faced with threats of job termination or school expulsion, chances are they’re addicted.
- They ask for help. One of the most obvious signs someone is addicted to opioids is when they come right out and say so. And that’s where those to whom they confess should be prepared to extend a hand.
For someone to admit they have a problem with opioids takes a great deal of courage, but more importantly, it’s the sign of a great deal of desperation. Fortunately, they’re not alone — a 2018 national poll by the American Psychiatric Association  revealed that “nearly a third of Americans say they know someone who is or has been addicted to opioids or prescription painkillers. Nearly half feel it is extremely or somewhat easy to access opioids for illicit use.”
The biggest takeaway from that poll, however is this: “Americans strongly favor improving access to treatment over imposing stricter punishments to address the problem.” Because that’s the singular upside to the crushing opioid epidemic that is laying waste to large swaths of American society — more people know about it, and many of them understand that it’s a disease from which those who suffer need help.
And that’s where drug and alcohol treatment comes in. It’s not a silver bullet; a drug and alcohol treatment center can’t “cure” opioid addiction any more than a cancer center can “cure” cancer. But it can be treated — with safe, medically supervised detox, combined with residential inpatient and intensive outpatient programs — and those afflicted can be given tools to cope. Most importantly, it can be sent into remission with time, effort and a combination of traditional and evidence-based tools that provide a way out of what amounts to physiological and psychological slavery.