Home > Encyclopedia of Drugs, Alcohol, and Addictive Behavior > Opioid Dependence: Course Of The Disorder Over Time

WHO IS SUSCEPTIBLE?

At the turn of the century, when opioid drugs were legally and easily available to all adults, only a few persons became dependent on them. Although the exact scale of opioid dependence at that time is not known, it probably did not exceed 2 percent of the adult population. An interview survey conducted in the 1970s of a national sample of young men in the United States revealed that 5.9 percent had used heroin at some time in their lives, but only 1.7 percent ever considered themselves dependent on this drug (O'Donnell et al., 1976). Other studies indicate that normal people free from physical pain tend to react to the effects of opioid drugs with indifference or dislike. With rare exceptions, patients who receive opioid drugs to relieve pain after surgery make no effort to continue drug use after they become free from pain. It is now well-known that opioid dependence develops in only a small proportion of those exposed to the effects of the drugs.

The characteristics of persons susceptible to opioid dependence have not been clearly defined, but clinical and other studies point to three personality problems that probably increase susceptibility. First, chronic emotional distress, such as DEPRESSION, tension, ANXIETY, anger, or mixtures of these, is relieved by opioid drugs, and this relief probably prompts repeated use of the drug. Second, impaired capacity to regulate emotional distress increases the urgency of the need for relief. Third, an antisocial attitude makes it easy for the person to perform the illegal actions needed for regular illicit opioid use. The notion that opioid drugs are used to relieve emotional distress is called the self-medication hypothesis. The origins of the personality problems that increase susceptibility probably lie partly in genetic inheritance and partly in adverse psychosocial experience. Modern opioid users often come from dysfunctional parental families.

Environmental conditions in the deteriorated areas of large cities in the United States place young persons living there at special risk for opioid dependence. Most of the retail illicit drug traffic and much of the opioid use takes place in these areas. Young persons are consequently exposed to available heroin and heroin-using role models and associated criminal behavior. Since these areas are heavily populated by minority groups—primarily African Americans, Puerto Ricans, and Mexican Americans—these groups are at special risk. The experience of POVERTY and adverse discrimination may contribute to emotional distress in members of these groups and thereby increase their susceptibility to opioid dependence. Apart from environmental conditions, ethnic status as such does not seem to affect susceptibility. Men seem to develop opioid dependence more often than women do; the ratio of men to women in treatment programs is about three to one.

ONSET OF OPIOID DEPENDENCE

Opioid use is usually preceded by use of tobacco, ALCOHOL, and MARIJUANA. Before their first opioid use, most users dropped out of school and began to associate with opioid users. Heroin is nearly always the drug of choice. With few exceptions, it is first used within a few years of the user's twentieth birthday. Users report that they were not coerced or urged to use heroin by either their associates or drug dealers. In a typical sequence a person becomes aware of drug use by his friends or relatives, becomes curious about its effects, and asks for the first injection. As already noted, most persons exposed to the effects of heroin do not become regular users.

Susceptible persons rarely become compulsive daily users immediately after first use. A variable period of occasional use—once a month or more often, but not daily—usually ensues. Curiosity fades as a motivation; the effects of the drug are what prompt repeated use. The drug users call these effects the "high." The high is not described as exhilaration or excitement but rather as relaxation and mood elevation. Descriptions of the high offered by many drug users suggest that it amounts to relief of the chronic emotional distress mentioned before as a factor in susceptibility. Susceptible persons increase the frequency of use until it reaches once or several times daily. From first use to daily use typically takes about one year, but it may take much longer. In a study of opioid users in San Antonio, one man reported that he first used heroin at the age of sixteen. He did not like it and did not use it again for fifteen years. At that time he felt depressed following the death of a friend and decided to try heroin again. This time the heroin made him feel better, and he quickly became a daily user (Maddux & Desmond, 1981).

With daily or nearly daily use, the user develops physiological DEPENDENCE on the drug. This means that when the drug use is reduced or stopped, the user develops distressing symptoms called the WITHDRAWAL illness. The threat or the onset of withdrawal symptoms provides additional strong motivation to continue daily use of the drug.

In the progression from initial use to daily use, heroin users learn how to inject heroin intravenously, how to acquire the drug and injection equipment, and with some exceptions, how to conduct illegal moneymaking activities to pay for the heroin. Those who began a delinquent career before their initial use of heroin were already oriented toward criminal activity. In some cases, heroin users or dealers provide a regular supply of heroin to their spouses or live-in companions; the latter thus do not have to engage in regular illegal activity to pay for their drug. Another exception to the pattern of illegal moneymaking activity is linked to opioid dependence among physicians and other health professionals. Health professionals rarely purchase heroin from street retailers. They have access to meperidine or other opioids available in pharmacies and hospital supplies, and they use these drugs instead of heroin.

Probably the most serious and disabling feature of opioid dependence is the inability to put a stop to it, also called loss of control of the drug use. After drug use has become daily and physiological dependence has developed, many opioid users try to stop using it and find themselves unable to do so. This inability to stop is a subjective mental state reported by drug users. It probably starts as a mild impairment of control and progresses to complete or nearly complete loss of control.

EARLY TERMINATION OF OPIOID DEPENDENCE

Continued daily use with loss of control depends partly on the availability of the drug and other environmental conditions. American soldiers serving in VIETNAM during the Vietnam War were exposed to an environment in which heroin was easily available and heroin use was common. An interview survey of a sample of returning veterans revealed that 35 percent had tried heroin while in Vietnam and 19 percent (about half of those who tried it) considered themselves addicted to it. During a three-year period after return to the United States, however, only 12 percent of those addicted in Vietnam became readdicted in the United States. These represented about 2 percent of the entire sample interviewed (Robins et al., 1980). Other studies of early termination of opioid dependence in the United States have identified various life events as probable causative factors in the termination. Among these are change of residence, marriage, a drug-related arrest, and death of a friend from overdose. Many persons who terminate their opioid dependence do so without treatment.

CHRONICITY, REMISSION, AND RELAPSE

With continued daily use and physiological dependence, the user's bond to the drug becomes stronger. Drug use, drug seeking, and illegal activity become the dominant activities of the user's life. Psychosocial development is retarded. Those who become dependent during adolescence often fail to complete high school and never develop regular work habits or job skills. With continued dependence, opioid users become impaired marital partners or parents.

Daily use does not continue indefinitely. In some cases, as noted, an important life change leads to cessation of use. In other cases, pressure from family or friends or other sources prompts entry into a treatment program. In still others, arrest, conviction, and incarceration interrupt the daily use. Sometimes conviction leads to probation with treatment as a requirement of the probation. After treatment or incarceration, the majority of chronic users resume opioid use within six months. The common long-term pattern consists of initial use followed by irregular sequences and varied durations of occasional use, daily use, treatment, abstinence, and incarceration. Remissions enduring for three years or longer followed by relapse are not unusual. Variations in the course of opioid dependence are illustrated in the following case summaries.

An employed man first used heroin at the age of twenty-six and after two months of occasional use began daily use. He continued working but engaged in the illicit heroin traffic to pay for his heroin. Two years after first use, he was arrested and convicted for sale of heroin. In lieu of prison, he was sent to a federal hospital for treatment. Released on parole at age twenty-nine, he remained abstinent for ten years, when he was last interviewed at age thirty-nine. He abstained from heroin, he said, because he did not want to return to "that miserable life."

Shortly after release from an institution for delinquents, a boy had his first injection of heroin at the age of sixteen. He became a daily user in about three months. During the next thirteen years he had two brief periods (each of about five months' duration) of abstinence from heroin. He used heroin occasionally or daily during the remaining time, except for four years in prison. He was murdered by gunshot at the age of twenty-nine.

After dropping out of school, a fourteen-year-old boy learned to make money by selling marijuana and heroin. He tried heroin at age sixteen, liked it, and promptly became a daily user. He used heroin daily for the next twenty years, except for relatively brief periods when he was in prisons and hospitals. Then, at age thirty-six, he was sent to prison for two years. During this period in prison, he felt some change in himself while participating in a THERAPEUTIC COMMUNITY program. After release, he abstained from heroin for the next eight years. He obtained employment as a counselor in a drug-abuse treatment program. He was aged forty-six when last interviewed.

Modern TREATMENT of opioid dependence includes drug withdrawal done as an inpatient or outpatient procedure, residential treatment, therapeutic community, drug-free outpatient treatment, the use of opioid ANTAGONISTS, and METHADONE MAINTENANCE. Prompt abstinence from opioid drugs is the goal of the first five of these types of treatments. Methadone maintenance, in contrast, consists of continued substitution of methadone, itself an opioid drug, for the illicit opioid. In addition to these forms of treatment, self-help groups such as NARCOTICS ANONYMOUS are available as well as special religious programs for drug users.

Opioid users who enter treatment aimed at prompt abstinence reveal mixed motivations for the treatment. They would like to become free of the burden of their drug dependence, but they do not want to give up the effects of the drug. Most leave treatment before completing it. Relapse after treatment is common, but the severity of the dependence is usually reduced, short periods of abstinence are often achieved, and for a small proportion of users, enduring cures of opioid dependence are attained. Methadone maintenance aims for social rehabilitation, with opioid abstinence as a possible distant goal. It has become a major mode of treatment for chronic opioid users and benefits many of them by helping them reduce or stop illicit opioid use and stop their criminal activity. This treatment, however, only infrequently leads to enduring abstinence.

USE OF MULTIPLE SUBSTANCES

In the early twentieth century, many alcoholics were converted from ALCOHOLISM to opioid dependence. If the opioid dependence was terminated, alcohol dependence often replaced it. In the later twentieth century, the patterns of use of other psychoactive substances during the course of opioid dependence have become more complex. Heroin users often substitute alcohol when they become abstinent from opioids, but, in addition, many use alcohol regularly while using heroin daily. They also use TOBACCO, marijuana, and cocaine. In a recent interview study of opioid users in California, 75 percent reported current use of tobacco, 20 percent reported being drunk on alcohol in the previous seven days, 38 percent reported use of marijuana in the previous thirty days, and 18 percent reported use of cocaine in the previous thirty days (Hser, Anglin & Powers, 1993).

WHY DOES OPIOID DEPENDENCE BECOME INTRACTABLE TO TREATMENT?

This important question can be answered only partially and tentatively. The conditions that contribute to the onset of opiod dependence also support the tendency to continued use. These, as previously noted, include chronic emotional distress, drug-using models, an available opioid drug, and withdrawal symptoms. Two other effects of the drug dependence probably contribute to relapse after treatment or incarceration. First, mild withdrawal symptoms such as muscular aching, insomnia, and irritability often persist for six months or longer after the last dose. These symptoms (called protracted withdrawal) are promptly relieved by an opioid drug, and they probably contribute to relapse after treatment. Second, the opioid user becomes conditioned to environmental conditions associated with withdrawal symptoms, so that after a period of abstinence, exposure to a conditioned stimulus will evoke withdrawal symptoms. This conditioned withdrawal probably contributes to relapse.

Three other changes in the mental state of the user probably also contribute to the intractable quality of the disorder, but these have not been as well defined and studied. First, over time the drug-using habit tends to become automatic, requiring no conscious decision to use or abstain. Second, the drug-seeking and the associated criminal behavior seem to become a part of an established lifestyle, and the user becomes enmeshed in a social network that includes illicit drug users and criminals. Third, with repeated relapses after treatment or incarceration, the opioid user comes to a self-perception as an addict with a diminishing capacity for change. This complex of learned attitudes and behaviors amounts to a personality change, which is probably accompanied by change in the brain. Such change may not become permanent, but it tends to endure.

LONG-TERM OUTCOMES

In follow-up studies extending from five to more than twenty years after admission to treatment, the percentages of users reported abstinent from opioid drugs have varied from 9 percent to 21 percent (Maddux & Desmond, 1992). Some of this variation was due to different ways of counting abstinence. In some studies the users were counted as abstinent only if they remained so during the entire period from treatment to follow-up, whereas in others the users were counted as abstinent if they were found so at the time of follow-up. Despite these differences, the studies collectively indicate that only a minority of opioid users are found to be abstinent on long-term follow-up.

Although only small to medium percentages were found to be abstinent, it should not be assumed that the remainder of people were using opioid drugs. Some were dead, some were in prison, and some were in treatment. The death rate of opioid users is about three times the expected rate. Overdose, homicide, suicide, accidents, and liver disease account for many of the deaths. In the 1980s the acquired immunodeficiency syndrome appeared as an additional hazard for drug injectors. A follow-up of opioid users in San Antonio revealed the following different statuses twenty years after first use: 16 percent were abstinent, 29 percent were using heroin, 30 percent were in prison or other institutions, 8 percent were maintained on methadone, and the remaining 17 percent were dead or their status was unknown (Maddux & Desmond, 1981).

WHAT CAN BE DONE?

Since policies and programs to reduce drug abuse are described elsewhere in this encyclopedia, only a brief comment will be offered here. Two broad approaches—supply reduction and demand reduction—have been put in place in the United States. Supply reduction consists of the enactment and enforcement of drug control laws. Although the supply-reduction effort has undoubtedly reduced the supply of illicit opioid drugs, it has failed by far to eliminate them from the environment of susceptible persons.

Demand reduction consists of treatment and prevention. Treatment of opioid dependence produces short-term abstinence and reduces the pool of daily users in the community, but it achieves few enduring cures. Publicly supported treatment programs in the United States are insufficiently financed to provide prompt treatment to all who seek it. A few pilot projects have been developed for reaching out to young persons at risk for opioid dependence and providing special services for them, but more research is needed on this type of preventive effort. Finally, opioid use in the United States seems embedded in a complex matrix of family dysfunction, poverty, undereducation, unemployment, and crime. Anything that reduces these problems would likely reduce illicit opioid use. Easy solutions seem unlikely.

(SEE ALSO: Addiction: Concepts and Definitions; Britain, Drug Use In; Causes of Substance Abuse; Coerced Treatment; Conduct Disorder and Drug Use; Crime and Drugs; Opioid Complications and Withdrawal; Opioids and Opioid Control: History; Vulnerability; )

JAMES F. MADDUX

DAVID P. DESMOND