Narcotic Abuse

• Pain is one of the most common reasons people seek medical treatment. Doctors can prescribe different types of medications to relieve pain. The most potent pain-relieving medications are narcotics (opiates or opioids).
• In the United States, narcotics are widely prescribed to treat painful conditions. Narcotics are often prescribed in conjunction with other less potent drugs (such as nonsteroidal antiinflammatory medications) or as a pill that has a combination of a narcotic with either acetaminophen (for example, Tylenol) or aspirin.
• Acetaminophen is also commonly found in many different products that are available as over-the-counter (OTC) medications. With the public often using OTC products that contain acetaminophen as well as prescription narcotics that might also have acetaminophen, the U.S. Food and Drug Administration (FDA) has become concerned about dangerous interactions from combining these medications.
• There is not just the potential for narcotic abuse but the concern that patients are accidentally ingesting too much acetaminophen from combining these products with the potential for severe liver damage or even death.
• The use of prescription pain relievers without a doctor's prescription only for the experience or the feeling it causes is often called "nonmedical" use. Narcotic use is considered abuse when people use narcotics to seek feelings of well-being apart from the narcotic's pain-relief applications.
• The U.S. Substance Abuse and Mental Health Services (SAMHSA) report that after marijuana, nonmedical use of painkillers is the second most common form of illicit drug use in the United States. An estimated 8.9 million people aged 12 and older (3.4 percent) were current users of illicit drugs other than marijuana in 2012. The majority of these users (6.8 million people, or 2.6 percent of the population) were non-medical users of psychotherapeutic drugs, including 4.9 million users of pain relievers.
  • SAMHSA's Drug Abuse Warning Network reported that approximately 597,000 emergency department visits in 2012 involved the nonmedical use of alcohol or other illicit drugs, including painrelievers
  • Morphine (Avinza, Kadian, Morphine IR, MS Contin, MSIR, Oramorph SR, Roxanol) and codeine are natural derivatives of the opium poppy. Related medications that are semisynthetic include drugs such as heroin, oxycodone (Percocet, Percodan, OxyContin), and hydrocodone and acetaminophen (Vicodin). Synthetic medications in this class include drugs such as methadone (Diskets, Dolophine, Methadose), meperidine (Demerol), and fentanyl. All medications in this group are called opiates or narcotics. Some chemicals, called endorphins, occur naturally in the body and produce a morphine-like effect.
• The most commonly abused illicit narcotic is heroin, but all prescription narcotics have the potential for abuse. In 2008, the Florida Medical Examiners Commission noted that prescription opioid painkillers (such as Vicodin, Percocet, and OxyContin) caused more deaths than illicit substances such as heroin.
• Narcotics have many useful pain-relieving applications in medicine. They are used not only to relieve pain for people with chronic diseases such as cancer but also to relieve acute pain after operations. Doctors may also prescribe narcotics for painful acute conditions, such as corneal abrasions, kidney stones, and broken bones.
• When people use narcotics exclusively to control pain, it is unlikely that they become addicted or dependent on them. A patient is given a dosage of opioids strong enough to reduce their awareness of pain but not normally potent enough to produce a euphoric state.
• Adequate pain control is the goal for the medical use of narcotics. Thus, patients or health-care professionals should not allow fear of addiction to interfere with using narcotics for effective pain relief.

There is somewhat of a continuum between opioid abuse, opioid dependence, and addiction. Individuals who use narcotics to the extent that they start to interfere with the person's ability to do routine activities or fulfill regular responsibilities at home, at school, or at work would be considered to be abusing opioids. Other signs that individuals are abusing opioids include maladaptive behaviors that impact adversely on relationships, worsening of interpersonal problems, or frequent involvement with legal problems related to opioid use.

Individuals who have opioid dependence often will manifest some of the following symptoms.

• Ingestion of larger and larger amounts of opioids or for longer periods of time than intended
• Desire or compulsion to take the drug with significant amount of time spent trying to obtain opioids
• Withdrawal symptoms if the drug is stopped or the amount taken is reduced
• The need for increased amounts of drug to achieve the original effects (tolerance)
• Social, recreational, occupational, or pleasurable activities are neglected
• Persistent use of narcotics even when evidence that is harmful to their body, mood, thinking, or actions
• Addiction is elevated narcotic abuse that becomes a craving, with compulsive need to use opioids and often self-destructive behavior

Narcotic drugs produce their effect by stimulating opioid receptors in the central nervous system and surrounding tissues.

The abuse of narcotics occurs as a result of the euphoria and sedation that narcotics produce within the central nervous system. Abusers of intravenously injected heroin describe the effects as a "rush" or orgasmic feeling followed by elation, relaxation, and then sedation or sleep.

Narcotics used for short-term medical conditions rarely require weaning since stopping the medication after a brief period rarely produces adverse effects. If circumstances allow, the dose for people using narcotics over an extended period of time for medical purposes is slowly lowered over a few weeks to prevent withdrawal symptoms. The goal is to wean individuals off narcotics so that they are pain-free or able to use a less potent nonnarcotic analgesic.

Narcotics users can develop tolerance, as well as psychological and physical dependence to opioids when they take them over an extended period of time.

• Tolerance refers to a decreased response to a drug, with increasing doses required to achieve comparable effects.
• Psychological dependence refers to compulsive drug use in which a person uses the drug for personal satisfaction, often in spite of knowing the health risks.
• Physical dependence occurs when a person stops using the narcotic but experiences a withdrawal syndrome (or set of symptoms).
• Signs and symptoms of narcotic abuse
  • analgesia (feeling no pain),
  • sedation,
  • euphoria,
  • respiratory depression (shallow breathing),
  • small pupils, bloodshot eyes,
  • nausea, vomiting,
  • itching skin, flushed skin,
  • constipation,
  • slurred speech,
  • confusion, poor judgment, and
  • needle marks on the skin.

Signs and symptoms of narcotic withdrawal: The withdrawal syndrome from narcotics generally includes signs and symptoms opposite of the drug's intended medical effects. The severity of the withdrawal syndrome increases as the drug dose increases. The longer the duration of the physical dependence to the narcotic increases, the more severe the withdrawal syndrome. Symptoms of heroin withdrawal generally appear 12-14 hours after the last dose. Symptoms of methadone withdrawal appear 24-36 hours after the last dose. Heroin withdrawal peaks within 36-72 hours and may last seven to 14 days. Methadone withdrawal peaks at three to five days and may last three to four weeks. Although uncomfortable, acute narcotic withdrawal for adults is not considered life-threatening unless the person has a medical condition that compromises their health (for example, if someone has severe heart disease). Some of the signs and symptoms of narcotic withdrawal are listed below:

• Anxiety
• Irritability
• Craving for the drug
• Increased respiratory rate (rapid breathing)
• Yawning
• Runny nose
• Salivation
• Gooseflesh
• Nasal stuffiness
• Muscle aches and pains
• Nausea or vomiting
• Abdominal cramping
• Diarrhea
• Sweating
• Confusion
• Enlarged pupils
• Tremors
• Lack of appetite

Complications of narcotic abuse: Many complications can result from narcotic abuse, the most common being infectious conditions.

• Infections of the skin and deeper layers
• Abscesses in skin, lungs, and brain
• Infection of the heart valves
• Pneumonia
• Fluid in the lungs
• Liver dysfunction
• Intestinal slowdown
• Seizures
• Coma and other neurological complications
• Infectious arthritis
• Loss of menstrual cycle
• Overdose and death
• Premature and growth-retarded infants
• Neonatal withdrawal: Up to 70% of babies delivered from pregnant women who use narcotics experience neonatal withdrawal, a potentially fatal condition.
• Memory problems

People who use narcotics or other drugs of abuse and are interested in quitting should contact their doctor or local hospital for information on how to get involved with a detoxification and addiction recovery program.

• Any person suspected of narcotic overdose requires immediate medical attention and must be taken to a hospital's emergency department.
• The main physical signs of narcotic overdose are small pupils and respiratory depression (shallow breathing) that can lead to decreased oxygen in the blood, coma, and death.
• Street methods of overdose resuscitation, such as packing the person in ice or injecting milk or saliva, do not work.

The initial diagnosis of narcotic overdose in the emergency department is made based on obtaining a history and considering the signs and symptoms that the patient is experiencing. Almost all unconscious people receive a drug called naloxone (Narcan), which is known as a narcotic antagonist because it blocks and reverses the effects of narcotics. After the initial resuscitation, opioids are easy to detect in a routine urine test. Information from friends and family or indicators such as pill bottles or drug paraphernalia may provide important clues to the emergency doctors about the person's drug use and abuse.

Information from friends and family or indicators such as pill bottles or drug paraphernalia may provide important clues to the emergency doctors about the person's drug use and abuse.

• Overdose: An unconscious person suspected of overdosing on narcotics is given naloxone, a narcotic antagonist. When given intravenously, it is effective in one to two minutes in reversing the coma and respiratory depression caused by a narcotic.
  • Withdrawal: Treating people who are addicted to narcotics is difficult. The most common long-term treatment of the narcotic withdrawal syndrome is substituting methadone for the illicit drug, followed by a slow process of then weaning the abuser off the methadone. Buprenorphine (Buprenex) is another medicine that can be used in the process of detoxification, with the concept being to replace one opioid (for example, heroin) with another and then taper the second opioid slowly.
  • The drug clonidine (Catapres) has been shown to relieve some of the symptoms of withdrawal, especially salivation, runny nose, sweating, abdominal cramping, and muscle aches. Clonidine, when used in combination with naltrexone (ReVia), a long-acting narcotic antagonist, produces a more rapid detoxification.
  • Buprenorphine is also used in the treatment of withdrawal symptoms

The first steps in remaining drug free are overcoming withdrawal symptoms and the physical dependence of narcotics. In addition, many treatment programs are available in the community to help addicts deal with usually intense, longer-term psychological dependence that goes along with being addicted to narcotics.

Programs such as Narcotics Anonymous and other detoxification programs emphasize abstaining from all narcotic drugs and other abused drugs by using a system of social support. Involvement in such a system has been shown to reduce a person's risk of returning to drug abuse. For information on Narcotics Anonymous meetings in your area, call 818-773-9999.