“The epidemic of deaths involving opioids continues to worsen. Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems.”
~ Tom Frieden, Director of the Centers for Disease Control and Prevention
Are opioids and opiates the same thing?
With all of the news about the ongoing “opioid epidemic”, accurate information is your best defense against potentially-dangerous drugs. Understanding the differences can help you decide which prescription painkiller medications are right for you and your family.
“Opioid” vs “Opiate” – Why the Confusion?
“The opioid epidemic is one of the most pressing public health issues in the United States today.”
~ Sylvia Burwell, then-United States Secretary of Health and Human Services
Part of the problem is due to the fact that the media tends to use the terms interchangeably. For example, The Seattle Times recently published an article on how best to address the state’s opioid epidemic. But a 2016 Associated Press headline has President Barack Obama discussing the opiate crisis in the United States.
They are referring to the same problem – skyrocketing rates of opioid misuse disorder, dependence, abuse, addiction, overdose, and death, all because of a particular type of painkilling narcotic.
Let’s take a closer look at the differences – and similarities – between opiates and opioids.
What Is an Opiate?
“…awaken every American to this simple fact: if this scourge has not found you or your family yet, without bold action by everyone, it soon will.”
~ the United States Commission on Combating Drug Addiction and the Opioid Crisis
A opiate is any drug or medication that has been directly refined or extracted from the opium poppy, scientific name, Papaver somniferum. These plants are primarily grown in Asia, the Middle East, and South America.
This poppy has been recognized as a healing plant for thousands of years, possibly as long ago as 3400 BC. Its use in Western medicine began in the 1500s, and before long, it was regarded as a virtual cure-all. Today, the opium poppy is absolutely essential to modern medicine.
Opium is the first product extracted from the poppy, and it serves as the basis for other opiate drugs. In 1980, only about 2000 tons of opium were needed to satisfy global demand, both legal and illegal. By 2014, production had risen to approximately 9500 tons.
The World Health Organization estimates that opium production needs to increase fivefold to meet the world’s medical needs.
But opiates have also been recognized as dangerous and addictive for centuries. In 1655, Acosta, a Portuguese physician, wrote about the symptoms of opium withdrawal. Likewise, in 1701, John Jones, a British physician, recommended moderation in the use of opium to avoid what he called “discomfort”.
What are Some Examples of Opiates?
“Nobody will laugh long who deals much with opium: its pleasures even are of a grave and solemn complexion.”
~ Thomas de Quincey, Confessions of an English Opium-Eater
Different parts and preparations of the opium poppy plant can be used to create a number of opiate drugs, including:
- B & O Supprettes
- Poppy Tea
What are Opioids?
“Opioids are devastating Washington families and communities, and overwhelming our safety nets.”
~ Washington State Attorney General Bob Ferguson
Opioids, on the other hand, refer to an entire class of drugs that act on specific receptors to neutralize or reduce pain. These opioid receptors are chiefly located in the brain, although some can be found in the spinal cord and the digestive tract.
By this definition, ALL opiates ARE opioids.
However, not ALL opioids are opiates.
It comes down to “natural” vs “synthetic”. Rather than being extracts, distillations, or simple mixtures as opiates are, opioids are chemical compounds either partially or wholly produced in a laboratory. The often-used term “synthetic opioid” is actually redundant, because almost all opioids ARE synthetic.
This is why the present public health crisis can properly be referred to as an opioid epidemic, because the term describes both natural and synthetic drugs.
What Are Some Examples of Opioids?
“We believe that the flooding of the city with OxyContin caused the crisis. Our capacity to respond has been overwhelmed…”
~ Hil Kaman, Public Health and Safety Director for the City of Everett, Washington
There are dozens of opioid painkiller formulations available in the United States, including:
- Hydrocodone (Vicodin, Lortab, Norco)
- Oxycodone (OxyContin, Percocet, Percodan)
- Oxymorphone (Opana)
- Tramadol (Ultram)
- Fentanyl (Actiq, Duragesic, Abstral)
- Methadone (Dolophine, Methadose)
- Dextropropoxyphene (Darvocet)
- Meperidine (Demerol)
In addition, there are many illicit opioid drugs and combinations that are often abused – carfentanil, Pink, and Gray Death, just to mention a few.
How Are Opiates and Opioids Alike?
“Everywhere I travel, I see communities devastated by opioid overdoses. I see families too ashamed to seek treatment for addiction.”
~ Dr. Vivek Murthy, then-United States Surgeon General
As stated earlier, both opiates and opioids reduce pain, either by blocking the pain signal or by changing how a person experiences that pain.
One of the ways these drugs accomplish that is by creating a euphoric sense of well-being in the user – the “high” that drives opioid dependence, addiction, and uncontrollable drug-seeking behaviors.
How Are the Effects of Opiates and Opioids Different?
“If you’re using heroin or opioid drug and you have fentanyl cut into your drug unknowingly, you can be subject to sudden death. These can be kill pills.”
~ Jeff Duchin, Health Officer for Seattle and King County, Washington
The fact that these opioid drugs are chemically altered is very significant, because it means their effects can be greatly magnified, sometimes, dangerously so. For example, some fentanyl analogues are up to 10,000 times more powerful than morphine.
This means that the difference between recreational misuse and death by overdose can be measured in micrograms. Some illicit opioid drugs are so potent that it takes multiple administrations of the anti-opioid overdose medication Narcan to save someone’s life in an emergency situation.
Why Are Opiates and Opioids So Addictive?
“Opioids literally cause very clear biochemical brain changes.”
~ Caleb Banta-Green, senior researcher for the University of Washington’s Alcohol and Drug Abuse Institute and part of the King County Heroin Task Force
According to the American Society of Addiction Medicine, there are almost 2.6 MILLION Americans with a substance abuse disorder involving prescription opioid painkillers or heroin.
To understand opioid addiction, you have to first understand the role that dopamine plays and how it is affected by substance abuse.
Dopamine is a neurotransmitter naturally produced by the body. It is associated with learning, motivation, and reward. Whenever a person performs some action that is necessary for survival – eating or sex, for example – dopamine production is increased and they are “rewarded” with pleasurable feelings.
Opioids and other addictive substances trigger a massive release of dopamine. For instance, one dose of heroin can instantly deliver up to 10 times the amount of dopamine produced naturally in a whole day.
Significantly, this happens from the very first use.
Consequently, the user’s brain starts to associate opioid misuse with a neurochemical reward that is both powerful and intensely pleasurable. And that reward reinforces the behavior – the opioid abuse.
With heavy, long-term use, the brain is fooled into believing that these artificially-elevated dopamine levels are “normal”. In response, it drastically reduces – or even completely halts – the natural production of dopamine.
Because natural dopamine levels are disrupted, this means that the ONLY time a person addicted to opioids is can experience pleasurable or positive feelings is when they are under the effects of an opioid.
This further reinforces drug use and drives addiction.
Opioid Addiction and Intravenous Drug Use
“We see this as a public health emergency.”
~ Jeff Duchin, Health Officer for Seattle and King County, Washington
Both prescription medications and the opiate heroin can be abused intravenously. This has led many drug manufacturers to create new formulations designed to resist or deter modification by drug addicts.
Unfortunately, the new products still have their limitations. 25% of people entering a drug treatment program for opioid addiction say that they were able to find a way around abuse-deterrent measures.
People who misuse opioids intravenously are also at far greater risk of contracting and spreading HIV or viral hepatitis. According to the National Institute on Drug Abuse and the CDC, intravenous drug users (IDUs):
- Are the most at-risk group for hepatitis C (HCV).
- Account for over half of new HCV infections.
- 1 out 5 IDUs has hepatitis B (HBV).
- The average IDU with HCV infects 20 other people.
- Approximately 9% of HIV cases and 14% of AIDS cases involve IDUs.
- Among IDUs, 1 out of 23 women and 1 out of 36 men will be diagnosed with HIV within their lifetime.
In fact, IV drug use is such a threat to public health and welfare that in January 2017, Seattle, Washington, became the first city in the country to approve safe injection sites.
Safe injection sites are places where people who use heroin and other illicit drugs can shoot up in a clean, medically-supervised environment. While there, they will be given clean needles and have access to overdose-reversal drugs. Those who want help will also be put in touch with local drug rehabs.
Supporters say this controversial move will save lives, deter crime, reduce the spread of disease, and steer more people towards drug treatment.
The Relationship between Prescription Opioid Medication and Heroin
“Some people have come to see it as a cost-effective method of getting high. If they can tolerate the intravenous injection and overcome their reluctance to give themselves a shot, many of the people in our study said it was a fairly simple decision and that heroin now represents a cheaper, more attractive alternative.”
~ Dr. Theodore J. Cicero, Professor of Neuropharmacology and Neurobiology, Washington University School of Medicine.
Heroin abuse, addiction, and overdose deaths are all increasing dramatically in the United States. What is surprising is the fact that prescription opiates/opioids are part of the reason WHY.
One tragic consequence of successful prescription opioid abuse prevention formulations is that it leaves people who are already-addicted in desperate need of an alternative.
When they try the black market, they find that more-easily-abused alternatives are far more expensive out on the street. For example, in Bellvue, Washington, a single 60 mg OxyContin tablet might sell for $30, while an alternative opiate – heroin – can be purchased for as little as $5.
The opioid epidemic began – and continues – because of overprescription. This is when some physicians give opioid painkillers indiscriminately, not in accordance with federal recommendations.
According to the National Survey on Drug Use and Health, almost 92 MILLION Americans were given an opioid prescription in 2015.
The current guidelines say that opioid painkillers should only be prescribed as a last resort, and even then, for the lowest dose and shortest duration possible. When these guidelines are not followed, it is far too easy for a person with a legitimate prescription to become opioid-dependent. And THAT leads to misuse, abuse, and addiction.
From there, it is only a short misstep to heroin.
- A person addicted to prescription painkillers is 40 times more likely to also be addicted to heroin.
- 45% of heroin addicts are also addicted to prescription opioids.
- 4 out of 5 new heroin users started out by abusing prescription painkillers.
- In 2014, 94% of people in treatment for an addiction to opioids said that they switched to heroin because prescription pain medications were “far more expensive and harder to obtain.”
In 2015, for the first time ever, more Americans died of heroin than because of gun homicides. To put that in perspective, in 2007, gun murders dwarfed heroin fatalities by a rate of 5 to 1.
What about “Opioid Agonists” – Are They the Same Thing?
“This (opioid addiction) is a changed brain. Medication-assisted treatment works. Nothing else works or we wouldn’t have the problem we have now.”
~ Captain Jonathan Larsen, Seattle Fire Department
On the contrary, opioid agonists are medications used to treat opioid addiction. They are very effective in reducing drug cravings and alleviating symptoms of opioid withdrawal. They do this by binding to the opioid receptors, thereby “blocking” the effects of other, more dangerous opioid drugs.
Opioid agonist medications include:
- Buprenorphine (Suboxone, Subutex)
- Levo-α-acetylmethadol (LAAM)
Although there is some potential for abuse, the risks are greatly reduced, primarily because opioid antagonist medications are dispensed under medical supervision. For example, patients given methadone must show up daily at a clinic to receive their dosage.
Some opioid agonists have a “ceiling effect” that does not increase, even at higher dosages. For instance, someone given buprenorphine cannot get high from ANY opioid drug.
Opioid agonists are essential tools during Opioid Replacement Therapy (ORT), because by lessening cravings and withdrawal symptoms, these medications allow addicts to focus on their own recovery.
What is The Biggest Danger of Opioid Addiction?
“The prescription opioid and heroin epidemic continues to devastate communities and families across the country—in large part because too many people still do not get effective substance use disorder treatment.”
~ Michael Botticelli, Director of National Drug Control Policy, 2014-2017
The most obvious danger of opioid addiction is the potential for overdose and death. According to the New York Times, an estimated 59,000-65,000 people in America died in 2016 because of drug overdoses.
This represents a 19% increase over 2015 – the largest year-over-year increase in history. In fact, fatal drug overdoses are now the leading cause of death for Americans under the age of 50.
And, by all accounts, opioid drugs are the leading cause of this continuing and escalating health crisis:
- 63% of overdose deaths are due to illicit or prescription opioids.
- Deaths involving opioids – not opiates – jumped 72% in 2015.
Even more telling:
- Natural opiate deaths decreased 6%
- Methadone-related deaths – went down 1%
- Heroin fatalities reached 12,990 in 2015.
- In 2010, there were 3036.
- That is a shocking 428% increase.
The threat is so real in some communities that police officers and other first responders are being issued Narcan, because it is so likely that they will encounter an opioid overdose emergency.
Even non-fatal opioid overdoses can have serious, perhaps permanent consequences. A lack of oxygen can cause hypoxic brain injury, possibly resulting in brain damage, cognitive impairment, hearing loss, or even a vegetative state.
Why Are Opiates and Opioids So Deadly?
“We are seeing traffickers mix fentanyl with heroin and calling it a ‘super high’, but in reality, just a few micrograms too much can be super deadly.”
~ San Diego Drug Enforcement Agency Special Agent in Charge William R. Sherman
One side effect that all opiates and opioids have in common is suppressed respiration. During an opioid overdose, breathing can even stop completely. In essence, the person falls asleep and “forgets” to breathe.
With some of the more powerful synthetics, fatal amounts are almost immeasurably small. For example, just 2 mg of fentanyl can be deadly. That’s roughly the size of six grains of salt.
What’s worse, extremely-powerful synthetic drugs, such as fentanyl or carfentanil are often mixed in with or even substituted for low-quality heroin to boost potency. This is almost always done without the knowledge of the buyer.
A opioid addict who unknowingly buys adulterated heroin and injects their normal dose can fall unconscious in a matter of seconds. And, if they are alone, the results can be tragic. Half of all fatal opioid overdoses happen when there is no one around to resuscitate the victim.
Opiates, Opioids, and Polydrug Abuse
“You definitely should not be using benzos with opioids. They’re both overused, and the danger of both together is way worse than the danger of opioids alone.”
~ Dr. Gary Franklin, Medical Director, Washington State Department of Labor and Industries
When opiates and opioids are mixed with other central nervous system depressants, such as alcohol or benzodiazepine tranquilizers – Xanax, Valium, Klonopin, etc. – the effects are greatly magnified.
- 75% of drug overdoses—and 98% of those that are FATAL—involve more than one substance.
- 80% of deaths involving heroin, methadone, or buprenorphine also involve benzodiazepines.
- 73% of heroin users admit to using benzos during the previous 12 months.
- One-quarter used them daily.
- A third of all heroin users have had a benzo prescription within the previous 30 days.
- 2 out of every 5 people in opioid replacement therapy have had a benzo prescription during the past year.
- This is 8X the rate for the general population as a whole.
- Up to 50% of new methadone therapy admissions will also need benzo detoxification.
- 51%–70% of people in methadone therapy test positive for benzos.
- 94% of methadone therapy clients use sedatives at some point in their lifetime.
- 40%-60% of people complaining of “chronic” pain are regular benzo users.
- 1 out of every 6 people given opioid pain medications test positive for benzos.
- Concurrent abuse of opioids and benzos triples the risk of psychiatric hospitalization.
- It also doubles the chances of needing medication for suicidal thoughts.
- Between 2005 and 2011, there were nearly 457,000 Emergency Room trips resulting from adverse reactions to some combination of opioids, benzos, and/or alcohol.
- Almost 40% of those ER visits ended with a “serious outcome”— hospitalization, injury, impairment, disability, or death.
Opioid or Opiate– What Does All This Mean?
In the end, the differences between opioids and opiates don’t matter as much as the similarities.
Both opiates and opioids are effective medications for pain management – when prescribed properly and taken as recommended.
But they are not the magic panaceas that Big Pharma promised in the 90s. As the FDA, CDC, and US Surgeon General all recommend, prescription painkillers should only be offered as a last resort, after other methods of pain management have been attempted.
This is because ALL opiate and opioid medications are highly-addictive and present unacceptable deadly risks. And that is the scariest similarity of all.