“Street” opioids are the main category involved in requests for addiction treatment. Morphine first, and heroin later, have been the main types of illicit opioids. However, pharmaceutical-derived opioid preparations can also become major causes of addiction and intoxication-related “accidents,” particularly in certain regions and social settings.
The basic pattern is more or less always the same. Consider morphine, for example: already known both as a medication and as a recreational drug, it has followed two parallel histories. One was medical and culminated in the development of slow-release preparations; the other was non-medical and culminated in heroin. The most recent example of a street opioid, krokodil, which causes tissue destruction and severe allergic reactions, is essentially methylmorphine.
Medical opioids are generally regulated, meaning that they cannot be freely purchased or prescribed on ordinary prescriptions without controls. Some opioids are restricted to hospital use or may only be prescribed by authorized physicians. These are “potent” opioids, available in rapidly or slowly absorbed formulations. Other, weaker opioids, or preparations containing lower doses, are subject to fewer restrictions. There are also preparations available over the counter.
The abuse of prescription opioids follows two main patterns.
The first involves people with current or past drug addiction who use these legally available products instead of heroin.
The second, less visible pattern involves people who begin using opioids because they have access to them—physicians or patients receiving treatment for pain, cough, or other conditions—and subsequently develop a pathological attachment to them. A particularly high-risk category is anesthesiologists, who have professional access to many types of opioid products, some of which carry a high risk of dependence.
Cases of addiction to pharmaceutical-derived opioids are increasing. They rose from 7% of all opioid addiction cases in 1995 to 21% in 2005, and from 1% to 4% of all registered cases of drug addiction, regardless of substance.
Common products include codeine (methylmorphine), viminol (Dividol), hydrocodone (Vicodin), tramadol, and injectable fentanyl. To enhance the effects of these products, when they do not have access to sufficient quantities, dependent individuals may combine them with alcohol or sedatives such as benzodiazepines.
Among popular fictional and cultural references, Dr. House, for example, is a habitual user of Vicodin, and Vicodin is also one of the substances mentioned by Eminem on his early albums, to the point that a depiction of it was included in one of the album covers. Sixty-four percent of American individuals with drug addiction have used hydrocodone at some point in their history, either alone or in the combination with acetaminophen marketed as Vicodin.
A third pattern, less common because it is highly controlled, involves the misuse of opioid medications among people who receive them as treatment for opioid dependence, namely patients treated with methadone and buprenorphine.
These patients, who are theoretically at high risk of misuse, become low-risk when, as a result of treatment, their pathological craving for opioids subsides, and in any case when they are no longer able to experience their effects in the same way.
Buprenorphine has a certain potential that is not strictly speaking “abuse potential.” If it is provided without adequate supervision to patients who do not respond well to treatment, or in unnecessarily high doses, it may be used by the patient in a non-therapeutic manner, for example by injection, thereby becoming a drug of abuse because of its rapid rather than slow delivery. Alternatively, it may be diverted to other people who use it intravenously, usually individuals with opioid dependence who are not accustomed to high doses, and only rarely as their first opioid substance.
People who develop opioid dependence should be distinguished not so much according to the substance they use, but according to their behavior. If the behavior indicates opioid dependence—which is fundamentally a behavioral diagnosis—the person should be referred for treatment.
Because people dependent on pharmaceutical opioids may, for social or biographical reasons, be less likely to turn to the illicit market and replace their usual opioids with others such as heroin, they may more easily shift toward dependence on more readily available substances, such as sedatives and alcohol. This can result in greater physical harm than opioid dependence itself.
Smoked heroin can be made even more rapid in its effects by using a product known as “heroin base.” During the production of ordinary heroin, this substance is a kind of residue or waste product, but it has been recycled and marketed as a “new drug” to be smoked under the name Kobret. Because of its extremely rapid onset, even faster than heroin itself, it is capable of inducing an even more intense and aggressive craving.