Opioids

DEFINITION: Natural substances derived from opium poppies and synthetic and semisynthetic substances that have properties similar to those derived from opium, generally used for pain relief in medical settings and also as drugs of abuse.

SIGNIFICANCE: Opioids are important medicinal drugs for the management of pain, but they are also highly additive and are therefore abused. Even when opioids are prescribed, users can develop problems such as drug dependence. Because of the addictive nature of opioids, these substances are widely bought and sold illegally.

“Opiate” is the term used to refer to naturally occurring compounds derived from the opium poppy, such as codeine, morphine, and opium. In contrast, “opioid” is a broader, more inclusive term used to describe both naturally occurring and synthetic or semisynthetic opiates. Examples of the latter include heroin, hydromorphone, hydrocodone, and oxycodone.

Uses and Effects

Opioids are generally considered narcotics, both in name and legally. Functionally, narcotics are drugs that numb the senses, promote sleep, and elicit stupor. Clinically they are prescribed for analgesia—that is, to reduce pain. The ability of opioids to reduce pain is pronounced, so for individuals who need to manage chronic pain, these drugs can be of significant help. For individuals with careers that may expose them to chronic pain, such as athletes, opioids may also be akin to performance-enhancing drugs, such as steroids and stimulants. Similarly, for soldiers on the battlefield opioids may be extremely useful, but if misused, these substances may be a source of danger to fellow soldiers and others. Given the potential dangers of these drugs, the forensic issues around opioids extend to the identification and regulation of their appropriate use in certain professional arenas, such as is achieved through drug testing.

In addition to analgesia, opioids may induce other changes, including initial warm flushing of the skin, a rush of feelings in the abdomen, and changes in mood. Other effects include constipation (as these drugs slow peristaltic muscle movement in the colon), decrease in rate of respiration, drowsiness, and euphoria. Opioids are also known to cause depression of the central nervous system and the heart (including to a potentially deadly degree, as in overdoses).

Common routes of administration for these drugs are oral (ingested as pills), sublingually (dissolved under the tongue), nasal (through snorting, or inhaling rapidly through the nostril), inhalation (through smoking), and injection directly into a vein. Individuals may also take these drugs in other ways, such as subdermally and anally, but these are less common.

Among the important complications associated with administration are those that come with intravenous injection use among individuals using illegally obtained drugs. For users who do not have access to sterile means of injection, shared or improperly cleaned needles and injection sites can lead to significant health problems such as abscesses and the contraction of flesh-eating diseases, hepatitis C, and human immunodeficiency virus (HIV), which causes acquired immunodeficiency syndrome (AIDS). Another significant and often fatal problem with opioid use is overdosing, which occurs when more of the drug is taken than the body can tolerate. Overdosing can also occur when opioids are combined with sedative agents such as alcohol or benzodiazepines or when opioids such as heroin are sold illegally and are "cut" with other substances to artificially extend the perceived quantity and quality of the drug. Illegally sold opiates can also be cut with contaminants such as rat poison.

Substance Abuse, Dependence, and Criminal Behavior

Opioids may trigger the disease of substance use disorder (SUD). As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5), substance use disorder is a pattern of drug use that results in impairment in daily life or in noticeable distress from using the drug. Individuals continue to use the drug regardless of the inevitable consequences. Individuals with substance use disorder experience at least two of the following symptoms during a twelve-month period: craving or unusually strong desire to use the substance; spending the majority of time using the substance, recovering from the use of the substance, or trying to obtain the substance; experiencing withdrawal symptoms—such as anxiety, sweating, nausea, and tremors—when not using the substance; using the substance in dangerous situations, such as driving or operating machinery, or in unsafe environments; continuing to use the substance despite recurring or worsening problems, such as blackouts, loss of job or family, or financial crises; failing to see to daily responsibilities, such as paying bills or going to work or school; giving up on what was once enjoyable; such as hobbies or activities; wanting to or worrying about cutting down on or stopping the use of the substance but being unable to do so; or the need to use more of the drug to get the same effect or getting less effect from the same amount of the drug (tolerance)

Those who use opioids illegally may also experience malnutrition and pronounced weight loss because the drugs tend to be so powerful that users fail to pay attention to hunger or to be motivated enough to eat. Often, chronic users of opioids ignore all other activities except what they need to do to obtain and use the drugs. Often this involves engaging in criminal behavior to secure the money to purchase drugs or to secure the drugs themselves. This may range from dealing drugs, so that they can maintain access to an adequate supply as well as theft or other crimes (including prostitution) that can provide them with resources to buy drugs.

Opioid dependency can occurs among persons who begin using opioid drugs for pain control under their doctors’ care. When the prescription runs out or the doctor refuses to refill it, individuals may then turn to illegal means to obtain the substance that their body is now physically addicted to. Sometimes users addicted to opioids will work to build up networks of doctors and other outlets where they can gain access to prescription drugs. Some may spend entire days going from doctor to doctor to procure the supplies of drugs they need. This may lead them to commit fraud and misrepresentation to doctors, prescription forgery, and theft or other crimes to secure the drugs. In some cases, prescribing doctors may be involved in significant violations of the law related to drug diversion. Oftentimes, the addiction will become evident to the prescribing physician who will then stop the patient's access to the drug. Many physicians will work with the patient to enter drug detoxification and rehabilitation is the patient is willing. However, some drug users turn to heroin or other illegal drugs on the black market.

During the early part of the twenty-first century, the United States, as well as Canada, experienced a significant rise in opioid-related deaths. The Centers for Disease Control and Prevention (CDC) noted in 2021 that between the years 1999 and 2019, approximately 500,000 individuals in the United States died from an opioid overdose. The CDC identified three waves of this opioid epidemic: in the 1990s there was a major increase in opioid prescriptions, and a corresponding rise in overdose deaths from prescription drugs; around 2010 a spike in heroin overdose deaths began; and in 2013 there was a marked rise in deaths from synthetic opioids, especially fentanyl, which by the 2020s had become responsible for a majority of fatal opioid overdoses. In the midst of the opioid epidemic, in September 2016, the journal Medical Care noted the economic strain in the United States was over $78 billion annually, with nearly $8 billion alone related to criminal-justice costs.

While the pattern and protocol among law enforcement for addressing drug-related crimes, even those considered nonviolent, had historically been to arrest, prosecute, and imprison offenders, there began to be a shift in approach in the mid-2010s. Law enforcement officials and addiction professionals began speaking up that it was not possible to "arrest their way out of the problem." In other words, it became evident that no amount of punishment or increased incarceration was helping to reduce the number of drug-related crimes and deaths, the number of people becoming addicted to opioids, or the occurrence of repeat and serial offenders. Many began advocating for more treatment for nonviolent drug offenders rather than jail time, and when incarceration was necessary, drug rehabilitation programs began being established and funded in jails and prisons throughout the country. In 2015, Gloucester, Massachusetts, police chief Leonard Campanello announced a revolutionary approach to fighting the so-called "war on drugs" when he announced the creation of the nonprofit Police Assisted Addiction and Recovery Initiative (PAARI), which had as its cornerstone the policy of taking any drug addict who asked for help to the hospital and a recovery program instead of jail. The PAARI program and method of addressing addiction took hold in police departments across the country, with hundreds of opioid-addicted individuals receiving access to treatment in the program's first year.

In October 2018, Congress passed a bipartisan bill addressing the opioid crisis; the bill packaged a number of smaller proposals relating to the issue. Among its provisions were a requirement for the US Postal Service to screen packages for the synthetic opioid fentanyl, some funding for research into nonaddictive painkillers, and a change to a rule that prevented Medicaid from covering residential treatment for substance abuse disorders. However, the bill was criticized for not committing to long-term funding for opioid-related programs.

Despite these efforts, in the US during the twenty-first century, many years saw an annual increase in the number of opioid deaths per year—according to the National Center for Health Statistics (NCHS), more than 100,000 people died from opioid overdoses in the twelve-month period ending in September 2021, an increase of nearly 30 percent from the previous year. Over 81,000 opioid related deaths were reported in the US in 2023, a slight decrease over the previous year and the first time since 2018 that annual opioid deaths in the US decreased instead of increased.

At that time, media attention surrounded various lawsuits and settlements over the role of pharmaceutical companies in triggering the epidemic by aggressively pushing prescription opioids and understating their addictive potential. Many of these lawsuits targeted Purdue Pharma, the manufacturer of OxyContin, an opiate widely credited with helping kick off the first phase of the North American opioid crisis, as well as the Sackler family, the owners of Purdue. An $8 billion class-action settlement between Purdue and the plaintiffs in a series of lawsuits was rejected by the US Supreme Court in June 2024.

Dangers and the Drug Trade

When opioid-dependent users cannot get enough of their preferred drugs, they frequently mix these substances with alcohol, other prescription or illicit drugs, and even herbal remedies and over-the-counter drugs. This practice can be very dangerous, as mixing opioids with barbiturates, benzodiazepines, alcohol, and other drugs that act as depressants on the body can cause synergistic effects that can detrimentally affect the body’s basic ability to function. Synergistic effects make the impact of the drugs together greater than the impact any of the drugs would have individually. With opioids, this will lead to respiratory distress or cardiac distress. These reactions may be magnified in persons whose health is compromised by other problems.

Given the broad medical value of opioids and the abuse potential of such narcotics, it is no surprise that a significant black market exists for their manufacture, distribution, and sale. The illicit trade in opioids ranges from the manufacture of illegal, unregulated supplies in small clandestine laboratories to the large-scale manufacture of look-alike drugs (some of which may fall into the hands of non-substance-abusing consumers), to the theft or diversion of legal drug supplies from their intended points of distribution. The legal and illegal uses of opioids thus pose significant challenges for government authorities who must balance the protection of appropriate medical uses of these substances against the need to address drug-related crimes such as theft, prostitution, forgery, fraud, and assault.

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