In 2017, more than 72,000 people in the U.S. died as a result of a drug overdose, and the sharpest increase in deaths was related to the opioid fentanyl, according to the National Institute on Drug Abuse (NIDA). Other opioids of abuse include heroin and prescription painkillers, such as oxycodone and hydrocodone, and methadone.
As someone continues to use these drugs, they can develop a tolerance to them, which can lead to eventual dependence and addiction.
People can build up a tolerance to opioids rather quickly, especially with morphine and heroin, according to the NIDA. As someone continues to take the drug, their body essentially gets used to it, and this usually means they will need higher doses to continue to experience the same effects.
There are opiate receptors in the body that opioids like morphine bind to. This causes the inhibition of adenylate cyclase, a type of enzyme. As the opiate receptors are activated repeatedly when someone keeps taking opioids, the enzyme eventually adapts. This means that the drug cannot cause cell firing changes anymore. To continue to produce the cell firing, the body needs a higher dose of the drug.
People with a substance use disorder will continue increasing the dosage of opioids to achieve the high, or euphoric effects, they desire. While the dosages are different, all opioids tend to have the same effect. Morphine and heroin can cause tolerance faster than other opioids, but with continued use, especially outside of a doctor’s order, tolerance can occur with all drugs in this class.
People develop tolerance and dependence even with legitimate medical use. If the same dose of your prescription opioid is not resulting in pain relief, talk to your doctor immediately.
How quickly a person develops a tolerance is highly individualized. Once someone continues to become tolerant to higher doses, the risk of dependence and addiction to opioids is present. While dependence can be an element of addiction, they are two separate states, according to the Safety Pharmacology Society.
If you recognize that the same dose doesn’t result in the same effects, you have likely built a tolerance to the drug. How to progress from there depends on your use of the substance.
Again, those taking opioids for legitimate pain issues should bring their pain management specialist into the equation. Their doctor may discuss moderating their use of opioids or finding non-opioid alternatives to control pain. In some instances, the doctor may prescribe a different opioid that may be more effective at a lower dosage level.
If a person has been abusing opioids recreationally, it’s time to reach out for professional help. A tolerance demonstrates that use has been repetitive enough to demonstrate a real problem.
If a person is already dependent on an opioid, medically supervised withdrawal is needed. Since opioid withdrawal can be so uncomfortable, relapse commonly happens when users go without professional help.
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Medications may be used during opioid withdrawal to smooth the detox process. Buprenorphine is commonly considered during this process, according to MedlinePlus. The purpose of this medication is to alleviate a person’s cravings for opioids and their withdrawal symptoms.
How long someone requires this medication is dependent on several factors, such as their response to treatment and how they are handling the recovery process. In some cases, a person remains on this medication on a long-term basis; others may only need it for a few months.
In addition to medications, people will benefit from behavioral therapies and counseling. Clients might attend an inpatient treatment program or one that is outpatient. There are also long-term residential treatment programs. People will live at the treatment facility for an average of six to 12 months, NIDA says. The purpose of this type of treatment is to help people with resocialization.
The treatment provided at these facilities tends to be highly structured. Clients will participate in numerous activities to examine their self-concepts, damaging beliefs, and patterns of behavior that are destructive. They will learn how to interact with others and make positive changes to their behavior.
People who have been taking opioids and consequently developed a tolerance may need to take a break from using this type of drug. One of the key ways to know if a break is necessary is to determine if a person has withdrawal symptoms after they stop using the medication or significantly reduce their dosage.
People who have a physical dependence on opioids may start to experience withdrawal symptoms as soon as 12 hours after their last dose. The symptoms of withdrawal are often described as similar to the flu. According to the National Drug and Alcohol Research Centre, they may include the following:
Withdrawal symptoms tend to be at their worst around days two and three. Medically supervised withdrawal can help to reduce these symptoms so that people are more comfortable during the process.
Tapering off opioids after tolerance or dependence occurs is another option that can reduce the withdrawal effects that occur with going cold turkey. People can get help with tapering from their pain management specialist or a substance abuse treatment specialist.
Those who have been using opioids for more than two weeks should taper the drug instead of just stopping use since withdrawal can be severe and dangerous, according to the Mayo Clinic. How long this process takes will depend on the dosage someone was taking and how long they were taking opioids. If the person was taking more than one type of opioid or using another substance, these factors would also play a role.
The taper will usually involve reducing the person’s dosage by about 10 percent of the starting dose per week, according to the U.S. Centers for Disease Control and Prevention. However, a slower taper can be done to keep the person comfortable.
The Hospital for Special Surgery recommends that people do the following during the tapering process to reduce the risk or severity of withdrawal symptoms:
It is best to consult with a professional substance abuse specialist before attempting to stop taking opioids once tolerance has formed. They can tailor a program to address what a person specifically needs to overcome their reliance on opioids.
(August 2018) Overdose Death Rates. National Institute on Drug Abuse. Retrieved December 2018 from https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
The Neurobiology of Drug Addiction. National Institute on Drug Abuse. Retrieved December 2018 from https://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-iii-action-heroin-morphine/6-definition-tolerance
Introduction to Tolerance, Physical Dependence, and Withdrawal. Safety Pharmacology Society. Retrieved December 2018 from https://www.safetypharmacology.org/AM2012/am12presentations/Markgraf_IntroPhysicalDependenceWD.pdf
Opioid Abuse and Addiction Treatment. MedlinePlus. Retrieved December 2018 from https://medlineplus.gov/opioidabuseandaddictiontreatment.html
Principles of Drug Addiction Treatment: A Research-Based Guide. National Institute on Drug Abuse. Retrieved December 2018 from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/drug-addiction-treatment-in-united-states/types-treatment-programs
Yes, People Can Die from Opiate Withdrawal. National Drug and Alcohol Research Centre. Retrieved December 2018 from https://ndarc.med.unsw.edu.au/blog/yes-people-can-die-opiate-withdrawal
Tapering Off Opioids: When and How. Mayo Clinic. Retrieved December 2018 from https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/tapering-off-opioids-when-and-how/art-20386036
Pocket Guide: Tapering Opioids for Chronic Pain. Centers for Disease Control and Prevention. Retrieved December 2018 from https://www.cdc.gov/drugoverdose/pdf/clinical_pocket_guide_tapering-a.pdf
A Patient’s Guide to Opioid Tapering. Hospital for Special Surgery. Retrieved December 2018 from https://www.hss.edu/conditions_patient-guide-opioid-tapering.asp