Fighting fire with fire: How we can use opioids to fight opioid addiction

Posted by JC Gorman on March 12, 2023 in Drugs, Education, Neuroscience | Leave a comment

JC Gorman

The dramatic rise in opioid overdose-related deaths has become a national health emergency. For decades now, countless dollars have been spent trying to both fight opioid substance abuse and also learn how to best treat people who have become reliant on this class of drugs. These therapies come in many forms, from rehab to drug therapy. Surprisingly, one of the best therapies to overcome opioid addiction is by using other opioids. In order to understand how treating opioid addiction works, first it is important to understand the mechanisms behind opioid addiction. 

Opioids are a class of drugs that derive from the opium poppy plant or mimic its effects. The traditional use of these drugs is for pain relief [1]. Due to the powerful analgesic effects of opioids, they are commonly prescribed by doctors or used in surgical situations. However, using opioids (whether legally or illegally) can lead to an opioid use disorder. Opioid use disorder is a complex illness characterized by compulsive use of opioid drugs even when the person wants to stop (for more information about addiction as a disease, read this previous Neuwrite article). Despite decades of research into opioid use disorder, it is not yet known why opioids can be so much more addictive to some people than others [2]. 

Your body naturally produces opioids, such as endorphins. Endorphins muffle your perception of pain and boost feelings of pleasure, creating a temporary but powerful sense of well-being.  An example of this is the “runner’s high” produced by endorphins in the body in response to exercise. While these naturally occurring endorphins are not problematic, introducing outside opioids to your brain can be. Opioids not produced by your body are more powerful and can make the “feel-good” sensation even stronger and without a link to natural behavior, making users used to a new level of pleasure. When an opioid dose wears off, individuals may try to seek back those good feelings as soon as possible. When you take opioids repeatedly over time, your body slows its production of natural endorphins, making it harder and harder to achieve the same baseline feeling of wellbeing than even before opioid use. Over time, the same dose of opioids stops triggering the same level of effects. Developing this phenomenon is called tolerance. One reason opioid addiction is so common is that people who become tolerant to opioids may feel driven to increase their doses- not just because they can keep feeling good, but also so they can not feel so low due to their bodies slowing down the production of natural endorphins. 

Each year thousands of people die due to drug overdoses, mainly from opioids (for a more in-depth look at the opioid epidemic, check out this previous Neuwrite article). Developing tolerance becomes risky when it leads to individuals taking higher doses of drugs until a fatal dose is reached. Furthermore, many people die of opioid-related drug overdoses who were not even aware they were taking opioids due to the prevalence of synthetic opioids like fentanyl in illicit street drugs [3]. In order to prevent drug overdoses, it is important that users are able to get to a place where they can safely stop taking the drug [1]. However, addiction is a complex disease: completely stopping drug use without help is not possible for many people and drug withdrawals can be serious and life-threatening.

Figure 1: This graph from the CDC shows over time how different waves of opioid abuse as contributed to deaths since 1999

How we can use opioids to fight opioid addiction

Studies show that people with opioid use disorder who attempt to detoxify the opioids out of their system through complete abstinence are very likely to relapse and return to using the drug [4]. While relapse is a normal step on the path to recovery, it can also be life-threatening, raising the risk of a fatal overdose. Thus, an important way to support recovery from opioid use disorder is to find therapies that allow people to maintain abstinence from those drugs and that prevent relapse. One way that someone in recovery can reduce the negative effects of withdrawal and cravings is through medication.

Methadone is one of these medications that can help maintain abstinence. It is a synthetic opioid that works by completely binding to opioid receptors- the same receptors that other opioids such as heroin, morphine, and opioid pain medications activate- in the brain. Although it occupies and activates these opioid receptors, it does so more slowly than other opioids [5]. At an appropriate dose, methadone does not produce the euphoric high that makes opioids so addictive [4]. It does, however, eliminate the physical withdrawal symptoms felt when opioids are no longer present in the system of the individual using the drugs. This is critical in controlling the cravings that cause relapse early in recovery for many users. When withdrawals and cravings are controlled, individuals are less likely to relapse and better able to focus on other types of therapy to address their addiction. Additionally, methadone has some opioid-blocking properties, limiting the effect of other opioids used while methadone is present, which can help individuals wean off opioids. 

Figure 2: Methadone works by fully attaching to opioid receptors in the brain, helping to relieve withdrawal symptoms.

Methadone has a large body of research supporting its effectiveness in reducing opioid use. It has been used to treat opioid addiction since 1947, making it the longest-used medication for that purpose. Patients using methadone were 4.44 times more likely to stay in treatment and had 33% fewer opioid-positive drug tests compared to controls [6.] Treatment with methadone was associated with a 76% reduction in overdose at 3 months and a 59% reduction in overdose at 12 months [7]. While methadone has been proven to be a powerful treatment, it is best when combined with other treatments to help patients understand the root cause of their addiction, such as noninvasive behavioral therapy [6].

Figure 3: How long it takes various opioids to take effect on the brain. Methadone being a slow-acting opioid relieves withdrawal symptoms and makes it less addictive than faster activing opioids like heroin.

Risks of taking methadone

Methadone is administered at a clinic or by a pharmacy and often has to be administered by a professional to make sure that a proper dose is achieved. Because methadone is also an opioid, it can be addictive if not administered properly, so it is important to take as prescribed and to be adjusted by a pharmacist. Other medications, especially alcohol or other opioids, can also interact with methadone and cause heart conditions. 

Opioid dependency can be a huge problem for pregnant people.  Going through drug withdrawal can cause a pregnant woman’s uterus to contract and may bring on miscarriage or premature birth [4]. Fortunately, women who are pregnant or breastfeeding can safely take methadone. Methadone can help women manage their addiction while also avoiding health risks to the mother and baby. Undergoing methadone maintenance treatment while pregnant will not cause birth defects, but some babies may go through withdrawal after birth. However, this does not mean that the baby is addicted to methadone, but rather just experiencing physical symptoms of drug withdrawal. These symptoms usually go away after birth.  

Preventing the stigma of methadone pharmacotherapy

Many people who are accessing methadone as a way to treat their opioid addiction experience stigma in several ways. People seeking methadone treatment often report that friends, family, or even other healthcare workers accuse them of substituting one opioid addiction for another, instead believing that it would be better to seek out treatment that requires complete abstinence from opioids [4]. Experiencing any kind of stigma can turn people away from treatment, which means they are unable to get the help they need. It is important to recognize that people on methadone programs are the same as anyone else who needs medication to manage a long-term health condition and they shouldn’t be treated any differently. 

While using methadone can seem scary or unintuitive, drug overdoses due to opioid abuse is a serious problem worldwide, and being able to treat opioid addiction through method treatment is a longstanding proven effective treatment.

References:

[1] Mayo Foundation for Medical Education and Research. (2022, April 12). Am I vulnerable to opioid addiction? Mayo Clinic. Retrieved March 8, 2023, from https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372 

[2] Opioid use disorder. Opioid Use Disorder | Johns Hopkins Medicine. (2022, November 11). Retrieved March 8, 2023,  https://www.hopkinsmedicine.org/health/conditions-and-diseases/opioid-use-disorder 

[3] Opioids. Opioids | Johns Hopkins Medicine. (2022, October 19). Retrieved March 8, 2023, from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/opioids 

[4] How does methadone work and why is it needed? How does methadone work and why is it needed? – Alcohol and Drug Foundation. (n.d.). Retrieved March 8, 2023, from https://adf.org.au/insights/methadone-works-legal/ 

[5] What is methadone?: UAMS Psychiatric Research Institute. Psychiatric Research Institute. (n.d.). Retrieved March 8, 2023, from https://psychiatry.uams.edu/clinical-care/cast/what-is-methadone/ 

[6] U.S. Department of Health and Human Services. (2021, April 13). How do medications to treat opioid use disorder work? National Institutes of Health. Retrieved March 8, 2023, from https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work#:~:text=Methadone%20is%20a%20synthetic%20opioid,and%20opioid%20pain%20medications%20activate 

[7] Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;(3):CD002209. doi:10.1002/14651858.CD002209.pub2.