The Psychology of Opioid Addiction

I REMEMBER HOW MY addiction to opioids began, and how difficult it was for me to quit. It was rather easy in 1987 to obtain scripts from multiple doctors and fill them at multiple pharmacies. Typically, I had at least three prescriptions for opiates going at the same time. I also began stealing Tylenol #3 from my mother-in-law in the late 1980s and rummaging through the medicine cabinets of friends and family. Although chronic pain was my initial push to use opiates, I became addicted for decades because I truly loved the warm, fuzzy feeling of euphoria. In fact, I abused cannabis, sleeping pills, opiates, and benzodiazepines because they mimic the brain’s feel-good chemicals. Consequently, these drugs became my coping mechanism for childhood trauma, fear, anger, hatred, depression, anxiety, and chronic low self-regard. But, substance use disorder hijacked my dopamine in ways I didn’t understand, and I remained dependent on opiates and other substances for over 40 years.

How Brains Get Hooked on Opiates

Societies have coveted the euphoria and pain relief provided by opioids since Ancient Sumerians referred to opium poppies as the “joy plant” circa 3400 B.C.E. Chinese patients swallowed opium cocktails before major surgeries, but by 1500 recreational use of opium became subversive and went underground.(1) The Mayo Clinic says, “…it’s impossible to predict who’s vulnerable to eventual dependence on and abuse of these drugs. Legal or illegal, stolen and shared, these drugs are responsible for the majority of overdose deaths in the U.S. today.”(2) Something that started as pleasurable becomes something you can’t live without: an irresistible craving that manifests in out-of-control chronic use despite repeated, harmful consequences. Incidentally, this definition of addiction is true for all substances, including alcohol.

Dr. Ajay Manhapra writes about “…neurobehavioral underpinnings of CPOD, explaining how long-term opioid use can lead to more pain even while experiencing relief with each opioid dose.”(3) CPOD is Complex Persistent Opioid Dependence. Manhapra says long-term opioid therapy for chronic cancer and non-cancer pain is often ineffective in providing good pain control. Frankly, opioids are contraindicated for treatment of long-term non-cancer pain. Thankfully, they are effective for postoperative pain, but the risk of dependence is great there as well. There are concerns about the appropriate use of opioids for acute pain management because of this risk. Manhapra adds, “…opioid-induced hyperalgesia and reward/anti-reward systems causing hyperkatefia* or suffering induces pain experience through the cognitive/emotional component of pain mechanisms.”(4)

Layman’s terms—and per my own experience—opioids hijack the brain’s reward center, affecting cognition or awareness of pain in order to justify the emotional component of seeking euphoria through narcotics. At this point, the patient has become an addict and is “med-seeking.” Individuals with poor impulse control are more likely to develop substance use disorders.

Francesca Fibey** writes, “Guided by multidisciplinary research in neuroscience, epidemiology, brain imaging, and genetics, addiction is now understood to be a brain disease due to the changes it exerts on the brain.”(5) According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), addiction is a chronic progressive disease with behavioral patterns that fall within a varying spectrum of severity. In other words, such drugs are “scheduled” by the Federal Controlled Substances Act*** based on the extent of harm they can cause. Heroin, Ecstacy, Methaqualone, and Peyote are Schedule I substances with a high potential for abuse and no currently accepted medical use. Vicodin, Cocaine, Methamphetamine, Methadone, Dilaudid, Demerol, OxyContin, oxycodone, and Fentanyl are Schedule II drugs with a high potential for abuse and a severe risk of dependence.

Opioid use—even short term—can lead to addiction and, too often, overdose.

Many of the genes that play a role in opioid addiction involve the endogenous opioid system: our body’s internal system for regulating pain, reward, and addictive behaviors. Our bodies naturally produce opioid substances (endogenous opioids). These natural opioids attach to receptors, fitting like keys into locks. Opioids introduced from outside the body (exogenous opioids), including opioid medications and heroin, exert their effects by acting on these receptors. Differences in the receptors’ structure and function influence how each body responds to opioids. It is interesting to me that I became addicted to opioids immediately. It is likely that this factor complicated my recovery. Whenever opioids bind to the receptors, the interaction triggers a series of chemical changes within and between neurons. This produces intense feelings of pleasure and pain relief. The mμ—opioid receptor is where opioid drugs are received into the brain. Delta opioid receptors are highly concentrated in superficial layers of the dorsal horn in the spinal cord, diffusely distributed in the gray matter of the spinal cord along the cervical and thoracic regions.

Sharon Walsh writes, “We’ve seen a near-total transition of the illicit opioid supply to fentanyl, which is highly potent and often fatal.”****

Are We Making Any Progress?

The SARS-cov-2 (COVID-19) virus brought with it a severe spike in substance abuse, particularly oxycodone, heroin, and fentanyl. I heard about the fatal overdose of 4 participants in my county’s drug treatment program during several months due to mandatory shutdowns. Because of these restrictions, there was no courtroom appearance for weekly status conferences; probation officers were not making routine visits (even to those on house arrest with an ankle monitor); participation in 12-step meetings (AA, NA, etc.) was suspended. There were no options for 12-step meetings or community service, so time in the drug program was frozen at each participant’s then-current position. I believe some addicts thought, Well, I might as well party for now. Addicts use because they are addicts, requiring routine monitoring and accountability for at least one year. This lack of supervision led to the death of 4 young individuals, one of whom had become a father 3 weeks earlier.

Herbert Kleber states, “While opioid dependence has more treatment agents available than other abused drugs, none are curative. They can, however, markedly diminish withdrawal symptoms and craving, and block opioid effects due to lapses.”(6) Higgins, Smith, and Matthews stated, “Chronic pain is highly prevalent in treatment-seeking opioid-dependent patients; therefore, this co-morbid presentation is an important clinical consideration for both addiction and pain specialists.”(7) They further said, “[individuals] reporting that pain caused opioid dependence disorder were characterised [sic] by poorer pain-related health and more illicit use of drugs with analgesic properties; and those reporting that opioid dependence disorder caused pain were characterised [sic] by more overall use of substances, multiple substance use and more intravenous substance use and poorer general health.”(8) Recovery from substance use disorder is a complex and complicated process that demands commitment and consistency.

Results of a Recent Clinical Study

Of the 615 patients in the National Health Service (NHS) Substance Misuse study conducted by Higgins, Smith, and Matthews, 221 (36%) were excluded due to having no pain, 54 (9%) were excluded due to having pain of less than 12 months duration and 88 (14%) were excluded due to reporting no perceived causal relationship, in either direction, between the onset of chronic pain opioid dependence. The remaining 252 patients (41% of the entire treatment population) comprised the study group. Just over two-thirds of the study cohort (69%, n = 174) reported the belief that chronic pain had caused opioid dependency (the CP→ODD group) while the remainder (31%, n = 78) reported the belief that opioid dependency had caused chronic pain (the ODD→CP group).

According to Barbara Andraka-Christou(9) criminal drug treatment programs, DUI court programs, and mental health court feature participants suffering with Substance Use Disorder, including opioid addiction. Criminal defendants suffering from addiction are referred to treatment. A “treatment team” establishes treatment-related requirements for criminal defendants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (often called “medically-assisted treatment”) are the most effective treatment for opiate addicts, but they are underutilized by court systems. Having graduated from a drug court treatment program, and currently nearly three-and-a-half-years clean from opiates, cannabis, and benzodiazepines, I believe court intervention programs rather than incarceration (depending on the criminal offense) provide far greater results than locking people up. Obviously, the best results come from 100% compliance with all treatment recommendations.

God’s Goodness in Recovery

Jody Brown writes, “Indisputable evidence of God’s grace and mercy can be seen in the lives of men who hit rock bottom from drugs or alcohol—but [find] forgiveness and healing.”(10) Bryan Tuggle, a former addict and director of John 3:16 Ministries, says, “We’ve all been there: rock bottom.” He adds, “We look into the man’s eyes and ask him questions about his life to see if he is at his personal rock bottom. Men at the bottom will be very willing and thankful to receive help.”(11) For several years, I thought I’d hit my bottom, only to keep digging. Finally, when at 60 years old I was facing 1½ to 5 years in state prison after I’d been there for 3 years some forty years ago, I was done with it all. This ends today, I thought. Thankfully, through God’s mercy and grace, I was granted entry into the county’s drug treatment court despite being ineligible because of a history of 4 felonies. I avoided incarceration, and I successfully completed the drug treatment program without any violations or positive drug screens.

In his new book How to Conduct Discipleship Training, Rufus McDowell writes, “Most drug or alcohol programs have provided spiritual, social, and emotional assistance for men and women who have lost the ability to cope with their problems and provide for themselves.”(12) He suggests that Christ-centered drug and alcohol treatment is implied in the Great Commission. I concur. Jesus demands that we not only share the gospel with the world, but that we make disciples, teaching them to observe all that He has commanded (See Matt. 28:19-20). To that end, McDowell writes, “…this book will equip you with biblical principles and modalities to teach holistically.”(13) Through recognizing the power of powerlessness and turning to Christ for redemption, and then becoming honest, open-minded and willing to let Christ change us, we are able to truly recover from a hopeless situation. And those of us who have recovered are in the best possible position to reach those who remain in bondage to sin and addiction.

So, let’s get busy.

Steven Barto, B.S. Psy., M.A. Theology

*Hyperkatefia is the “pain of addiction” due to the overlapping mechanisms and association with chronic pain.
** Francesca Mapua Filbey is a Professor of Cognition and Neuroscience and Ber Moore Endowed Chair of BrainHealth for the School of Behavioral and Brain Science at the University of Texas at Dallas. She conducts research aimed at understanding the bio-behavioral mechanisms of addictive disorders.
***Federal Controlled Substances Act, 21 U.S. Code § 812.
****Sharon Walsh, PhD, is Director of the Center on Drug and Alcohol Research at the University of Kentucky.

References
(1) Julia Griffin, “How a Brain Gets Hooked on Opioids,” PBS News Hour, a blog, Oct. 9, 2017, accessed Oct. 4, 2022, https://www.pbs.org/newshour/science/brain-gets-hooked-opioids
(2) Mayo Clinic Staff, “How Opioid Addiction Occurs,” Mayo Clinic, a blog, n.d., accessed Oct. 4, 2022, https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372
(3) Ajay Manhapra, MD, “Complex Persistent Opioid Dependence—An Opioid Induced Chronic Pain Syndrome,” April 18, 2022, https://link.springer.com/article/10.1007/s11864-022-00985-x
(4) Ibid.
(5) Francesca Mapua Filbey, The Neuroscience of Addiction (Cambridge, UK: University Printing House, 2019), 1.
(6) Herbert D. Kleber, “Pharmacologic Treatments for Opioid Dependence: Detoxification and Maintenance Options,” Dialogues in Clinical Neuroscience, April 1, 2022, https://doi.org/10.31887/DCNS.2007.9.2/hkleber
(7) Cassie Higgins, Blair H. Smith, and Keith Matthews, “Opioid Dependence Disorder and Co-Morbid Chronic Pain,” June 18, 2021, Sage Journals, https://doi.org/10.1177/20494637211026339
(8) Ibid.
(9) Barbara Andraka-Christou, JD, PhD, “Criminal Problem-Solving and Civil Dependency Court Policies Regarding Medications for Opioid Use Disorder,” Substance Abuse, July 8, 2021, https://doi.org/10.1080/08897077.2021.1944958
(10) Jody Brown, “Evidence of God’s Goodness,” The Stand, March 2022, 16.
(11) Ibid.
(12) Rufus McDowell, Jr., D. Min., How to Conduct Discipleship Training: Transforming Christians With Prior Drug and Alcohol Dependence (Meadville, PA: Christian Faith Publishing, Inc., 2021), chapter 2, “Rehabilitation.”
(13) Ibid., chapter 1, “Introduction.”

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