Opioids. Everything you need to know about America’s Most Lethal Drugs

Imagine waking up tomorrow in San Jose, California, or in Austin, Texas and you’re the only soul left alive. The entire city’s inhabitants have died overnight. The thought is both shocking and disturbing. An entire population of over a million Americans wiped out overnight. Opioid-related deaths have done exactly this, killing over a million Americans in the last two decades. The deaths continue, unabated.

Death is relative unless of course, it affects someone close to you. How we measure deaths and over what period of time matters in how the public perceives these deaths. Here a few figures about deaths related to opioids, and we’ve changed the way they’re presented. Rather than spreading them out over time, we’ve aggregated them. They make for pretty shocking figures.

Opioid-related data demonstrated an almost fourfold increase in overdose deaths from 1999 to 2008, according to a 2018 review published in NCBI.

By 2016, deaths had risen to over 42,000 for that calendar year. Keep in mind these are deaths directly caused by overdose or abuse of the drug. Many deaths aren’t shown as such, so this figure is conservative. People die in drug-related crimes, violence, and suicide, directly linked to their addiction lifestyle. Opioids pulled the trigger, but arent recorded as the primary cause of death.

Opioid overdoses related to illegally manufactured fentanyl (the most powerful of the opioids) represented the greatest contribution to the increasing numbers, accounting for 20,000 of the 42,000 deaths. As a result, on October 16, 2017, the US Government declared the opioid epidemic a public health emergency.

The medical community, and particularly pain medicine practitioners, had been active participants and fully aware of the development of the current state. Prescription drug monitoring programs (PDMPs) and the National All Schedules Prescription Electronic Reporting Act (NASPER) have effectively contributed to the reduction in opioid prescriptions by 8%, but on the ground, these initiatives have not translated into saved lives. In fact, quite the opposite.

Fast forward to 2021. From emerging figures, it becomes evident that we are losing this battle, and spectacularly so. In 2019, nearly 50,000 people in the United States died from opioid-involved overdoses.

From 1999 to 2019, nearly 841,000 Americans died from a drug overdose.³ Over 70% of overdose deaths involved an opioid-like prescription, opioids, heroin, or synthetic opioids (like fentanyl). If you add in figures from 2019 to now, 2021 you can safely assume we are over a million deaths, of which more than 700 000 are related to opioid addiction.

How did we get here?

Opioids and cocaine were widely prescribed in the late 19th century for anything from toothache to diarrhea. No regulation existed and only when street addition became evident was regulation enforced. The Harrison Narcotic Control Act of 1914, passed in response to the sudden emergence of street heroin abuse as well as iatrogenic morphine dependence, influenced both physicians and patients alike to avoid opiates.

It would take nearly eighty years for opioids to come back into vogue as one of the most effective treatments we have to manage pain, particularly extreme and chronic pain. The concept was a simple one. If cancer patients could benefit from opioid use to manage pain, why not extend the benefit to chronic pain sufferers too? The flaw in this concept, evident even to a layman, lies in the fact that the two types of pain differ significantly, cancer pain and chronic, non-cancer pain, and ignores the etiologies of malignant and non-malignant pain

This dangerous conflation disregarded the complex biopsychosocial phenomena that is chronic pain, and despite many cautions to this effect, opioids grew into the primary modality of chronic non-cancer pain treatment we know today in the USA¹.

It can therefore be argued that pressure from within Pharma and the decision to widely ignore the cautionary voices raised across the industry are directly responsible for the opioid scourge that now blights American Healthcare. This is worth noting as we look to assign responsibility for the opioid pandemic.

To explain the depth of complicity, consider this. In 2000 the Federation of State Medical Boards and the Drug Enforcement Agency issued statements promising less regulatory scrutiny over opioid prescribers, thereby assuaging physician reluctance to prescribe more liberal amounts of opioid analgesics.²

Provider abetted addiction in modern-day American Healthcare had just been given the official green light.

How opioids work

All opioids are chemically related and interact with opioid receptors on nerve cells in the body and brain. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use — even as prescribed by a doctor — can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose incidents, and deaths.

Exactly how addictive are opioids? That depends on a number of factors and varies from patient to patient. It should take a couple of weeks to become physically dependent on an opioid, but that varies. If you take an opioid for a day or two, it should not be a problem and, generally, you will not become addicted. However, some studies show even the first dose of an opioid can have physiological effects.

There is no exact data and by ingesting an opioid, you are in effect playing a pharmacological version of Russian roulette. If you suffer from cancer-related pain, then you are in a category where the risk is justified by the pain you are experiencing. It is important to understand that you can be physically dependent on a substance but you don’t necessarily have problematic use. A cancer patient with chronic pain may be physically dependent but not addicted.

Opioids are one of the most addictive medications prescribed. Even doctors can become caught up in this dependency cycle, popping a few pills over the course of a few days for sorting out a nagging pain. Ingesting an opioid exposes you to the risk of addiction.

Examining the types of opioids

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others.

Brand names (generic names)

• Abstral (fentanyl),
• Actiq (fentanyl),
• Avinza (morphine sulfate extended-release capsules),
• Butrans (buprenorphine transdermal system),
• Demerol (meperidine [also known as isonipecaine or pethidine]),
• Dilaudid (hydromorphone [also known as dihydromorphinone])
• Dolophine (methadone hydrochloride tablets)
• Duragesic (fentanyl transdermal system)
• Fentora (fentanyl)
• Hysingla (hydrocodone)
• Methadose (methadone)
• Morphabond (morphine)
• Nucynta ER (tapentadol extended-release oral tablets)
• Onsolis (fentanyl)
• Oramorph (morphine)
• Oxaydo (oxycodone)
• Roxanol-T (morphine)
• Sublimaze (fentanyl)
• Xtampza ER (oxycodone)
• Zohydro ER (hydrocodone)

Street Names

Captain Cody, Cody, Schoolboy, Doors & Fours, Pancakes & Syrup, Loads, M, Miss Emma, Monkey, White Stuff, Demmies, Pain killer, Apache, China girl, Dance fever, Goodfella, Murder 8, Tango and Cash, China white, Friend, Jackpot, TNT, Oxy 80, Oxycat, Hillbilly heroin, Percs, Perks, Juice, Dillies.

Opioids listed by strength

Opioids are not all created equally and are available in varying strengths, with carfentanil and fentanyl widely recognized as the most potent. This list, provided with thanks by the Dana Point Rehab Campus lists the typical opioids by strength.

1. Carfentanil — Carfentanil is an extremely dangerous opioid that is 10,000 times more potent than morphine and 100 times more potent than fentanyl. Carfentanil is used to tranquilize elephants and other large animals and is not intended for use in humans. Drug dealers may mix carfentanil into their drug supplies to provide their customers with a more potent, addictive high.

2. Fentanyl — Fentanyl is 50 to 100 times more potent than morphine and has been the main contributor to the rise in overdose deaths in recent years. The majority of fentanyl-related deaths involve synthetic fentanyl that is manufactured overseas and mixed with other illicit drugs including heroin, cocaine, and methamphetamine.

It is sold under brand names including Sublimaze, Duragesic, and Actiq. It also has many street names including China Death, TNT, Murder 8, Jackpot, Goodfella, Dance Fever, Apache, and China Girl.

3. Buprenorphine (Butrans) — Buprenorphine is an FDA-approved medication for the treatment of opioid use disorder. It is about 25 to 100 times more potent than morphine, but it does not provide a euphoric high like other opioids. Buprenorphine is used in drug detox to relieve and reduce opioid withdrawal symptoms.

4. Oxymorphone — Oxymorphone is sold under brand names such as Opana and Numorphone. It is an extended-release opioid that has many street names including O Bomb, Stop Signs, Biscuits, and Blues. Oxymorphone is used to relieve moderate to severe pain in patients who are unable to reduce or control pain with other medications. Oxymorphone is 3 times stronger than morphine when taken in tablet form, and 10 times stronger than morphine when received as an intravenous injection.

5. Hydromorphone — Hydromorphone is used to relieve moderate to severe pain and is about two to eight times more potent than morphine, reports the DEA. It is available as an injection, tablet, liquid, and rectal suppository.

6. Heroin — Heroin is an illicit drug classified as a Schedule I substance with a high potential for abuse. Heroin is usually two to five times stronger than morphine and commonly mixed with other potent substances such as fentanyl or carfentanil. In 2018, heroin was involved in 14,996 overdose deaths in the U.S.

7. Methadone (Dolophine, Methadose) — Methadone is another FDA-approved medication for the treatment of opioid addiction and is about three times stronger than morphine. Methadone is often used for long-term maintenance in people in recovery from opioid addiction, and can only be dispensed at an outpatient clinic under direct medical supervision.

8. OxyContin — OxyContin is a brand name for Oxycodone, a well-known extended-release opioid. Oxycodone is prescribed to treat moderate to severe pain and is about 50% stronger than morphine. The CDC reports that oxycodone is one of the most common drugs involved in prescription opioid overdose deaths. In 2018, prescription opioids like oxycodone contributed to 14,975 overdose deaths in the U.S.

It is usually sold as a tablet that is meant to last an entire day, which is often bypassed by drug abusers to quicken the release time. Street names include O.C., Oxy, Oxycet, Oxycotton, and Hillbilly Heroin.

9. Percocet — This drug is a combination of oxycodone and acetaminophen. It comes in tablet, liquid oral solution, and capsule form. Some of the street names for the drug include Percs and Hillbilly Heroin since it also contains oxycodone.

10. Hydrocodone — The next in the list of opioids strongest to weakest is hydrocodone, which is sold under many different brand names such as Norco, Vicodin, and Zohydro. It is usually sold as a way to manage pain after surgery, chronic pain, or pain from an injury. It comes in both syrup and tablet form. Street names for hydrocodone include names such as Watson-387 and Vike.

Hydrocodone has about the same strength as morphine and is commonly combined with other pain relievers such as ibuprofen and acetaminophen.

11. Morphine — The drug that was known as the “soldier’s disease” due to addictions it caused during war times, is the next in our list of opiates. Brand names include MS Contin and Duramorph among others. It is often used as a pain-management solution for cancer patients. It is available in tablet, capsule, suppository, and injectable form. It has street names such as White Stuff, Monkey, and Miss Emma.

12. Tramadol (Ultram) — Tramadol is used to relieve moderate to moderately severe pain and has about one-tenth the potency of morphine. This drug is the only opioid categorized as a Schedule IV substance on the Controlled Substances Act.

13. Demerol (Meperidine) — The brand name opioid, Demerol, is most frequently used to treat moderate to severe pain, and is about 7 to 10 times less potent than morphine. It may also be used as anesthesia due to its potency. The drug comes in a variety of forms including an injectable solution, tablet, and liquid oral solution. Common street names include Pain Killer and Demmies.

Though meperidine is less potent than many other opioids, it is classified as a Schedule II narcotic along with oxycodone and fentanyl.

14. Codeine — This opioid is a relatively short-acting opiate. It is commonly prescribed along with aspirin and acetaminophen. Tablet, capsule, and liquid forms of the drug are sold. Some of the names that Codeine goes by when sold illegally include Purple Drank, Lean, Cody, and Sizzurp.

Overcoming opioid addiction

It will probably come as no surprise that pharma has been beavering away to create treatments it can sell you to counter opioid addition. Ironic and possibly the most glaring indictment of an industry bereft of ethics or patient-focused motives. Weaning a patient off opioids is a lengthy, expensive and demanding process, for both provider and patient and is often met with failure.

Methadone, when administered properly, is included in treatment with counseling and is always provided in a clinical setting. It helps to block the effects of opioids and to reduce cravings.

The medicine buprenorphine also helps opioid cravings without giving the same high as other opioid drugs. Prescribed by many physicians, this is typically a daily dose placed under the tongue and can also be delivered as a once-a-month injection or through thin tubes placed under the skin every six months.

These medicines both activate opioid receptors in the body that suppress cravings, and are effective and similar in safety and side effects, and typically used for maintenance treatment. They can be used as a taper agent as well but some patients relapse. Patients who are highly motivated and have good social support have a tendency to do better.

Naltrexone

This medicine is very different and doesn’t activate the opioid receptor the way that buprenorphine and methadone do, but instead blocks the euphoric/sedative effects of opioids. Your system must be completely free of all opioids before beginning naltrexone. It can be taken orally or as a once-a-month injection.

References

1. Opioid treatment of chronic nonmalignant pain. Stein C Anesth Analg. 1997 Apr; 84(4):912–4. [PubMed] [Ref list]
2. Pain management, controlled substances, and state medical board policy: a decade of change. Joranson DE, Gilson AM, Dahl JL, Haddox JD J Pain Symptom Manage. 2002 Feb; 23(2):138–47. [PubMed] [Ref list]
3. America’s Drug Overdose Epidemic. [CDC]