The population of the United States represents about 5% of the population of the world; however, the United States consumes approximately 80% of the prescription opiate drugs in the world. Opiate drugs are synthesized from substances found in the Asian poppy plant. The primary use for these drugs is to control pain, to control diarrhea, and to treat other medical conditions that are not associated with pain such as diabetes.
According to the National Institute on Drug Abuse (NIDA) and the Centers for Disease Control and Prevention (CDC), in 2016, about 40% of all opioid overdoses in the United States occurred as a result of prescription opiate drugs, but this trend has reversed. Instead, heroin has become the major drug of choice for opiate abusers. Approximately 75% of new heroin users began their opiate drug abuse with the use of prescription opiates; however, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), the vast majority of individuals who are prescribed opiate drugs do not become opiate drug abusers. Thus, while many individuals who are eventually diagnosed with opiate use disorders began using opiates as a result of having a prescription for an opiate painkiller, the vast majority of people who are prescribed opiate painkillers do not develop an addiction.
In fact, many of the above sources report that well over half of individuals who abuse prescription pain medications report that they did not have a prescription for the medication. Moreover, while the use of prescription opioids has declined recently, overdose rates have increased, especially overdoses associated with heroin and fentanyl.
Opiate Use Disorders and Physical Dependence
There is a difference between physical dependence on a drug and having a substance use disorder. Physical dependence represents a complex situation where an individual has been taking a drug or medication for a significant length of time, and the body has made adjustments to accommodate having the medication in the system. The body alters its production of hormones, neurotransmitters, and other substances to account for the presence of the substance. When the person stops using the drug and levels of the drug become depleted, the system is thrown out of balance (the withdrawal syndrome).
Individuals who take opiate medications for chronic pain due to cancer, arthritis, or some other condition will often develop some level of physical dependence on the medication; however, as long as they continue to use the medication as prescribed and under the supervision of their physician, they would not be diagnosed with a substance use disorder (addiction).
Instead, a substance use disorder represents a situation where a person’s use of the drug for nonmedical reasons results in significant impairment and/or distress in functioning. The symptoms of physical dependence are part of the diagnostic criteria for substance use disorders, but the person must demonstrate that their use of the drug is resulting in significant distress and dysfunction in their life. When a person only uses a drug for medical reasons and according to its prescribed purposes, the typical outcome is a reduction of distress and dysfunction in the person’s life.
Stage Models of Addiction
Stage models of development are very common in theoretical psychology, psychiatry, and neuroscience. Stage models posit that a particular ability or situation develops as a consequence of a person going through specific stages. The early stages are typically very simple and well-defined, and the later stages in the model are dependent on an individual successfully completing the earlier stages.
For instance, the very famous model of personality development that was first theorized by Sigmund Freud consisted of five very discrete stages of personality development in humans. All individuals would start at the earliest stage (the oral stage) and move on to later stages. Healthy development was a result of certain conflicts being effectively resolved at each stage. People who develop certain types of psychological problems were believed by Freud to have some type of unresolved conflict in one or more of the stages.
Most stage models operate on the following assumptions:
- The stages are discrete and have separate boundaries from one another.
- People progress through the stages in an orderly fashion. They begin in the early stages and progress to the later stages in order.
- The particular stage that a person is in can be identified by some relatively discrete and defining factors associated with that stage.
- People at the higher levels of the stage model have gone through all of the stages below their current level.
Unfortunately, while stage models of development are extremely common in theoretical psychology, psychiatry, and neuroscience, they also have numerous flaws.
- The first flaw is that stage models are often not supported by empirical observations. For instance, even though there are numerous stage models of the different types of addictive behaviors, many individuals who are diagnosed with these behaviors do not appear to go through the stages outlined in the model.
- Stage models assume that people move through the stages in a specified order, but in reality, many individuals appear to skip stages, start at the later stages of the model, and sometimes even regress to the earlier stages after being in a so-called later or more advanced stage.
- Often, the progression of addiction is different for different groups of people. For instance, females may show a different progression than males when it comes to certain types of addictive behavior.
Nonetheless, the prevailing notion is that individuals who abuse different types of drugs, including opiate drugs, may go through a specific series of stages. Depending on the specific model, there will be three or more stages. The model presented here represents a combination of several different stage models of addiction, including the Jellinek model, the model of addiction presented by Dr. George E. Vaillant, and a more recent neurobiological model of addiction.
This stage is often referred to as the initiation or experimentation stage. Experimentation typically happens early in an individual’s development (e.g., adolescence) but not always. SAMHSA reports that every year, millions of people misuse an illicit drug for the first time.
People begin to test the effects of drugs because they are curious, because their peers do it, or because they have seen others do it to deal with stress. A person who has a prescription for an opiate drug may begin to experiment with misusing the drug. They may notice that they achieve mild euphoria, relaxation, or sedation when they use the drug to control pain and may use the drug when they are not in pain to achieve these results. Such an individual may attempt to use the drug in conjunction with another drug, such as alcohol, to see if this effect is enhanced.
In this stage, the individual has not developed any serious dysfunctional behavior. As time goes on, the individual may begin to use the drug in specific situations, such as to deal with stress, on weekends, or with specific friends, but their use of the drug is still intermittent or occasional.
This stage is often described as the regular use stage. It is at this point where the person begins to develop a predictable pattern of drug misuse. A person with a prescription opioid prescription may take more of the drug than normal on weekends, or when they are feeling stressed or lonely. Some people may binge on the drug during this stage.
Occasional problems with drug use may begin to occur during the stage. For instance, the person may miss work the day after abusing the opiate drug, get into legal trouble, or experience relationship issues as a result of their misuse of the drug.
Various theorists will include a stage where the person begins to experience negative ramifications associated with their misuse of opiate drugs. This risky use stage is defined by an increase in misuse of the drug that occurs in situations where it is potentially dangerous or hazardous to use the drug. These situations can be quite variable. For example, this may involve using it while driving an automobile, caring for children, or operating machinery, or it may involve mixing very powerful drugs.
People in the risky use stage are often experiencing problems in their personal relationships, at work, at school, or with the legal system as a result of their opiate misuse. They may attempt to get opiates from others who have a prescription for them, steal them from others, buy them illicitly, or engage in doctor shopping to get multiple prescriptions for their drug of choice.
In this stage, the person begins to show signs of physical dependence on the drug. All of the major stage theories describe this stage. Physical dependence is a syndrome that occurs when an individual has developed tolerance and withdrawal symptoms associated with their drug abuse.
Tolerance to the drug always develops first, and the development of tolerance results in a person needing more and more of the drug to get the effect they once got at a smaller amount. As the person’s tolerance increases, they may find themselves suffering from withdrawal symptoms when they are not using the drug. Withdrawal symptoms from opiates can be quite variable and range from significant cravings to the development of severe nausea, fever, and chills.
Most stage models of addiction consider the development of physical dependence, particularly withdrawal symptoms, as the defining sign that an individual has developed a formal addiction (substance use disorder).
At this point, the person has developed the symptoms that would formally qualify them for a diagnosis of a substance use disorder, is suffering significant distress and/or functional impairment, and is frequently engaging in nonmedical use of opiate drugs. In this stage, most individuals are formally diagnosed with substance use disorders.
The last stage consists of the treatment and recovery phase where an individual becomes involved in formal treatment to address their issues and begins to struggle with all of the issues that occur during recovery.
In order to be diagnosed with a formal substance use disorder, such as an opiate use disorder, the person must meet specific diagnostic criteria that have been verified by a licensed mental health professional. The above stage model is based on the major stage models of addiction and contains all the assumptions of these stage models. Thus, individuals are assumed to begin with initiation and experimentation, and then move through the stages of regular use up to a formal diagnosis of a substance use disorder.
Movement Through the Stages
The theory assumes that individuals progress through each stage; however, as mentioned above, this does not often occur in the real world. For instance, many individuals initiate their misuse of opiate drugs in what theorists might describe as a risky or regular use stage. Others may experiment, move on to hazardous use, and then go back to regular use.
Several of the more neurobiological-focused models also suggest that addictive behaviors are not choices, but represent compulsions based on neurobiological factors. It is true that the chronic use of opiate drugs can lead to significant changes in a person’s neurobiological makeup; however, it is not true that an individual is totally robbed of their ability to choose as a result of their addiction. Research studies have consistently pointed out that individuals who are successful in treatment choose to follow their treatment recommendations. These choices are in direct opposition to the types of compulsions that the individual’s neurobiological makeup would dictate. Thus, individuals eventually decide that stopping use of opiate drugs is far more beneficial than any of the perceived benefits they get by continuing to engage in their use of these drugs.
While it is true that many individuals with opiate use disorders require significant coaxing, experience numerous relapses, and may even need to be coerced into participating in their treatment program, the bottom line is that these individuals eventually decide to be compliant with treatment. There is no medication, therapy, or medical procedure that can be used to alter the changes associated with the use of opiate drugs, such that a person automatically conforms to their treatment recommendations. Instead, the person must eventually decide to make this choice. Thus, the so-called stages associated with stage models of addiction actually reflect the choices an individual engages in, even if the individual’s choices are influenced by factors associated with alterations in their neurobiology.
The Usefulness of Stage Models
While stage models of addiction remain popular in theory, it appears that they offer very little clinical utility. The understanding that misuse of any drug, including a prescription or illicit opiate, represents a potential danger in any context is the best tool for individuals to rely on when judging the ramifications of their behavior. Individuals are not slaves to a stage model process of addiction but can take an active part in choosing how their scenario will turn out.