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Stages of Opioid Addiction | Understanding Each Stage

Some people work through the stages of opioid addiction quickly, while others take longer in every stage or one of the first two stages. Each person is different. 

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The development of opioid addiction doesn’t happen overnight. Instead, it generally builds from opioid use to abuse and ultimately addiction over a period that varies from person to person.[1] In most cases, this process happens in three stages: initiation, misuse, and addiction.

Stage 1: Initiation

The initiation stage of opioid addiction begins with the initial exposure or introduction to opioids. 

It usually happens when someone is prescribed opioids by a healthcare provider for legitimate purposes, such as managing acute or chronic pain.[2] However, initiation can also occur when someone experiments with the recreational use of opioids, either using leftover medications for nonmedical purposes or recreational drugs bought on the black market. 

While most people who are prescribed painkillers will use the drugs as prescribed, some will begin to crave the euphoric feelings associated with the drugs. For some people, this may occur due to underlying risk factors for addiction, such as a genetic predisposition to the development of addiction, a co-occurring mental health disorder, or the experience of trauma. 

For those who use the drug recreationally, there is a greater risk of moving on to the next stage of addiction more quickly. This is because they have initiated use by abusing the drug.

Signs of Opioid Use

If someone is using these drugs, opioid side effects may be apparent. Some of the signs that someone might be using opioids include the following:[3-5]

Euphoria & Pleasure

Opioids have the power to create feelings of euphoria and relaxation, triggering the pleasure pathway and often causing a shift in the person’s behavior.

Sedation & Sleepiness

Opioids have sedating properties, which may induce sleepiness, even in situations where it is inappropriate. 

Slowed Breathing

Respiratory depression can occur with opioid use, which may look like shallow breathing or stopping breathing entirely. This is a sign of overdose, and prompt medical care, including administration of naloxone, is needed to reverse the overdose.

Nausea & Vomiting

This is a sign of opioid use, especially in people who are new to using the drug.

Gastrointestinal Issues

Constipation can occur with ongoing use of opioids.

Stage 2: Misuse

The misuse stage of opioid addiction occurs when people deviate from the prescribed use of opioids, start using them for nonmedical purposes, or begin to use them recreationally on a regular basis. 

During the misuse stage, people will begin to experience negative consequences personally and in their relationships as a result of opioid use. Over time, continued misuse will lead to the third stage of addiction.

The misuse stage of opioid use disorder (OUD) is characterized by the following:[6-8]

Taking Higher Doses

Some people may increase their opioid dose beyond the prescribed amount to achieve a stronger effect or a more intense high. This can involve taking larger quantities than prescribed, crushing or otherwise using drugs outside the bounds of the prescription, or combining use of the medication with other substances.

Using Opioids Without a Prescription

For those who don’t have a prescription, any ongoing use of painkillers is considered misuse of the drug and falls into the second stage of addiction development. For those who do have a prescription, this can look like buying more pills on the street or seeking out multiple prescriptions from different doctors.

Combining Opioids With Other Substances

Some people engage in polydrug use, mixing opioids with alcohol, benzodiazepines, or stimulants. This practice is extremely risky and potentially deadly because it intensifies the effects of both substances, which increases the risk of overdose.

Engaging in Risky Behaviors

While under the influence or focused solely on getting high, the awareness of risk is diminished, which means an increase in harmful behaviors, such as driving under the influence or sharing needles for injection drug use. 

Stage 3: Addiction

Addiction is present when an opioid use disorder has fully developed.[1] This stage is marked by compulsive drug-seeking behavior and loss of control over opioid use.

People in the addiction stage often prioritize obtaining and using opioids over other responsibilities, connections, and activities. When this becomes habitual, they begin to see the detrimental effects that addiction has on their physical health, mental well-being, family and romantic relationships, and overall functioning.

The addiction stage of an opioid use disorder is usually characterized by the following:[1,9-11]

Intense Cravings

Individuals often experience intense and persistent cravings for opioids that can be triggered by various cues associated with drug use. Such cravings lead to compulsive drug-seeking behavior and make resisting opioid use incredibly difficult without professional assistance.

Tolerance

Prolonged opioid use leads to tolerance, a condition that occurs when the body adjusts to a specific dose of opioids, and that dose no longer triggers the same effects it once did. As a result, the person feels compelled to take more and more of the drug in order to experience a high.

Physical Dependence

Prolonged opioid consumption may also lead to physical dependency, which happens when the body adapts its functioning with the expectation that a certain amount of opioids will be in the system. Should that level drop for any reason, withdrawal symptoms are triggered. Opioid withdrawal symptoms may include restlessness, agitation, muscle aches, insomnia, nausea, and vomiting. 

Psychological Dependence

Opioid addiction also involves psychological dependency. People feel that they cannot function without their drug of choice. For many, this dependence is incredibly hard to break.

Social, Occupational & Health Consequences

Opioid addiction comes with significant repercussions, which may include strained relationships with loved ones and friends, job loss or academic issues at school, financial strain, and legal trouble. Additionally, high-dose use, regular use, and use of needles can come with consequences like HIV or hepatitis C, respiratory difficulties, cardiovascular problems, and overdose.

Compulsive Use of Opioids

The negative effects of untreated addiction are impossible to ignore in this stage, yet the person may still be unable to control their opioid use even if they genuinely want to quit using the drugs.

Help for Opioid Addiction

Though there is no cure for opioid addiction at any stage, there are a number of treatments that have been proven to be effective in managing the issue. Evidence-based opioid addiction treatment include medication-assisted treatment, behavioral therapies, alternative therapies like music or art therapy, and support groups.[12]

If you or a loved one are dealing with opioid abuse, no matter which stage of the addiction process you may be in, help is available. Reach out for comprehensive addiction treatment today.

Updated January 12, 2024
Resources
  1. Opioid addiction. Huecker MR, Azadfard M, Leaming JM. StatPearls. Published February 28, 2019. Accessed December 26, 2023.
  2. Managing acute pain. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Evidence-Based Clinical Practice Guidelines for Prescribing Opioids for Acute Pain. Washington (DC):National Academies Press (US); 2019.
  3. Opioid use disorder. Dydyk AM, Jain NK, Gupta M. StatPearls. Published 2022. Accessed December 26, 2023.
  4. Opioid‐induced euphoria among emergency department patients with acute severe pain: An analysis of data from a randomized trial. Abril Ochoa L, Naeem F, White DJ, Bijur PE, Friedman BW. Quest TE, ed. Academic Emergency Medicine. 2020;27(11):1100-1105.
  5. Preventing opioid overdose with peer-administered naloxone: findings from a rural state. Hanson BL, Porter RR, Zöld AL, Terhorst-Miller H. Harm Reduction Journal. 2020;17(1).
  6. CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. Dowell D, Ragan K, Jones C, Baldwin G, Chou R. MMWR Recommendations and Reports. 2022;71(3).
  7. HIV and injection drug use | HIV Transmission | HIV Basics | HIV/AIDS. Centers for Disease Control and Prevention. Published November 3, 2020. Accessed December 26, 2023.
  8. The neurobiology of opioid dependence: Implications for treatment. Kosten T, George T. Science & Practice Perspectives. 2002;1(1):13-20.
  9. Craving in opioid use disorder: From neurobiology to clinical practice. Kakko J, Alho H, Baldacchino A, Molina R, Nava FA, Shaya G. Frontiers in Psychiatry. 2019;10.
  10. Withdrawal management. World Health Organization. Published 2009. Accessed December 26, 2023.
  11. Analysis of opioid efficacy, tolerance, addiction and dependence from cell culture to human. Morgan MM, Christie MJ. British Journal of Pharmacology. 2011;164(4):1322-1334.
  12. Information about medication-assisted treatment (MAT). U.S. Food and Drug Administration. Published May 23, 2023. Accessed December 26, 2023.
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