Addiction & Recovery

Opioid Use: A Q&A with Dr. Sunil Khushalani


September is Recovery Month. We sat down with our expert, Sunil D. Khushalani, MBBS, MD, FAPA, FASAM, Medical Director of Adult Services, to learn more about opioids and opioid use disorder.

Q: What are opioids?

A: Opioids are a group of chemical compounds. These chemical compounds interact with opioid receptors in the body to reduce pain and create pleasurable sensations. Opioids come from four sources:

  1. Naturally occurring in poppy plants: poppy seeds yield opium, which is a milky fluid that hardens into a resin. Drug companies use that resin to create drugs like morphine or codeine.
  2. Naturally occurring and modified in a lab: That is how drugs like oxycodone, hydromorphone, and buprenorphine are created.
  3. Artificially created in a lab: Some opioids can be created entirely in the lab. Examples of this kind of opioid include methadone and fentanyl.
  4. Naturally produced by our own bodies: these are endorphins.

Q: Why are opioids addictive?

A: Opioids act on our opioid receptors. When these receptors are activated, a neurotransmitter called dopamine is released. Dopamine is the neurotransmitter in the ‘reward circuit’ in your brain and creates a sense of pleasure. Opioids ‘hijack’ this reward circuit and release a large quantity of dopamine. 

Anywhere from 21% to 29% of patients prescribed opioids for chronic pain misuse them; 8 – 12% will develop an opioid use disorder. About 4 – 6% of those who misuse prescription opioids transition to using heroin. Approximately 80% of people who use heroin actually first misused prescription opioids.

Q: What are some of the warning signs that someone is struggling with opioid abuse?

A: Family members and loved ones should be vigilant if someone is prescribed opioid medications. Check in on how they are functioning – people abusing opioids may sleep or nod off more, or they might be unable to go to work. They may also become especially moody.

Medical professionals should look out for signs of someone trying to get more medication. A patient may say that they’ve lost their prescription, or they consistently need to refill early. Patients may also become overly irate if something goes wrong with their prescription. Providers should note whether their patient has a psychiatric disorder when prescribing opioids – these individuals may be more prone to developing a dependence on opioids.

Q: How are opioid use disorders related to mental health disorders?

A: In the United States, about 55 – 56 million people have a mental health disorder or a substance use disorder. Of that 56 million, 9 million have both – these are called co-occurring disorders.

This correlation likely exists for a number of reasons: people struggling with mental illness may be more vulnerable to addiction, genetic risks for both may overlap, and family history probably plays a role. There also could be elements of trauma, whether physical, emotional, or sexual. 

Q: What treatment approaches do you use for opioid use disorder?

A: When developing a treatment plan for someone, it’s important to consider what stage of change they are in. There are 5 stages:

  1. Pre-contemplation: the person doesn’t think they have a problem, or they may be denying or minimizing the problem
  2. Contemplation: the person thinks they might have a problem, but are ambivalent about making a change 
  3. Preparation: the person is beginning to ask questions and getting ready to make a change. What can I do? How can I get help? Are there meetings I can attend?
  4. Action: the person is starting to get help. They may attend their first support group or take their first dose of medication.
  5. Maintenance: after someone has sustained their behavior change for a period of time, an individual is in maintenance.

The treatment approach we use depends on a person’s stage of change. When someone is in an earlier stage of change, we use motivational interviewing techniques to make them aware of the problem they have. If someone is in a later stage of change, we will generally use a combination of: 

  • Counseling: individual and group therapy can be very helpful
  • Treatment programs: different levels of care are available depending on a person’s needs 
  • Medication: individuals with opioid addiction are offered one of three FDA-approved medications (methadone, naltrexone, or buprenorphine)

Support groups can be especially helpful as well. There are a variety of support groups and educational lectures offered on Sheppard Pratt campuses; see that list here.

Q: How do I encourage someone to seek help?

A: First and foremost, make sure your offer comes from a place of caring and concern. It is also important that you be nonjudgmental. The more someone sees you as their ally, they more likely they will let you help. If your loved one is comfortable with it, you should also speak with their doctor about your concerns.

I also recommend educating yourself on opioid addiction and learning to use Naloxone. Naloxone can reverse an opioid overdose and keep someone alive until emergency medical help arrives.

Finally, start researching treatment facilities – I look for facilities that are accredited and utilize medication as part of treatment.

Q: Are there any helpful resources you recommend?

A: I recommend the Substance Abuse and Mental Health Services Administration (SAMHSA) website and the National Institute on Drug Abuse (NIDA) website. Narcotics Anonymous (NA) also has helpful information. The Opioid Epidemic: What Everyone Needs to Know, by Yngvild Olden and Joshua M. Sharfstein, is an excellent resource.

For practitioners, I recommend obtaining copies of the SAMHSA Treatment Improvement Protocols and reviewing the American Society for Addiction Medicine (ASAM) website.