Opioids

Types of opioids

Opioid medications

Opioid-based medications are only available from the chemist with a prescription, or provided by a doctor/nurse for medical treatment.^16,17

Opioid medications have many uses. Two important categories are:

• Opioid pain medications

Also known as painkillers, these medications are prescribed to treat different types of pain. This includes chronic pain, cancer-related pain, and acute pain resulting from injury or surgery.¹⁸

• Opioid pharmacotherapy

Opioid pharmacotherapy is the use of medications to treat opioid dependence. It involves replacing opioids that are short acting (such as heroin or oxycodone) with a longer-acting, medically prescribed substitute (such as methadone or buprenorphine).^18,19

Learn more about accessing opioid pharmacotherapy in Australia here.

Types of opioid-based medications include:

• Buprenorphine (Buvidal®, Sublocade®, Suboxone®, Subutex®)
• Codeine (Panadeine®, Panadeine Forte®, Nurofen Plus®),
• Fentanyl (Actiq®, Durogesic®, Sublimaze®)
• Methadone (Biodone Forte Solution®, Methadone Syrup®)
• Morphine (MS Contin®)
• Oxycodone (Endone®, OxyContin®, Oxynorm®, TARGIN®)
• Tramadol.^18,20-25

Opioid antagonists (temporary overdose reversal medication)

Opioid antagonists are different to other opioid medications, as they don’t have any intoxicating effects. These drugs can be used to reverse an opioid overdose (naloxone), and less commonly for the long-term treatment of opioid dependence (naltrexone). They work by binding to the same receptors in the brain as opioids, blocking the drug’s effects.^26,27

Illegal opioids

Illegal opioids are drugs that have been banned due to their health risks, or drugs that were created to get around current drug laws or supply issues (such as nitazenes).^28-30

Illicit opioid use includes using legal medications in ways that are not prescribed.²⁸

Types of illegal opioids include:

• heroin
• nitazenes
• opium.²⁸

Potent synthetic opioids

Potent synthetic opioids, sometimes known as ‘novel synthetic opioids’, are a lot stronger than other opioids, meaning people can overdose on a small amount.^31,32

Many of these drugs were created in the mid-20th century for use in medicine. However, some were not authorised for medical use due to concerns about their potential for harm and risk of dependence.³²

Types of potent synthetic opioids include:

• fentanyl
• nitazenes.

How are opioids used?

Opioids can be taken in different ways.

Medications can be:

• swallowed (e.g. tablets, capsules, or syrup)
• dissolved under the tongue (films or tablets)
• taken as a nasal spray
• absorbed through the skin via a patch
• through injections given by health professionals.^4,33-35

Illegal or illicitly used opioids can be:

• swallowed
• injected
• smoked
• snorted
• inhaled.^10,13,35,36

Crushing, chewing, or splitting and taking a slow or modified-release opioid medication tablet or pill causes the drug to be released all at once, which can lead to a fatal overdose.^37-40

Effects of opioids

The use of any drug can have risks. It’s important to be careful when taking any type of drug.

Opioids affect everyone differently, based on:

• size, weight and health
• whether the person is used to taking it
• whether other drugs are taken around the same time
• the amount taken
• the strength of the drug (varies from batch to batch)
• the environment (where the drug is taken).

Onset and duration of effects

For short acting opioid medications, effects may be felt within 10 to 15 minutes if swallowed, and last for 3 to 6 hours.^7,21

The effects of controlled release or long-acting opioids can be felt for up to 12 to 36 hours.^7,21,41

For illicit use of opioids, effects can be felt within seconds if injecting or smoking, or in around 10 to 15 minutes if snorting.^9,42,43

The effects of illegal opioids can be felt for 3 to 7 hours.^43,44

Immediate effects

The immediate effects of opioids can include:

• pain relief
• psychological effects including feelings of comfort, euphoria, contentment, relaxation, detachment, and happiness
• drowsiness or falling asleep
• slow breathing and heartbeat
• nausea and vomiting
• headache
• slurred and slow speech
• confusion
• muscle weakness
• clumsiness and dizziness
• sweating
• mild allergic rash or hives
• itching
• aching muscles and joints
• abdominal cramps
• dry mouth
• tiny pupils
• reduced appetite
• lowered blood pressure
• orgasm suppression
• decreased sex drive
• difficulty urinating.^{4,7,9,21,41-43,45-50}

Impact of mood and environment

Drugs that affect a person’s mental state (psychoactive drugs) can also have varied effects depending on a person’s mood (often called the ‘set’) or the environment they are in (the ‘setting’):

• Set: a person’s state of mind, previous encounters with the drug, and expectations of what’s going to happen. For example, feelings of sadness or anxiety before using opioids may result in an unpleasant experience and make those feelings worse.
• Setting: the environment in which someone consumes opioids – whether it’s known and familiar, who they’re with, if they’re indoors or outdoors, the type of music and light. For example, using opioids in a calm, quiet and relaxed environment can lead to, or contribute to, a pleasant experience. But being in a noisy, crowded place may result in a negative experience.⁵¹

Being in a good state of mind, with trusted friends and a safe environment before taking opioids reduces the risk of having a bad experience.⁵¹

Overdose

If you take a large amount, have a strong batch, or mix opioids with alcohol or other drugs you could overdose.

Opioids can cause death.

Call triple zero (000) and request an ambulance if you or someone else has any of the following symptoms (emergency services are there to help and can provide more instructions).

Signs of an opioid overdose can include:

• passed out and non-responsive
• slow breathing, abnormal breathing or not breathing at all
• slow or no heartbeat and pulse
• choking or gurgling sounds
• skin colour changes, especially lips and fingernails:
• typically, bluish-purple skin for people with lighter complexions
• or greyish or ashen skin for people with darker complexions
• vomiting
• cool or clammy (wet and sweaty) skin
• small ‘pinpoint’ pupils.^48,52

Naloxone

Naloxone (also known as Nyxoid®/Narcan®) is a medication that temporarily reverses the effects of opioid overdose including heroin, oxycodone, and fentanyl.

It’s available for free over the counter from local pharmacies and can be easily administered by anyone including family, friends, or bystanders.^53,54

Learn more about how naloxone reverses overdose and saves lives here

Find naloxone near you

Mixing with other drugs

Mixing opioids with other drugs can have unpredictable effects and increase the risk of harm.

Mixing includes using more than one drug (including alcohol or medications) at the same time or one after another. You should also consider what drugs you’ve taken in the last 24 hours.

• Opioids and antidepressants (SSRIs): Rare reports of serotonin syndrome (a dangerous build-up of serotonin in the brain) when using SSRIs with opioids.
• Opioids and cannabis: Risk of increased impairment as it can amplify the effects of both drugs.
• Opioids and depressants such as alcohol, benzodiazepines, GHB, other opioids, and nitrous oxide (nangs): High risk of overdose. Can cause impaired coordination, passing out, difficulty breathing, nausea, vomiting, memory loss, slowed or stopped breathing, slowed or stopped heart rate, loss of consciousness, and possible death.
• Opioids and ketamine: Can cause nausea, vomiting, passing out and possible death.
• Opioids and monoamine oxidase inhibitors (MAOIs – antidepressants): Risk of delirium, convulsions, breathing failure, coma, and death. Rare reports of severe and varied reactions.
• Opioids and stimulants such as amphetamines, cocaine, methamphetamine (ice): Opioids lower your heart rate while stimulants speed it up, masking the effects of each drug. This can increase the risk of overdose. Depending on how much you take, you could overdose on either drug if one wears off before the other. Also causes strain on the heart and kidneys, further increasing risk of overdose.^{4,14,15,19,21,43-46,55-60}

Using more than one drug or type of drug at the same time is called polydrug use.⁴⁸

Reducing harm 

There are ways in which you can reduce the risks associated with using opioids.

• If you have a prescription - take opioids as advised.
• Start low, go slow – try a little bit first, to see how you feel. Wait at least 5 hours before deciding whether to take more.
• Keep naloxone nearby - if a person does not respond to the first dose after 3 minutes, give them a second dose. This can be repeated until the ambulance arrives.
• Test your drugs - if there is an available drug checking (pill testing) service, to find out what the drugs contain and how strong they are.
• Never use alone – use around people you trust and somewhere you feel safe. If you are using with someone else, use at separate times.
• Avoid operating machinery, driving or swimming.^{4,21,53-55,61-67}

If snorting:

• Do not crush or break slow-release tablets – this can release the entire dose at once, significantly increasing the risk of overdose.
• Crush into a fine powder - as crystals can cause cuts.
• Rinse your nose with water before and after - to protect your nose from irritation.
• Use your own or a disposable straw and avoid money notes - to reduce the risk of infections or transmission of viruses like HIV or Hep C.
• Switch nostrils and take breaks - to avoid nasal damage.^{44,53-55,64,65,67,68}

If injecting:

• Always use new needles – never share needles and safely dispose of used equipment.
• Visit a needle and syringe program - for sterile equipment, disposal of used equipment, and expert medical advice.^{4,44,53-55,61,62,64,65,67}

If taking opioid pharmacotherapy:

• Follow your doctors’ instructions - on how and when to take your medication. Do not stop taking it or change the dose without talking to your doctor.
• Drink plenty of water each day - to prevent dehydration and constipation.
• Speak to a health professional - as soon as possible if you are planning to have a baby or find out you are pregnant.
• Check with your doctor if you can drive or operate machinery - it’s usually recommended patients do not drive or use machinery when first taking their medication, or if changing dose.
• Talk with your doctor - if you experience any side effects or discomfort, to ensure your dose is correct and that the medication is right for you.^{4,19,21,43,53,54,56,61,62,64-67, 69-71}

Long term effects

Regular use of opioids may eventually contribute to:

• physical and psychological dependence on opioids
• tolerance to the effects of opioids
• constipation
• sleep problems
• intense sadness
• irregular periods and difficulty having children in people assigned female at birth
• decreased sex drive, erectile dysfunction and infertility in people assigned male at birth
• heightened sensitivity to pain (opioid-induced hyperalgesia)
• reduced bone density and higher risk of fractures
• dental issues
• suppressed immune system leading to more colds, flu, or other infection
• damage to heart, lungs, liver, and brain
• vein damage and infections from injecting.^{7,9,21,42,45,50,72-74}

Pain management plans

If you are prescribed opioid medications, ask your doctor about a ‘pain management plan’.

This can include non-medicine treatments (such as physical therapy), and non-opioid strategies (such as other medications) that you can use to complement your treatment.¹⁸

Your views and preferences matter.

Pain management plans should be developed through open and honest discussions between you and your doctor.¹⁸

All patients, including those who use opioids, have the right to best practice care that is respectful and promotes their dignity, privacy and safety.¹⁸

If you are looking for more information on the treatment of chronic pain, check out the links below.

• Chronic Pain | Pain Management Network
• Pain Directory - Pain Australia

Opioids and mental health

Mental health and opioid overdose 

Research has found a link between some mental health conditions and the risk of opioid overdose.^75,76

There is evidence that as many as 1 in 3 people with an opioid use disorder also have post-traumatic stress disorder (PTSD).⁷⁷

People experiencing mental health concerns such as depression, anxiety, PTSD, psychosis, or bipolar disorder are also more likely to experience an opioid overdose compared to those without these conditions.⁷⁵

This association has been seen across different groups, including people in emergency departments, veterans, and those in prison settings.⁷⁵

Stigma and opioid overdose

Evidence suggests that the relationship between opioid dependence, overdose, and mental health is complex and influenced by many factors.^75,76,78

Stigma, stress, and social exclusion are often experienced by people who use opioids and can negatively affect mental wellbeing.^75,78

Some people may illicitly use opioids to cope with emotional distress or symptoms of mental health conditions.^75,78

There is no single explanation for the connection between opioid overdose and mental health problems.^75,76,78

Social and emotional factors often work together to impact mental health. This shows the need for compassionate, person-centred care that looks beyond drug use alone.^75,76,78

Tolerance

People who regularly take opioids may develop a tolerance to it, which means they need to take larger amounts to get the same effect.^{7,9,21,42,45,50,72-74}

Tolerance can fade after a few weeks or months without opioid use. This means people who have used opioids before, might take too much if they start again. This is because their tolerance may be lower than it once was.⁶⁸

This can increase the risk of overdose.⁶⁸

If you use opioids again after a period of not taking them, it’s recommended to start with a much smaller dose than you might have been used to.⁶⁸

Dependence

People who regularly use opioids can become dependent. They may feel they need to use opioids to go about usual activities like working, studying and socialising, or just to get through the day.^9,72

Withdrawal

Withdrawal refers to the symptoms that can occur when someone who is dependent on opioids, or has used them regularly over time, stops or reduces their use.^79,80

Withdrawal can include physical symptoms (such as headaches, or nausea) and psychological symptoms (such as anxiety, or depressed mood).⁸⁰

Symptoms - including how strong they are and how long they last - will vary depending on the type of drug and a person’s history of use.⁸⁰

Withdrawal from opioids can be potentially dangerous and life-threatening. If you, or someone you care about, plan to withdraw from opioids, it’s important to consult a medical professional for guidance and supervision before stopping use.⁸¹

Withdrawal symptoms can include:

• nausea, vomiting and diarrhoea
• anxiety and agitation
• yawning and sneezing
• runny nose
• dilated pupils
• sweating and chills
• muscle aches.⁸²

Withdrawal symptoms can begin within hours after the last use, depending on the type of opioid, and usually last between 3 to 10 days.⁸²

Getting help

If your use of opioids is affecting your health, family, relationships, work, school, financial or other life situations, or you’re concerned about someone you care about, you can find help and support.

• Call the National Alcohol and Other Drug Hotline on 1800 250 015 for free and confidential advice, information and counselling about alcohol and other drugs.
• Use ADF’s Path2Help portal to get matched with information and services specific to your needs.
• Search our Help and Support database directly to find your preferred support, by adding your location or postcode and filtering by service type.
• Medicines Line offers information from registered pharmacists on prescription, over-the counter and other medicines: Phone: 1300 633 424.