CHAPTER 1
Introduction to Opioids and the Counseling Approach

A Note on Terminology

Terminology remains controversial in the addiction field. Broyles et al. (2014) encouraged writers to use people-first language (e.g., individuals with opioid use disorders). Research by J. F. Kelly et al. (2010) found that a largely female sample (n = 314, 76%) rated individuals more harshly when they were described as a "substance abuser" versus "having a substance use disorder."

Interestingly, very little research has specifically addressed the effect of labels on addicted individuals themselves (Callinan et al., 2017). Valencia-Payne (2018) noted that identifying as "an addict" can act as a positive label for individuals seeking help (e.g., "I am an addict in recovery"). The American Psychological Association (n.d.) recognizes that it is permissible to use identity-first language (e.g., addicted individual) when referring to a group that prefers this style over the person-first form. In this book, we use both styles to add variety and improve readability.

The Beginnings of a Crisis

It began innocently enough . . . or so we thought. Pharmaceutical companies reassured physicians in the late 1990s that patients could not become addicted to opioids.

Consequently, the medical profession came to believe that these medications were safe (National Institute on Drug Abuse [NIDA], 2020c). Physicians began writing prescriptions for opioids at increasing rates, which, in turn, increased their manufacture and distribution. A substantial supply of these medications, however, was diverted and misused before it became abundantly clear that this class of drugs, more than any other, produced the greatest degree of tolerance (J. M. White & Hay, 2007). They were highly addictive. Heroin, for example, was rated by a panel of experts as the most addictive drug on the planet (Nutt et al., 2007).

Besides marijuana, nonprescription opioids are the most used illicit drugs in the United States (Frohe et al., 2019). The dual use of marijuana and nonprescription opioids has been increasing, and this combination is causing poorer perceived health, greater experience of pain at work, psychiatric problems, and suicidal thinking (Frohe et al., 2019).

Prescription opioid usage is also problematic. Between 21% and 29% of individuals in chronic pain who are prescribed opioids misuse them (NIDA, 2020c). About 8% to 12% of these individuals develop opioid use disorders (OUDs), and between 4% and 6% of them begin using heroin (NIDA, 2020c).

Now we are in the grip of an opioid crisis (NIDA, 2020c) because of the number of people who have become addicted or died. Opioids do not just affect strangers; they affect us. They have killed individuals such as Janis Joplin, Philip Seymour Hoffman, and Prince, and they have killed some of our friends and acquaintances. They kill without discrimination-they kill whoever takes the "lethal dose," which is different for not only every person but also even the same person at different points in their lives.

Where are we at regarding drug overdose deaths? Drug overdoses killed 63,632 Americans in 2016 (Centers for Disease Control and Prevention [CDC], 2018), 70,237 in 2017 (Hedegaard et al., 2020), and 67,367 in 2018 (Hedegaard et al., 2020). These annual figures are shocking when we consider that fewer American military casualties occurred during the entire Vietnam War (i.e., 58,220; National Archives, 2018).

According to NIDA (2020d), the number of deaths from an opioid (including methadone, synthetic opioids, and heroin) rose from 18,615 deaths in 2007 to 47,600 deaths in 2017. In 2016, 15,466 deaths occurred from heroin overdoses, and another 20,145 deaths resulted from fentanyl (CDC, 2018). In 2017, 47,600 (67.8%) of the 70,237 deaths involved opioids, with reported increases in all age groups (Scholl et al., 2019).

Accordingly, opioids now account for about two thirds of the total number of overdose deaths both in the United States (CDC, 2018) and worldwide (United Nations Office on Drugs and Crime [UNODC], 2019). Furthermore, Pardo et al. (2020) reported that in 2018, synthetic opioids, primarily fentanyl, were responsible for more than 31,000 deaths in the United States, and this represents about two thirds of all opioid-related deaths. Remember then that opioids cause two thirds of drug overdose deaths, and two thirds of these deaths are due to synthetic opioids, specifically. As far as we know, this is the first time in the illegal drug trade where "killing" customers has become a common hazard of "doing business."

UNODC (2019) estimated that in 2017, there were 53.4 million opioid users globally, which was 56% higher than its previous estimates. UNODC also reported that in 2017, 585,000 people died from drug use (167,000 deaths specifically from drug use disorders, including 110,000 from opioid use and the remaining 57,000 from other drug use disorders).

The Substance Abuse and Mental Health Services Administration (SAMHSA; Lipari & Park-Lee, 2019) reported its findings from the 2018 National Survey on Drug Use and Health. SAMHSA found that 7.4% of the U.S. population ages 12 and older experienced a substance use disorder in the past year. That equals approximately 20.3 million people: 14.8 million with alcohol use disorder and 8.1 million with an illicit drug use disorder.

The number of Americans who die from drug overdoses (67,367 in 2018; Hedegaard et al., 2020) added to the number who die from smoking (about 480,000 annually; CDC, n.d.) and drinking (about 88,000; National Institute on Alcohol Abuse and Alcoholism [NIAAA, 2020]) is roughly 635,000. In other words, more Americans die annually from psychoactive substance use than all the men, women, and children who live in Baltimore (population about 593,400 in 2019) or Albuquerque (population about 560,500 in 2019). The United States is in a drug-crazed grip, and the war on drugs is not working.

Kilmer et al. (2014) reported that between 2000 and 2010, the U.S. government spent somewhere between $40 billion and $50 billion annually in its unsuccessful battle against the illegal drug trade. Over the same period, Americans spent about $1 trillion buying illegal drugs (about $100 billion each year). The problem is that the war on drugs is not lurking outside; it is among us. Although many people use illegal drugs sporadically and recreationally (nearly 1 in 5 Americans, ages 12 and older, according to NIAAA, 2020), the people who become addicted often struggle mentally, emotionally, and spiritually (May, 1988; NIDA, 2020a). As a poignant example of this, "multiple national population surveys have found that about half of those who experience a mental illness during their lives will also experience a substance use disorder and vice versa" (NIDA, 2020a, p. 2).

There is one caveat with opioids. Between 8% and 12% of opioid users will become addicted, regardless of their health (NIDA, 2020c). It is estimated that 23% of people who begin using heroin will become addicted to it (Tracy, 2019). This speaks to how addictive opioids are. Most adults are not naive enough to be unaware of the dangers of ongoing opioid use, but even recreational users can deny a drug's effects. At the same time, children and youth may simply not know any better.

It is in these latter three categories (i.e., mentally, emotionally, and spiritually) that you, the counselor (note that the term counselor will be used to be inclusive of all mental health professionals), can make a difference. Especially for this class of drugs, a physical intervention will also be necessary in working with most individuals who have developed an OUD. These drugs are simply too addictive. To give you an idea, let us bring you into the mind of a person addicted to heroin, see Box 1.1.

An Introduction to Opioids

Psychoactive drugs can be broadly classified as hallucinogens, stimulants, or depressants. Opioids can be classified as depressants, which are drugs that depress the central nervous system (Csiernik, 2016). Although the use of the term narcotic is sometimes used to refer to all drugs that create narcosis (i.e., a state of stupor or drowsiness), it will be used here as a synonym for opioids. (It is also used as a synonym for opioids by the National Cancer Institute, n.d.) Opioids can be smoked, ingested orally, injected intravenously, or absorbed through a mucous membrane. A mucous membrane lines body cavities (e.g., eyes, ears, nose, mouth, lips, vagina, urethra, anus).

There are three types of opioids based on how they are produced: death-row prisoners. Potent opioids such as carfentanil are approved only for veterinary use, whereas others such as heroin are illegal in most countries in the world.

• Naturally occurring narcotics, which are also called opiates (i.e., codeine, morphine, oripavine, and thebaine).
• Semisynthetic narcotics, which are produced in labs using natural opiates (e.g., heroin is made from morphine, whereas oxycodone can be made from thebaine or codeine, which itself can be made from morphine).
• Synthetic narcotics, which are also produced in labs and have a chemical structure similar to opiates (e.g., fentanyl, methadone).

Box 1.1 Frank's Story: Getting High on Heroin and Other Opioids1

For many people who first experiment with heroin, they feel under-whelmed (not including intravenous usage, but most experimenters rarely inject the first time). They just feel...