Opioid vs Opiate – What is the Difference?

What exactly is an opioid? What is an opiate? What’s the difference? Opioids are substances that have effects similar to those of morphine. Medically speaking, they are primarily used for pain relief and anesthesia. To help with understanding the difference between the opioids and opiates, just remember:

All opiates are opioids, but not all opioids are opiates.

If you automatically think of heroin when you hear the word ‘opioid’, you are on the right track. Heroin is a narcotic analgesic and its classified as a Scheduled I substance by the DEA. Scheduled I substances do not currently have any medical applications and carry a high risk for addiction. . As an umbrella term, opioids can include illegal drugs as well as manufactured prescription medications.

• The term opioid is defined by Oxford Dictionary as “any class of drugs that are similar to opium in their effects on the human system”.
• Opiates are a type of opioid and are defined as drugs “derived from or related to opium”.

Our opioid epidemic – the pain treatment substance with a secret

Initially, drug manufacturers assured American physicians that prescription opioid, such as OxyContin, do not have any remarkable negative effects and carry a risk for addiction. 

 Today, we know this could not be further from the truth. Prescription drugs can have dangerous side effects and have fueled the current opioid epidemic.

Since then, the US Government has made efforts to make addictive opioid medications more difficult to obtain and doctors have grown hesitant to prescribe them in an effort to reduce adverse effects. Unfortunately, individuals who rely on these medicines for pain management, or those who have become addicted, will often turn to the streets for cheaper alternatives, including illicit opioids like heroin, an illegal opioid often cut with Fentanyl. Fentanyl has become a driving factor in the increase of fatal overdose events in recent years. Another common opiate is codeine.

Opioid painkillers are often prescribed to treat mild to severe pain in patients, but also have a high potential for addiction. Their ability to induce powerful euphoric effects often leads to misuse, abuse, and subsequently to opioid addiction.

Addiction, potential misuse, and opioid abuse are an increasingly serious problem among Americans. This has been driven largely by synthetic opioids and semi-synthetic opioids. There are differences between opioids. Semi-synthetic opioids include prescription painkillers like hydrocodone and oxycodone, sold under the brand names Vicodin and OxyContin.

List of popular naturally occurring opioids (examples of opiates):

• Morphine
• Codeine
• Narcotine
• Thebaine
• Papaverine
• Narceine

List of popular synthetic opioids:

• Buprenorphine
• Fentanyl
• Methadone
• Tramadol
• Carfentanil

List of popular semi-synthetic opioids:

• Heroin
• Oxycodone
• Hydrocodone
• Oxymorphone

Key differences in prescription medications – opiates and opioid drugs

We commonly hear the terms opioid and opiate used interchangeably, but there are some notable differences between the two. In medicine, any drugs derived naturally from parts of the opium poppy plant (poppy seeds) are considered opiates, such as morphine and codeine.

Although opiates are natural opioids and natural substances, it is important to note that this does not mean they are less harmful than opioids. Opiates can still be extremely addictive substances, misused and commonly abused, just like the rest of the opioid family.

Opioids, on the other hand, are any substances (natural or synthetic), that mimic the chemical structure and effects of opium, and bind to opioid receptors in the body. Opiates are a type of opioid, but not all opioids are opiates.

Painkillers and their potential for addiction

Opioid receptors are located in the brain’s central nervous system. These receptors are a part of a system responsible for controlling natural effects like pain, pleasure, reward, and addictive behaviors. Chemically speaking, both opioids and opiates function in a similar manner, as they will both bind to opioid receptors in the brain. Opioids and opiates will attach themselves to available opioid receptors and send signals to the brain in order to block pain while producing a sense of dose-dependent effects like pleasure or euphoria.

The addictive nature of opioids and opiates can not be emphasized enough. When these substances bind with receptors in the brain, they also act as a catalyst for the brain to produce more opioid receptors. Thus begins a dangerous game of supply and demand as the medication-related symptoms of addiction begin to present themselves. These receptors will require ever-increasing amounts of opioids each and every time an individual uses the drug, often leading to drug overdose death.

Opiates – at the center of pain management

Opiates are often prescribed for chronic pain management and are known as agonists. Drugs that counteract the action of opioids are known as antagonists.

Agonists mimic the effects of naturally-occurring endorphins in the body, producing the classic natural effects of opium. Morphine and fentanyl are two incredibly strong and highly addictive agonist opiates (and opioid analgesics) used as treatment options for serious pain in medication-assisted treatment settings.

Morphine or fentanyl can be prescribed as pain medications for:

• Chronic noncancer pain.
• Musculoskeletal pain.
• Chronic back pain.
• Acute pain.
• Moderate to severe pain and severe feelings of pain.
• Extended duration of pain and high intensity of pain signals.

Fentanyl is 50 to 100 times more powerful than morphine and has become a popular cutting agent for heroin. Hydrocodone, Oxycodone, and Buprenorphine are also considered agonists and have a high potential for abuse.

Antagonists work by blocking agonists from reaching the brain’s opioid receptors. Naloxone and naltrexone are two examples of opioid antagonists. These drugs block the signals that the receptors send to the nervous system, and can actually reverse the effects of opioids already in the system. Often, naltrexone is used when an individual wants to stop abusing opiates or opioids, or during the detoxification and withdrawal treatment process.

Opioid addiction & opioid use disorder

Following an injury or accident, doctors or a health care provider will routinely prescribe patients opioid analgesics (painkillers) to manage discomfort. Over the course of taking their prescription medication, individuals may feel like the dose is not having the same effect as it had originally.  This describes a developing tolerance to the drug.

When an individual begins to ‘build up’ a tolerance to opioid analgesics, they may start to take larger doses in order to effectively manage their pain or to achieve the familiar feelings of euphoria. These are the beginning symptoms of a physical dependence. . Someone who continues to misuse an opiate or opioid will develop drug addiction.

Dependence among individuals simply means the need to continue using a substance in order to function normally. Once an individual is dependent on opioids or opiates, it is very hard to simply quit cold turkey due to the intense withdrawal symptoms. These drugs are habit-forming, provide an on-demand feeling of euphoria, and in the long run physically alter how the brain operates in regard to pain and pleasure.

These symptoms often develop into intense urges to use, despite any adverse effects. The brain is constantly seeking a state of balance, so when it begins to require larger doses to feel a sense of normalcy, it is only natural to want to satisfy this urge. The compulsive use of any drug, whether an opioid such as a prescription painkiller, or an opiate such as morphine, is considered a drug addiction.

Opioid overdose study

Statistics consistently show the highly addictive, and even lethal nature of opioids. While there are indications for the successful use of synthetic opioids in medical settings, it is paramount to understand the inextricable risk of dependence among individuals and opioid or opiate addiction for patients. 

According to the Center for Disease Control and Prevention (CDC): 

• Opioids were involved in 68,630 overdose deaths in 2020(74.8% of all drug overdose deaths).¹
• 82.3% of opioid-involved overdose deaths involved synthetic opioids.²

Long-term side effects of opioid misuse – substance use disorder and dependence

An opioid use disorder is defined as a problematic pattern of opioid use that leads to serious impairment or distress. Doctors use a specific set of criteria to determine if a person has a substance use problem.

Physicians today have become increasingly hesitant to prescribe painkillers as liberally as in the past. Except for severe cases of pain, such as in patients battling cancer, chronic pain, musculoskeletal pain, and chronic back pain, medical recommendations have been evolving to avoid opioid prescribing wherever possible. This change comes as a response to the high risk of abuse, dependence, and drug addiction to both opioids and opiates.

Aside from these potentially devastating consequences, other side effects of opioid use can include respiratory issues, gastrointestinal problems, and cardiovascular disorders. Central nervous system side effects may include confusion, difficulty concentrating, and insomnia.

Patients suffering from chronic pain, who are prescribed opioids, down the line will often have a diagnosed psychiatric disorder such as depression or anxiety. Higher levels of emotional suffering have been reported in individuals with chronic pain, which can intensify mental and emotional disturbances. Approximately 10% of all patients develop depression while taking opioids. 

An actual increase in patients’ pain is also a possibility when taking opioids. While not fully understood yet, patients can experience a sudden onset of an increase in severe pain after taking an opioid painkiller. Whenever this is the case, different avenues must be explored to account for any inadequate pain management resources.³

The immune system also becomes compromised while taking opiates. The ability to fight off infection weakens immediately upon taking opioids or opiates, regardless if this effect is obvious to the individual or not. The only way to manage this unwanted side effect is to stop taking the opioid altogether.

These side effects are serious enough to warrant the careful consideration of the risks versus benefits of long-term opioid therapy. Wherever possible, opioids should be used for short periods of time. Whenever appropriate, an alternative means of managing pain is preferred altogether. The role of opioids in medicine needs to change so that we can save lives.

References

1. Hedegaard H, Miniño AM, Warner M.Drug Overdose Deaths in the United States, 1999–2018.NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020.
2. Wilson N, Kariisa M, Seth P, et al.Drug and Opioid-Involved Overdose Deaths—United States, 2017-2018. MMWR Morb Mortal Wkly Rep 2020;69:290-297.
3. Family Health Team. The Down Side and Side Effects of Painkillers. Health Essentials. 2013 July [cited May 2018]. Available from: https://health.clevelandclinic.org/the-down-side-and-side-effects-of-painkillers 

Death Rate Maps & Graphs | Drug Overdose | CDC Injury Center

About the author

Dr. Waismann identified the biological roots of opioid dependency. Since then he has successfully treated more than 24,000 patients worldwide that were struggling with opioid addiction. Throughout his career, he has lectured and educated health professionals in dozens of countries around the world.

I hope one day it will be covered by insurance, like the many other treatments out there.