Opioid addiction

What is opioid addiction?

Opioids are a group of substances that come from the opium poppy, or are made in a laboratory to act in the same way. They relieve pain and produce a feeling of calm and pleasure. This group includes heroin (often sold as smack, brown sugar or chitta), opium (afeem) and poppy husk (doda or post), as well as prescription painkillers and some cough syrups.

Opioid addiction, known medically as opioid use disorder or opioid dependence, is when using opioids becomes very hard to control even though it is causing harm. The brain adapts quickly to opioids. A person needs more to get the same effect (tolerance) and feels physically ill without them (withdrawal). Before long, many people use opioids not to feel high but simply to avoid feeling sick.

It is not a sign of bad character or a lack of love for the family. It is a health condition that affects the brain, and it responds to treatment.

Opioid problems are a serious concern in India. A national survey led by AIIMS found that heroin is the most commonly used opioid, followed by pharmaceutical opioids used without a prescription. About 60 lakh people in India are estimated to have an opioid use disorder, and Delhi, Haryana and Punjab are among the states most affected. Yet only about one in four people with dependence on illicit drugs has ever received any treatment.

Signs to look out for

You or someone close to you may have a problem with opioids if you notice several of these:

• Using more, or more often, than intended, or moving from smoking or chasing to injecting
• Wanting to cut down, or trying to, without success
• Strong cravings, and spending much of the day getting, using or recovering from opioids
• Body aches, yawning, a runny nose and watery eyes, loose motions, goosebumps or restlessness when not using
• Using first thing in the morning to feel normal
• Pinpoint pupils, drowsiness or ‘nodding off’ mid-conversation
• Money, jewellery or household items going missing, or new debts
• Missing work or college, or losing interest in family and friends
• Needle marks, long sleeves in hot weather, or burnt foil and lighters lying around
• Continuing to use despite health problems, legal trouble or repeated promises to stop

Doctors look at how many of these apply and how much opioid use is affecting health and daily life.

Different ways opioids are used

Heroin and smack. Heroin is usually smoked from foil (‘chasing’) or injected. Street heroin varies in strength and is often mixed with other substances, so a person never knows exactly how much they are taking. This makes overdose more likely.

Prescription opioids and tramadol. Opioid painkillers, including tramadol, are useful medicines when prescribed for pain for a short time. Problems start when they are taken for longer or in higher amounts than advised, bought from a chemist without a prescription, or used for their calming effect. Some people also inject pharmaceutical opioids.

Codeine cough syrups. Cough syrups containing codeine are misused by some young people because they are cheap and easy to get. Regular use can lead to dependence just like other opioids. Our page on prescription medicine misuse explains this in more detail.

Injecting: extra risks

Injecting carries serious added dangers. India has about 8.5 lakh people who inject drugs, and in the national survey about 27% said they had shared needles or syringes with others in the past year.

• HIV and hepatitis C spread through shared needles, syringes and other injecting equipment. Hepatitis B can spread the same way.
• Vein damage, abscesses and wounds at injection sites, which can become badly infected
• Blood and heart valve infections, which can be life-threatening
• Higher overdose risk, because the drug reaches the brain very quickly

Anyone who has ever injected, even once, should get tested for HIV, hepatitis B and hepatitis C. These infections can now be treated very effectively, and testing is confidential.

Why does it happen?

There is rarely a single cause. Several factors usually combine:

• Early exposure. Many people first try opioids in their teens or early twenties, often through friends.
• Pain and prescriptions. Some people start with a genuine prescription for pain and slowly lose control of their use.
• Stress, trauma and emotional pain. Opioids numb difficult feelings, which makes them especially hard to give up.
• Mental health conditions. Depression, anxiety, ADHD and trauma-related problems often go hand in hand with opioid use.
• Genes and family history. Addiction in a parent or sibling increases the risk.
• Easy availability in the neighbourhood or peer group, and unemployment or lack of purpose.

How opioids affect the body and mind

Regular opioid use can lead to:

• Constipation, loss of appetite and weight loss
• Hormonal and sexual problems, including irregular periods and low sex drive
• Poor dental health, skin infections and chest infections
• Low mood, anxiety, poor sleep and irritability, and a higher risk of self-harm
• Problems in pregnancy, and withdrawal symptoms in newborn babies
• Family conflict, debt, job loss and legal trouble

Opioid use also makes other health problems worse, especially when mixed with alcohol or sleeping pills.

Opioid withdrawal: very uncomfortable, rarely dangerous on its own

When someone who uses opioids regularly stops, withdrawal symptoms often begin within about 12 hours of the last heroin use, and later with longer-acting opioids. They include:

• Body aches, bone and muscle pain
• Runny nose, watery eyes, sneezing and yawning
• Sweating, goosebumps and dilated pupils
• Stomach cramps, nausea, vomiting and diarrhoea
• Restlessness, anxiety, irritability and poor sleep
• Intense cravings

Many people describe it as a very bad flu with severe restlessness. Unlike alcohol withdrawal, opioid withdrawal is rarely life-threatening on its own in otherwise healthy adults. It still needs care, though. Severe vomiting and diarrhoea can cause dehydration. People with heart, lung or other medical problems, and pregnant women, need medical supervision. And many people also take alcohol or sleeping pills, whose withdrawal can be dangerous.

The real danger comes after withdrawal, as explained below. With the right medical support, withdrawal is far more comfortable and far safer.

Overdose, and the danger after a break

An opioid overdose slows breathing until it stops. The warning signs are pinpoint pupils, extreme drowsiness or unresponsiveness, and very slow or no breathing, often with blue lips. An overdose is a medical emergency: call 112 at once.

The most dangerous time is after a break from opioids. After detox, a stay in jail, hospital or a rehabilitation centre, or even a few days without using, the body loses its tolerance quickly. If the person then goes back to the amount they used before, it can be enough to stop their breathing. Most opioid overdose deaths happen in people who have recently gone through withdrawal.

Overdose is also more likely when:

• Opioids are mixed with alcohol or sleeping and anxiety pills
• Someone injects, or uses a new batch or a different supplier
• Someone uses alone, with no one to call for help

An emergency medicine that reverses opioid overdose can save a life if given in time. Treatment that keeps a person stable over the long term is one of the most effective ways to prevent overdose.

When to see a psychiatrist

Consider speaking to an addiction psychiatrist if:

• You use opioids daily, or feel unwell when you don’t
• You have tried to stop and started again
• You have started injecting, or have shared needles
• Opioids are affecting your health, money, work or relationships
• You have been taking painkillers or cough syrup for longer or in larger amounts than advised
• You are about to leave jail, hospital or a rehabilitation centre and worry about relapse
• You are pregnant or planning a pregnancy and using opioids

Please do not wait until things become severe. Help at any stage makes a difference.

How opioid addiction is diagnosed

A first consultation is a conversation, not a judgement. The psychiatrist will ask which opioids you use, how and how much, previous attempts to stop, withdrawal symptoms, other substances, physical health, mood, sleep, family history and what you would like to change. With your permission, a family member can join part of the discussion.

You may be advised blood tests, including tests for HIV, hepatitis B and hepatitis C, and a urine drug test. The diagnosis follows international criteria (ICD-11), and the plan is built around your goals and circumstances. Teenagers under 18 are seen with a parent or guardian.

Treatment

It helps to think of opioid addiction as a long-term health condition. Treatment usually combines the following, and your plan may change over time.

1. Supervised withdrawal

For some people, the first step is to come off opioids with medical support. Medicines are prescribed for a short, closely monitored period to ease aches, diarrhoea, sleeplessness and cravings. This can often be done as an outpatient; some people need a short admission.

Withdrawal alone is rarely enough. Without ongoing treatment, relapse is common, and relapse after detox carries a high risk of overdose. So supervised withdrawal is usually followed straight away by one of the longer-term options below.

2. Long-acting opioid substitution (agonist) treatment

In substitution treatment, a psychiatrist prescribes a long-acting medicine that acts on the same brain receptors as heroin, but steadily and gently. Taken once a day in a carefully set amount, it prevents withdrawal and reduces cravings without the highs and lows of street drugs.

This helps people stop injecting, lowers the risk of HIV and hepatitis, reduces overdose deaths and crime, and lets them return to work and family life. WHO and Indian Psychiatric Society guidelines recommend it as an effective, evidence-based treatment. It is usually continued for months or years, and any later reduction is gradual and planned together.

These medicines must be taken exactly as prescribed, never shared, and never combined with alcohol or sleeping pills. Missing several days lowers tolerance, so tell your doctor before restarting.

3. Medicines that block the effects of opioids

For some people, a medicine that blocks opioid effects is a better fit. If the person uses heroin while taking it, they don’t get a high, which helps them stay off opioids. It can only be started once withdrawal is fully complete; starting too early brings on sudden, severe withdrawal. It tends to suit people who are highly motivated and have strong support at home. If someone stops the medicine and uses again, their tolerance will be low, so the overdose risk is high.

All these medicines must only be started, changed or stopped with your doctor.

4. Counselling and talking therapies

Therapy helps a person understand their use and build a life without opioids. Common approaches include:

• Motivational enhancement: building your own reasons and confidence to change
• Cognitive behavioural therapy (CBT): managing cravings, triggers and unhelpful thoughts
• Relapse prevention: planning for high-risk people, places and moods
• Family sessions: improving trust and communication at home
• Practical support: returning to work or studies, managing money and handling legal problems

5. Harm reduction

Recovery rarely happens in a straight line. Harm reduction means keeping a person as safe and healthy as possible at every stage, including:

• Using sterile needles and syringes and never sharing any equipment
• Regular testing for HIV and hepatitis, and hepatitis B vaccination
• Not using alone, and not mixing opioids with alcohol or pills
• Taking extra care after any break from use
• Making sure family knows the signs of overdose and to call 112

6. Treating other conditions together

Depression, anxiety, ADHD, trauma, and alcohol or sleeping-pill use are common alongside opioid use. Treating them together, known as dual diagnosis care, improves the chances of lasting recovery.

Outpatient, online or inpatient care?

• Outpatient care suits most people, with regular visits while living at home and working.
• Online consultations are convenient for follow-up, counselling and family guidance.
• Inpatient or residential rehabilitation may help when there is heavy use of several substances, serious medical or mental health problems, repeated relapse, or no safe place to recover.

Dr. Tarwani sees patients at Sukoon Health in Gurugram and South Delhi, where inpatient rehabilitation is also available, and online.

Recovery and relapse

Recovery is a process that often takes years, not weeks. Staying in treatment is one of the strongest protections against relapse and overdose.

A slip does not mean failure. If it happens, the most important things are to stay safe, remember that tolerance may be low, and get back in touch with your treatment team quickly. Many people who once felt hopeless now live full lives with work, family and good health.

For families

Watching a loved one struggle with opioids can be frightening, and many families in India feel shame and try to handle it quietly. A few things help:

• Talk calmly when they are not intoxicated or in withdrawal, without labels or insults
• Focus on specific worries (“I’m scared when you lock yourself in the bathroom”) rather than their character
• Avoid giving cash that may be used for drugs, but keep showing that you care
• Do not lock someone up at home to force withdrawal; it is unsafe and rarely works
• Be extra alert after they return from rehab, hospital or jail, when overdose risk is highest
• Learn the signs of overdose and keep emergency numbers handy
• Look after your own health and seek support for yourself

Marriage is not a treatment for addiction, and it can place a heavy burden on a new spouse. You are welcome to consult Dr. Tarwani first, on your own, to plan the next steps.

Common myths

• “Opioid withdrawal can kill you, so it’s too dangerous to stop.” Withdrawal is very uncomfortable but rarely life-threatening on its own. With medical help it is manageable.
• “After detox the problem is solved.” Detox is only the start. Without ongoing treatment, relapse is common, and relapse with low tolerance can be fatal.
• “Substitution treatment is just legal addiction.” It is a proven medical treatment that stabilises life and saves lives.
• “Smoking smack is safe as long as you don’t inject.” Any form of heroin can cause dependence and overdose.
• “Cough syrup and painkillers are medicines, so they can’t be addictive.” Opioid-containing medicines can cause dependence when misused.
• “Getting married will make him give it up.” Recovery needs treatment, not added pressure.