Are Opioid Pill Addicts Different From Heroin Addicts?

Most of the opioid addicts I have treated over the last ten years have been addicted to pills, not heroin. But information about prognosis and treatment of opioid addiction was gleaned from studies with heroin addicts. I’ve often wondered if the old data fits the new patients.           

Over the last ten years, the number of people addicted to prescription opioids has ballooned. Prescription opioids are now more likely to cause or contribute to drug overdose deaths than heroin or cocaine. As prescription opioids outpace heroin in many parts of the country, scientists have wondered if there are significant differences between these prescription addicts and heroin addicts. Biologically, addiction to heroin or prescription opioids would appear to be the same disease, because both types of drugs are opioids, and opioids affect the body the same way. But do all opioid addicts respond the same to treatment?

 In the latest issue of Addiction, there was an article describing a study that compared different groups of opioid users. The researchers described four separate groups: opioid users of only heroin, opioid users of only prescription opioids, opioid users of both heroin and prescription opioids, and drug users that used only non-opioid drugs. In this study, drug users weren’t further classified as addicts, abusers, or occasional users. (1)

This study of over nine thousand drug users found that users of both prescription opioids and heroin were more likely to use other, non-opioid drugs than the other three groups. These addicts seemed to have worse mental health issues than the other groups, too, while users of non-opioid drugs tended to have less severe mental health issues than opioid addicts of all types.

The prescription opioid-only addicts were found to use significantly more non-opioid prescription drugs, while the heroin-only addicts were significantly less likely than prescription opioid addicts to abuse sedatives and tranquilizers, like benzodiazepines, than the other two groups of opioid users.

 This last fact definitely squares with what I’ve been seeing. So many of my patients are struggling or have struggled with benzodiazepine addiction. I wonder if opioid pill users are at increased the risk of overdose death when treated with methadone, compared to the heroin-only users of past decades.

This article, at the very least, shows there are significant differences in clinical features for at least three types of opioid users. It’s possible people who are addicted to prescription opioid pills have different prognoses and different responses to treatment than heroin-only addicts. Hopefully we’ll see further studies to guide our treatments.

1. Wu, LT; Woody, GE; Yang, C; Blazer, DG; “How Do Prescription Opioid Users Differ From Users of Heroin or Other Drugs in Psychopathology: Results From the National Epidemiologic Survey on Alcohol and Related Conditions,” Journal of Addiction Medicine, Vol. 5, No. 1, March 2011.

4 responses to this post.

  1. Our agency operates three OTP clinics in the greater Greensboro, NC area. In my experience, those presenting with opioid addiction plus benzodiazepine abuse have a higher likelihood of co-occurring disorders. These two drugs classes are a particularly difficult combination.

    When both are present, it seems to take individuals longer to achieve sustained abstinence. The synergistic effect of opioids + benz creates overdose risks which are greater during induction when addicts may not be quite comfortable yet on their methadone dose and more apt to supplement their discomfort with an old standby, like benz. A slippery slope.

    I’m also of the impression that regular benzodiazepine use with opioid addicted people requires a longer recovery timeline on average. Maybe this is because a dual dependency introduces more radical brain chemistry changes & related effects. With longer term benz abuse clients, I often see a pronounced fear of giving up benz even when they are ready to give up opioids. Cognitive behavioral therapy can lead to new skills for managing anxiety, but doesn’t provide the quick fix expectation of a Xanax or Valium.

    Since our agency adopted a “no benz” policy (for safety reasons), we have been unable to admit a large number of clients who are currently abusing benz. Some have detoxed successfully and re-presented for admission, but others I fear stay out in active addiction and endure the risk of fatal overdose sooner or later.


    • Well said. That is the dilemma. I’ll take a patient into methadone treatment if he doesn’t appear to be addicted to benzos, since many opioid addicts use them to treat withdrawal…but it’s hard to tell who will be able to give them up, and who needs more help that can be provided as an outpatient.

      Of course, as I remind these patients, the choice isn’t methadone or no treatment. There are other treatments for opioid addiction, though admitedly they can be harder to access for a variety of reasons.


  2. Dr. Burson – This is somewhat off topic, but there is a very interesting article in the New York Times in regard to treating newborns with methadone (or buprenorphine) when they are showing signs of opioid withdrawal. The link is here:


    • Thanks Max,
      That’s a really good article, surprisingly balanced. I’m glad they interviewed Drs. Jones and Kaltenbach. I had the honor of talking to both of these women about their work on the MOTHER study that came out in December when I was at the AAAP conference last year. They both emphasized that the study still supports the use of methadone, and it’s a bit more likely to keep moms in treatment, but it also appears that the babies born to moms on buprenorphine have the same incidence of withdrawal, but not as severe and not as long. For opioid addicted pregnant women, I’d say buprenorphine is now the treatment of choice for that reason. But the problem is still the expense, and access.

      Thanks for letting us know about the article!


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