Opioids

Opioids are powerful substances used to relieve pain. Some opioids are alkaloids derived from the opium poppy or their derivatives, while others are entirely synthetic [1]. Opioids are used as pain medications, but they are also used without a prescription or in doses exceeding medical instructions. In such cases, the use is considered misuse [2]. In addition to pharmaceutical preparations, there are opioids produced for the illegal drug market, such as heroin and various synthetic designer opioids [3].

Buprenorphine is the most commonly misused opioid in Finland [4]. In medically sanctioned use, it is prescribed for pain relief and in substitution treatment for opioid dependence [2]. Other commonly misused prescription opioids include oxycodone, tramadol, codeine, methadone, and fentanyl [1] [5]. Opioids are used orally, by snorting, smoking, or intravenously [6] [7].

Legal status: Opioids used in medical treatment, as well as heroin, are classified as narcotics in Finland [8]. The Supreme Court has ruled that heroin, buprenorphine, fentanyl, methadone, and U-4700 are highly dangerous narcotic substances [9] [10] [11] [12] [13].

The use, possession, purchase, sale, and manufacture of narcotics is prohibited. Possession of medicinal products containing narcotic substances is permitted only when done in accordance with the law and for medical purposes [14].

Some synthetic designer opioids have been classified either as narcotics or as banned psychoactive substances for the consumer market (so-called KKP substances) [8] [15]. The production, import, and sale of KKP substances is prohibited, although possession and use are not [16]. In certain situations, importing KKP substances may be considered smuggling, in which case acquiring or receiving smuggled substances is also prohibited [17].

How does it work?

Opioids work by binding to opioid receptors in the brain. They act through the same mechanisms as naturally occurring endorphins in the brain [18]. The duration and intensity of the effect depends on which opioid is used, how much is taken, and by what route. When used intravenously or through smoking, the effects of opioids begin more rapidly and tend to be more intense in nature [19].

Desired effects: Opioids relieve pain and generally produce feelings of well-being [18] [20]. In addition to physical pain, opioids also alleviate the emotional suffering associated with pain [18]. For individuals with opioid dependence, the most desired effect may be the avoidance or relief of withdrawal symptoms [19].

Side effects: Undesirable effects of opioids may include constipation, nausea, vomiting, dizziness, and skin itching [18]. Opioids can also impair memory and concentration [19].

Key risks

Acute risks: Opioids carry the risk of life-threatening overdose. They depress the central nervous system and, in large doses, can lead to respiratory depression. Respiratory depression is the most common cause of death in acute opioid poisoning [18].

A person under the influence of opioids may appear indifferent and drowsy. Even small doses can impair reaction time, which can create dangerous situations, especially in traffic [21].

Polydrug use risks: Combining opioids with other depressant substances—such as alcohol, benzodiazepines, gabapentinoids (e.g., Lyrica), GHB, or GBL—is extremely dangerous. These substances enhance each other’s effects, increasing the risk of fatal poisoning [22]. In Finland, opioid-related deaths typically involve concurrent use of buprenorphine and benzodiazepines or alcohol. Death has often occurred while the person was asleep [23] [24].

Risks of heavy use: The most significant long-term harm associated with opioids is the development of severe dependence [18].

Dependence: Opioids are highly addictive substances. However, withdrawal symptoms typically appear only after 1–2 weeks of continuous daily use [18].

The withdrawal symptoms of buprenorphine are generally milder than those of heroin, but they can still be very painful. Common symptoms include restlessness, irritability, depression, sweating, tearing, nausea, vomiting, diarrhea, and severe runny nose. A person with opioid dependence may find it difficult to think about anything other than the substance. Withdrawal symptoms usually peak 2–4 days after discontinuation of use [4] [20].

With repeated use, tolerance to the effects of opioids develops, meaning that increasingly larger doses are required to achieve the same effect [25]. However, tolerance decreases relatively quickly after discontinuation [19]. For this reason, overdoses are very common among individuals who resume opioid use after a break.

Although opioids are highly addictive, not all users become dependent. The risk of dependence increases with co-occurring psychiatric disorders—especially anxiety and behavioral disorders—as well as psychosocial stress [19].

Intravenous use of opioids carries a risk of serious infectious diseases such as HIV and hepatitis C [26] [27]. Hepatitis C is the most common injection-related complication: in Finland, approximately 75% of people who inject drugs have contracted the virus [26] [28]. Injection can also lead to infections at the injection site. Infections may occur when fungi or bacteria enter the bloodstream during injection [29].

Pharmaceutical tablets are not intended for intravenous use. They may contain corn starch, talc, or other binding agents that, when injected, can cause damage and inflammation to veins as well as severe changes to the retina of the eye [30]. Injecting tablets can also lead to the accumulation of talc in the lungs, resulting in a lung condition known as talcosis [29].

Use during pregnancy: Opioids have been shown to affect the growth and development of the fetal brain. Babies born to mothers who have used opioids during pregnancy are typically smaller in size. Between 60–90% of infants exposed to opioids in utero experience withdrawal symptoms at birth. [31]

How can risks be reduced?

Opioid medications intended for medical use should only be taken under a doctor’s prescription and in accordance with provided treatment instructions. Illicit recreational use always carries significant risks.

Under no circumstances should opioids be combined with other central nervous system depressants such as alcohol, benzodiazepines, gabapentinoids (e.g., Lyrica), or GHB/GBL. These combinations can cause loss of consciousness and life-threatening respiratory depression. A person suffering from an overdose must be taken to emergency care immediately.

Some of the risks associated with use can be avoided by not using opioids intravenously. However, if opioids are injected, it is crucial to always use only one’s own sterile injecting equipment and preparation containers. This is the most effective way to prevent the spread of infectious diseases associated with intravenous drug use [32]. To minimize the risk of infection and organ damage caused by binding agents, it is also important to filter the solution with a filter specifically designed for injection preparation [33].

Used needles and syringes can be exchanged for clean ones at health counseling centers.

Discontinuing long-term use may result in severe withdrawal symptoms, which often require medically supervised detoxification or substitution treatment.