Endorphins and addiction

11How do opioids mimic endorphins?

Endorphins and opioids are “keys” that fit the same “locks,” the opioid receptors, the most important of which is the mu receptor. But the difference is huge: the body releases endorphins in small amounts, in specific situations, and clears them quickly. The outside substance floods the receptors at a higher concentration and for longer, and bypasses the natural control systems.

That is why the person at first feels strong pain relief, calm and detachment from problems, a state doctors describe as a temporary drug-induced euphoria that is followed by a high price. The same receptors are present in the breathing centers of the brainstem, which is why an excess of opioids can slow breathing until it stops, something that does not happen with natural endorphins.

Opioids also raise dopamine in the reward circuit indirectly, by lifting the brake on its cells, so pain relief is combined with the power of reward learning. We explain the dopamine side in detail in Dopamine and Addiction.

12Which substances act on the endorphin system?

13Why does tolerance develop with opioids?

When opioid receptors are flooded day after day, the body defends its balance: the receptors become less sensitive, some are pulled inside the cell, and opposing systems become active to try to offset the effect. The result is tolerance: the amount that used to be enough no longer gives the same effect.

The endogenous opioid system itself is believed to be disrupted with long-term use, so the body becomes dependent on the outside substance to feel “normal.” The exact details of what happens to endorphin production are still being researched, but what is certain is that the whole system is thrown off and needs time to regain its balance.

14What happens to the endorphin system in opioid withdrawal?

When use stops suddenly, the body faces poorly sensitive receptors with no substance to occupy them, and opposing systems that are still active. Effects flip: instead of calm there is anxiety and tension, instead of constipation there is diarrhea, and instead of pain relief there are bone and muscle aches. Norepinephrine surges, causing sweating, chills, a racing heart and insomnia, while severe distress is partly linked to the activity of “dynorphin,” which is related to endorphins and opposite to them in its effect on mood.

1. The first hours
   Onset of craving and anxiety

   Starts depending on the substance: faster with short-acting opioids and slower with long-acting ones.

2. The first days
   Peak of physical symptoms

   Muscle and bone aches, diarrhea, chills, runny nose, insomnia and severe tension.

3. The following weeks
   Gradual physical improvement

   Physical symptoms settle, while insomnia, fatigue and cravings remain to varying degrees.

4. The first months
   Protracted withdrawal

   Mood swings and sensitivity to pain and stress in some people in recovery, which improve with treatment and time.

The time frames are approximate and vary with the substance, the length of use and health status. Details are on pages such as heroin withdrawal and tramadol withdrawal. Opioid withdrawal is painful but rarely directly life-threatening in a healthy person, unlike alcohol and sedative withdrawal, yet it is still best done under medical supervision.

15Why does pain sensitivity increase after opioids?

One of the strangest things doctors notice is that long-term opioid use can make a person more sensitive to pain, not less, a phenomenon called “opioid-induced hyperalgesia.” The person complains of widespread pain in the back, bones and joints, assumes they need more to relieve it, and enters a vicious circle.

This explains why many people who use tramadol say they “hurt everywhere” after stopping. Pain sensitivity improves gradually with abstinence and treatment, and graded exercise, physical therapy and regular sleep help the body regain its natural pain-relief system, as we explain in Natural Ways to Boost Endorphins.

16What is the link between alcohol and endorphins?

Alcohol is not an opioid, but it releases endorphins in the brain. In an imaging study published in 2012, drinking alcohol led to the release of endogenous opioids in the nucleus accumbens and the orbitofrontal cortex, and the pleasure associated with it was greater in heavy drinkers than in others.

This partly explains why the medication naltrexone, which blocks opioid receptors, is used in the treatment of alcohol addiction: it reduces the reward that drinking gives some patients and helps reduce cravings. It is prescribed only after a medical assessment, and has contraindications determined by the doctor.

17Is endorphin involved in behavioral addiction?

Research suggests that endogenous opioids take part in the reward linked to some behaviors, and naltrexone has been studied in the treatment of gambling and betting addiction with encouraging results in some patients. Its role in compulsive exercise that harms the body is also discussed. But dopamine remains the clearer player in most behavioral addictions, such as video game addiction, and the evidence for endorphin in them is weaker.

18Why does the danger of overdose rise after a period of abstinence?

After weeks of stopping, whether in prison, in hospital or in a treatment center, tolerance falls and the receptors regain part of their sensitivity. If the person relapses and returns to the amount they used before, it may be enough to slow their breathing until it stops. That is why the period after leaving treatment or custody is among the most dangerous.

19How do the endorphin system and the body recover with treatment?

The body gradually regains the balance of its opioid system after stopping, and receptor sensitivity, sleep, mood and pain perception improve over weeks to months. There is no single exact timeline, because it varies with the substance, length of use, age and health. The following treatments help get through this stage safely:

At Eradah, we design a detox plan for each substance that eases withdrawal symptoms safely, then treat the accompanying pain, insomnia and depression, and build a relapse prevention plan with the patient and their family. We explain these stages in detail in heroin addiction treatment and tramadol addiction treatment.

20How can the family help with recovery from opioid addiction?

• Take complaints of pain and insomnia seriously; they are real in withdrawal and not an act.
• Encourage activities that release endogenous opioids naturally: walking, laughing and warm family time.
• Don’t keep spare opioid painkillers at home, and dispose of old ones safely.
• Learn the signs of overdose and keep the ambulance number (123) at hand.
• Support sticking to the prescribed medication treatment without stigmatizing it as a “substitute addiction.”
• Seek support for yourselves; a stable family is the strongest support for a person in recovery.