How does an opioid addiction start?

Since 2011, the leading cause of unintentional deaths in the United States for people younger than 45 hasn’t been falls, drownings, or even car accidents. It’s been accidental poisonings, most of which are drug overdoses.

While overdoses have been a serious public health issue for some time, the problem worsened significantly during the COVID-19 pandemic. In 2022, there were about 108,000 drug overdose deaths, a 65 percent increase from 2019, according to the National Institute on Drug Abuse. After the pandemic ended, those numbers declined. By 2024, roughly 79,000 people in U.S. died of a drug overdose.

About three-quarters of these overdose deaths have involved opioids, a class of drugs used to reduce pain. Fentanyl, a synthetic (lab-made) opioid 50 times more potent than heroin, has played the largest role.

Illegally produced synthetic opioids like fentanyl are now the primary drivers of the drug epidemic. It’s a major shift from previous decades, when prescribed opioids were a much bigger issue. Learning how and why this changed—and what it is about opioids that creates dependency—is key to understanding addiction in the U.S.

Understanding opioid overdose trends

In the 1990s and 2000s, opioid overdose deaths were driven largely by prescription drugs. Healthcare providers (HCPs) often prescribed these medications to help people manage chronic pain from injuries or medical conditions. Communities across the U.S. were flooded with these highly addictive painkillers, leading to widespread misuse and addiction.

By the early 2010s, overdose deaths involving heroin began to rise. For some people already misusing prescription opioids, heroin was a stronger, cheaper, and more widely available alternative.

In 2013 and 2014, synthetic opioids—especially fentanyl—started to take over. Overdose deaths surged. Price and accessibility were factors, as well as the following.

• Synthetic opioids are far more potent, making overdose easier.
• Many people take synthetic opioids in combination with cocaine, methamphetamine, and other drugs, which increases the likelihood of overdose.
• Synthetic opioids—especially fentanyl—are frequently laced into other drugs without users knowing, raising overdose risk.

To put the trend into perspective: Fewer than 20,000 people die of drug overdoses in 2001. Twenty years later—in 2021—there were more than five times that amount. While overdose deaths have declined more recently, synthetics continue to play an outsized role.

Opioid overdose—what to look for

An overdose occurs when the body cannot handle the amount of a drug taken. This can lead to serious health problems or even death. Signs of an opioid overdose include:

• Pale or clammy skin
• Limp body
• Purple or blue fingernails or lips
• Vomiting
• Not being able to speak
• Not waking up from being asleep
• Breathing or heartbeat that slows or stops

Call 911 right away if you see someone with any of these signs.

Why opioids are so addictive—and deadly

“There may be some genetic predisposition,” says Mark Cardillo, LCSW, program director for behavioral health and addictions at Tampa Community Hospital in Tampa, Florida. “You also have a segment that may turn to drugs and alcohol because they have some issue, like trauma or their upbringing. In order to escape, they turn to drugs. Another group has some sort of mental health disorder and uses drugs to deal with that. Usually there’s some component in their lives that pushes them to addiction.”

Whether snorted, swallowed, or injected, opioids do more than dull pain. They trigger an intense rush of euphoria. They also affect parts of the brain that control several vital body functions, including the breathing instinct. If you overdose on opioids, you may stop breathing. This the most common cause of death during an overdose.

How dependence develops

Your body naturally produces opioids. But when you repeatedly flood it with opioids from drugs, it adapts to that influx. Over time, your body may become dependent on the drug.

If you’re dependent and stop using opioids, the body’s natural opioid levels are no longer enough. This leads to withdrawal. Common withdrawal symptoms include:

• Agitation and anxiety
• Muscle aches
• Insomnia
• Diarrhea
• Nausea, and vomiting

Many people, even if they want to quit, will go back to using opioids once they experience withdrawal symptoms.

Getting clean and staying clean

According to Cardillo, the first stage of recovery is detox, which involves a difficult withdrawal process. “You just have to get the drug out of your system, so you can think clearly,” he says. Detox takes between five and seven days, says Cardillo, but it could take up to a month before you start feeling more physically well.

“Once you tackle that, you work on the psychological part,” Cardillo says. Treatment is vital to dealing with an opioid addiction, and behavioral therapy is widely acknowledged to be an effective approach—especially when it’s combined with prescription medications. Treatment may also involve altering aspects of a person’s environment that may trigger their drug use.

In fact, Cardillo says that the biggest mistake people recovering from an opioid addiction make is “not changing the people, places and things that will put them in situations where they’re going to use again.”

Not embracing therapy is another stumbling block. “Therapy can be painful, so the first instinct is to go back to using,” he says. “The reality is that drugs and alcohol work. You take them and you don’t have to think about your trauma.”

"You have to be extremely diligent to maintain sobriety,” adds Cardillo. “Most people say you go ‘into recovery,’ not necessarily that you’re cured. People may have been in recovery for 30 years, but they’re not cured. Any day something could trigger them and make them start using again. They have to take it one day at a time.”

Where to start seeking help

If you or a loved one is misusing or addicted to opioids, get help as soon as you can. Support groups and counseling can be key to recovery. Organizations such as the Substance Abuse and Mental Health Services Administration (SAMHSA) national helpline (1-800-662-4357), Mental Health America, and Narcotics Anonymous can provide information and support for managing withdrawal and preventing relapse. Your HCP is also a valuable resource. The sooner you reach out, the sooner you can start the journey.