Painkiller Addiction - Opioids

Painkillers feel safe. The most common ones we buy without a prescription, take after an injury or a procedure, and treat as a routine part of the medicine cabinet. Others, especially opioids such as tramadol and codeine, act far more strongly and can lead to addiction, even when taken exactly as the doctor advised. Poland is among the world's leading consumers of painkillers, and sales of opioids alone rose by 255% over two decades (OSOZ, 2002-2021). Painkiller addiction develops quietly: the dose grows, the medication stops working, and an attempt to stop ends in malaise that is easy to mistake for the pain coming back. In this article we explain which painkillers are addictive, how to recognise the physical and psychological symptoms of addiction, how opioid withdrawal unfolds, and what effective treatment involves, from detox to psychotherapy.

In brief

• The painkillers that cause addiction are mainly opioids (tramadol, codeine, morphine, oxycodone). Common over-the-counter products based on ibuprofen, paracetamol or acetylsalicylic acid do not cause addiction.
• Addiction develops through tolerance: the body gets used to the drug, so the same dose works more weakly and the person takes larger amounts to regain the earlier pain relief or mood lift.
• Stopping an opioid abruptly triggers a withdrawal syndrome resembling a severe flu. The first symptoms usually appear within 6-36 hours of the last dose and intensify over 1-3 days.
• Treatment includes medically supervised detox, pharmacotherapy (including buprenorphine and naltrexone) and psychotherapy. Stopping on your own, abruptly, tends to be ineffective and dangerous.

Which painkillers are addictive?

The painkillers that cause addiction are opioids, because they act on opioid receptors in the brain that are responsible not only for suppressing pain but also for the sense of pleasure. The most commonly abused in Poland are tramadol, codeine, morphine, oxycodone, dihydrocodeine and fentanyl. Codeine is also present in some over-the-counter painkillers and cough preparations, which is why pharmacists are obliged to limit its sale. The scale of the problem is growing: according to OSOZ data, opioid sales in Poland rose by 255% between 2002 and 2021 (from 4.80 to 11.08 million packs), and the number of available products increased from 58 to 293.

Opioids versus non-steroidal anti-inflammatory drugs (NSAIDs) - where the difference lies

Not every painkiller is addictive. Non-steroidal anti-inflammatory drugs (ibuprofen, ketoprofen, naproxen), paracetamol and metamizole work through a different mechanism and do not stimulate the reward system, so they do not cause addiction. That does not mean they are harmless: overusing them burdens the liver, kidneys and digestive tract, and combining them with other substances can be risky (we write about this in the article on painkillers after alcohol). So when reaching for an over-the-counter painkiller, it is worth checking the leaflet to see whether the formula contains codeine.

How does painkiller addiction develop?

Opioid addiction develops gradually and usually starts with medically justified pain treatment. Over time tolerance appears: the opioid receptors become less sensitive, so the previous dose is no longer enough. The person increases the amount of the drug or shortens the intervals between doses, often without realising they are exceeding the recommendations. In parallel, psychological dependence sets in - the drug starts to regulate not only pain but also tension, anxiety and mood. It is the same reward-system pattern that drives other addictions (we describe it in the text on the mechanisms of addiction).

From pain to addiction - when does the drug stop healing?

In the DSM-5 classification, opioid use disorder is diagnosed on the basis of a set of criteria, such as loss of control over the amount of medication taken, a strong urge to take it (craving), continued use despite harm, and withdrawal symptoms. DSM-5 introduces a severity grading into mild, moderate and severe. Research shows that the problem is not limited to people buying street drugs - in one cohort of patients treated long-term with opioids for chronic pain, the lifetime rate of opioid use disorders reached 41.3% (Boscarino et al., 2015, PMID 26316838). We speak of addiction once the drug stops serving pain treatment and reaching for it becomes an end in itself.

Symptoms of painkiller addiction - physical, psychological and behavioural

The symptoms of painkiller addiction fall into three areas: physical, psychological and behavioural. The more of them occur at once, the greater the likelihood that this is addiction rather than ordinary pain treatment.

Physical symptoms include rising tolerance (the need for ever larger doses), withdrawal symptoms after a missed dose, drowsiness or, on the contrary, agitation, constipation, pinpoint pupils, nausea and weakness. Psychological symptoms are mainly drug craving, irritability and anxiety when the drug is unavailable, low mood and the conviction that one cannot function without the tablet. Behavioural symptoms concern changes in conduct: obtaining prescriptions from several doctors, buying the drug in many pharmacies, hiding the number of tablets taken, neglecting duties and withdrawing from loved ones. Addiction often combines with other substances - opioids are sometimes mixed with alcohol or sedatives, which we describe in the article on cross-addiction and which significantly raises the risk of life-threatening respiratory depression.

Opioid withdrawal syndrome - course and risks

Opioid withdrawal syndrome is the set of symptoms that appear after abruptly stopping or reducing the dose of a drug the body has grown used to. The characteristic complaints resemble a severe flu: muscle and joint pain, anxiety, insomnia, runny nose, watering eyes, yawning, chills, goosebumps, nausea, vomiting, diarrhoea and dilated pupils. The Summary of Product Characteristics for tramadol additionally lists agitation, anxiety, nervousness, tremor and gastrointestinal symptoms, and in rare cases panic attacks, hallucinations, paraesthesia, tinnitus and disturbances of consciousness.

How long do opioid withdrawal symptoms last?

The course depends on the specific drug, the dose and how long it was used. For short-acting opioids the first symptoms usually appear 6-36 hours after the last dose, the peak falls on days 1-3, and the acute phase resolves within 5-14 days. Some symptoms, such as sleep disturbances, low mood and drug craving, can persist for weeks and sometimes for several months. Opioid withdrawal syndrome rarely poses a direct threat to life, unlike withdrawal from alcohol or sedatives, but it does carry real risks: dehydration after heavy vomiting and diarrhoea, and overdose on relapse, when tolerance has dropped after a period of abstinence and the person returns to the earlier dose. That is why stopping should be gradual and medically supervised.

Treatment of painkiller addiction

Treatment of painkiller addiction rests on three pillars: detox, pharmacotherapy and psychotherapy. The first stage is detox, that is the controlled withdrawal of the drug. The Summary of Product Characteristics for tramadol explicitly recommends gradually reducing the dose rather than stopping abruptly, in order to limit withdrawal symptoms. Symptomatic treatment is used to ease the complaints, including clonidine to reduce anxiety, sweating and pain. We describe how detox proceeds in a treatment centre in the article on drug rehab.

The second pillar is pharmacotherapy. In opioid addiction, drugs such as buprenorphine and methadone are used to reduce craving and withdrawal symptoms, along with naltrexone, which blocks the effect of opioids. Choosing and running this therapy is solely the doctor's responsibility. The third pillar, which determines how lasting the result is, is psychotherapy, which helps to recognise the mechanisms of addiction and to cope with craving and relapse. Stopping the drug alone is rarely enough - we explain why willpower is not sufficient in the text on getting out of addiction on your own. Specialist care is provided by medication addiction treatment and addiction therapy. The goal of treatment is not a one-off withdrawal of the tablet, but a lasting change in the relationship with the drug and a return to functioning without it.

Frequently asked questions

Does tramadol cause addiction? After how long?

Yes, tramadol is an opioid and can lead to addiction, especially with long-term use or doses higher than recommended. The Summary of Product Characteristics indicates that tolerance and psychological and physical dependence may develop during treatment. There is no single time threshold after which addiction is certain - the risk rises with the dose, the duration of use and individual predisposition, which is why tramadol should be taken at the lowest effective dose and for as short a time as possible.

Does over-the-counter codeine cause addiction?

Codeine taken briefly and in therapeutic doses usually does not cause addiction, but abusing it can lead to both physical and psychological dependence. For this reason, the over-the-counter sale of codeine preparations in Poland is limited by pharmacists. People who reach for codeine medicines for the intoxicating effect, rather than to treat pain or a cough, are particularly at risk.

Can paracetamol and ibuprofen be addictive?

No. Paracetamol and non-steroidal anti-inflammatory drugs such as ibuprofen do not act on opioid receptors and do not cause addiction. Their regular overuse is nevertheless harmful to the liver, kidneys and stomach, so these drugs too should not be taken in excess or for longer than necessary.

How do you safely stop taking painkillers?

An opioid painkiller is stopped gradually, by reducing the dose according to a plan agreed with a doctor, not from one day to the next. Stopping abruptly intensifies the withdrawal syndrome and increases the risk of relapse. If taking the drug has got out of control, the safest option is a consultation with a doctor or an addiction treatment centre, where withdrawal proceeds under supervision and with symptomatic cover.

How long do opioid withdrawal symptoms last?

For short-acting opioids the acute symptoms begin 6-36 hours after the last dose, peak on days 1-3 and resolve within 5-14 days. Milder complaints, such as sleep disturbances, low mood and drug craving, can persist longer, sometimes for several months, which is one of the causes of relapse and an argument for continuing therapy after detox.