Opioid-based drugs originate from the resin of the opium poppy plant and are predominantly used in the area of medicine to help relieve pain, they work by connecting to opioid receptors in the brain and central nervous system as well as the peripheral nervous system. (1)

Opioid drugs such as heroin and codeine produce pleasure-enhancing effects which makes them a very desirable substance for recreational drug users to experiment with. Codeine is obtained directly from the sap of the opium poppy, whereas heroin is obtained from morphine.

What are the main opioid drugs?

The main opioid drugs prescribed for pain relief are semi-synthetic products such as oxycodone, hydrocodone, and the synthetic opioid fentanyl.

These are very powerful drugs and should not be overused as their effects can diminish quickly if they are taken regularly as all opioid drugs have the potential to be highly addictive. (4)

This is because people tend to quickly build up a quick tolerance towards the drug as the brain and body become accustomed to processing its chemical constituents.

To continue experiencing the desired effects of opioid drugs users will find that they will gradually need to take greater amounts of the drug as time progresses.

Reasons for taking opioids

It is worth distinguishing between recreational users deliberately seeking to gain a heightened experience by combining alcohol and opioids such as heroin, and patients who take prescription pain-relieving opioids such as oxycodone and mistakenly drink too much alcohol when they are on a course of pain-relieving drugs.

Polysubstance use

Polysubstance use is the name given to the practice of taking more than one drug/substance at the same time, e.g. drinking alcohol and taking heroin.

This can include taking the substance within a short time frame of each other as well as consuming them both simultaneously (taking heroin during a drinking session).

The term polysubstance covers unintentional use as well as deliberate use, which is the case with recreational users, for example, patients on pain relieving medication may drink alcohol whilst on their medication after failing to read or fully comprehend the accompanying medical guidance material. (3,4)

The positive effects of combining alcohol with opioid drugs

Opioid drugs such as heroin can produce many positive effects for the user, as in addition to their analgesic qualities opioid drugs contain chemicals that act on compatible receptors in the human brain.

These activate the dopamine pathway and produce feelings of euphoria and pleasure that are so intense they are unable to be replicated by any natural means.

Alcohol can enhance the positive effects of heroin, so consuming the two substances together provides a highly positive experience for the user which makes it a very appealing combination for people seeking to gain a more euphoric experience.

Recreational drug users are more likely to engage in polydrug use as their primary motivation for taking the substances is to experience the positive effects elicited by taking the substances. (2,3)

Alcohol and opioid use

There has over recent years been a strong increase in the prevalence of heavy alcohol use and opioid use, with key research in the USA reporting that a large number of people are now consuming these substances together and placing themselves in grave danger.

People who binge drink are reported as being more likely to participate in opioid use as well compared to people who do not binge drink. The researchers also found that more than 50% of people who take prescription opioid drugs also binge drink. (2,3)

Reasons for mixing drugs

There are several reasons why people may mix alcohol with opioid drugs, such as;

Increased Tolerance to one substance

As substance users begin to escalate their use of one substance, they will start to develop a tolerance to that substance which means the amount of the substance they usually consume is not enough for them to experience the effects they were looking for.

Because of this, they may seek to enhance their experience by combining alcohol with heroin or codeine to obtain the feelings and sensations that would satisfy them.

Combining alcohol and opioid drugs does provide users with a more enhanced and intense experience compared with just taking one of the substances separately. (3,8)

Reduce chances of addiction/dependence

Some recreational substance users may be under the mistaken assumption that they are reducing the likelihood of becoming addicted to one substance by combining lesser amounts of that substance with another substance, so they are not taking too much of one substance but still experiencing positive effects.

Some substance users may also incorrectly believe that one substance can help to negate the unpleasant effects of another substance

However, these are inaccurate beliefs that they probably hear from uninformed peers and absorbing these beliefs could cause them serious harm if they fail to understand the nature of drug interactions and the chemical and biological interactions that occur when mixing substances as there are many different factors to consider. (2,8)

Alcohol and Opioids are central nervous system depressants

Both alcohol and opioids depress the central nervous system which means they decrease the level of arousal and stimulation within the brain.

This is because chemicals in both substances activate areas of the brain that slow down certain physiological processes and these areas then send messages to the rest of the body which results in the whole body relaxing and calming down.

When the CNS is depressed respiratory processes are significantly affected and this leads to irregular breathing patterns and a decrease in the volume of oxygen that the body and brain can draw on to help it function if too many depressants are taken together.

This can cause significant damage to vital organs in the body including the brain, the effects of which may be permanent. (2,8)

The dangers of drug interaction effects

Both alcohol and opioid-cased drugs are psychoactive substances that when taken individually can lead to serious physical and psychiatric problems if taken to excess.

However, when taken together they can exacerbate each other’s physical effects and cause a person a great deal of harm much quicker as very often their combined effects are unpredictable and depend on many factors such as:

• How much of each substance they have taken?
• The potency of each substance
• The time gap between taking each substance.
• Individual differences, such as underlying medical conditions, age and tolerance levels to each substance.

When people mix these two substances the chemicals will combine to enhance each other’s effects.

This will lead to the person becoming intoxicated much more quickly, which means that is a greater probability that the user is at risk of:

• Having accidents and falls which could lead to serious injury.
• A decline in their reasoning, and cognition, which could to poor decision-making.
• Their coordination will be affected.
• They may suffer from bouts of vomiting.
• Blackouts and spells of amnesia.
• Becoming unconscious and slipping into a coma.
• Their breathing is more likely to become shallow.
• Consuming alcohol while simultaneously taking any opioid drug can lead to intense negative symptoms including problems with the cardiovascular and respiratory systems and severe disruption to brain chemistry all of which can be life-threatening. (5,7,8)

Dose dumping

Most prescription opioids such as oxycodone and hydrocodone are slow-release drugs that are intended to be absorbed into the body over a period of time.

Drinking alcohol after taking these drugs does speed up the absorption process meaning the drugs will be metabolised and take effect quicker, this means that a large dose of opioids will be released quickly into the body all at once, at the same time as the alcoholic drink they consumed.

High levels of toxicity within the body

When alcohol and opioid drugs such as oxycodone and tramadol are consumed together there tend to be slower disposal rates apparent for both substances, this means that they stay in the body for longer rather than be processed and which means any harmful chemicals are not eliminated from the body.

This causes a high level of internal toxicity for longer as both the drugs and the alcohol need to be processed/metabolised by the liver.

However, the liver can only process one standard alcoholic drink per hour and with the added pressure of metabolising an opioid drug as well, it will not be able to process the content of both substances quickly enough which places people in a vulnerable position. This is likely to be even more dangerous if the person has been binge drinking. (3,7)

Serious medical consequences of combining alcohol with opioids

There are several negative health consequences of mixing alcohol and opioids most of which can have severe consequences for the individual and there is a strong probability of loss of life.

Respiratory depression

Alcohol strongly enhances the negative effects that opioids have on our respiratory system, and whereas people taking just opioid painkillers alone will be able to put up with uncomfortable symptoms, anyone who consumes alcohol as well will find that these effects are likely to be intensified, placing the patient in grave danger.

Symptoms of respiratory depression

• Feeling tired.
• Feeling sleepy during the day.
• Shortness of breath / shallow breathing.
• Feeling depressed.
• As the condition worsens a patient may experience;
• Their lips, fingers and toes may turn blue.
• They may appear confused and disorientated.
• Potential for developing seizures. (3,8)

Overdose risk

Opioid drugs such as heroin tend to slow down a person’s heart rate and breathing patterns and the risk of overdose is significantly increased when you drink alcohol alongside using heroin.

This is because if a person’s breathing rate slows down the vital organs in the human body, including the brain do not get enough oxygen to function effectively which means the organs will eventually shut down if the amount of alcohol and opioid drugs present in the body reaches a critical point.

Both alcohol and opioids individually can have this effect on a person’s biology so taking them together produces the same effect as overdosing on either substance. The act of binge drinking will produce a similar effect. (1,7)

Risk of entering a coma

Scientific research has shown that when people drink alcohol and take opioid drugs (even prescription drugs) close together they are at risk of experiencing slow or arrested breathing, their blood pressure and pulse rate will drop significantly and they are in danger of slipping into a coma, and depending on the amount of each substance taken and other risk factors may die. (5,6)

Acetaminophen (Paracetamol)

Some prescription opioids contain acetaminophen which is a form of paracetamol, which can be potentially very toxic for the liver and lead to serious damage if too much of the chemical is taken within a short space of time.

Alcohol is also metabolised in the liver which increases the risk of damage if the opioid you are taking contains paracetamol. (5,7)

Danger of choking

If you vomit due to the high levels of toxicity present in your system then there is a strong likelihood that you may choke as both substances together interfere with several brain processes and one of these involves the activation of the gag reflex which is impaired when these two substances are taken within a short time frame.

Loss of consciousness

Drinking alcohol while taking opioid drugs will augment the sedating effects of the drug and will lead to the user feeling lethargic and drowsy, and it is only a matter of time before they lose consciousness if they continue to drink.

Co-ordination is impaired

It is also known that mixing alcohol and opioid will severely reduce the area of the brain responsible for our perception and coordination which means people are at risk of becoming unbalanced and falling or tripping over which can cause severe physical injury and lead to spending time in hospital.

The likelihood of experiencing increased drowsiness alongside any impairment to coordination means that activities such as driving, operating machinery and engaging in any physical activity could result in people who mix alcohol and opioids causing harm not just to themselves but to other people, they come into contact with. (6,7)

Psychological effects

It is likely that the two substances combined will have many psychological effects including poor decision-making, confusion, and memory loss and people diagnosed with dementia may find that their symptoms become much worse

Older adults are particularly vulnerable if they are taking painkillers as even combining their regular dose size with a small amount of alcohol can have serious consequences.

The added danger of binge drinking and opioids

Taking any opioid-based drugs within a few hours of binge drinking (5 alcoholic drinks in 2 hours for men, 4 for women) will almost certainly lead to serious consequences.

The addition of an opioid drug on top of excessive alcohol consumption will simply overload the liver and very quickly lead to a high level of toxicity in the blood and several adverse reactions such as:

• Extreme fatigue.
• Nausea and vomiting.
• Losing consciousness.
• Hand tremors.
• Slow and weak pulse.
• Shallow breathing.
• Drastic mood swings.
• Poor dexterity.
• Irregular cardiac activity.
• Respiratory depression (2,7)

Be careful with alcohol use if using opioids for pain relief

Even individuals who are not deliberately seeking to combine alcohol and opioids for a thrill-seeking, pleasurable experience are at risk if they are on strong pain-relieving drugs to help manage pain after physical trauma.

Prescription drugs such as Oxycodone and Hydrocodone are very powerful drugs and medical research has demonstrated that even taking one oxycodone tablet per day and then drinking a moderate amount of alcohol significantly increases the possibility of experiencing respiratory depression. (2,5)

Warning for excessive drinkers

Anyone who drinks excessively and struggles to stop or control their alcohol intake should make their GP aware of this before they start taking opioid prescription drugs for pain relief, regardless of whether it is for the short-term or long term as they are likely to suffer severe consequences if they do not stop drinking alcohol whilst taking their medication.

People who are vulnerable to mixing heroin and alcohol

Not everyone who mixes opioids with alcohol does so to heighten the pleasurable effects of opioids, some people lack the scientific knowledge necessary to understand the threat of doing so and are therefore ignorant of the danger.

It may be the case that some polysubstance users may simply have mistaken beliefs about the effects of mixing drugs or that they will not be affected by mixing the two substances.

Individuals who are more susceptible to mixing opioids and alcohol include:

• People addicted to, or dependent on one substance are more vulnerable to developing another addiction if certain factors come together.
• Experimental substance users (recreational users) who are looking to try a new experience.
• Individuals who have developed a tolerance to one substance so need to take it to another level and experience the heightened pleasure of engaging in polydrug use.
• People who are managing pain and drink alcohol to numb strong emotions and deal with anxiety.
• Individuals with depression who are looking to boost their mood.
• Patients who, as a result of post-traumatic stress disorder use opioids and alcohol to elevate their mood and manage the distressing symptoms of their condition.
• People who are dependent on alcohol and suffer an injury that requires pain relief and who cannot give up alcohol. (3,5,8)

Should I seek treatment if I regularly mix alcohol and opioids?

Yes, if you take either substance frequently and/or mix alcohol and opioids then you should definitely stop mixing the substances and stop or reduce consumption of both substances.

If you would like to stop but are unable to do so, then it is likely that you have a substance use disorder and require professional treatment to help you stop.

What can I do?

You can book an appointment with your GP who can organise an assessment and diagnosis for you, and once that has been established they can advise you on your next course of action.

You may need to be referred to a local drug and alcohol team who can help you reduce or stop your substance use by utilising specialist behaviour change strategies, or you may be required to enter residential rehab for a period of 4-6 weeks to tackle your physical (by using a detox procedure) and psychological dependence of alcohol and/or opioids.

If you are addicted to alcohol and opioids, then the rehab practitioners will probably tackle one addiction first before moving on to treat the second addiction. (4)

References

(1) American Society of Addiction Medicine (2016) Opioid Addiction: Facts and figures. available@opioid-addiction-disease-facts-figures.pdf (asam.org)

(2) American Society of Anaesthesiologists (2017) Mixing Opioids and alcohol may increase the likelihood of dangerous respiratory complications. available@ Mixing Opioids and Alcohol May Increase Likelihood of Dangerous Respiratory Complication, Especially in the Elderly, Study Finds | American Society of Anaesthesiologists (ASA) (asahq.org)

(3) Centre for Disease Control and Prevention (2019) More than Half of People who Misuse Prescription Opioids also Binge Drink. Available @ More than Half of People who Misuse Prescription Opioids also Binge Drink | CDC Online Newsroom | CDC

(4) Ghodse, H.  (2010) Drugs and addictive behaviour: A guide to treatment. Cambridge University Press. New York.

(5) National health service (2022) Can I drink alcohol if I’m taking painkillers? Available@Can I drink alcohol if I’m taking painkillers? – NHS (www.nhs.uk)

(6) NI Direct (2022) Mixing alcohol with other drugs. available@Mixing alcohol with other drugs | nidirect

(7) Public Health Agency (2022) Mixing: Reduce your risk of harm. available@ Mixing_leaflet_05_2019.pdf (hscni.net)

(8) University of Michigan (2022). The Effects of combining alcohol with other drugs. available@The Effects of Combining Alcohol with Other Drugs | University Health Service (umich.edu)

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