Mixing Opioids and Alcohol

What are Opioids?

The opioid class of drugs includes both illegal substances (e.g., heroin) and prescription drugs (e.g., oxycodone, morphine, hydrocodone, fentanyl, etc.).² While some of these drugs are manufactured from opiate alkaloids extracted from opium poppy plant materials, others such as fentanyl are entirely lab synthesized, with pharmacological activity similar to the plant-based versions.³

Note that while the terms “opiate” and “opioid” are frequently used interchangeably, they technically mean different things. Opiates (e.g., codeine, morphine, thebaine, etc.) are poppy-derived substances that sometimes serve as the chemical precursors for manufacturing various other opioid drugs. Meanwhile, the term “opioids” is often used more generally and may refer to all substances within the drug class, regardless of whether they’re natural or synthetic.⁴

Prescription opioids are used primarily to treat severe and/or chronic pain, but some have additional uses, such as treating cough.^3,5 Along with their therapeutic benefits, opioids can have some side effects, such as euphoria (i.e., a high), drowsiness, and confusion, as well as gastrointestinal issues such as nausea and constipation.⁶

When used at high doses and/or when mixed with other substances, opioids can slow breathing and ultimately lead to death.⁶ Plus, those who develop significant physiological opioid dependence may experience unpleasant opioid withdrawal symptoms when they stop using or significantly reduce their dosage.³

In the U.S., the Controlled Substances Act established policies that included the scheduling of drugs into 5 categories based on their acceptable medical use as well as any potential for abuse. By these measures, many opioids are Schedule I or Schedule II controlled substances. Heroin, for example, is a Schedule I drug, as it has no currently accepted medical use and a high potential for abuse. Meanwhile, Schedule II drugs, which include many prescription opioids such as hydrocodone, oxycodone (e.g., OxyContin), and fentanyl, have a medical use but also a high potential for abuse and can potentially lead to severe psychological and/or physical dependence.⁷

When it comes to opioids, then, the potential for misuse is high, even in those who take prescription opioids as prescribed.⁵ In fact, according to results from the 2021 U.S. National Survey on Drug Use and Health, 9.2 million people aged 12 and older misused opioids within the last year. Among these individuals, the vast majority (8.7 million people) misused prescription pain relievers, compared to 1.1 million who misused heroin.⁸

Additionally, opioids pose a significant danger for overdose, particularly because of their respiratory depressing effects in the brain. Overdose, then, is often due to breathing that slows to the point of suffocation.⁵ Among the significant risk factors for opioid overdose is the accompanying use of alcohol and/or other central nervous system depressants, which can additionally impact breathing.⁹

According to 2020 data from the Centers for Disease Control and Prevention, an average of 44 people died each day as a result of a prescription opioid overdose, totaling more than 16,000 people that year.¹⁰ All told between 1999 and 2020, more than 263,000 people in the U.S. died due to prescription opioid overdoses.¹¹ And in 2020 alone, more than 56,000 deaths involving synthetic opioids (not including methadone) occurred.¹²

Common Opioid Drugs

Several distinctions can be made between the various types of opioids, including whether they are naturally derived or fully synthetic, prescription or illicit, etc. However, as a drug class, some of the more common types of opioids include:^5,7,13-17

• Hydrocodone: The most frequently prescribed opioid in the U.S., hydrocodone is typically used to treat moderate to severe pain.
• Oxycodone: Oxycodone is often used for moderate to severe pain relief. A long-acting formulation of the medication is available as OxyContin. When oxycodone is combined with aspirin or acetaminophen, it’s marketed under brands such as Percodan and Percocet, respectively.
• Morphine: Commonly considered the archetypal opioid painkiller, morphine is widely used to address severe pain before or after surgical procedures. A controlled-release morphine is available under the brand name MS-Contin.
• Codeine: Often prescribed for relatively milder pain than the aforementioned opioids, codeine is also used to reduce coughing and is available in combinations with acetaminophen and aspirin.
• Fentanyl. Like morphine, fentanyl is widely used in a variety of clinical settings. However, in contrast to morphine, fentanyl is a fully synthetic opioid roughly 50 to 100 times more potent than its counterpart. While pharmaceutical fentanyl is available in a prescription form that’s used to treat pain, a large supply of it is illegally manufactured.
• Heroin. A relatively short-acting opioid manufactured using poppy-derived morphine, heroin is an illegal and highly addictive Schedule I opioid.

Effects and Dangers of Mixing Alcohol and Opioids

The intentional or unintentional use of more than one substance within a short period of time is referred to as polysubstance use.¹ Those who practice polysubstance use intentionally may do so to:¹⁸

• Modify or enhance the effects of a single substance.
• Compensate for weakened effects of one substance.
• Prevent alcohol and opiate withdrawal symptoms.
• Attempt to alleviate some of the stresses related to previous trauma, life circumstances, and/or health issues.
• Replace their preferred drug of choice when it’s unavailable.

Unfortunately, polysubstance use isn’t rare, as those who use one substance often use another. In previous years, 90% of people with an opioid use disorder used more than 2 other substances within the last year, and more than 25% of these individuals had at least two other substance use disorders.¹⁸

Despite its prevalence, polysubstance use is never safe. Even when prescription drugs are used in combination or with other substances, the effects of drug mixing can be unpredictable, stronger than either drug alone, and/or deadly.¹

Mixing two respiratory depressants such as alcohol and opioids (e.g., hydrocodone, oxycodone, etc.) is particularly dangerous.^1,19 In fact, black-box warnings on prescription opioid labels advise against mixing these substances with alcohol, as doing so can produce severe respiratory depression, sedation, and heightened risk of overdose.^9,20

Combining alcohol with substances such as opioids also increases the risk of overdose toxicity and multiple other adverse health outcomes such as:^1,19

What’s more, for those with a substance use disorder (SUD), polysubstance use is associated with higher likelihood of the following issues compared to people with an SUD alone:¹⁸

• Financial and legal issues.
• Arrests and incarceration.
• Suicide attempts.
• More severe medical and psychiatric comorbidities (i.e., the presence of two or more conditions at the same time).
• Overdose.

Are There Risks to Mixing Non-opioid Pain Medications and Alcohol?

Mixing even over-the-counter pain medications with alcohol can be harmful. For example, mixing alcohol with the following analgesic, fever-reducing, and/or anti-inflammatory medications can lead to stomach upset, bleeding ulcers, and rapid heartbeat:²¹

• Ibuprofen (e.g., Advil, Motrin).
• Naproxen (e.g., Aleve).
• Aspirin (e.g., Excedrin).
• Acetaminophen (e.g., Tylenol).

In the case of Tylenol and other acetaminophen-containing products, concurrent alcohol use can decrease the threshold at which acetaminophen-mediated liver injury may occur.²¹

Overdosing on Opioids and Alcohol

As previously described, overdose is a clear danger of mixing alcohol and opioids such as morphine, oxycodone, hydrocodone, fentanyl, and more.¹ In fact, 2017 data indicates that roughly 1 in 7 opioid-related deaths involved drinking alcohol within a few hours of opioid use.¹

Potential signs and symptoms of an opioid or alcohol/opioid overdose include:^1,22

• Profoundly altered mental status.
• Loss of consciousness.
• Unresponsiveness and inability to awaken.
• Weak pulse.
• Shallow or slow breathing, breathing difficulties (e.g., making choking sounds, gurgling, snoring, etc.).
• Blue or purple lips or fingernails.

What Should I Do If I Witness an Overdose?

If you believe that someone has overdosed on opioids or an opioid/alcohol combination, there are several things you can do to help:¹

• Call 911 immediately. If possible, explain what substances you believe the person has taken.
• Administer naloxone (aka the brand name Narcan), if available.
• Attempt to keep the person awake and breathing.
• Lay the person on their side to prevent choking if the person vomits.
• Monitor the person until emergency assistance arrives.

Treatment for Opioid and Alcohol Addiction

Treatment for polysubstance use is possible, though it may necessitate some customization of the care plan to meet the combined recovery needs of each individual. These care plans vary according to the patient’s substance use disorder(s) types, the presence of any co-occurring mental health issues, any specific polysubstance detox needs, availability of treatment, treatment option preferences, and more.¹⁸

Often, a care plan involving concurrent substance use includes withdrawal management, psychological treatment, pharmacological treatment, and monitoring. Due to the complexity of this treatment, individuals may need services and treatment from a variety of providers, settings, and care levels.¹⁸

Treatment settings may include:^{18, 23-25}

• Detox. The body rids itself of substances such as alcohol and opioids over a period of detoxification, during which a person may experience symptoms of alcohol and opiate withdrawal. During a medically supervised detox, treatment professionals can offer supportive care and pharmacological intervention to manage symptoms and cravings and ensure the patient’s safety. Keep in mind, however, that detox is the first step toward recovery, not a solution in itself.
• Inpatient rehab. With inpatient rehab, patients live within a facility where care is available 24/7. Here they participate in various treatment approaches, such as one-on-one counseling, group therapy, pharmacotherapy, and psychoeducation.
• Traditional outpatient rehab. Standard outpatient rehab allows patients to live at home. However, treatment options are similar to those of inpatient programs; they’re just provided at a lower intensity.
• Partial hospitalization program (PHP). As a highly structured type of outpatient offering, a PHP (aka day treatment program) is the midway point between inpatient and outpatient treatment. Many PHPs such as those offered via American Addiction Centers treatment facilities provide treatment 3 to 7 days a week in 6 to 8 hour blocks.
• Intensive outpatient program (IOP). More intense than traditional outpatient treatment though relatively less time intensive than partial hospitalization, IOPs may require patients to attend roughly 6 to 30 hours a week over the course of 90 days or more.
• Aftercare. To prevent relapse and continue to support the patient’s transition from inpatient or outpatient care to the new normal of everyday life, aftercare options include 12-Step programs, ongoing counseling, etc.
• Sober living. Offering substance-free environments in which to continue recovery, sober living homes include solutions such as halfway houses, Oxford Houses, and more.
• Telehealth. A convenient and flexible form of treatment that’s offered via phone or online, telehealth comprises group or individual counselling, various therapies, peer meetings, etc.

Whether you or a loved one is struggling with opioid or alcohol misuse—or both concurrently—American Addiction Centers can help. With facilities scattered across the country, AAC offers all of the treatment types and levels of care listed above and provides effective rehab solutions for those with a host of substance misuses issues.

To learn more about treatment options for polysubstance use, insurance verification, payment options, and more, contact an admissions navigator at . No matter what substances or mental health conditions you’re battling, AAC can help you take your first steps toward recovery today.