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HomeAddictionPrescription DrugsOpioidsList Of Opioids Strongest to Weakest

7 Minutes

Edited & medically reviewed by THE BALANCE Team
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Narcotics or narcotic analgesics are drugs with potent painkiller properties. They belong to the opioid class of drugs and exert their effect by acting on the opioid receptors in the central nervous system. The word narcotic has been derived from the Greek word “narcosis,” which means to numb or cause loss of sensations. Narcotics or opioids are either naturally occurring or can be synthetic or semisynthetic. All these offer varying degrees of pain relief and vary slightly in their properties or potency. 

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All of the narcotics have great potential for abuse. According to the Centre of Disease Control (CDC), the third wave of opioid-use disorder began in 2013 and has been predominated by death due to opioid overuse. Within the last few years (2917-2017), there has been a significant increase in opioid-related deaths by almost 6% and synthetic opioid-related deaths by 15%. The most likely culprit or causative agent is fentanyl which is found illicitly in combination with various other drugs including heroin. 

Opiates have been arranged according to their potency from the strongest to the weakest. Although some of these drugs are available as prescription drugs, they have controlled substances. These drugs rapidly-produce tolerance in the body so more and more of the same drug is required to produce the desired effects. Moreover, failure to take the drug may result in undesirable withdrawal symptoms and at a later stage, patients take the drugs just to fight the craving and withdrawal rather than deriving any actual pleasure from it. 

  1. Carfentanil 
  2. Fentanyl 
  3. Heroin 
  4. Hydromorphone 
  5. Oxymorphone 
  6. Methadone 
  7. Morphine 
  8. Codeine 
  9. Meperidine (Demerol) 
  10. Tramadol 

Carfentanil is the strongest known synthetic opiate and is an analog of fentanyl. It is more potent than either fentanyl or morphine, and heroin is often laced with Carfentanil to produce an extra kick or euphoria. It is approximately 10,000 times more potent than morphine and 5000 times stronger than heroin. In fact, heroin which is laced with Carfentanil may lead to overdose, hypotension, constricted pupils, and respiratory depression and may prove to be rapidly fatal.

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It is often illegally smuggled into the United States and has the potential to be used in bioterrorism as a weapon of mass destruction. It is so potent that it can exert its adverse effects even by touching or smelling it. It is advisable to use gloves while handling this lethal drug. 

Fentanyl is an extremely potent synthetic opioid painkiller. It is approximately 50 times as potent as heroin and 100 times as potent as morphine. It is used primarily for sedation in patients who are intubated and mechanically ventilated. Certain antibiotics like azithromycin may potentiate the effects of fentanyl and may precipitate respiratory depression. It is a cheaply synthesized drug and is often mixed on the streets with heroin to increase its potency. It can be rapidly fatal especially in opioid-naive patients. 

Heroin is an illicit opioid and is used commonly in patients with opioid use disorder. It is almost twice as potent as morphine and is available in different preparations. It may be used by subcutaneous, intranasal, intramuscular, and intravenous routes, and the oral route is less desirable. It rapidly crosses the blood-brain barrier (less than one minute after injecting it intravenously) and produces a feeling of euphoria or rush.

Heroin has marked variation in the concentration or potency of the drug. The dose that produces pleasurable side effects may rapidly prove to be fatal. The same dose which produces euphoria one day can kill the patient the following day. Due to its low cost, it is commonly used as a recreational drug. 

Hydromorphone is a semisynthetic analog of morphine and is also called dihydromorphinone or Dilaudid. It has strong addiction potential and is used as a painkiller. It is two to eight times as powerful as morphine and can be taken orally, snorted, or used via intravenous injections to exert a rapid effect. It has also been used rectally by patients (plugging). 

Oxymorphone is a strong opioid and is available by the name of Opana. On the streets it is referred to by various names including pink lady, new blues, and Mrs. O. It is potent and withdrawal starts within 14 hours of last using the drug. 

Methadone is a synthetic long-acting opioid that is prescribed for chronic pain. It is also used to manage opioid use disorder, particularly in patients who are undergoing detoxification. It is also given as maintenance therapy and is prescribed for cancer-related pain, pain at the end of life, and severe neuropathic pain. Since it is given for detoxification, there is a misconception that it is safe.

Methadone abuse can be fatal and can cause tolerance, constipation, and decreased rate of breathing, It is available in oral and injection forms. Moreover, some other medications may interact with it and precipitate withdrawal symptoms. Alcohol and certain drugs may produce toxicity by augmenting its effects. 

Morphine is a potent naturally occurring opioid that is extracted from the seed of the opium poppy plant. About 10-12% of opium is made up of morphine and it can later be processed to produce heroin and other semisynthetic and synthetic narcotic painkillers. It has extremely strong analgesic or pain relief properties as it alters pain perception in the brain and increases the pain threshold.

It is available in immediate release, controlled release, and extended-release tablets and is often used for excruciating or severe pain, particularly at the end of life. Intravenous forms are preferred by patients with opioid use disorder due to instantaneous effects. It has strong addiction potential. In fact, the over-prescription of morphine by physicians has triggered the opiate pandemic. In addition, it may also cause breathing to slow down (respiratory depression), constipation, and increased sedation. 

Codeine is a weak opioid and is available in prescription opioid cough and cold medicines. It is often present in combination with antihistamines and decongestants. Codeine is also available in combination with aspirin or acetaminophen in both oral and intravenous forms. Although it is a weak opioid, it can still be used by patients with substance use disorder. 

Pethidine, also known as meperidine, is a synthetic form of opioid. It is used to treat moderate to severe pain and is also given preoperatively to reduce shivering. It is available in tablet, syrup, and parenteral forms and has a great potential for abuse.

It can be injected in the skin, in the veins, and intramuscularly. However, it can cause seizures and fits. It causes withdrawal, respiratory failure, seizures, cardiac arrest, abnormal rhythm disturbances of the heart (arrhythmia), decreased heart rate, and hypotension. It can be particularly dangerous when taken concomitantly with alcohol or sedatives like benzodiazepines. 

Tramadol is a potent synthetic opioid analgesic and is a controlled substance available only on prescription. It is licensed for use in moderate to severe pain not relieved by non-opioid pain relief medication. It is available only in oral preparation and has extended-release and immediate-release formulations. Although it is a very weak opioid, it has the potential for abuse and can prove to be dangerous.

All opioids can be used for abuse and can result in rapid tolerance. Most people start with prescription painkiller use before trying more potent street drugs. Seeking help early from a drug rehab center can be the key to successful treatment. Opioid use disorder is treatable. The first step is to seek help. 

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