Rue in Episode 6, Season 2 of HBO's Euphoria

Rue, the main character of HBO's Euphoria, struggles with opioid addiction. Recent episodes have portrayed the physical and emotional experiences of withdrawal.

It seems like nearly everyone is talking about Euphoria. But one of its central themes, addiction, has long been stigmatized. 

The acclaimed HBO original series features 17-year-old Rue, played by Zendaya, as she deals with drug addiction. Season two, currently airing Sunday evenings on HBO Max, has displayed Rue's highs and lows.

For many, Rue's struggles are not unfamiliar. Nearly 40,000 Missourians misuse pain medication, and 17,000 use heroin, according to the Missouri Center for Addiction Research and Engagement. The most recent episodes of Euphoria have featured Rue's daunting withdrawal experience.

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Roberto Cofresí holds out an EEG testing device that measures electrical activity in the brain on Feb 16 at MU Cognitive Neuroscience Systems Core in Columbia. “This sensor net system is meant to make it easy for members of the community to have their brain activity measured,” Cofresí says.

Ending the cycle isn't easy

Withdrawal symptoms can occur in people facing various forms of substance use. Euphoria portrays examples of opioid withdrawal. For some opioids such as heroin, withdrawal symptoms can begin as soon as eight hours after using and last for four to 10 days. For other opioids like methadone, the onset of withdrawal can begin 12 hours post usage and continue for 10 to 20 days.

Withdrawal symptoms can include nausea, vomiting, anxiety, insomnia, fever, muscle cramps and diarrhea — physical symptoms that can take a devastating emotional toll, says Roberto Cofresí, a postdoctoral neuroscientist at MU. But the effects of withdrawal aren't limited to physical ones.

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Cofresí inspects parts of an EEG testing device. “There’s this misconception that dopamine releases translate into a pleasurable experience,” Cofresí says. “But dopamine itself has little to do with a pleasure aspect — it seems to have more to do with learning and memorizing and stamping things as biologically or emotionally significant.”

“(Withdrawal) keeps people in this vicious downward spiral of use to cure or avoid that psychological state,” Cofresí says. “I'm glad that the depictions (in Euphoria) are able to emphasize the emotional experience that goes along with being in that state and how powerfully it can drive that desire to escape this hell.”

Biology and the body

Cofresí earned a doctoral degree in neuroscience from the University of Texas at Austin in 2018, and he's spent his career attempting to uncover how neurobiology can support treatments for substance use disorders. 

Now, Cofresí works to tie the neurobiological concepts that had long been tested on rodents to clinical human applications. At MO-CARE, he takes an interdisciplinary approach to tackling addiction by collaborating with other researchers. Cofresí specializes in studying the systems of the brain affected by alcohol.

“Your perception of the world is rooted in how your brain is working,” Cofresí says. “If substance use is changing how systems in the brain are working, that behavior is fundamentally altering how that person perceives the world and experiences their reality.”

Changes in an individual's decision-making and personality such as Rue's outbursts in season two episode five aren't just “a societal, cultural or individual problem.” As Cofresí explains it, understanding addiction and withdrawal comes from acknowledging how “it's grounded in biology and our bodies.”

Changed priorities

Kenneth Sher, an MU professor and MO-CARE colleague of Cofresí's, has spent 40 years studying the psychology of addiction. “One thing that was interesting (about Euphoria) was the lifestyle aspects around addiction,” Sher says. 

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Postdoctoral fellow Roberto Cofresí heads to his office on Feb 16 at MU Cognitive Neuroscience Systems Core facility in Columbia. Cofresí specializes in the neurobiology of addiction.

Sher explained how the concept of “role compatibility” can play into the likelihood that someone uses substances. Euphoria viewers might have noticed the lack of backpacks, textbooks and homework in the show. Personal responsibilities, such as school, work or relationships, can make substance usage incompatible with someone's lifestyle. 

“Opioid withdrawal is dramatic and painful,” Sher says. These words perfectly describe Rue's withdrawals in season two.

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Alex Brown, MRI coordinator for the MU Brain Imaging Center, analyzes an image of a brain scan on Feb 16 at the MU Cognitive Neuroscience Systems Core facility in Columbia. MRI scanners help locate where notable occurrences are happening in the brain. “Whether that means viewing images that are cues for particular drugs of abuse or engaging in some sort of task inside the scanner, where typically we are measuring their ability to inhibit their behavior,” Cofresí says.

Although opioid withdrawal can be uncomfortable, withdrawal from other substances can be more medically severe, Sher says.

Sher notes that it's important to keep in mind that media portrayals cannot fully capture the wide range of experiences had by substance users. “Everybody is different, and drug addiction affects everyone differently,” he says.

Destigmatizing the conversation

In Euphoria, Rue navigates opioid and opiate usage. The two are similar but not exactly the same. Opiates, such as morphine, come from natural plant matter. Opioids are synthetic versions, but both are responsible for the feeling of euphoria that the show is named after.

In 2020, opioid overdose caused one in every 54 deaths in Missouri. Unfortunately, there are barriers to getting treatment for those who are suffering from addiction. Cofresí hopes that media portrayals of addiction will get people talking and inspire those suffering from substance use disorders to get help. 

“I’ve seen treatment of a variety of kinds, psychological realm, group therapy and individual therapy, help people improve their lives and functioning so they can experience whatever beautiful tragic thing is the human experience,” Cofresí says. 

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An MRI brain scan* of postdoctoral fellow Roberto Cofresí displays on a screen at the MU Cognitive Neuroscience Systems Core facility. “This can really take on a disease-like nature that’s hard for them to get treatment for, find treatment for or feel like it’s even treatable,” Cofresí says. “So with any luck, the enterprises trying to understand the neurobiology of it will help make it seem more treatable and something that should be treated, as opposed to the default societal approach which is, in large part, just jail.” Cofresí gave explicit permission for his scan to be photographed and shown.

*Updated to include more information about the brain scan.

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