Opioid use disorder is a problematic pattern of opioid use leading to clinically significant impairment or distress. Heroin and prescription opioid misuse is a major health concern.
From a diagnostic perspective, it is imperative that the physician understands the criteria for opioid use disorder.
Comorbid medical and psychiatric illnesses, as well as other substance use disorders, should be assessed.
Physicians should be aware of methods for screening and detection of opioid use in clinical settings.
Evidence-based treatments include detoxification, maintenance therapy with a relapse prevention medication, and psychosocial treatment.
Treatment requires a multidisciplinary approach, is long term, and involves modifying deeply ingrained behaviours through the use of medications and psychosocial treatments.
An opioid is a synthetic or natural agent that stimulates opioid receptors and produces opium-like effects. Opiates are a type of opioid that are naturally derived from the opium poppy (e.g., codeine, morphine, opium). They are used to treat pain but may also be abused because of their euphoric effects. Naturally derived opiates are commonly abused alongside semisynthetic and synthetic opioids such as fentanyl, heroin (diamorphine), methadone, oxycodone, and hydrocodone. The Diagnostic and statistical manual of mental disorders, 5th edition, text revision (DSM-5-TR) defines opioid use disorder as a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least 2 out of 11 criteria within a 12-month period.
History and exam
Key diagnostic factors
- presence of risk factors
- maladaptive pattern of opioid use
- high Addiction Severity Index (ASI) score
- blunting of pleasurable opioid effects
- dilated pupils
- shallow/slow respirations or apnoea
- needle marks, scars, or necrosis on skin near veins
- pulse <40 bpm
Other diagnostic factors
- chronic constipation
- weight loss
- restless sleep/insomnia
- memory impairment
- abdominal cramps
- backache/muscle spasms
- hot and cold flashes
- slurred speech
- aggressive behaviour
- excess perspiration or lacrimation
- young age
- history of a mental health disorder
- history of substance use
- long-term opioid therapy
- childhood trauma
- family history of substance use
1st investigations to order
- urine or saliva drug screen
- gas chromatography-mass spectroscopy (GC-MS)
- serum electrolytes
- hepatitis serology
- HIV serology
- purified protein derivative (PPD) skin test
Investigations to consider
- rapid plasma reagin
- blood cultures
- beta human chorionic gonadotrophin (beta-hCG)
non-pregnant adults in inpatient/outpatient detoxification programme
non-pregnant adolescents in inpatient/outpatient detoxification programme
pregnant women in inpatient/outpatient detoxification programme
non-pregnant adults after detoxification programme
non-pregnant adolescents after detoxification programme
pregnant women after detoxification programme
Ashwin A. Patkar, MD, MRCPsych
Duke Addictions Program
Department of Psychiatry and Behavioral Sciences
Duke University Medical Center
AAP has received payments for being Consultant to Radeas Labs that performs drug testing and is a member of the Speakers Bureau for Janssen Pharmaceuticals, manufacturer of Spravato, and Otsuka Pharmaceuticals, manufacturer of Rexulti. AP is a stockholder in Generys Biopharmaceuticals that has compounds in development for drug addiction.
Jonathan C. Lee, MD
The Farley Center at Williamsburg Place
Community Assistant Professor
Department of Family Medicine
Eastern Virginia Medical School
Assistant Clinical Professor
Department of Psychiatry
Virginia Commonwealth University
Affiliate Assistant Professor
Department of Psychiatric Medicine
East Carolina University
JCL declares that he has no competing interests.
Douglas M. Burgess, MD
Department of Psychiatry
University of Missouri - Kansas City
Outpatient Behavioral Health
Truman Medical Centers
DMB declares that he has no competing interests.
Dr Ashwin A. Patkar, Dr Jonathan C. Lee, and Dr Douglas M. Burgess would like to gratefully acknowledge Dr Kamal Bhatia and Dr Srilakshmi Musham, previous contributors to this topic.
KB declares that he has received grant support from National Institutes of Health, Lundbeck, Pfizer, and Titan Pharmaceuticals. SM declares that she has received grant support from Pfizer, Titan Pharmaceuticals, Shire, and the Forest Research Institute.
Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD
Consultant Psychiatrist and Honorary Senior Lecturer
Institute of Psychiatry
King's College London
CK declares that he has no competing interests.
George E. Woody, MD
Department of Psychiatry
Perelman School of Medicine
University of Pennsylvania
GEW declares that he has no competing interests. GEW is an author of a number of references cited in this topic.
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