Opioid use disorder

Last reviewed: 29 Oct 2022

Last updated: 23 Nov 2022

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.

Definition

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.[1]

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
miosis
dilated pupils
shallow/slow respirations or apnoea
needle marks, scars, or necrosis on skin near veins
unconsciousness
pulse <40 bpm

More key diagnostic factors

Other diagnostic factors

chronic constipation
weight loss
nausea/vomiting
sedation
restless sleep/insomnia
memory impairment
sneezing
yawning
abdominal cramps
diarrhoea
backache/muscle spasms
hot and cold flashes
hypotension
sedation
confusion
slurred speech
aggressive behaviour
excess perspiration or lacrimation
rhinorrhoea
restlessness
piloerection
tachypnoea
hypertension
arrhythmias
seizures

Other diagnostic factors

Risk factors

young age
history of a mental health disorder
history of substance use
long-term opioid therapy
childhood trauma
family history of substance use

More risk factors

Diagnostic investigations

1st investigations to order

urine or saliva drug screen
gas chromatography-mass spectroscopy (GC-MS)
serum electrolytes
FBC
urea/creatinine
LFTs
hepatitis serology
HIV serology
purified protein derivative (PPD) skin test

More 1st investigations to order

Investigations to consider

rapid plasma reagin
blood cultures
beta human chorionic gonadotrophin (beta-hCG)

More investigations to consider

Treatment algorithm

ACUTE

non-pregnant adults in inpatient/outpatient detoxification programme

non-pregnant adolescents in inpatient/outpatient detoxification programme

pregnant women in inpatient/outpatient detoxification programme

ONGOING

non-pregnant adults after detoxification programme

non-pregnant adolescents after detoxification programme

pregnant women after detoxification programme

Contributors

Authors

Ashwin A. Patkar, MD, MRCPsych

Associate Professor

Medical Director

Duke Addictions Program

Department of Psychiatry and Behavioral Sciences

Duke University Medical Center

Durham

Disclosures

AAP is a consultant/member of the advisory board for Cubist Pharma, Biodelivery Sciences (BDSI), Kaleo, Forest Research Institute, and Titan Pharma; is on the speaker’s bureau and received honoraria from Otsuka, Alkermes, Sunovion, and BDSI; and is a shareholder in Ironwood Sciences LLC and Patkar Medical Consultants. AAP's institution has received grant support from National Institutes of Health (NIDA, NIAAA), SAMHSA, AstraZeneca, Bristol-Myers Squibb, Cephalon, Daiichi Sankyo, Envivo Pharma, Forest, J & J, Jazz Pharmaceuticals, Lundbeck, Merck, Organon, Pfizer, Sunovion, Shire, and Titan. AAP holds unpaid positions on the Board of Directors of Southlight Inc, the Board of Advisors of People's Medical Care, the Executive Committee of Triangle Indian American Physicians Society, and also as President of Indo American Psychiatric Association.

Jonathan C. Lee, MD

Medical Director

The Farley Center at Williamsburg Place

Williamsburg

Community Assistant Professor

Department of Family Medicine

Eastern Virginia Medical School

Norfolk

Assistant Clinical Professor

Department of Psychiatry

Virginia Commonwealth University

Richmond

Affiliate Assistant Professor

Department of Psychiatric Medicine

East Carolina University

Greenville

Disclosures

JCL is a full-time employee at The Farley Center at Williamsburg Place.

Douglas M. Burgess, MD

Assistant Professor

Department of Psychiatry

University of Missouri - Kansas City

Medical Director

Outpatient Behavioral Health

Truman Medical Centers

Kansas City

Disclosures

DMB declares that he has no competing interests.

Acknowledgements

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.

Disclosures

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.

Peer reviewers

Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD

Consultant Psychiatrist and Honorary Senior Lecturer

Institute of Psychiatry

King's College London

London

Disclosures

CK declares that he has no competing interests.

George E. Woody, MD

Emeritus Professor

Department of Psychiatry

Perelman School of Medicine

University of Pennsylvania

Philadelphia

Disclosures

GEW declares that he has no competing interests. GEW is an author of a number of references cited in this topic.

Differentials
- Alcohol intoxication
- Sedative intoxication
- Anticholinergic intoxication
More Differentials
Guidelines
- Diagnostic and statistical manual of mental disorders, 5th edition, text revision
- Use of long-acting injectable buprenorphine for opioid substitution therapy
More Guidelines
Patient leaflets
Opioid-use disorder
More Patient leaflets
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Opioid use disorder

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

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

Contributors

Authors

Ashwin A. Patkar, MD, MRCPsych

Disclosures

Jonathan C. Lee, MD

Disclosures

Douglas M. Burgess, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD

Disclosures

George E. Woody, MD

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

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