Opioid use disorder

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 8 Sep 2025

Last updated: 25 Sep 2025

Opioid use disorder is a significant and rapidly evolving public health concern worldwide, with increasing use of synthetic opioids such as fentanyl driving increases in opioid use disorder and in overdose deaths.

Opioid use disorder is a problematic pattern of opioid use leading to clinically significant impairment or distress.

It is important to assess comorbid medical and psychiatric illnesses, as well as other substance use disorders.

Physicians should be aware of methods for screening and detection of opioid use in clinical settings.

Opioid use disorder is a treatable, chronic disease. Evidence-based treatments include medically supervised withdrawal, maintenance therapy with relapse prevention pharmacotherapy, and psychosocial treatment.

Treatment requires a multidisciplinary approach, is long term, and involves modifying deeply ingrained behaviors through the use of pharmacotherapy 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 misused because of their euphoric effects. Naturally derived opiates are commonly misused 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

maladaptive pattern of opioid use
high Addiction Severity Index (ASI) score
blunting of pleasurable opioid effects
miosis
dilated pupils
shallow/slow respirations or apnea
needle marks, scars, or necrosis on skin near veins
unconsciousness
pulse <40 bpm

Full details

Other diagnostic factors

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

Full details

Risk factors

young age
history of a mental health disorder
history of substance use
long-term opioid therapy
childhood trauma
homelessness/housing instability
family history of substance use
criminal justice system involvement

Full details

Diagnostic tests

1st tests to order

Addiction Severity Index (ASI)
clinical opiate withdrawal scale (COWS)
urine or saliva drug screen
gas chromatography-mass spectroscopy (GC-MS)
serum electrolytes
CBC
BUN/creatinine
LFTs
hepatitis serology
HIV serology
purified protein derivative (PPD) skin test

Full details

Tests to consider

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

Full details

Treatment algorithm

ACUTE

nonpregnant adults in inpatient/outpatient medically supervised withdrawal program

nonpregnant adolescents in inpatient/outpatient medically supervised withdrawal program

pregnant women in inpatient/outpatient medically supervised withdrawal program

nonpregnant adults after medically supervised withdrawal or suitable for initial or early maintenance therapy

nonpregnant adolescents after medically supervised withdrawal or suitable for initial or early maintenance therapy

pregnant women after medically supervised withdrawal or suitable for initial or early maintenance therapy

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 stockholder in Generys Biopharmaceuticals that has compounds in development for drug addiction (for stimulant use disorder). AAP provides expert testimony for United States Federal Agencies and is an expert reviewer for North Carolina Medical Board. AAP is the author of references cited in this topic.

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 declares that he has no competing interests.

Isabel Patton, B.S, B.A

Medical Assistant

Department of Psychology

Emory University

Atlanta

Georgia

Disclosures

IP declares being an employee of AAP who has declared interests above. IP has co-authored a manuscript with AAP which has not yet been published.

Acknowledgements

Dr Ashwin A. Patkar, Dr Jonathan C. Lee, and Isabel Patton would like to gratefully acknowledge Dr Douglas M. Burgess, Dr Kamal Bhatia and Dr Srilakshmi Musham, previous contributors to this topic.

Disclosures

DMB declares that he has no competing interests. 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.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.Full text

World Health Organization. WHO releases 2025 update to the International Classification of Diseases (ICD-11). Feb 2025 [Internet publication].Full text

American Society of Addiction Medicine. The ASAM national practice guideline for the treatment of opioid use disorder: 2020 focused update. 2020 Mar/Apr;14(2S suppl 1):1-91.Full text Abstract

Substance Abuse and Mental Health Services Administration. TIP 63: medications for opioid use disorder. Jul 2021 [internet publication].Full text

National Institute for Health and Care Excellence. Drug misuse in over 16s: opioid detoxification. Jul 2007 (reaffirmed 2019) [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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Guidelines
- Management of opioid use disorder: 2024 update to the national clinical practice guideline
- Comprehensive, evidence-based, consensus guidelines for prescription of opioids for chronic non-cancer pain
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Patient information
Opioid-use disorder
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Calculators
Clinical Opioid Withdrawal Scale (COWS) for adults and adolescents
More Calculators
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Opioid use disorder

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

nonpregnant adults in inpatient/outpatient medically supervised withdrawal program

nonpregnant adolescents in inpatient/outpatient medically supervised withdrawal program

pregnant women in inpatient/outpatient medically supervised withdrawal program

nonpregnant adults after medically supervised withdrawal or suitable for initial or early maintenance therapy

nonpregnant adolescents after medically supervised withdrawal or suitable for initial or early maintenance therapy

pregnant women after medically supervised withdrawal or suitable for initial or early maintenance therapy

Contributors

Authors

Ashwin A. Patkar, MD, MRCPsych

Disclosures

Jonathan C. Lee, MD

Disclosures

Isabel Patton, B.S, B.A

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD

Disclosures

George E. Woody, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Calculators

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice