Opioid use disorder

Last reviewed: 1 Nov 2022
Last updated: 23 Nov 2022



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
More key diagnostic factors

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
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
  • CBC
  • BUN/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 gonadotropin (beta-hCG)
More investigations to consider

Treatment algorithm


nonpregnant adults in inpatient/outpatient detoxification program

nonpregnant adolescents in inpatient/outpatient detoxification program

pregnant women in inpatient/outpatient detoxification program


nonpregnant adults after detoxification program

nonpregnant adolescents after detoxification program

pregnant women after detoxification program



Ashwin A. Patkar, MD, MRCPsych

Associate Professor

Medical Director

Duke Addictions Program

Department of Psychiatry and Behavioral Sciences

Duke University Medical Center




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


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 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



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.

Peer reviewers

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

Emeritus Professor

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.

  • Opioid use disorder images
  • Differentials

    • Alcohol intoxication
    • Sedative intoxication
    • Anticholinergic intoxication
    More Differentials
  • Guidelines

    • Diagnostic and statistical manual of mental disorders, 5th edition, text revision
    • VA/DoD clinical practice guideline for the management of substance use disorders
    More Guidelines
  • Patient leaflets

    Opioid-use disorder

    More Patient leaflets
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