Opioid Use Disorder: Diagnosis and Treatment

Educational Objectives

After completing the activity, the clinician will be better able to:

1. Use established criteria to diagnose opioid use disorder (OUD).
2. Evaluate and treat opioid intoxication, overdose, and withdrawal.
3. Develop strategies for treatment of OUD using pharmacologic and nonpharmacologic interventions.

Summary

Statistics on drug-induced deaths: ≈107,000 deaths from drug-induced overdoses occurred in 2021 (>80,000 involved opioids); of these, ≈16,000 were from prescription opioids, 9,000 were from heroin (many also involved fentanyl), 53,000 were from stimulants (increase from 2020, largely driven by fentanyl contaminating drugs sold recreationally as stimulants); >12,000 deaths were from benzodiazepines (increase since 2015 driven by fentanyl contamination)

Opioid use disorder (OUD): Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, Text Revision; DSM-5-TR) criteria — problematic pattern of opioid use leading to clinically significant impairment or distress, manifested by ≥2 of 11 criteria in a 12-mo period; problematic pattern is compulsive and prolonged self-administration, use for nonmedical purposes or in a nonmedical manner, or (when prescribed) using amounts greater than needed for prescribed purpose

Impaired control: opioids are taken in larger amounts or over a longer period than intended; persistent desire or unsuccessful efforts to control use; extensive time is spent in activities necessary to obtain and use opioids or recover from effects; craving or strong desire to use

Social impairment: recurrent use resulting in failure to fulfill obligations at work, school, home; continued use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of opioids; giving up or reducing important social, occupational, or recreational activities because of use

Risky use: recurrent use in physically hazardous situations; continued use despite knowledge of a persistent or recurrent physical or psychological problem likely to have been caused or exacerbated by the substance

Pharmacologic properties: tolerance — need for markedly increased amounts of opioids to achieve intoxication or the desired effect, or a markedly diminished effect with continued use of the same amount of an opioid; withdrawal — characteristic opioid withdrawal syndrome, and opioids (or related substance) are taken to relieve or avoid withdrawal symptoms; people taking opioids under medical supervision who experience only tolerance and/or withdrawal do not meet criteria for OUD

Specifiers: early remission — no OUD criteria met for >3 mo and <12 mo; sustained remission — no criteria met for ≥12 mo; criterion 4 (cravings) is the exception for early and sustained remission; on maintenance therapy — includes methadone, buprenorphine, naltrexone; criteria 10 and 11 (tolerance and withdrawal) are exceptions; in a controlled environment — access to opiates is restricted, eg, tightly controlled inpatient units, therapeutic communities, jails (drugs may still be available)

Coding based on severity: mild — 2 to 3 criteria; moderate — 4 to 5 criteria; severe — ≥criteria; add remission specifier, if applicable

Clinical signs of intoxication: include altered mental status (eg, euphoria, lethargy, coma), miotic pupils (mydriasis may be observed with extreme overdose of fentanyl or other opioids), slowed bowel sounds, low heart rate and blood pressure (hypertension and tachycardia may be observed with extreme overdose), and hypoventilation and respiratory depression, which can be actively life-threatening

Emergency treatment of overdose: naloxone (Narcan) dosing depends on clinical presentation; larger doses push person into profound withdrawal; goal is adequate ventilation, not normalization of mental status; large doses can awaken the patient, and they are likely to experience unpleasant withdrawal symptoms; this may reduce the likelihood of effective intervention for OUD; opioids with a long half-life can outlast naloxone, and respiratory depression can return after naloxone wears off; therefore, patient needs to be monitored; available forms include intravenous, intramuscular, and intranasal (response is slower, and larger dose is required); kits and cartridges are available in some states without prescription

Clinical signs of withdrawal: gastrointestinal — abdominal cramps, diarrhea, nausea, vomiting; flu-like symptoms — lacrimation, rhinorrhea, diaphoresis, sweating, shivering, piloerection; sympathetic nerve and central nervous system arousal — dilated pupils, mild hypertension and tachycardia, anxiety and irritability, insomnia, agitation, restless leg syndrome, general restlessness, tremor, low-grade temperature and tactile sensitivity (less common); other signs — yawning, sneezing, anorexia, dizziness, myalgia, arthralgia, leg cramps

Management of withdrawal: duration of withdrawal symptoms is proportional to opiate half-life; withdrawal precipitated by medication is more abrupt, and severe autonomic instability and delirium can occur (rare); Clinical Opiate Withdrawal Scale (COWS; Wesson, Ling [2003]) is an 11-item scale that quantifies symptoms of withdrawal

Buprenorphine (Subutex): also available in combination with naloxone (Suboxone); partial μ-opioid agonist and κ-receptor antagonist; weaker μ-opioid agonism relieves withdrawal symptoms, protects against respiratory depression, but does not provide full euphoric effect; naloxone is added to sublingual formulation to deter diversion; can be prescribed and administered through an outpatient program; patient needs to be in moderate withdrawal before starting (drug can precipitate withdrawal if given too soon; withdrawal symptoms persist if given too late)

Methadone: long-acting full μ-receptor agonist; can be lethal when overdosed due to cardiac arrhythmia; only given in supervised settings (need to travel to clinic may be burdensome to the patient); methadone and buprenorphine are superior to clonidine for keeping patients off illicit opioids, but patient remains opioid dependent; medications are beneficial for public and individual safety, help patients maintain sobriety

Clonidine: can be used in combination with opioid treatment or as a primary agent (less effective), particularly in settings where opioid treatments are undesirable or unavailable; most effective against autonomic symptoms; often used in early withdrawal; less effective against myalgias, restlessness, insomnia, craving

Considerations: calm, quiet environment, along with staff who are supportive, reassuring, and educated about OUD can help patients overcome most symptoms of acute withdrawal and decrease need for pharmacologic interventions

Motivational interviewing: assesses person’s willingness to engage in treatment and is a tool to help with decision-making about treatment; not intended to coerce person into accepting treatment; meet person where they are at and help them look toward change thinking; helps to increase motivation and consider positive changes

Psychotherapeutic treatment: cognitive behavioral therapy — includes psychoeducation, functional analysis of use, identify triggers, enhance overall functioning, build healthy coping skills; contingency management — involves behavior modification through use of incentives (eg, money) to assist patient in staying in treatment and progressing through program; 12-step facilitation — group setting and social support; highly peer-based; addiction counseling — given by substance use counselors; family therapy — many issues are initiated or continued by family issues; can be effective for preventing relapse

Readings

References

1. Diagnostic and Statistical Manual of Mental Disorders (5th ed, text rev; DSM-5-TR). American Psychiatric Association; 2022
2. Johnson K, Vanderhoef D, Magrath N.Psychiatric-mental health neurse practitioner review and resource manual (4^th ed). American Nurses Association; 2020
3. Luo SX, Bisaga A. Opioid use and related disorders: From neuroscience to treatment. In B Sadock, V Sadock, & P Ruiz (Eds), Kaplan & Sadock’s Comprehensive Textbook of Psychiatry (10th ed, 1352-1373). Wolters Kluwer; 2017; Stahl SM.Stahl’s essential psychopharmacology (5th ed). Cambridge University Press; 2021
4. Stahl SM. Stahl’s essential psychopharmacology: prescriber’s guide (7th ed). Cambridge University Press; 2020
5. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259. doi:10.1080/02791072.2003.10400007

Disclosures

For this program, Mr. D'Errico and the planning committee reported nothing relevant to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.00 CE contact hours.

Lecture ID:

NP240604

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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