Over the past 10 years, the prevalence of heroin and prescription opioid misuse has significantly increased, in large part because of the increased prescribing of opioid analgesics in the US. As a result, there has been an unparalleled rise in the number of people affected with opioid use disorders and great concerns about the associated morbidity and mortality—including opioid-related overdoses and deaths in conjunction with the spread of infectious diseases, such as HIV infection and hepatitis C.
In this environment, it is imperative that physicians, particularly psychiatrists, are able to identify opioid use disorders; provide education and strategies for harm reduction; and offer effective, evidence-based treatments.
In this brief overview, we provide a step-by-step process for clinical decision making with 2 common-scenario case vignettes.
Mr Gordon is a 45-year-old construction worker who had been injured a year earlier when picking up a heavy piece of equipment. His primary care physician (PCP) prescribed oxycodone for the pain. After 3 months, the original dose prescribed no longer controlled his pain, and Mr Gordon began gradually increasing the dose and subsequently running out of his medication earlier than anticipated. After multiple discussions about his increasing use of oxycodone and his failed attempts to cut down on his use, Mr Gordon’s PCP stopped prescribing the medication.
After using the last dose of oxycodone, Mr Gordon woke up sweating profusely, with diarrhea, nausea, bone aches and pains, and anxiety. The next morning, he experienced very strong urges to use oxycodone, and he made 3 appointments with different physicians and managed to obtain prescriptions from each of them. In addition, he began buying “blue roxies” (colloquial term for oxycodone 30-mg tablets) from a neighbor, and learned to crush and use 5 to 8 tablets intranasally daily, noting a faster onset of effect.
In a short time, Mr Gordon found himself frequently calling in sick to work so he could continue using the pain-killers. He felt sick on the mornings when he did not have enough pills. He also became depressed and uninterested in socializing, and he had poor appetite and no sex drive. He stopped going to the gym, which had previously been his passion.
After missing work for the third time in a week, he was fired. Out of work and with only a few tablets of oxycodone left, Mr Gordon feels that his use of oxycodone is out of control and that he has become “a different person.”
Mr Gordon’s diagnosis
In DSM-5, opioid use disorders, like all substance use disorders, have been redefined as a spectrum of pathology and impairment. The criteria for an opioid use disorder are generally the same as in DSM-IV. The diagnostic criteria for DSM-IV abuse and dependence were combined in DSM-5 except for 2 changes: (1) the criterion for recurrent legal problems has been removed and (2) a new criterion for craving, or a strong desire or urge, to use opioids has been added (see Table 1 for all 11 criteria).
In DSM-5, the two disorders of opioid abuse and opioid dependence are replaced by a category of opioid use disorder. A patient must meet at least 2 diagnostic criteria to qualify as having an opioid use disorder. Severity is characterized as “mild” if 2 or 3 criteria are met, “moderate” if 4 or 5 criteria are met, and “severe” if 6 or more criteria are met.
Mr Gordon meets 7 criteria, which qualifies him for a severe opioid use disorder. He demonstrates tolerance to oxycodone; is using more and for longer than intended; has had multiple failed attempts to decrease his use, withdrawal, and craving; has increased time spent obtaining opioids; and has failed to fulfill work obligations.
Dr Brezing is a Fellow in Addiction Psychiatry at the New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons in New York. Dr Bisaga is a Professor of Psychiatry at Columbia University College of Physicians and Surgeons and a Chair of the mentoring program “Physicians’ Clinical Support Service for Medication-Assisted Treatment.” (PCSS-MAT). The authors report no conflicts of interest concerning the subject matter of this article.
The PCSS-MAT is a national training and mentoring project developed in response to the prescription opioid misuse epidemic and the availability of newer pharmacotherapies to address opioid dependence. The overarching goal of PCSS-MAT is to make available the most effective evidence-based education and training resources about medication-assisted treatments to serve patients in a variety of settings, including primary care, psychiatry, and pain management. The PCSS-MAT mentors are a national network of trained providers with expertise in medication-assisted treatment and who are skilled in clinical education. The PCSS-MAT mentoring program is available at no cost to providers. Funding for this initiative was made possible by a grant from SAMHSA (Substance Abuse and Mental Health Services Administration).